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334: Neonatal and maternal outcomes with prolonged second stage of labor
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Clinical Obstetrics, Diabetes, Labor, Medical-Surgical-Disease, Physiology/Endocrinology, Prematurity
have an Apgar of ⬍7 at 5min (p⫽0.5), a cord pH of ⬍7.1 (p⫽0.5) or require admission to the neonatal unit (p⫽0.47) regardless of onset of labor. CONCLUSION: This study represents robust and reliable data relating to IOL in multiparous twin pregnancies. Women who were induced were more likely to be older, and deliver larger infants. IOL did not carry an increased risk of Cesarean or instrumental delivery. There was also no evidence of increased maternal or neonatal morbidity associated with IOL.
333 Admission pulse pressure is a novel predictor of fetal heart rate abnormalities following initial dosing of a labor epidural: a retrospective cohort study Nathaniel Miller1, Rebecca Cypher1, Samantha Thomas1, Peter Nielsen1, Lisa Foglia1 1
Madigan Healthcare System, Obstetrics and Gynecology, Tacoma, WA
OBJECTIVE: Administration of prophylactic intravenous fluid preload
for labor regional anesthesia is commonly performed to reduce the incidence of maternal hypotension and fetal heart rate abnormalities. However studies suggest that this intervention does not decrease the incidence of new onset fetal heart rate abnormalities. We hypothesized that a lower maternal pulse pressure at admission increases the risk of maternal hypotension and fetal heart rate abnormalities following initial bolus of a labor epidural. STUDY DESIGN: A retrospective cohort study was conducted on nulliparous, singleton, vertex-presenting women admitted to labor and delivery after 37 0/7 weeks. Subjects were identified by their admission pulse pressure. An admission pulse pressure of ⬍ 45 mmHg was defined as a low pulse pressure. A group of randomly selected control subjects with an admission pulse pressure ⱖ 45 mmHg was selected for comparison. The primary outcome was new onset fetal heart rate abnormalities defined as recurrent late or prolonged fetal heart rate decelerations in the first hour following initial dosing of a labor epidural. RESULTS: The incidence of fetal heart rate abnormalities in the 95 subjects with a low admission pulse pressure and the 95 subjects with a normal admission pulse pressure were 6.3% and 20% respectively with an odds ratio of 3.7 (CI 1.4 –9.8). We performed a multivariate logistic regression analysis generating an adjusted odds ratio of 8.5 (CI 1.8 – 40.5). CONCLUSION: New onset fetal heart rate abnormalities following initial labor epidural bolus occurs more frequently in women with an admission pulse pressure ⬍ 45 mmHg than those who have an admission pulse pressure ⱖ 45 mmHg. Admission pulse pressure appears to be a novel predictor of post-epidural fetal heart rate changes and may help clinicians make decisions regarding appropriate prophylactic measures during the initial bolus of a labor epidural in those patients at highest risk.
334 Neonatal and maternal outcomes with prolonged second stage of labor S. Katherine Laughon1, Vincenzo Berghella2, Rajeshwari Sundaram1, Uma Reddy1, Zhaohui Lu1, Matt Hoffman3 1
NIH, Eunice Kennedy Shriver National Institute of Child Health & Human Development, Bethesda, MD, 2Thomas Jefferson University, Division of MFM, Department of Obstetrics and Gynecology, Philadelphia, PA, 3 Christiana Care Health System, Department of Obstetrics and Gynecology, Newark, DE
OBJECTIVE: Clinical guidance as to duration of second stage of labor has largely been based on retrospective data from single centers. We quantitated chance of vaginal delivery once these guidelines were exceeded and compared maternal and neonatal risks in a large, contemporary U.S. cohort. STUDY DESIGN: We performed an analysis of 39,121 nulliparous and 49,958 multiparous singleton deliveries ⱖ 36 weeks’ who reached second stage with vertex presentation from the Consortium on Safe Labor, excluding antepartum stillbirths and prior cesarean. Duration of
Poster Session II
second stage outside ACOG guidelines was defined as: nulliparas with epidural ⬎ 3 hours, without ⬎ 2 hours; multiparas with epidural ⬎ 2 hours, without ⬎ 1 hour. The primary outcome was vaginal delivery. Secondary outcomes included a composite and individual maternal outcomes (postpartum hemorrhage, blood transfusion, cesarean hysterectomy, endometritis, or intensive care admission (ICU)) and composite and individual neonatal outcomes (sepsis, shoulder dystocia, hypoxic-ischemic encephalopathy, 5 minute Apgar ⬍4, need for CPAP resuscitation, neonatal ICU admission, seizure, intracranial hemorrhage, pneumonia or perinatal death). RESULTS: Vaginal delivery was highly successful for women within guidelines, as well as outside of the guidelines (Table). Composite maternal morbidity for within versus outside of the guidelines was 5.9% versus 7.6% for nulliparas with epidural (p ⬍0.001) and 3.7% versus 4.2% without epidural (p⫽0.5); 5.4% versus 5.1% for multiparas with epidural (p⬍0.001) and 1.8% versus 3.7% without epidural (p⬍0.001). Composite neonatal morbidity for within versus outside of guidelines was 6.1% versus 8.8% for nulliparas with epidural (p ⬍0.001) and 6.3% versus 9.8% without epidural (p⫽0.001); 4.3% versus 6.6% for multiparas with epidural (p⬍0.001) and 4.0% versus 6.7% without (p⫽0.001). CONCLUSION: Vaginal delivery was successful ⱖ 80% of the time in deliveries with duration of second stage outside of ACOG guidelines with a slight increase in adverse maternal and neonatal outcomes.
Success of vaginal delivery by ACOG guidelines for duration of second stage of labor
335 Alteration in progesterone receptors mRNA in maternal leucocytes–an indicator of true labor Sangeeta Jain1, Karin Fox1, Sanmaan Basraon1, Huazhi Yin1, Egle Bytautiene1, George Saade1 1 University of Texas Medical Branch, Obstetrics & Gynecology, Galveston, TX
OBJECTIVE: Alterations in myometrial progesterone receptor A (PR-A) & B (PR-B) precede term & preterm labor (PTL). Progesterone receptors (PRs) are also expressed in peripheral T lymphocytes and NK cells in pregnant women. Our objective was to determine if changes in leucocyte PR-A & B mRNA and protein also occur with labor. STUDY DESIGN: Women with singleton gestation presenting in labor between 24 to 41 weeks, and gestational age matched women not in labor, were recruited. Those with history of LEEP, cervical cerclage, known fetal or uterine anomalies, HIV, hepatitis, medical conditions requiring chronic steroids, or indicated delivery were excluded. PTL was defined as regular contractions accompanied by progressive cervical dilation to ⬎⫽ 4cm. Maternal leucocytes were separated by differential centrifugation and stored at ⫺800C. PR-A & PR-B mRNA was extracted measured by quantitative RT-PCR. Kruskall-Wallis test was used for statistical analysis (p⬍0.05). RESULTS: Leucocyte PR-B mRNA was significantly lower in women in term labor but not in PTL, compared to controls (Figure not shown). PR-AB/PR-B ratio was significantly higher in term & PTL as compared to controls (Figure). PR-A & B protein analysis is underway. CONCLUSION: In labor, PR-A and B mRNA and protein in maternal leucocytes change in a similar direction as in the myometrium. Future research to determine whether this test can be used as a biomarker of labor is warranted.
Supplement to JANUARY 2013 American Journal of Obstetrics & Gynecology
S149
Clinical Obstetrics, Diabetes, Labor, Medical-Surgical-Disease, Physiology/Endocrinology, Prematurity
have an Apgar of ⬍7 at 5min (p⫽0.5), a cord pH of ⬍7.1 (p⫽0.5) or require admission to the neonatal unit (p⫽0.47) regardless of onset of labor. CONCLUSION: This study represents robust and reliable data relating to IOL in multiparous twin pregnancies. Women who were induced were more likely to be older, and deliver larger infants. IOL did not carry an increased risk of Cesarean or instrumental delivery. There was also no evidence of increased maternal or neonatal morbidity associated with IOL.
333 Admission pulse pressure is a novel predictor of fetal heart rate abnormalities following initial dosing of a labor epidural: a retrospective cohort study Nathaniel Miller1, Rebecca Cypher1, Samantha Thomas1, Peter Nielsen1, Lisa Foglia1 1
Madigan Healthcare System, Obstetrics and Gynecology, Tacoma, WA
OBJECTIVE: Administration of prophylactic intravenous fluid preload
for labor regional anesthesia is commonly performed to reduce the incidence of maternal hypotension and fetal heart rate abnormalities. However studies suggest that this intervention does not decrease the incidence of new onset fetal heart rate abnormalities. We hypothesized that a lower maternal pulse pressure at admission increases the risk of maternal hypotension and fetal heart rate abnormalities following initial bolus of a labor epidural. STUDY DESIGN: A retrospective cohort study was conducted on nulliparous, singleton, vertex-presenting women admitted to labor and delivery after 37 0/7 weeks. Subjects were identified by their admission pulse pressure. An admission pulse pressure of ⬍ 45 mmHg was defined as a low pulse pressure. A group of randomly selected control subjects with an admission pulse pressure ⱖ 45 mmHg was selected for comparison. The primary outcome was new onset fetal heart rate abnormalities defined as recurrent late or prolonged fetal heart rate decelerations in the first hour following initial dosing of a labor epidural. RESULTS: The incidence of fetal heart rate abnormalities in the 95 subjects with a low admission pulse pressure and the 95 subjects with a normal admission pulse pressure were 6.3% and 20% respectively with an odds ratio of 3.7 (CI 1.4 –9.8). We performed a multivariate logistic regression analysis generating an adjusted odds ratio of 8.5 (CI 1.8 – 40.5). CONCLUSION: New onset fetal heart rate abnormalities following initial labor epidural bolus occurs more frequently in women with an admission pulse pressure ⬍ 45 mmHg than those who have an admission pulse pressure ⱖ 45 mmHg. Admission pulse pressure appears to be a novel predictor of post-epidural fetal heart rate changes and may help clinicians make decisions regarding appropriate prophylactic measures during the initial bolus of a labor epidural in those patients at highest risk.
334 Neonatal and maternal outcomes with prolonged second stage of labor S. Katherine Laughon1, Vincenzo Berghella2, Rajeshwari Sundaram1, Uma Reddy1, Zhaohui Lu1, Matt Hoffman3 1
NIH, Eunice Kennedy Shriver National Institute of Child Health & Human Development, Bethesda, MD, 2Thomas Jefferson University, Division of MFM, Department of Obstetrics and Gynecology, Philadelphia, PA, 3 Christiana Care Health System, Department of Obstetrics and Gynecology, Newark, DE
OBJECTIVE: Clinical guidance as to duration of second stage of labor has largely been based on retrospective data from single centers. We quantitated chance of vaginal delivery once these guidelines were exceeded and compared maternal and neonatal risks in a large, contemporary U.S. cohort. STUDY DESIGN: We performed an analysis of 39,121 nulliparous and 49,958 multiparous singleton deliveries ⱖ 36 weeks’ who reached second stage with vertex presentation from the Consortium on Safe Labor, excluding antepartum stillbirths and prior cesarean. Duration of
Poster Session II
second stage outside ACOG guidelines was defined as: nulliparas with epidural ⬎ 3 hours, without ⬎ 2 hours; multiparas with epidural ⬎ 2 hours, without ⬎ 1 hour. The primary outcome was vaginal delivery. Secondary outcomes included a composite and individual maternal outcomes (postpartum hemorrhage, blood transfusion, cesarean hysterectomy, endometritis, or intensive care admission (ICU)) and composite and individual neonatal outcomes (sepsis, shoulder dystocia, hypoxic-ischemic encephalopathy, 5 minute Apgar ⬍4, need for CPAP resuscitation, neonatal ICU admission, seizure, intracranial hemorrhage, pneumonia or perinatal death). RESULTS: Vaginal delivery was highly successful for women within guidelines, as well as outside of the guidelines (Table). Composite maternal morbidity for within versus outside of the guidelines was 5.9% versus 7.6% for nulliparas with epidural (p ⬍0.001) and 3.7% versus 4.2% without epidural (p⫽0.5); 5.4% versus 5.1% for multiparas with epidural (p⬍0.001) and 1.8% versus 3.7% without epidural (p⬍0.001). Composite neonatal morbidity for within versus outside of guidelines was 6.1% versus 8.8% for nulliparas with epidural (p ⬍0.001) and 6.3% versus 9.8% without epidural (p⫽0.001); 4.3% versus 6.6% for multiparas with epidural (p⬍0.001) and 4.0% versus 6.7% without (p⫽0.001). CONCLUSION: Vaginal delivery was successful ⱖ 80% of the time in deliveries with duration of second stage outside of ACOG guidelines with a slight increase in adverse maternal and neonatal outcomes.
Success of vaginal delivery by ACOG guidelines for duration of second stage of labor
335 Alteration in progesterone receptors mRNA in maternal leucocytes–an indicator of true labor Sangeeta Jain1, Karin Fox1, Sanmaan Basraon1, Huazhi Yin1, Egle Bytautiene1, George Saade1 1 University of Texas Medical Branch, Obstetrics & Gynecology, Galveston, TX
OBJECTIVE: Alterations in myometrial progesterone receptor A (PR-A) & B (PR-B) precede term & preterm labor (PTL). Progesterone receptors (PRs) are also expressed in peripheral T lymphocytes and NK cells in pregnant women. Our objective was to determine if changes in leucocyte PR-A & B mRNA and protein also occur with labor. STUDY DESIGN: Women with singleton gestation presenting in labor between 24 to 41 weeks, and gestational age matched women not in labor, were recruited. Those with history of LEEP, cervical cerclage, known fetal or uterine anomalies, HIV, hepatitis, medical conditions requiring chronic steroids, or indicated delivery were excluded. PTL was defined as regular contractions accompanied by progressive cervical dilation to ⬎⫽ 4cm. Maternal leucocytes were separated by differential centrifugation and stored at ⫺800C. PR-A & PR-B mRNA was extracted measured by quantitative RT-PCR. Kruskall-Wallis test was used for statistical analysis (p⬍0.05). RESULTS: Leucocyte PR-B mRNA was significantly lower in women in term labor but not in PTL, compared to controls (Figure not shown). PR-AB/PR-B ratio was significantly higher in term & PTL as compared to controls (Figure). PR-A & B protein analysis is underway. CONCLUSION: In labor, PR-A and B mRNA and protein in maternal leucocytes change in a similar direction as in the myometrium. Future research to determine whether this test can be used as a biomarker of labor is warranted.
Supplement to JANUARY 2013 American Journal of Obstetrics & Gynecology
S149