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608 Fetal growth potential as a predictor of neonatal morbidity
SMFM Abstracts S245
Volume 185, Number 6 A m J Obstet Gynecol 605
T H O R A C O A M N I O T I C SHUNTS: PREGNANCY O U T C O M E FOR CONGENITAL CYSTIC ADENOMATOID MALFORMATION (CCAM) AND PLEURAL EFFUSION (PE) JASON K BAXTER 1, MARK P J O H N S O N 2, R DOUGLAS W1LSON2, MARY KING2, STEFANIE KASPERSKF-', TIMOTHY M CROMBLEHOLME 3, ALAN W FLAKE3, HOLLY L HEDRICK4, LORIJ HOWELL 4, N SCOTT ADZ1CK4; 1Abington Memorial Hospital, Abington, PA; 2Children's Hospital of Philadelphia, Center for Fetal Diagnosis & Treatment, Philadelphia, PA: 3Children's Hospital of Philadelphia, Pediatric Surgery, Philadelphia, PA; 4Children's Hospital of Philadelphia, Pediatric Surgery, Philadelphia, PA OBJECTIVE: Review pregnancy outcomes in fetuses that u n d e r w e n t tboracoamniotic shunt placement for treatment of macrocystic CCAM or PE during 1998-2001. STUDY DESIGN: Retrospective review of cases from a single tertiary center that underwent shunt placement for hydrops secondary to macrocystic CCAM or PE. RESULTS: 17 pregnancies (CCAM = 9, PE = 8) u n d e r w e n t shunt placement. All CCAM masses were unilateral, while 5 PE were unilateral (u-PE) and 3 bilateral (b-PE). Average gestational age (GA) at diagnosis for CCAM was 20 weeks (w) 2 days (d), and for PE was 22w2d. Shunt procedures per patient ranged fi'om 1-3 (single - 13, double = 3 [CCAM, b-PE, u-PE], triple = 1 [bPE]). Average age at procedure was 23wld (CCAM) and 26w2d (PE). For CCAM, the mean pre- and post-shunting mass volumes were 46.3 and 18.1cc, representing a 61% m e a n reduction in mass volume following shunt placement. Hydrops resolved fbllowing shunting in all but one severe case (bPE). Average delh,ery age was 36w3d (CC~_M) and 33w0d (PE) wks. Average shunt to delivery time was 13w2d (CCAM) and 6w5d (PE). Fetal or neonatal loss for CCAM was 1/8 (13%) and for PE was 3 / 6 (50%) with 3 pregnancies not yet delivered. CONCLUSION: 1) Thoracoamniotic shunts should be considered as a treatment option for selected macrocystic CCAM and PE fetuses with hydrops. 2) Neonatal survival was greater in the macrocystic CCAM group (87%) compared to PE groups (50%). 3) Shunting of large cystic components in CCAM can result in significant mass volume reduction and resolution of hydrops.
607
OBSTETRICAL O U T C O M E OF EXTREMELY MACROSOMIC FETUSES (1986-2000) DAN FARINE ], SAHAR AL-SUNNAR[], MATHEW SERMER 1, GARETH SEAWARD], ]Mount Sinai Hospital, University of Toronto, Obstetrics & Gynecology, Toronto, Ontario OBJECTIVE: To review the obstetrical outcome of a large cohort of newborns weighing 5 kg or more. STUDY DESIGN: A retrospective review of all deliveries coded for birth weight of 5 kg or more in a tertiary obstetrical center during 1986-2000. Four data bases (delivery, newborn, NICU and hospital admission) were screened for extreme macrosomia, shoulder dystocia, Erb's palsy, obstetrical trauma and other outcome variables. RESULTS: There were 124 deliveries ~vith extreme macrosomia. The m e a n birth weight was 5,228 grams (range: 5000-6,100). There were 64 cesarean deliveries (in labor- 36, elective 28). The 60 vaginal deliveries were complicated by 15 (25%) shoulder dystocias' and 3(5%) Erb's palsies. The shoulder dystocia occurred with spontaneous deliveries (11/42), low vacuum (3/12) and vacumn & forceps (1/2). The Erb's palsies were associated with low vacuum (2/12) an vacuum & forceps (1/2). None occurred with low (0/2) or mid (0/2) forceps. There were only 7 neonates with an Apgar score <5 at 1 minute. All but one neonate had Apgar score >5 at 5 minutes (The neonates with shoulder dystocia had Apgars of 3/7, 6/7 and 5/9). Oxytocin induction occurred 5/15 cases of shoulder dystocia (and 8/45 without it). Augmentation occurred in 5/15 shoulder dystocia (and 8/45 without it) The n u m b e r of shoulder dystocia in the earlier years (1986-1993 n = 8) was similar to the later vears (1993-2000 n = 7). However, the n m n b e r of larger babies was higher (n = 77) in the later years then the earlier ones (n = 47). CONCLUSION: The risk for Shoulder dystocia (25%) and Erb's palsy (5%) in this series is small but significant. The majority of shoulder dystocias (11/15) occurred in non-instrumental deliveries, while 2 / 3 Erb palsies occurred following low vacuum. The rate of extreme macrosomia seemed to increase despite more aggressive diagnosis and therapy in the later period.
606
BIPOLAR UMBILICAL CORD CAUTERIZATION FOR SELECTIVE TERMINATION OF COMPLICATED MONOCHORIONIC PREGNANCIES MARK JOHNSON ] , TIMOTHY M CROMBLEHOLME2, HOLLY L HEDRICK~-, MARY KING2, STEFANIE KASPERSKI2, R DOUGLAS WILSON2, ALAN W FLAKE2, LORIJ HOWELL2, N SCOTT ADZICK'-'; ]Children's Hospital of Philadelphia, Center for Fetal Diagnosis & Treatment, Philadelphia, PA; 2Children's Hospital of Philadelphia, Center for Fetal Diagnosis & Treatment, Philadelphia, PA OBJECTIVE: To evaluate outcomes following selective umbilical cord cauterization in monochorionic gestations. STUDY DESIGN: 21 monochorionic pregnancies (20 twins, 1 triplet) underwent selective umbilical cord cauterization since November 1998 using ultrasound or endoscopic guidance. Procedures were p e r f o r m e d for twin reverse arterial perfusion (TRAP) sequence (N = 9) or discordant fetal anomalies (DFA; p r e m o r b i d cardiomyopathy of twin-twin transfusion = 6, cardiac anomaly = 2, hydrops 1, encephalocele = 1, discordant aneuploidy = 1, and severe 1UGR = 1). Monochorionic placentation was determined by concordant fetal gender, sonographic appearance of single placenta and thin intertwin membranes. A 3.0 m m bipolar cautery device (Everest Medical) passed through a 4 m m trocar sheath nsing 60-100 watts of power (gestational age dependant) applied for 15-20 seconds was used to achieve cord occlusion. Cauterization was performed at 2-3 adjacent segments of cord, and complete occlusion confirmed using color and power Doppler. All procedures were successful and performed under epidural anesthesia, and received 12-24 hours of MgSO4 tocolysis postoperatively. RESULTS: 3 pregnancies have not delivered. Mean gestational age (GA) at surgery = 21 weeks (w) 2 days (d) (TRAP = 22w4d, DFA = 20w6d), mean GA at delivery = 32w2d (TRAP = 33w0d, DFA - 31w3d), mean time from surgery to delivery = 10w4d (TRAP = 10w4d, DFA = 10w5d), and postnatal survival was 16/19 (84%; TRAP = 8/9, DFA = 8/10). A m n i o n / c h o r i o n separations occurred in 2 cases that lead to PROM/PTD and neonatal deaths. No maternal complications occurred. CONCLUSION: 1 ) Bipolar cord cauterization is a sate, reliable, minimally invasive approach to selective termination in monochorionic twin gestations where placental vascular communications place the normal co-twin at risk for in utero loss or neurologic injury tollowing singleton demise. 2) The maiority of bipolar cautery procedures can be successtully performed using a single 4 toni operative port.
608
FETAL GROWTH POTENTIAL AS A PREDICTOR OF NEONATAL MORBIDITY RADEK BUKOWSKI1, JIM ZHANG2, J. GARDOSI 3, GEORGE SAADE4; 1University of Texas Medical Brancht Galveston, Obstetrics and Gynecology, Galveston, TX; 2National Institute of Child Health and H u m a n Development, NI, Bethesda, MD; 3University of Nottingham, H u m a n Development, Nottingham; 4University of Texas Medical Branch, Obstetrics and Gynecology, Galveston, TX OBJECTIVE: The percentile of growth potential (GP) is a measure of the actual fetal weight relative to the optimal weight in the absence of pathological conditions. Our objective was to test the hypothesis that i m p a i r m e n t of individualized growth potential is associated with increased neonatal morbidity. STUDY DESIGN: The study population consisted of 7191 nulliparous w o m e n with singleton pregnancies and early prenatal care from the Collaborative Perinatal Project. For each fetus, GROW v.2 software was used to generate an individual optimal growth curve and calculate percentile of achieved growth potential for birthweight based on 6 i n d e p e n d e n t factors (maternal weight, height, parity, etbnicity, fetal gender and gestational age) identified as determining fetal weight from multivariate logistic regression analysis of 40,000 uncomplicated term pregnancies. The outcome measure was severe neonatal morbidity defined as _>1 of: stillbirth, neonatal death, preterm delivery <34 weeks, 5 min Apgar <4, cesarean section for fetal distress, and abrnptio placenta. Chi-square test, Receiver Operating Characteristic (ROC) curve and multiple logistic regression were used to test the relationship between neonatal morbidity and (GP) as well as gestational age at delivery (GA) and birthweight (BW). RESULTS: GP was a significant predictor of morbidity (Area under ROC: 0.79, P < .001). Sensitivities and specificities for prediction of morbidity were 71% and 70% tbr GP <10%lie and 62% and 93% for GP <25%ile, respectively. Neonates with GP <10%ile had a significantly higher risk for morbidity c o m p a r e d with those with GP ->10%ile (RR [95%CI] - 9.2 [8.2-10.3]; P < .0001). This risk remained significant after correcting for GA and BW (P = .01 ). CONCLUSION: I m p a i r m e n t of GP is a good predictor of neonatal morbidity i n d e p e n d e n t of GA and BW. This indicates that impairment of growth identified by individualized assessment and not reflected in abnormal BW results in neonatal morbidity. GP may prove to be a valuable tool in fetal risk assessment.
Volume 185, Number 6 A m J Obstet Gynecol 605
T H O R A C O A M N I O T I C SHUNTS: PREGNANCY O U T C O M E FOR CONGENITAL CYSTIC ADENOMATOID MALFORMATION (CCAM) AND PLEURAL EFFUSION (PE) JASON K BAXTER 1, MARK P J O H N S O N 2, R DOUGLAS W1LSON2, MARY KING2, STEFANIE KASPERSKF-', TIMOTHY M CROMBLEHOLME 3, ALAN W FLAKE3, HOLLY L HEDRICK4, LORIJ HOWELL 4, N SCOTT ADZ1CK4; 1Abington Memorial Hospital, Abington, PA; 2Children's Hospital of Philadelphia, Center for Fetal Diagnosis & Treatment, Philadelphia, PA: 3Children's Hospital of Philadelphia, Pediatric Surgery, Philadelphia, PA; 4Children's Hospital of Philadelphia, Pediatric Surgery, Philadelphia, PA OBJECTIVE: Review pregnancy outcomes in fetuses that u n d e r w e n t tboracoamniotic shunt placement for treatment of macrocystic CCAM or PE during 1998-2001. STUDY DESIGN: Retrospective review of cases from a single tertiary center that underwent shunt placement for hydrops secondary to macrocystic CCAM or PE. RESULTS: 17 pregnancies (CCAM = 9, PE = 8) u n d e r w e n t shunt placement. All CCAM masses were unilateral, while 5 PE were unilateral (u-PE) and 3 bilateral (b-PE). Average gestational age (GA) at diagnosis for CCAM was 20 weeks (w) 2 days (d), and for PE was 22w2d. Shunt procedures per patient ranged fi'om 1-3 (single - 13, double = 3 [CCAM, b-PE, u-PE], triple = 1 [bPE]). Average age at procedure was 23wld (CCAM) and 26w2d (PE). For CCAM, the mean pre- and post-shunting mass volumes were 46.3 and 18.1cc, representing a 61% m e a n reduction in mass volume following shunt placement. Hydrops resolved fbllowing shunting in all but one severe case (bPE). Average delh,ery age was 36w3d (CC~_M) and 33w0d (PE) wks. Average shunt to delivery time was 13w2d (CCAM) and 6w5d (PE). Fetal or neonatal loss for CCAM was 1/8 (13%) and for PE was 3 / 6 (50%) with 3 pregnancies not yet delivered. CONCLUSION: 1) Thoracoamniotic shunts should be considered as a treatment option for selected macrocystic CCAM and PE fetuses with hydrops. 2) Neonatal survival was greater in the macrocystic CCAM group (87%) compared to PE groups (50%). 3) Shunting of large cystic components in CCAM can result in significant mass volume reduction and resolution of hydrops.
607
OBSTETRICAL O U T C O M E OF EXTREMELY MACROSOMIC FETUSES (1986-2000) DAN FARINE ], SAHAR AL-SUNNAR[], MATHEW SERMER 1, GARETH SEAWARD], ]Mount Sinai Hospital, University of Toronto, Obstetrics & Gynecology, Toronto, Ontario OBJECTIVE: To review the obstetrical outcome of a large cohort of newborns weighing 5 kg or more. STUDY DESIGN: A retrospective review of all deliveries coded for birth weight of 5 kg or more in a tertiary obstetrical center during 1986-2000. Four data bases (delivery, newborn, NICU and hospital admission) were screened for extreme macrosomia, shoulder dystocia, Erb's palsy, obstetrical trauma and other outcome variables. RESULTS: There were 124 deliveries ~vith extreme macrosomia. The m e a n birth weight was 5,228 grams (range: 5000-6,100). There were 64 cesarean deliveries (in labor- 36, elective 28). The 60 vaginal deliveries were complicated by 15 (25%) shoulder dystocias' and 3(5%) Erb's palsies. The shoulder dystocia occurred with spontaneous deliveries (11/42), low vacuum (3/12) and vacumn & forceps (1/2). The Erb's palsies were associated with low vacuum (2/12) an vacuum & forceps (1/2). None occurred with low (0/2) or mid (0/2) forceps. There were only 7 neonates with an Apgar score <5 at 1 minute. All but one neonate had Apgar score >5 at 5 minutes (The neonates with shoulder dystocia had Apgars of 3/7, 6/7 and 5/9). Oxytocin induction occurred 5/15 cases of shoulder dystocia (and 8/45 without it). Augmentation occurred in 5/15 shoulder dystocia (and 8/45 without it) The n u m b e r of shoulder dystocia in the earlier years (1986-1993 n = 8) was similar to the later vears (1993-2000 n = 7). However, the n m n b e r of larger babies was higher (n = 77) in the later years then the earlier ones (n = 47). CONCLUSION: The risk for Shoulder dystocia (25%) and Erb's palsy (5%) in this series is small but significant. The majority of shoulder dystocias (11/15) occurred in non-instrumental deliveries, while 2 / 3 Erb palsies occurred following low vacuum. The rate of extreme macrosomia seemed to increase despite more aggressive diagnosis and therapy in the later period.
606
BIPOLAR UMBILICAL CORD CAUTERIZATION FOR SELECTIVE TERMINATION OF COMPLICATED MONOCHORIONIC PREGNANCIES MARK JOHNSON ] , TIMOTHY M CROMBLEHOLME2, HOLLY L HEDRICK~-, MARY KING2, STEFANIE KASPERSKI2, R DOUGLAS WILSON2, ALAN W FLAKE2, LORIJ HOWELL2, N SCOTT ADZICK'-'; ]Children's Hospital of Philadelphia, Center for Fetal Diagnosis & Treatment, Philadelphia, PA; 2Children's Hospital of Philadelphia, Center for Fetal Diagnosis & Treatment, Philadelphia, PA OBJECTIVE: To evaluate outcomes following selective umbilical cord cauterization in monochorionic gestations. STUDY DESIGN: 21 monochorionic pregnancies (20 twins, 1 triplet) underwent selective umbilical cord cauterization since November 1998 using ultrasound or endoscopic guidance. Procedures were p e r f o r m e d for twin reverse arterial perfusion (TRAP) sequence (N = 9) or discordant fetal anomalies (DFA; p r e m o r b i d cardiomyopathy of twin-twin transfusion = 6, cardiac anomaly = 2, hydrops 1, encephalocele = 1, discordant aneuploidy = 1, and severe 1UGR = 1). Monochorionic placentation was determined by concordant fetal gender, sonographic appearance of single placenta and thin intertwin membranes. A 3.0 m m bipolar cautery device (Everest Medical) passed through a 4 m m trocar sheath nsing 60-100 watts of power (gestational age dependant) applied for 15-20 seconds was used to achieve cord occlusion. Cauterization was performed at 2-3 adjacent segments of cord, and complete occlusion confirmed using color and power Doppler. All procedures were successful and performed under epidural anesthesia, and received 12-24 hours of MgSO4 tocolysis postoperatively. RESULTS: 3 pregnancies have not delivered. Mean gestational age (GA) at surgery = 21 weeks (w) 2 days (d) (TRAP = 22w4d, DFA = 20w6d), mean GA at delivery = 32w2d (TRAP = 33w0d, DFA - 31w3d), mean time from surgery to delivery = 10w4d (TRAP = 10w4d, DFA = 10w5d), and postnatal survival was 16/19 (84%; TRAP = 8/9, DFA = 8/10). A m n i o n / c h o r i o n separations occurred in 2 cases that lead to PROM/PTD and neonatal deaths. No maternal complications occurred. CONCLUSION: 1 ) Bipolar cord cauterization is a sate, reliable, minimally invasive approach to selective termination in monochorionic twin gestations where placental vascular communications place the normal co-twin at risk for in utero loss or neurologic injury tollowing singleton demise. 2) The maiority of bipolar cautery procedures can be successtully performed using a single 4 toni operative port.
608
FETAL GROWTH POTENTIAL AS A PREDICTOR OF NEONATAL MORBIDITY RADEK BUKOWSKI1, JIM ZHANG2, J. GARDOSI 3, GEORGE SAADE4; 1University of Texas Medical Brancht Galveston, Obstetrics and Gynecology, Galveston, TX; 2National Institute of Child Health and H u m a n Development, NI, Bethesda, MD; 3University of Nottingham, H u m a n Development, Nottingham; 4University of Texas Medical Branch, Obstetrics and Gynecology, Galveston, TX OBJECTIVE: The percentile of growth potential (GP) is a measure of the actual fetal weight relative to the optimal weight in the absence of pathological conditions. Our objective was to test the hypothesis that i m p a i r m e n t of individualized growth potential is associated with increased neonatal morbidity. STUDY DESIGN: The study population consisted of 7191 nulliparous w o m e n with singleton pregnancies and early prenatal care from the Collaborative Perinatal Project. For each fetus, GROW v.2 software was used to generate an individual optimal growth curve and calculate percentile of achieved growth potential for birthweight based on 6 i n d e p e n d e n t factors (maternal weight, height, parity, etbnicity, fetal gender and gestational age) identified as determining fetal weight from multivariate logistic regression analysis of 40,000 uncomplicated term pregnancies. The outcome measure was severe neonatal morbidity defined as _>1 of: stillbirth, neonatal death, preterm delivery <34 weeks, 5 min Apgar <4, cesarean section for fetal distress, and abrnptio placenta. Chi-square test, Receiver Operating Characteristic (ROC) curve and multiple logistic regression were used to test the relationship between neonatal morbidity and (GP) as well as gestational age at delivery (GA) and birthweight (BW). RESULTS: GP was a significant predictor of morbidity (Area under ROC: 0.79, P < .001). Sensitivities and specificities for prediction of morbidity were 71% and 70% tbr GP <10%lie and 62% and 93% for GP <25%ile, respectively. Neonates with GP <10%ile had a significantly higher risk for morbidity c o m p a r e d with those with GP ->10%ile (RR [95%CI] - 9.2 [8.2-10.3]; P < .0001). This risk remained significant after correcting for GA and BW (P = .01 ). CONCLUSION: I m p a i r m e n t of GP is a good predictor of neonatal morbidity i n d e p e n d e n t of GA and BW. This indicates that impairment of growth identified by individualized assessment and not reflected in abnormal BW results in neonatal morbidity. GP may prove to be a valuable tool in fetal risk assessment.