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444 Transverse Uterine Incision Closure: One Versus Two Layers
398
444
SPO Abstracts
TRANSVERSE UTERINE INCISION CLOSURE: ONE VERSUS TWO LAYERS
J.C. Hauth, J. Owen, R.O. Davis, T. Lincolnx, J. Piazzax University of Alabama Hospitals, Birmingham In 1926, Munro Kerr described the transverse lower uterine segment incision and recommended a two layer closure. Theoretically, a one layer closure should disrupt less tissue, introduce less foreign material, require less operative time, and perhaps achieve hemostasis more rapidly. To test this hypothesis, we prospectively randomized 761 women to closure with either one continuous layer of a locking #1 chromic gut suture using a CTX needle (#384) or two continuous layers of #1 chromic gut with the first layer locked (#377). Both groups had similar demographic and intrapartum risk factors. Women who had a one layer closure required less operative time, 39 versus 45 minutes, (p=.004) and fewer uterine hemostatic sutures, a mean of 0.65 versus 0.82 for one and two layers respectively (p=0.03). Endometritis (excluding patients with chorioamnionitis) was similar in both groups (21 vs. 18% p=0.34) and a Hct decrease of 2! 8% from the pre- to postoperative day one occurred in 11.7% (one) vs. 15.5% (two) p=.14. In no outcome assessment was the two layer closure of more benefit than the one layer. We recommend that a transverse incision be placed in the true lower uterine segment and that a one layer closure be used when anatomically feasible.
445
SOCIOBEHAVIORAL CHARACTERISTICS AND INTRAUTERINE GROWTH RETARDATION: A MULTIVARIATE ANALYSIS. L.C. Castro. C. Hobel, L. Platt. Dept OB-GYN, Cedars-Sinai Med Cit. LA, CA. The purpose of this study was to determine the prevalence rates for tobacco use (TV) & substance abuse (SA) in a broad spectrum of pregnant women & to evaluate the individual & interactive effects of TU, SA & sociodemographiccharacteristics on intrauterine growth retardation (IUGR). Methods: 8,914 women delivering in a university affiliated hospital from 1986-90 were studied. Information on TU, SA (use of alcohol, marijuana and other illicit drugs) & sociodemographics was obtained antenataUy. IUGR was a birthwt < IOth% for gestational age (GA). Univariate logistic regression was used to assess the association between each sociobehavioral factor & IUGR. Stepwise multivariate analysis was used to determine their interactive effects on IUGR. Results: Prevalence Rates Race-ethnicity White Black Asian Hispanic p-value Tobacco use 17% 13% 8% S% <.0001 Substance abuse 7% 7% S% 3% < .0001 Insurance status Uninsured HMO Private p-value S% < .001 Tobacco use 14% 8% S% 4% < .01 Substance abuse 6% Marital status Single Married p-value Tobacco use 17% 8% < .0001 Substance abuse 9% 4% < .0001 TU & SA were lowest in 30-39 year old women (6% & 4%) vs other ages (p < .(01). Univariate analysis showed that TU, alcohol, marijuana, race & non-private insurance were significantly associated with IUGR. Multivariate analysis showed that TU (odds ratio; 1.96, p< .00(1), marijuana use (odds ratio; 1.69, p<.03) & race (odds ratio; 1.66 for blacks, p<.OOI) were most strongly associated with IUGR. For the categories SA, TU, & SA plus TU the prevalence of IUGR progressively increased (p < .00(1) & this increase was greatest in black women. Conclusions: There are significant interactive effects of TU, SA & race on IUGR. Supp. by UCTRDRP.
January 1992 Am J Obstet Gynecol
446 PREDICTORS
OF SUCCESS IN THE EMERGENT CERCLAGE. T.F.Kelly MO: L.R.Troyer MO, K.M.Piacquadio MOo' C.J.Cantrell MO, V.M.Parisi MO,MPH, T.R.Moore MD. From fhe Divisions of Matemal Fetal Medicine of the Unil'ersity of Califomia, Sail Diego and the Ulliversity of Texas ." H Alston IJnd the Departl1lellt of Obstetrics alld Gynecology, Balboa Naval Hospital, San Diego. It is difficult to counsel the mid trimester patient who presents with advanced cervical dilatation. Available literature does not dciineate the variables most prognostic for the success of emergent cerclage. We retrospectively reviewed charts of 20 patients (21 fetuses) who presented within the last 6 years with advanced cervical dilatation and visible or prolapsing membranes, in the second trimester. The average gestational age (GA) on admission was 20.9 ± 3 (SO) weeks (wks), weeks gained were 8.9 ± 7.4 wks and GA at delivery was 30 ± 7.7 wks. Neonatal survival correlated negatively with cervical dilatation on admission (R=O.46, P<0.04). If cervical dilatation was> 3.5 cm, survival was 0% (n;3); if 53.5 cm survival was 83% (n= 18) (P=0.015). Cervical effacement and membrane prolapse on admission were not predictive of weeks gained. Of 8 who had prolapsing membranes, 80% went greater than 50 days from cerclage to delivery. There was no significant relationship between time from admission to surgery or the time on tocolytics to weeks gained. We conclude that (1) cervical dilatation> 3.5 cm is prognostic of poor outcome in the performance of emergent cerclage, (2) neither cervical effacement nor evidence of membrane prolapse were predictive of successful outcome, and (3) use of tocolytics prior to cerclage appcars not to improve outcome.
447 THE MANAGEMENT OF BREECH PRESENTATION: CESAREAN SECTION VERSUS VAGINAL DELIVERY Tracy L. Wells', Luis Sanchez-Ramos M P M.D., Mark T. Cullen, M.D. Division of Maternal-Fetal Medicine, University of Florida, Jacksonville, FL
The management and perinatal outcome of 451 cases of singleton breech presentation occurring at 34 or more weeks' gestation and with a fetal weight greater than 2000 grams are reviewed. Beginning in 1986 a trial of labor was offered if the breech was frank or complete, had an estimated weight between 2000 and 4000 grams, adequate pelvimetry, and a non-extended fetal head. Three hundredthirty patients underwent a cesarean section without a trial of labor; most of these cesarean deliveries were for patients' "choice". The incidence of elective cesareans because of this indication decreased from 62% to 6% in a five year period. Of the 121 patients who qualified for a trial of labor, 22 had a cesarean section, and 99 had a successful vaginal delivery. Approximately 80% of patients who met protocol criteria delivered vaginally. Comparing the 330 patients with an elective cesarean delivery to the 99 who delivered vaginally revealed no difference in several outcome parameters including: NICU admissions, Apgar scores less than 7 at 1 and 5 minutes, umbilical cord gases, and birth trauma. There was a significant increase in maternal morbidity and length of hospital stay in the cesarean section group. We conclude that a trial of labor in selected patients can be achieved without an increase in perinatal or maternal morbidity and mortality.
444
SPO Abstracts
TRANSVERSE UTERINE INCISION CLOSURE: ONE VERSUS TWO LAYERS
J.C. Hauth, J. Owen, R.O. Davis, T. Lincolnx, J. Piazzax University of Alabama Hospitals, Birmingham In 1926, Munro Kerr described the transverse lower uterine segment incision and recommended a two layer closure. Theoretically, a one layer closure should disrupt less tissue, introduce less foreign material, require less operative time, and perhaps achieve hemostasis more rapidly. To test this hypothesis, we prospectively randomized 761 women to closure with either one continuous layer of a locking #1 chromic gut suture using a CTX needle (#384) or two continuous layers of #1 chromic gut with the first layer locked (#377). Both groups had similar demographic and intrapartum risk factors. Women who had a one layer closure required less operative time, 39 versus 45 minutes, (p=.004) and fewer uterine hemostatic sutures, a mean of 0.65 versus 0.82 for one and two layers respectively (p=0.03). Endometritis (excluding patients with chorioamnionitis) was similar in both groups (21 vs. 18% p=0.34) and a Hct decrease of 2! 8% from the pre- to postoperative day one occurred in 11.7% (one) vs. 15.5% (two) p=.14. In no outcome assessment was the two layer closure of more benefit than the one layer. We recommend that a transverse incision be placed in the true lower uterine segment and that a one layer closure be used when anatomically feasible.
445
SOCIOBEHAVIORAL CHARACTERISTICS AND INTRAUTERINE GROWTH RETARDATION: A MULTIVARIATE ANALYSIS. L.C. Castro. C. Hobel, L. Platt. Dept OB-GYN, Cedars-Sinai Med Cit. LA, CA. The purpose of this study was to determine the prevalence rates for tobacco use (TV) & substance abuse (SA) in a broad spectrum of pregnant women & to evaluate the individual & interactive effects of TU, SA & sociodemographiccharacteristics on intrauterine growth retardation (IUGR). Methods: 8,914 women delivering in a university affiliated hospital from 1986-90 were studied. Information on TU, SA (use of alcohol, marijuana and other illicit drugs) & sociodemographics was obtained antenataUy. IUGR was a birthwt < IOth% for gestational age (GA). Univariate logistic regression was used to assess the association between each sociobehavioral factor & IUGR. Stepwise multivariate analysis was used to determine their interactive effects on IUGR. Results: Prevalence Rates Race-ethnicity White Black Asian Hispanic p-value Tobacco use 17% 13% 8% S% <.0001 Substance abuse 7% 7% S% 3% < .0001 Insurance status Uninsured HMO Private p-value S% < .001 Tobacco use 14% 8% S% 4% < .01 Substance abuse 6% Marital status Single Married p-value Tobacco use 17% 8% < .0001 Substance abuse 9% 4% < .0001 TU & SA were lowest in 30-39 year old women (6% & 4%) vs other ages (p < .(01). Univariate analysis showed that TU, alcohol, marijuana, race & non-private insurance were significantly associated with IUGR. Multivariate analysis showed that TU (odds ratio; 1.96, p< .00(1), marijuana use (odds ratio; 1.69, p<.03) & race (odds ratio; 1.66 for blacks, p<.OOI) were most strongly associated with IUGR. For the categories SA, TU, & SA plus TU the prevalence of IUGR progressively increased (p < .00(1) & this increase was greatest in black women. Conclusions: There are significant interactive effects of TU, SA & race on IUGR. Supp. by UCTRDRP.
January 1992 Am J Obstet Gynecol
446 PREDICTORS
OF SUCCESS IN THE EMERGENT CERCLAGE. T.F.Kelly MO: L.R.Troyer MO, K.M.Piacquadio MOo' C.J.Cantrell MO, V.M.Parisi MO,MPH, T.R.Moore MD. From fhe Divisions of Matemal Fetal Medicine of the Unil'ersity of Califomia, Sail Diego and the Ulliversity of Texas ." H Alston IJnd the Departl1lellt of Obstetrics alld Gynecology, Balboa Naval Hospital, San Diego. It is difficult to counsel the mid trimester patient who presents with advanced cervical dilatation. Available literature does not dciineate the variables most prognostic for the success of emergent cerclage. We retrospectively reviewed charts of 20 patients (21 fetuses) who presented within the last 6 years with advanced cervical dilatation and visible or prolapsing membranes, in the second trimester. The average gestational age (GA) on admission was 20.9 ± 3 (SO) weeks (wks), weeks gained were 8.9 ± 7.4 wks and GA at delivery was 30 ± 7.7 wks. Neonatal survival correlated negatively with cervical dilatation on admission (R=O.46, P<0.04). If cervical dilatation was> 3.5 cm, survival was 0% (n;3); if 53.5 cm survival was 83% (n= 18) (P=0.015). Cervical effacement and membrane prolapse on admission were not predictive of weeks gained. Of 8 who had prolapsing membranes, 80% went greater than 50 days from cerclage to delivery. There was no significant relationship between time from admission to surgery or the time on tocolytics to weeks gained. We conclude that (1) cervical dilatation> 3.5 cm is prognostic of poor outcome in the performance of emergent cerclage, (2) neither cervical effacement nor evidence of membrane prolapse were predictive of successful outcome, and (3) use of tocolytics prior to cerclage appcars not to improve outcome.
447 THE MANAGEMENT OF BREECH PRESENTATION: CESAREAN SECTION VERSUS VAGINAL DELIVERY Tracy L. Wells', Luis Sanchez-Ramos M P M.D., Mark T. Cullen, M.D. Division of Maternal-Fetal Medicine, University of Florida, Jacksonville, FL
The management and perinatal outcome of 451 cases of singleton breech presentation occurring at 34 or more weeks' gestation and with a fetal weight greater than 2000 grams are reviewed. Beginning in 1986 a trial of labor was offered if the breech was frank or complete, had an estimated weight between 2000 and 4000 grams, adequate pelvimetry, and a non-extended fetal head. Three hundredthirty patients underwent a cesarean section without a trial of labor; most of these cesarean deliveries were for patients' "choice". The incidence of elective cesareans because of this indication decreased from 62% to 6% in a five year period. Of the 121 patients who qualified for a trial of labor, 22 had a cesarean section, and 99 had a successful vaginal delivery. Approximately 80% of patients who met protocol criteria delivered vaginally. Comparing the 330 patients with an elective cesarean delivery to the 99 who delivered vaginally revealed no difference in several outcome parameters including: NICU admissions, Apgar scores less than 7 at 1 and 5 minutes, umbilical cord gases, and birth trauma. There was a significant increase in maternal morbidity and length of hospital stay in the cesarean section group. We conclude that a trial of labor in selected patients can be achieved without an increase in perinatal or maternal morbidity and mortality.