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390 Adverse obstetrical outcome in women with VTE in pregnancy
SMFM Abstracts $187
Volume 185, N u m b e r 6 A m J Obstet Gynecol 387
HIGH RATE OF DYSPAREUNIA AFTER DELIVERY IN PRIMIPARAE DEPENDING O N MODUS OF DELIVERY KAI BUHLING 1, SYBILLE STEGMEIER 1, CHRISTINE KLApp1, JULIAN ROBINSON DR z, GERDA SIEBERT3, KLAUS-DIETER WERNECKE 3, JOACHIM W DUDENHAUSEN1; 1 H u m b o l d t University, Clinic of Obstetrics, Berlin; 2Columbia University, Obstetrics/Gynecology, New York, NY; 3 H u m b o l d t University, Institute of Medical Biometry OBJECTIVE: To study the time to resumption ot sexual intercourse and the rate of dyspareunia after vaginal delivery, vaginal-operative delivery a n d C~ section m prlnnparae STUDY DESIGN: Retrospective data sampled by a n o n y m o u s questionnaire for patients who were delivered ira the prior 6-30 months. RESULTS: 1.138 out of 3.131 delivered questionnaires were r e t u r n e d . 6 5 5 / 1 . 1 3 8 (58%) of t h e m were fi'om primiparae. 4 5 5 / 6 5 5 (68%) were delivered vaginally (20% without perineal injury), 62 (9,5%) with a c-section, a n d 148 (23%) with a vaginal-operative delivery. The rate of episiotomy and perineal laceration was 44%. 49% resumed sexual intercourse within 8 weeks after delivery. 31% did not experience pain during intercourse, whereas 20.3% of all patients noted, "significant pain," d e p e n d i n g on the m o d e of delivery (Table). Between 3.4% (c-section a n d vaginal), 11% (episiotomy a n d perineal laceration) a n d 13.8% (vaginal-operative) complained of pain during sexual intercourse l o n g e r t h a n 6 m o n t h s (P = .02). But there was n o significant difference between the groups concerning the "joy at sexual intercourse." CONCLUSION: Sexuality should be taken into consideration when connseling patients about m o d e of delivery.
389
PERIPARTUM CARDIOMYOPATHY: 13 YEARS EXPERIENCE AT THE UNIVERSITY OF CHICAGO HEATHER B HEIBERGER t, JUDITH U HIBBARD 1, LYNN WEINERT 2, ROBERTO M LANG2; 1University of Chicago, Obstetrics a n d Gynecology, Chicago, IL; 2University of Chicago, Medicine, Chicago, IL OBJECTIVE: Periparmm cardiomyopathy (PPCM) is a rare but sometimes fatal form of heart failure. To assess long-term maternal a n d fetal outcomes in patients with PPCM. STUDY DESIGN: Retrospective chart review of 35 patients with PPCM who met strict inclusion criteria over a 13-year period. Left ventricular (LV) size a n d fimction were evaluated using serial e c h o c a r d i o g r a p h y (ECHO) (LV dysfunction = Fractional shortening (FS) < 30%). RESULTS: We identified 35 patients fitting criteria. 80% were AfricanAmerican with m e a n age at diagnosis 27 -+ 6 yrs; median parity 2. PPCM was diagnosed a n t e p a r t u m in 20%; postpartum in 80%, with 31% diagnosed within 1 mo postpartum. Mean FS, at diagnosis, of the entire study g r o u p was 17.3 -+ 7.0% (22.5 _+4.8% in those who recovered LV function; 14.0 _+6.2% in those with persistent dysfunction). 3 patients were lost to follow-up. O f 32 remaining, 41% h a d improvement of LV function to the normal range, mean FS 32.9 + 2.6%, median time 3 mos (0.03-36): 59% h a d no improvement, mean FS 18.8 -+ 6.0% over 45.7 _+ 38.7 mos follow-up. 2 patients u n d e r w e n t cardiac transplantation (6.3%), 3 died (9.4%). 6 / 3 5 patients h a d subsequent pregnancies: 4 with recovered LV function each had 1 infant; 2 with persistent LV dysfunction had 1 a n d 3 subsequent pregnancies. All 4 patients with recovered LV function had recurrence of symptoms a n d LV dysfunction during gestation. 3 persisted after delivery, while 1 recovered fully. 2 patients with persistent LV dysfnnction p r i o r to the s u b s e q u e n t p r e g n a n c y h a d n o r e c u r r e n c e of symptoms in gestation. Neonatal outcomes overall were excellent. CONCLUSION: Morbidity, measured by persistent LV dysfunction, is similar to previous reports; however, mortality is much lower. Advances in cardiac care and the availability of transplants may underlie improvement in overall mortality. Resolved PPCM patients remain at high risk for recurrence in subsequent pregnancies, despite seemingly full recovery.
390
ADVERSE OBSTETRICAL OUTCOME IN WOMEN WITH VTE IN PREGNANCY SARAH FERGUSON 1, .JOHN KINGDOM 2, GRAEME SMITH s, MATHEW SERMER 2, MARK WALKER4; 1University of Toronto, Obstetrics a n d Gynecology, Toronto, Ontario; 2Mount Sinai Hospital, Toronto, Ontario; ~Queen's University, Obstetrics a n d Gynecology, Kingston, Ontario: 4University of Ottawa, Maternal Fetal Medicine, Ottawa, Ontario OBJECTIVE: T h r o m b o p h i l i a s are associated with an increased risk of venous thromboembolism (VTE) as well as adverse obstetrical outconms. The primary ol~jective of this study was to d e t e r m i n e if VTE in p r e g n a n c y was associated with adverse obstetrical outcome. STUDY DESIGN: In this retrospective c o h o r t study, w o m e n with a d o c u m e n t e d VTE confirmed by objective testing were identified from 1989 to 1999. The obstetrical outcome of these women in the index pregnancy was c o m p a r e d to controls who delivered in the same time period. Controls were identified by computerized r a n d o m n u m b e r generation. The primary outcome measure was a composite of obstetric morbidity defined as stillbirth, severe PET, placental a b r u p t i o n , a n d IUGR (<10 %ile). Proportions were c o m p a r e d with the chi-squared test with Fisher's exact test used where appropriate. Assuming a baseline event rate of the primary outcome of 5%, a sample size of 124 women with 3:1 matching was needed to detect a 20 percent rate difference in the primary outcome. RESULTS: Between 1989 a n d 1999 there were a total of 75,000 deliveries. There were 31 d o c u m e n t e d VTE consisting of 26 deep venous thrombosis a n d 5 p u h n o n a r y emboli. T h e r e were 93 controls reviewed. Cases a n d controls were sinfilar for all baseline characteristics. The majority of DVT's were in the left leg (19/26). There was a significant increase in adverse obstetrical events in the VTE g r o u p 10/31 c o m p a r e d to controls 4 / 9 3 (RR 3.7 2.3-6.2). The relative risk of stillbirth was 4.2 (3.1-5.8), IUGR 3.8 (2.3-6.9), placental abruption 2.0 (0.54~,4) a n d severe PET 2.1 (0.7-5.8). Thrmnbophilia testing was p e r f o r m e d on case patients a n d 6/11 (55%) were positive; three of these patients had multiple thrombophilias. CONCLUSION: To our knowledge this is the first study to demonstrate a relationship between VTE a n d adverse obstetrical outcomes. T h e r e is a significant increase in IUGR a n d stillbirth. These results have i m p o r t a n t implications when following pregnancies in women with a history of VI'E.
Table Pain at first SI after delivery EPISIOTOMY SPONTANOUS AND WITHOUT PRIMARY SECONDARY PERINEAL VAGINALINJURIES C-SECTION C-SECTION LEIZURE OPERATIVE
No pain Less Medimn Considerable Strong
388
44% 20% 26% 5.2% 5.2%
50% 17% 25% 8.3% 0%
48% 11% 30% 6.5% 4.3%
24% 19% 30% 19% 7.2%
26% 22% 29% 13% 10%
PERIPARTUM THROMBOEMBOLIC DISEASE: CLINICAL SUSPICION WARRANTS PROMPT EVALUATION JILL HECHTMAN I, JERRIE REFUERZO l, MARK REDMAN 1, STANLEY BERRY2, JANICE WHITTY3; tWayne State University, Obstetrics a n d Gynecology, Detroit, MI; 2Wayne State University, O b / G y n , Detroit, MI; 3Wayne State University, O b / G y n / M a t e r n a l Fetal Med, Detroit, MI OBJECTIVE: Clinical suspicion, early detection a n d p r o m p t treatment are i m p o r t a n t in i m p r o v i n g m a t e r n a l o u t c o m e in patients with p u l m o n a r y embolism (PE) a n d deep venous thrombosis (DVT) during the p e r i p a r m m period. We hypothesize that a l t h o u g h diagnostic tests may be p e r f o r m e d unnecessarily, this p a t t e r n is vital in d i a g n o s i n g the few cases of thromboembolism that potentially may lead to death. The aim of our study was to determine: 1) the postive yield in evaluations of patients suspected of a thromboembolic event, and 2) if there are specific clinical signs a n d symptoms particular to these patient,s. STUDY DESIGN: We conducted a retrospective chart review of patients evaluated tor the presence of a thromboembolic event from 1999 to 2001. Demographics a n d clinical presentations of patients with either a PE or DVT were c o m p a r e d to patients with negative diagnostic tests. Statistical analysis included student's t test, chi square a n d Mann Whitney U. RESULTS: O f 40 patients that were assessed for evidence of a thromboembolic event, 12.5% (n - 5) h a d confirmatory diagnostic testing. Four patients were diagnosed with PE a n d 1 patient with both DVT a n d PE. In both groups, 57% of patients were evaluated in the a n t e p a r t u m period, whereas 43% presented p o s t p a r t u m . There was no difference in age, gravidity, parity or race between groups. Also, both groups h a d similar frequencies of clinical findings including shortness of breath, chest pain, cough,leg swening, leg pain, hypoxia, tachycardia, a n d tachypnea. No maternal deaths occurred in either group. CONCLUSION: In our patient population, 12.5% of patients assessed for thromboembolism were positive tor the disease. Lack of definitive signs a n d symptoms of t h r o m b o e m b o l i c disease in the p e r i p a r t u m p e r i o d warrants complete evaluation of patients clinically suspected of having a PE or DVT.
Volume 185, N u m b e r 6 A m J Obstet Gynecol 387
HIGH RATE OF DYSPAREUNIA AFTER DELIVERY IN PRIMIPARAE DEPENDING O N MODUS OF DELIVERY KAI BUHLING 1, SYBILLE STEGMEIER 1, CHRISTINE KLApp1, JULIAN ROBINSON DR z, GERDA SIEBERT3, KLAUS-DIETER WERNECKE 3, JOACHIM W DUDENHAUSEN1; 1 H u m b o l d t University, Clinic of Obstetrics, Berlin; 2Columbia University, Obstetrics/Gynecology, New York, NY; 3 H u m b o l d t University, Institute of Medical Biometry OBJECTIVE: To study the time to resumption ot sexual intercourse and the rate of dyspareunia after vaginal delivery, vaginal-operative delivery a n d C~ section m prlnnparae STUDY DESIGN: Retrospective data sampled by a n o n y m o u s questionnaire for patients who were delivered ira the prior 6-30 months. RESULTS: 1.138 out of 3.131 delivered questionnaires were r e t u r n e d . 6 5 5 / 1 . 1 3 8 (58%) of t h e m were fi'om primiparae. 4 5 5 / 6 5 5 (68%) were delivered vaginally (20% without perineal injury), 62 (9,5%) with a c-section, a n d 148 (23%) with a vaginal-operative delivery. The rate of episiotomy and perineal laceration was 44%. 49% resumed sexual intercourse within 8 weeks after delivery. 31% did not experience pain during intercourse, whereas 20.3% of all patients noted, "significant pain," d e p e n d i n g on the m o d e of delivery (Table). Between 3.4% (c-section a n d vaginal), 11% (episiotomy a n d perineal laceration) a n d 13.8% (vaginal-operative) complained of pain during sexual intercourse l o n g e r t h a n 6 m o n t h s (P = .02). But there was n o significant difference between the groups concerning the "joy at sexual intercourse." CONCLUSION: Sexuality should be taken into consideration when connseling patients about m o d e of delivery.
389
PERIPARTUM CARDIOMYOPATHY: 13 YEARS EXPERIENCE AT THE UNIVERSITY OF CHICAGO HEATHER B HEIBERGER t, JUDITH U HIBBARD 1, LYNN WEINERT 2, ROBERTO M LANG2; 1University of Chicago, Obstetrics a n d Gynecology, Chicago, IL; 2University of Chicago, Medicine, Chicago, IL OBJECTIVE: Periparmm cardiomyopathy (PPCM) is a rare but sometimes fatal form of heart failure. To assess long-term maternal a n d fetal outcomes in patients with PPCM. STUDY DESIGN: Retrospective chart review of 35 patients with PPCM who met strict inclusion criteria over a 13-year period. Left ventricular (LV) size a n d fimction were evaluated using serial e c h o c a r d i o g r a p h y (ECHO) (LV dysfunction = Fractional shortening (FS) < 30%). RESULTS: We identified 35 patients fitting criteria. 80% were AfricanAmerican with m e a n age at diagnosis 27 -+ 6 yrs; median parity 2. PPCM was diagnosed a n t e p a r t u m in 20%; postpartum in 80%, with 31% diagnosed within 1 mo postpartum. Mean FS, at diagnosis, of the entire study g r o u p was 17.3 -+ 7.0% (22.5 _+4.8% in those who recovered LV function; 14.0 _+6.2% in those with persistent dysfunction). 3 patients were lost to follow-up. O f 32 remaining, 41% h a d improvement of LV function to the normal range, mean FS 32.9 + 2.6%, median time 3 mos (0.03-36): 59% h a d no improvement, mean FS 18.8 -+ 6.0% over 45.7 _+ 38.7 mos follow-up. 2 patients u n d e r w e n t cardiac transplantation (6.3%), 3 died (9.4%). 6 / 3 5 patients h a d subsequent pregnancies: 4 with recovered LV function each had 1 infant; 2 with persistent LV dysfunction had 1 a n d 3 subsequent pregnancies. All 4 patients with recovered LV function had recurrence of symptoms a n d LV dysfunction during gestation. 3 persisted after delivery, while 1 recovered fully. 2 patients with persistent LV dysfnnction p r i o r to the s u b s e q u e n t p r e g n a n c y h a d n o r e c u r r e n c e of symptoms in gestation. Neonatal outcomes overall were excellent. CONCLUSION: Morbidity, measured by persistent LV dysfunction, is similar to previous reports; however, mortality is much lower. Advances in cardiac care and the availability of transplants may underlie improvement in overall mortality. Resolved PPCM patients remain at high risk for recurrence in subsequent pregnancies, despite seemingly full recovery.
390
ADVERSE OBSTETRICAL OUTCOME IN WOMEN WITH VTE IN PREGNANCY SARAH FERGUSON 1, .JOHN KINGDOM 2, GRAEME SMITH s, MATHEW SERMER 2, MARK WALKER4; 1University of Toronto, Obstetrics a n d Gynecology, Toronto, Ontario; 2Mount Sinai Hospital, Toronto, Ontario; ~Queen's University, Obstetrics a n d Gynecology, Kingston, Ontario: 4University of Ottawa, Maternal Fetal Medicine, Ottawa, Ontario OBJECTIVE: T h r o m b o p h i l i a s are associated with an increased risk of venous thromboembolism (VTE) as well as adverse obstetrical outconms. The primary ol~jective of this study was to d e t e r m i n e if VTE in p r e g n a n c y was associated with adverse obstetrical outcome. STUDY DESIGN: In this retrospective c o h o r t study, w o m e n with a d o c u m e n t e d VTE confirmed by objective testing were identified from 1989 to 1999. The obstetrical outcome of these women in the index pregnancy was c o m p a r e d to controls who delivered in the same time period. Controls were identified by computerized r a n d o m n u m b e r generation. The primary outcome measure was a composite of obstetric morbidity defined as stillbirth, severe PET, placental a b r u p t i o n , a n d IUGR (<10 %ile). Proportions were c o m p a r e d with the chi-squared test with Fisher's exact test used where appropriate. Assuming a baseline event rate of the primary outcome of 5%, a sample size of 124 women with 3:1 matching was needed to detect a 20 percent rate difference in the primary outcome. RESULTS: Between 1989 a n d 1999 there were a total of 75,000 deliveries. There were 31 d o c u m e n t e d VTE consisting of 26 deep venous thrombosis a n d 5 p u h n o n a r y emboli. T h e r e were 93 controls reviewed. Cases a n d controls were sinfilar for all baseline characteristics. The majority of DVT's were in the left leg (19/26). There was a significant increase in adverse obstetrical events in the VTE g r o u p 10/31 c o m p a r e d to controls 4 / 9 3 (RR 3.7 2.3-6.2). The relative risk of stillbirth was 4.2 (3.1-5.8), IUGR 3.8 (2.3-6.9), placental abruption 2.0 (0.54~,4) a n d severe PET 2.1 (0.7-5.8). Thrmnbophilia testing was p e r f o r m e d on case patients a n d 6/11 (55%) were positive; three of these patients had multiple thrombophilias. CONCLUSION: To our knowledge this is the first study to demonstrate a relationship between VTE a n d adverse obstetrical outcomes. T h e r e is a significant increase in IUGR a n d stillbirth. These results have i m p o r t a n t implications when following pregnancies in women with a history of VI'E.
Table Pain at first SI after delivery EPISIOTOMY SPONTANOUS AND WITHOUT PRIMARY SECONDARY PERINEAL VAGINALINJURIES C-SECTION C-SECTION LEIZURE OPERATIVE
No pain Less Medimn Considerable Strong
388
44% 20% 26% 5.2% 5.2%
50% 17% 25% 8.3% 0%
48% 11% 30% 6.5% 4.3%
24% 19% 30% 19% 7.2%
26% 22% 29% 13% 10%
PERIPARTUM THROMBOEMBOLIC DISEASE: CLINICAL SUSPICION WARRANTS PROMPT EVALUATION JILL HECHTMAN I, JERRIE REFUERZO l, MARK REDMAN 1, STANLEY BERRY2, JANICE WHITTY3; tWayne State University, Obstetrics a n d Gynecology, Detroit, MI; 2Wayne State University, O b / G y n , Detroit, MI; 3Wayne State University, O b / G y n / M a t e r n a l Fetal Med, Detroit, MI OBJECTIVE: Clinical suspicion, early detection a n d p r o m p t treatment are i m p o r t a n t in i m p r o v i n g m a t e r n a l o u t c o m e in patients with p u l m o n a r y embolism (PE) a n d deep venous thrombosis (DVT) during the p e r i p a r m m period. We hypothesize that a l t h o u g h diagnostic tests may be p e r f o r m e d unnecessarily, this p a t t e r n is vital in d i a g n o s i n g the few cases of thromboembolism that potentially may lead to death. The aim of our study was to determine: 1) the postive yield in evaluations of patients suspected of a thromboembolic event, and 2) if there are specific clinical signs a n d symptoms particular to these patient,s. STUDY DESIGN: We conducted a retrospective chart review of patients evaluated tor the presence of a thromboembolic event from 1999 to 2001. Demographics a n d clinical presentations of patients with either a PE or DVT were c o m p a r e d to patients with negative diagnostic tests. Statistical analysis included student's t test, chi square a n d Mann Whitney U. RESULTS: O f 40 patients that were assessed for evidence of a thromboembolic event, 12.5% (n - 5) h a d confirmatory diagnostic testing. Four patients were diagnosed with PE a n d 1 patient with both DVT a n d PE. In both groups, 57% of patients were evaluated in the a n t e p a r t u m period, whereas 43% presented p o s t p a r t u m . There was no difference in age, gravidity, parity or race between groups. Also, both groups h a d similar frequencies of clinical findings including shortness of breath, chest pain, cough,leg swening, leg pain, hypoxia, tachycardia, a n d tachypnea. No maternal deaths occurred in either group. CONCLUSION: In our patient population, 12.5% of patients assessed for thromboembolism were positive tor the disease. Lack of definitive signs a n d symptoms of t h r o m b o e m b o l i c disease in the p e r i p a r t u m p e r i o d warrants complete evaluation of patients clinically suspected of having a PE or DVT.