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370: Risk of intrauterine death in monochorionic-diamniotic twins
SMFM Abstracts 367
DOES USE OF CERVIDIL CHANGE ELECTRICAL UTERINE ACTIVITY DURING INDUCTION OF LABOR? KAREN PLAYFORTH1, ODED LANGER1, CHRISTINE FARINELLI2, GAL BEN DAVID3, ILAN CALDERON3, 1St. Luke’s-Roosevelt Hospital Center, Obstetrics and Gynecology, New York, New York, 2St. Luke’s Roosevelt Hospital Center, Obstetrics and Gynecology, New York, New York, 3Bnai Zion Medical Center, Obstetrics and Gynecology, Haifa, Israel, Israel OBJECTIVE: To characterize the myometrial electrical activity during induced labor in patients who received cervidil for cervical ripening compared to those receiving pitocin only. STUDY DESIGN: Patients undergoing induction of labor were recruited into a prospective, double-blind IRB-approved study. Demographic data and Bishop Score were determined at baseline. Cervidil was placed in all patients with baseline Bishop Score 4. Patients with Bishop score ⬎4 received pitocin. Electrical activity of the uterine myometrium was measured with a multi-channel electromyogram (EMG) amplifier and a 3-dimensional position sensor at preset intervals. EMG and cervical exam data were obtained within 2 hours of placement of cervidil, at cervidil removal, at entry into active phase of labor (4 cms cervical dilatation), and every 2 hours during active labor. EMG data was recorded and sent offsite to an individual blinded to all clinical data for analysis. RESULTS: Twenty patients participated in the study (10 cervical ripening and 10 pitocin induction). There was no difference between the 2 groups in age, parity, BMI, or race. Evaluation with the EMG revealed no difference in the electrical uterine activity between those with cervidil and those without during the latent phase of labor (cervical dilatation ⬍4 cms). There was marginally increased electrical uterine activity in the cervidil group during the active phase of labor (cervical dilatation 4 cms) (511.6 vs. 445.8, p⫽0.06). In patients who received cervidil for cervical ripening, the maximum pitocin dose received was lower (11munits vs. 16 munits, p⫽0.068). CONCLUSION: Our data suggests that patients undergoing cervical ripening with cervidil may develop stronger uterine contractions during the active phase of labor with lower doses of pitocin.
www.AJOG.org 369
EFFECTS OF MAGNESIUM SULFATE ON FETAL CEREBRAL BLOOD FLOW DIANE TWICKLER1, DONALD MCINTIRE1, JAMES ALEXANDER1, KENNETH LEVENO1, 1University of Texas Southwestern Medical Center at Dallas, Dallas, Texas OBJECTIVE: To evaluate the effects of maternal administration of magnesium sulfate (MgSO4) on the fetal middle cerebral artery (MCA) using Doppler. STUDY DESIGN: This is a single center ancillary study done in conjunction with a randomized, double-masked placebo controlled trial in 20 centers. 2241 women at imminent risk for preterm delivery were randomly allocated to MgSO4 or placebo. Doppler measurements of the fetal MCA were obtained before blinded study drug administration and subsequently at hourly intervals X 4. Parameters studied included time-average velocity, peak systolic velocity, vessel diameter, heart rate, and calculated blood volume flow. A random effects model with repeated measures design was used for analysis. RESULTS: A total of 38 fetuses were studied: 18 received MgSO4 and 20 received placebo. Peak systolic velocity was significantly related to gestational age (P⬍0.0001). There were no differences between the study groups for MCA peak systolic velocity, time-average velocity, vessel diameter or calculated volume flow. As shown in the figure, fetal heart rate significantly decreased after MgSO4 treatment.
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.395
368
THE MODE OF DELIVERY IN TWIN PREGNANCIES JENNIFER HOGAN1, NADINE FARAH1, BERNARD STUART2, SEAN DALY3, 1Coombe Women and Infant’s University Hospital, Obstetrics, Dublin, Ireland, Ireland, 2Coombe Women and Infant’s University Hospital, Dublin, Ireland, Ireland, 3Coombe Women and Infant’s University Hospital Dublin, Dublin, Ireland, Ireland OBJECTIVE: The mode of delivery in twins is controversial. Some institutions suggest that all twin pregnancies should be delivered by caesarean section as there is thought to be significant morbidity in delivering a second twin by caesarean section STUDY DESIGN: We analyzed a database of all 972 twin pairs delivered in our teaching hospital in Dublin where there are over 7,500 babies born each year. We included all twins over a period of 8 years where one twin weighed more than 500g in order to establish the complication rate with caesarean delivery for the second twin. RESULTS: Among 1944 infants from 972 twin pairs there were 1050 (54%) delivered vaginally and 894 (46%) delivered by caesarean section. Among 972 sets of twins, there were 16 cases where the first twin was delivered vaginally and the second was delivered by LSCS. In 533 cases a vaginal delivery of both twins was anticipated but this was unsuccessful on 16 occasions (3%). There were 235 operative vaginal deliveries, representing 12.1% of the deliveries overall and 22.3% of the vaginal deliveries. The 16 babies that were born by LSCS following a vaginal delivery of their co-twin were reviewed. There was one death from TTTS in the second twin, who was the recipient twin and died of cardiac failure. There was one baby whose apgar score at 5 minutes was less than 8 and there were 5 admissions to either the NICU or SCBU (which is 33%). There was no long term morbidity in any of the 15 survivors. CONCLUSION: Vaginal delivery should be anticipated in twin pregnancies, as in our population it occurred in 54% of cases. The need to perform a caesarean section for the second twin is rare. If the second twin is delivered by caesarean section, this is not associated with any significant morbidity. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.396
CONCLUSION: MgSO4 had no significant effects on fetal cerebral blood flow analyzed using Doppler. The only parameter in the fetal cerebral circulation significantly modified by MgSO4 was the heart rate. The significance of this heart rate change, vis-à-vis the neuroprotective effects of MgSO4, is unknown. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.397
370
RISK OF INTRAUTERINE DEATH IN MONOCHORIONIC-DIAMNIOTIC TWINS ROBIN B. KALISH1, NEIL SIMMERMAN1, RACHEL MOQUETE1, STEPHEN T. CHASEN1, 1Weill Cornell Medical College, Obstetrics and Gynecology, New York, New York OBJECTIVE: This study aims to calculate the prospective gestational age specific risk of fetal death in MCDA twins after viability. STUDY DESIGN: We performed a retrospective review of all MCDA twins who where followed antenatally and delivered after 24 weeks gestation from 2000-2008 at our institution. Study subjects were identified from our ultrasound database. All maternal and neonatal charts were reviewed. The risk of fetal death was calculated for each gestational age. Fisher=s exact and Mann-Whitney U tests were used for analysis of categorical and continuous variables. Binomial distribution 95% confidence intervals were calculated using standard statistical formulas. RESULTS: Eight intrauterine deaths occurred in 5/94 pregnancies (5.3%). Twin-twin transfusion syndrome (TTTS) was diagnosed in 8/94 pregnancies (8.5%). The risk of fetal death was higher in pregnancies complicated by TTTS (25% vs 5.8%, p⫽ 0.05). Of 180 live newborns in our study there were 2 neonatal deaths (1.1%) both of which were severely premature (25 weeks) and complicated by TTTS. The prospective risk of fetal demise was calculated for 2 week blocks starting at 24 weeks gestation. The prospective risk of fetal death was 5.3% at 2425wks, 3.3% at 26-27wks, 3.4% at 28-29wks, 3.5% at 30-31wks, 3.7% at 32-33wks, 2.7% at 34-35wks, and 1.8% at ⬎36wks. The overall risk of perinatal death was 10 per 188 fetuses (5.3%). CONCLUSION: There is a high risk of intrauterine death in MCDA pregnancies. While elective pre-term delivery may reduce the risk of intrauterine death, it could potentiate an increase in the rate of neonatal complications associated with prematurity. The optimal gestational age for delivery in MCDA pregnancies not complicated by TTTS remains controversial and warrants further investigation. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.398
S112
American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2008
DOES USE OF CERVIDIL CHANGE ELECTRICAL UTERINE ACTIVITY DURING INDUCTION OF LABOR? KAREN PLAYFORTH1, ODED LANGER1, CHRISTINE FARINELLI2, GAL BEN DAVID3, ILAN CALDERON3, 1St. Luke’s-Roosevelt Hospital Center, Obstetrics and Gynecology, New York, New York, 2St. Luke’s Roosevelt Hospital Center, Obstetrics and Gynecology, New York, New York, 3Bnai Zion Medical Center, Obstetrics and Gynecology, Haifa, Israel, Israel OBJECTIVE: To characterize the myometrial electrical activity during induced labor in patients who received cervidil for cervical ripening compared to those receiving pitocin only. STUDY DESIGN: Patients undergoing induction of labor were recruited into a prospective, double-blind IRB-approved study. Demographic data and Bishop Score were determined at baseline. Cervidil was placed in all patients with baseline Bishop Score 4. Patients with Bishop score ⬎4 received pitocin. Electrical activity of the uterine myometrium was measured with a multi-channel electromyogram (EMG) amplifier and a 3-dimensional position sensor at preset intervals. EMG and cervical exam data were obtained within 2 hours of placement of cervidil, at cervidil removal, at entry into active phase of labor (4 cms cervical dilatation), and every 2 hours during active labor. EMG data was recorded and sent offsite to an individual blinded to all clinical data for analysis. RESULTS: Twenty patients participated in the study (10 cervical ripening and 10 pitocin induction). There was no difference between the 2 groups in age, parity, BMI, or race. Evaluation with the EMG revealed no difference in the electrical uterine activity between those with cervidil and those without during the latent phase of labor (cervical dilatation ⬍4 cms). There was marginally increased electrical uterine activity in the cervidil group during the active phase of labor (cervical dilatation 4 cms) (511.6 vs. 445.8, p⫽0.06). In patients who received cervidil for cervical ripening, the maximum pitocin dose received was lower (11munits vs. 16 munits, p⫽0.068). CONCLUSION: Our data suggests that patients undergoing cervical ripening with cervidil may develop stronger uterine contractions during the active phase of labor with lower doses of pitocin.
www.AJOG.org 369
EFFECTS OF MAGNESIUM SULFATE ON FETAL CEREBRAL BLOOD FLOW DIANE TWICKLER1, DONALD MCINTIRE1, JAMES ALEXANDER1, KENNETH LEVENO1, 1University of Texas Southwestern Medical Center at Dallas, Dallas, Texas OBJECTIVE: To evaluate the effects of maternal administration of magnesium sulfate (MgSO4) on the fetal middle cerebral artery (MCA) using Doppler. STUDY DESIGN: This is a single center ancillary study done in conjunction with a randomized, double-masked placebo controlled trial in 20 centers. 2241 women at imminent risk for preterm delivery were randomly allocated to MgSO4 or placebo. Doppler measurements of the fetal MCA were obtained before blinded study drug administration and subsequently at hourly intervals X 4. Parameters studied included time-average velocity, peak systolic velocity, vessel diameter, heart rate, and calculated blood volume flow. A random effects model with repeated measures design was used for analysis. RESULTS: A total of 38 fetuses were studied: 18 received MgSO4 and 20 received placebo. Peak systolic velocity was significantly related to gestational age (P⬍0.0001). There were no differences between the study groups for MCA peak systolic velocity, time-average velocity, vessel diameter or calculated volume flow. As shown in the figure, fetal heart rate significantly decreased after MgSO4 treatment.
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.395
368
THE MODE OF DELIVERY IN TWIN PREGNANCIES JENNIFER HOGAN1, NADINE FARAH1, BERNARD STUART2, SEAN DALY3, 1Coombe Women and Infant’s University Hospital, Obstetrics, Dublin, Ireland, Ireland, 2Coombe Women and Infant’s University Hospital, Dublin, Ireland, Ireland, 3Coombe Women and Infant’s University Hospital Dublin, Dublin, Ireland, Ireland OBJECTIVE: The mode of delivery in twins is controversial. Some institutions suggest that all twin pregnancies should be delivered by caesarean section as there is thought to be significant morbidity in delivering a second twin by caesarean section STUDY DESIGN: We analyzed a database of all 972 twin pairs delivered in our teaching hospital in Dublin where there are over 7,500 babies born each year. We included all twins over a period of 8 years where one twin weighed more than 500g in order to establish the complication rate with caesarean delivery for the second twin. RESULTS: Among 1944 infants from 972 twin pairs there were 1050 (54%) delivered vaginally and 894 (46%) delivered by caesarean section. Among 972 sets of twins, there were 16 cases where the first twin was delivered vaginally and the second was delivered by LSCS. In 533 cases a vaginal delivery of both twins was anticipated but this was unsuccessful on 16 occasions (3%). There were 235 operative vaginal deliveries, representing 12.1% of the deliveries overall and 22.3% of the vaginal deliveries. The 16 babies that were born by LSCS following a vaginal delivery of their co-twin were reviewed. There was one death from TTTS in the second twin, who was the recipient twin and died of cardiac failure. There was one baby whose apgar score at 5 minutes was less than 8 and there were 5 admissions to either the NICU or SCBU (which is 33%). There was no long term morbidity in any of the 15 survivors. CONCLUSION: Vaginal delivery should be anticipated in twin pregnancies, as in our population it occurred in 54% of cases. The need to perform a caesarean section for the second twin is rare. If the second twin is delivered by caesarean section, this is not associated with any significant morbidity. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.396
CONCLUSION: MgSO4 had no significant effects on fetal cerebral blood flow analyzed using Doppler. The only parameter in the fetal cerebral circulation significantly modified by MgSO4 was the heart rate. The significance of this heart rate change, vis-à-vis the neuroprotective effects of MgSO4, is unknown. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.397
370
RISK OF INTRAUTERINE DEATH IN MONOCHORIONIC-DIAMNIOTIC TWINS ROBIN B. KALISH1, NEIL SIMMERMAN1, RACHEL MOQUETE1, STEPHEN T. CHASEN1, 1Weill Cornell Medical College, Obstetrics and Gynecology, New York, New York OBJECTIVE: This study aims to calculate the prospective gestational age specific risk of fetal death in MCDA twins after viability. STUDY DESIGN: We performed a retrospective review of all MCDA twins who where followed antenatally and delivered after 24 weeks gestation from 2000-2008 at our institution. Study subjects were identified from our ultrasound database. All maternal and neonatal charts were reviewed. The risk of fetal death was calculated for each gestational age. Fisher=s exact and Mann-Whitney U tests were used for analysis of categorical and continuous variables. Binomial distribution 95% confidence intervals were calculated using standard statistical formulas. RESULTS: Eight intrauterine deaths occurred in 5/94 pregnancies (5.3%). Twin-twin transfusion syndrome (TTTS) was diagnosed in 8/94 pregnancies (8.5%). The risk of fetal death was higher in pregnancies complicated by TTTS (25% vs 5.8%, p⫽ 0.05). Of 180 live newborns in our study there were 2 neonatal deaths (1.1%) both of which were severely premature (25 weeks) and complicated by TTTS. The prospective risk of fetal demise was calculated for 2 week blocks starting at 24 weeks gestation. The prospective risk of fetal death was 5.3% at 2425wks, 3.3% at 26-27wks, 3.4% at 28-29wks, 3.5% at 30-31wks, 3.7% at 32-33wks, 2.7% at 34-35wks, and 1.8% at ⬎36wks. The overall risk of perinatal death was 10 per 188 fetuses (5.3%). CONCLUSION: There is a high risk of intrauterine death in MCDA pregnancies. While elective pre-term delivery may reduce the risk of intrauterine death, it could potentiate an increase in the rate of neonatal complications associated with prematurity. The optimal gestational age for delivery in MCDA pregnancies not complicated by TTTS remains controversial and warrants further investigation. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.398
S112
American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2008