- Email: [email protected]
515: Cesarean delivery in extreme preterm birth does not improve survival or survival without severe morbidity
Poster Session III
Doppler Assess, Fetus, Prematurity, U/S, Med-Surg-Diseases
10%. A second consecutive term born baby had a perinatal mortality of 1.7%. CONCLUSION: Previous delivery of a preterm infant is a strong predictor of future preterm births. Previous or repeated preterm births increase the risk of perinatal death substantially in Sub-Saharan Africa.
515 Cesarean delivery in extreme preterm birth does not improve survival or survival without severe morbidity Michael Trifiro1, Sima Parmar2, Guibo Xing3, Bryon Jacoby2 1 University of California Davis Medical Center, Obstetrics and Gynecology, Sacramento, CA, 2University of California Davis Medical Center, Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, Sacramento, CA, 3 University of California Davis Medical Center, Center for Healthcare Policy and Research, Sacramento, CA
OBJECTIVE: To determine if mode of delivery affects survival of extremely preterm neonates. STUDY DESIGN: This is a retrospective cohort study of early preterm deliveries between 22 weeks 0 days and 27 weeks 6 days occurring between January 1, 2000 and December 31, 2009 at the University of California Davis Medical Center. Genetic abortions and inductions for stillbirths were not included. Maternal characteristics, obstetrical data, and neonatal information were collected. Statistical analysis was performed to evaluate obstetrical and neonatal factors associated with total survival and survival without a severe morbidity. Severe morbidities included intraventricular hemorrhage ⱖ3, periventricular leukomalacia, retinopathy of prematurity ⱖ3, necrotizing enterocolitis, or broncho-pulmonary dysplasia. RESULTS: Over the study period, 238 early preterm births occurred. Factors associated with improved survival included weeks gestation (p⬍0.0001), birthweight (p⬍0.0001), female gender (OR 2.12 95% CI 1.20-3.72), and steroid administration (OR 4.85 95% CI 2.678.83). 146 deliveries were by cesarean section and 92 deliveries were vaginal. Delivery by cesarean section was associated with improved survival in univariate analysis (OR 2.15 95% CI1.23-3.77), but this association was not significant in multivariate analysis adjusting for birthweight, gender and steroid administration (OR 1.85 95% CI 0.89-3.87). There was no association with cesarean section and survival to discharge without severe morbidity in univariate (OR 1.35 95% CI 0.79-2.28) or multivariate analyses (OR 1.15 95% CI 0.582.27). CONCLUSION: Delivery of the extremely preterm neonate is complicated with limited data to guide care and counseling. A limited number of studies have compared mode of delivery in extreme preterm birth and there is insufficient evidence to support cesarean delivery in extremely preterm neonates. In this study, cesarean delivery was not associated with total survival or survival without severe morbidity in multivariate analysis.
516 Clinical findings in amniotic fluid of women with asymptomatic short cervix in the midtrimester Ming Zhou1, David Cool2, William Grunwald2, Harry Khamis3, David McKenna1 1
Wright State University, Maternal-Fetal Medicine, Dayton, OH, 2Wright State University, Pharmacology & Toxicology, Dayton, OH, 3Wright State University, Mathmatics & Statisitcs, Dayton, OH
OBJECTIVE: To correlate amniotic fluid (AF) findings in women with asymptomatic short cervix in the midtrimester to pregnancy outcome. STUDY DESIGN: 30 women with an asymptomatic singleton pregnancy, and an incidental finding of transvaginal cervical length ⬍15mm at 16-27 weeks gestation underwent amniocentesis. AF was analyzed for chemistry (glucose and LDH), cytology (WBC and total cell count), and microbiology (gram stain, aerobic, anaerobic, and mycoplasma cultures). Women were divided into a cerclage (WBC ⬍⫽ 5, negative cultures and gram stain) or vaginal progesterone (200 mg nightly) treatment arm depending on their AF findings. Pregnancy outcome data was collected and compared with initial AF findings.
S222
www.AJOG.org
RESULTS: 5 women met criteria for cerclage and four underwent the procedure. The remaining 25 were treated with vaginal progesterone. AF fluid gram stain and cultures were negative for pathogens. Average gestational age (GA) at birth for the entire population was 31.9 weeks. When compared with the patients who had WBC ⬎5 and received progesterone, women who had AF WBC⬍5 had lower rates of birth before 37 weeks (20% v 72%, p⫽0.047) and before 32 weeks (0% v 64% p⫽0.014). Women who received cerclage had longer latency days than those who received progesterone, (median 118.5 v 52, p⫽0.009). Cervical length at enrollment correlated to latency period, (r⫽0.4687, p⫽0.009). The Spearman’s rank correlation coefficients for gestational age at delivery and AF glucose, LDH, or WBC count were not statistically significant. CONCLUSION: Cervical length at the time of discovery of short cervix in the midtrimester ultrasound correlated to the latency period. In women with AF negative for inflammation and infection the outcome was improved. It remains to be determined if cervcal cerclage is beneficial in this subgroup.
517 Twin pregnancy in patients with a uterine malformation Nathan Fox1, Ashley Roman4, Daniel Saltzman2, Chad Klauser3, Andrei Rebarber3 1 Mount Sinai School of Medicine, Obstetrics, Gynecology and Reproductive Science, New York, NY, 2Carnegie Imaging for Women, PLLC, Obstetrics and Gynecology, New York, NY, 3Maternal Fetal Medicine Associates, PLLC, Obstetrics and Gynecology, New York, NY, 4NYU School of Medicine, Obstetrics and Gynecology, New York, NY
OBJECTIVE: In singleton pregnancies, uterine malformation is a known risk factor for preterm birth and fetal growth restriction. Limited data on outcomes of twin pregnancies with uterine malformations exists. The objective of this study was to compare outcomes in twin pregnancies based on the presence or not of a uterine malformation. STUDY DESIGN: This was a retrospective cohort of twin pregnancies managed by a single maternal-fetal medicine practice from 2005 2012. Patients with monoamniotic twins, twin-twin transfusion syndrome, and major fetal anomalies were excluded. Pregnancy outcomes were compared between patients with and without a uterine malformation. Nonparametric tests (Fisher’s exact test, Mann-Whitney U) were used for analysis. A p-value of ⱕ0.05 was considered significant. RESULTS: 516 patients were included, 16 (3.1%) of whom had a uterine malformation (4 bicornuate, 3 arcuate, 1 unicornuate, 1 didelphys, 1 T-shaped, 6 repaired uterine septae). Patients with uterine malformation had significantly worse outcomes, including cerclage, preterm birth, and lower birthweights (Table). IUGR and birthweight discordancy were not more common in patients with uterine malformation. CONCLUSION: Twin pregnancies with uterine malformation are associated with an increased risk of preterm birth and lower birthweights, but not fetal growth restriction.
%, or Median (25,75).
American Journal of Obstetrics & Gynecology Supplement to JANUARY 2013
Doppler Assess, Fetus, Prematurity, U/S, Med-Surg-Diseases
10%. A second consecutive term born baby had a perinatal mortality of 1.7%. CONCLUSION: Previous delivery of a preterm infant is a strong predictor of future preterm births. Previous or repeated preterm births increase the risk of perinatal death substantially in Sub-Saharan Africa.
515 Cesarean delivery in extreme preterm birth does not improve survival or survival without severe morbidity Michael Trifiro1, Sima Parmar2, Guibo Xing3, Bryon Jacoby2 1 University of California Davis Medical Center, Obstetrics and Gynecology, Sacramento, CA, 2University of California Davis Medical Center, Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, Sacramento, CA, 3 University of California Davis Medical Center, Center for Healthcare Policy and Research, Sacramento, CA
OBJECTIVE: To determine if mode of delivery affects survival of extremely preterm neonates. STUDY DESIGN: This is a retrospective cohort study of early preterm deliveries between 22 weeks 0 days and 27 weeks 6 days occurring between January 1, 2000 and December 31, 2009 at the University of California Davis Medical Center. Genetic abortions and inductions for stillbirths were not included. Maternal characteristics, obstetrical data, and neonatal information were collected. Statistical analysis was performed to evaluate obstetrical and neonatal factors associated with total survival and survival without a severe morbidity. Severe morbidities included intraventricular hemorrhage ⱖ3, periventricular leukomalacia, retinopathy of prematurity ⱖ3, necrotizing enterocolitis, or broncho-pulmonary dysplasia. RESULTS: Over the study period, 238 early preterm births occurred. Factors associated with improved survival included weeks gestation (p⬍0.0001), birthweight (p⬍0.0001), female gender (OR 2.12 95% CI 1.20-3.72), and steroid administration (OR 4.85 95% CI 2.678.83). 146 deliveries were by cesarean section and 92 deliveries were vaginal. Delivery by cesarean section was associated with improved survival in univariate analysis (OR 2.15 95% CI1.23-3.77), but this association was not significant in multivariate analysis adjusting for birthweight, gender and steroid administration (OR 1.85 95% CI 0.89-3.87). There was no association with cesarean section and survival to discharge without severe morbidity in univariate (OR 1.35 95% CI 0.79-2.28) or multivariate analyses (OR 1.15 95% CI 0.582.27). CONCLUSION: Delivery of the extremely preterm neonate is complicated with limited data to guide care and counseling. A limited number of studies have compared mode of delivery in extreme preterm birth and there is insufficient evidence to support cesarean delivery in extremely preterm neonates. In this study, cesarean delivery was not associated with total survival or survival without severe morbidity in multivariate analysis.
516 Clinical findings in amniotic fluid of women with asymptomatic short cervix in the midtrimester Ming Zhou1, David Cool2, William Grunwald2, Harry Khamis3, David McKenna1 1
Wright State University, Maternal-Fetal Medicine, Dayton, OH, 2Wright State University, Pharmacology & Toxicology, Dayton, OH, 3Wright State University, Mathmatics & Statisitcs, Dayton, OH
OBJECTIVE: To correlate amniotic fluid (AF) findings in women with asymptomatic short cervix in the midtrimester to pregnancy outcome. STUDY DESIGN: 30 women with an asymptomatic singleton pregnancy, and an incidental finding of transvaginal cervical length ⬍15mm at 16-27 weeks gestation underwent amniocentesis. AF was analyzed for chemistry (glucose and LDH), cytology (WBC and total cell count), and microbiology (gram stain, aerobic, anaerobic, and mycoplasma cultures). Women were divided into a cerclage (WBC ⬍⫽ 5, negative cultures and gram stain) or vaginal progesterone (200 mg nightly) treatment arm depending on their AF findings. Pregnancy outcome data was collected and compared with initial AF findings.
S222
www.AJOG.org
RESULTS: 5 women met criteria for cerclage and four underwent the procedure. The remaining 25 were treated with vaginal progesterone. AF fluid gram stain and cultures were negative for pathogens. Average gestational age (GA) at birth for the entire population was 31.9 weeks. When compared with the patients who had WBC ⬎5 and received progesterone, women who had AF WBC⬍5 had lower rates of birth before 37 weeks (20% v 72%, p⫽0.047) and before 32 weeks (0% v 64% p⫽0.014). Women who received cerclage had longer latency days than those who received progesterone, (median 118.5 v 52, p⫽0.009). Cervical length at enrollment correlated to latency period, (r⫽0.4687, p⫽0.009). The Spearman’s rank correlation coefficients for gestational age at delivery and AF glucose, LDH, or WBC count were not statistically significant. CONCLUSION: Cervical length at the time of discovery of short cervix in the midtrimester ultrasound correlated to the latency period. In women with AF negative for inflammation and infection the outcome was improved. It remains to be determined if cervcal cerclage is beneficial in this subgroup.
517 Twin pregnancy in patients with a uterine malformation Nathan Fox1, Ashley Roman4, Daniel Saltzman2, Chad Klauser3, Andrei Rebarber3 1 Mount Sinai School of Medicine, Obstetrics, Gynecology and Reproductive Science, New York, NY, 2Carnegie Imaging for Women, PLLC, Obstetrics and Gynecology, New York, NY, 3Maternal Fetal Medicine Associates, PLLC, Obstetrics and Gynecology, New York, NY, 4NYU School of Medicine, Obstetrics and Gynecology, New York, NY
OBJECTIVE: In singleton pregnancies, uterine malformation is a known risk factor for preterm birth and fetal growth restriction. Limited data on outcomes of twin pregnancies with uterine malformations exists. The objective of this study was to compare outcomes in twin pregnancies based on the presence or not of a uterine malformation. STUDY DESIGN: This was a retrospective cohort of twin pregnancies managed by a single maternal-fetal medicine practice from 2005 2012. Patients with monoamniotic twins, twin-twin transfusion syndrome, and major fetal anomalies were excluded. Pregnancy outcomes were compared between patients with and without a uterine malformation. Nonparametric tests (Fisher’s exact test, Mann-Whitney U) were used for analysis. A p-value of ⱕ0.05 was considered significant. RESULTS: 516 patients were included, 16 (3.1%) of whom had a uterine malformation (4 bicornuate, 3 arcuate, 1 unicornuate, 1 didelphys, 1 T-shaped, 6 repaired uterine septae). Patients with uterine malformation had significantly worse outcomes, including cerclage, preterm birth, and lower birthweights (Table). IUGR and birthweight discordancy were not more common in patients with uterine malformation. CONCLUSION: Twin pregnancies with uterine malformation are associated with an increased risk of preterm birth and lower birthweights, but not fetal growth restriction.
%, or Median (25,75).
American Journal of Obstetrics & Gynecology Supplement to JANUARY 2013