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759: Emergent cesarean deliveries for fetal bradycardia
Poster Session IV 758 Pregnancy outcomes of cardiothoracic transplant recipients: a systematic review and meta-analysis Rohan D. D’Souza1,2, Sergio Acuna2, Nusrat Zaffar1, Catriona Bhagra3, Heather Ross4, Candice Silversides3 1
Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada, 3Mount Sinai Hospital and University Health Network, University of Toronto, Canada, Toronto, ON, Canada, 4Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada 2
OBJECTIVE: To systematically review the literature reporting preg-
nancy outcomes in cardiothoracic transplant recipients and to estimate the incidence of maternal, fetal and neonatal complications in these women. STUDY DESIGN: A search strategy was designed for MEDLINE, EMBASE, and Cochrane Central from inception to July 2016 to identify studies reporting outcomes in three or more pregnancies following cardiothoracic transplant. Pooled incidence of maternal outcomes (maternal mortality, organ rejection and preeclampsia) and fetal and neonatal outcomes (livebirth, fetal anomalies, preterm births and fetal growth restriction) were calculated using randomeffect meta-analysis and reported per 100 pregnancies with 95% confidence intervals (CI). Risk of bias was determined using the Institute of Health Economics’ Quality Appraisal Tool for Uncontrolled Observational Studies. Subgroup analysis was conducted based on transplanted organ and sensitivity analysis based on the studies’ risk of bias. RESULTS: A total of 3,002 records were identified, 172 full texts reviewed and 19 studies included. The included studies reported on a total of 406 pregnancies in 301 cardiothoracic transplant recipients (183 heart, 42 heart-lung, and 76 lung). Maternal mortality was 2.5%, (0.2-4.7%), organ rejection occurred in 10.4% (6.4-14.4%) and preeclampsia in 16.3% (10.6-21.9%). Live births were reported in 77.1% (69.8-84.9%) pregnancies of which 37.0% (25.7-48.2%) resulted in preterm births. Compared with heart transplant recipients, lung transplant recipients were more likely to experience preterm births [50.3% (35.5-65.0) vs. 39.8% (30.7-49.0)] and organ rejection [18.5% (7.8-29.3) vs. 8.5% (2.0-15.0)]. No other significant differences in the pregnancy outcomes were observed in subgroup meta-analyses by transplanted organ. CONCLUSION: With appropriate multidisciplinary care, women with cardiothoracic transplants can have successful pregnancies with high livebirth rates. Although maternal mortality is rare, these women are at risk for organ rejection, preeclampsia and preterm births.
ajog.org fetal anomalies were excluded. Emergent deliveries for fetal bradycardia with recovery of the fetal heart rate prior to delivery were also excluded. Chart review was performed to ensure the validity of the emergent nature of the case and fetal tracings were reviewed to calculate the event to delivery (ETD) interval. The primary outcome was the association between ETD and umbilical artery (UA) pH. RESULTS: Of the 5,438 CD performed during the study period, 5% of the cases were emergent and 93 met inclusion criteria. When evaluated as an entire cohort there was no clinically significant relationship between ETD and UA pH (R¼0.06, p¼0.54). When stratified by fetal heart rate at the time of bradycardia, however, emergent cesareans performed for a bradycardia < 90 bpm had a statistically significant decrease in pH the longer the ETD (R¼ -0.22, p<0.05, Figure 1). There was no significant association between ETD and UA pH for bradycardia > 90 bpm (R¼ -0.38, p¼0.07). CONCLUSION: This data suggests that in the setting of a terminal bradycardia with a heart rate less than 90 bpm one should move as expeditiously as possible given the increased risk of acidemia with longer event to delivery intervals in this cohort.
760 Variation of fetal lung size in congenital diaphragmatic hernia - biology or measurement error? Rosa M. Polan, Dana Block-Abraham, Eric B. Jelin, Janine Bullard, Viola Seravalli, Sarah Millard, Cyrethia McShane, Jena L. Miller, Ahmet A. Baschat
759 Emergent cesarean deliveries for fetal bradycardia
Johns Hopkins University School of Medicine, Baltmore, MD
Bethany Sabol, Aaron Caughey
be prenatally assessed by normalizing measurements of the contralateral lung for the head circumference (HC, lung to head ratio¼LHR). Unlike the LHR, which increases with gestational age, the observed to expected (O/E) LHR is constant and expressed as a fixed percentage. This may detect variations in lung compression due to dynamic changes in organ herniation. We sought to determine variability of O/E LHR measurement, its potential impact on the accuracy of severity assessment and the ability to detect longitudinal variation in lung compression. STUDY DESIGN: CDH patients undergoing standard assessment from 2010-2015 were retrospectively studied. Anterior/posterior (A/P) dimensions of the contralateral lung were expressed as O/E LHR after correcting the observed LHR for gestational age (GA). Distributions of multiple O/E LHR measurements at a single and on serial
Oregon Health & Science University, Portland, OR
OBJECTIVE: Fetal bradycardia is one of the most common indications
for emergent cesarean deliveries (CD). We know from previous research that terminal bradycardia at the time of vaginal delivery is associated with increased rates of acidemia, with a predictable decrease in umbilical cord gas the longer the duration of the bradycardia. We sought to evaluate the relationship between umbilical artery pH in the setting of emergent cesarean deliveries performed for fetal bradycardia. STUDY DESIGN: This was a retrospective cohort study at Oregon Health & Science University from 2009-2016 of all women undergoing emergent CD for fetal bradycardia. Multiple gestations and
OBJECTIVE: The severity of congenital diaphragmatic hernia (CDH) can
S440 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2017
Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada, 3Mount Sinai Hospital and University Health Network, University of Toronto, Canada, Toronto, ON, Canada, 4Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada 2
OBJECTIVE: To systematically review the literature reporting preg-
nancy outcomes in cardiothoracic transplant recipients and to estimate the incidence of maternal, fetal and neonatal complications in these women. STUDY DESIGN: A search strategy was designed for MEDLINE, EMBASE, and Cochrane Central from inception to July 2016 to identify studies reporting outcomes in three or more pregnancies following cardiothoracic transplant. Pooled incidence of maternal outcomes (maternal mortality, organ rejection and preeclampsia) and fetal and neonatal outcomes (livebirth, fetal anomalies, preterm births and fetal growth restriction) were calculated using randomeffect meta-analysis and reported per 100 pregnancies with 95% confidence intervals (CI). Risk of bias was determined using the Institute of Health Economics’ Quality Appraisal Tool for Uncontrolled Observational Studies. Subgroup analysis was conducted based on transplanted organ and sensitivity analysis based on the studies’ risk of bias. RESULTS: A total of 3,002 records were identified, 172 full texts reviewed and 19 studies included. The included studies reported on a total of 406 pregnancies in 301 cardiothoracic transplant recipients (183 heart, 42 heart-lung, and 76 lung). Maternal mortality was 2.5%, (0.2-4.7%), organ rejection occurred in 10.4% (6.4-14.4%) and preeclampsia in 16.3% (10.6-21.9%). Live births were reported in 77.1% (69.8-84.9%) pregnancies of which 37.0% (25.7-48.2%) resulted in preterm births. Compared with heart transplant recipients, lung transplant recipients were more likely to experience preterm births [50.3% (35.5-65.0) vs. 39.8% (30.7-49.0)] and organ rejection [18.5% (7.8-29.3) vs. 8.5% (2.0-15.0)]. No other significant differences in the pregnancy outcomes were observed in subgroup meta-analyses by transplanted organ. CONCLUSION: With appropriate multidisciplinary care, women with cardiothoracic transplants can have successful pregnancies with high livebirth rates. Although maternal mortality is rare, these women are at risk for organ rejection, preeclampsia and preterm births.
ajog.org fetal anomalies were excluded. Emergent deliveries for fetal bradycardia with recovery of the fetal heart rate prior to delivery were also excluded. Chart review was performed to ensure the validity of the emergent nature of the case and fetal tracings were reviewed to calculate the event to delivery (ETD) interval. The primary outcome was the association between ETD and umbilical artery (UA) pH. RESULTS: Of the 5,438 CD performed during the study period, 5% of the cases were emergent and 93 met inclusion criteria. When evaluated as an entire cohort there was no clinically significant relationship between ETD and UA pH (R¼0.06, p¼0.54). When stratified by fetal heart rate at the time of bradycardia, however, emergent cesareans performed for a bradycardia < 90 bpm had a statistically significant decrease in pH the longer the ETD (R¼ -0.22, p<0.05, Figure 1). There was no significant association between ETD and UA pH for bradycardia > 90 bpm (R¼ -0.38, p¼0.07). CONCLUSION: This data suggests that in the setting of a terminal bradycardia with a heart rate less than 90 bpm one should move as expeditiously as possible given the increased risk of acidemia with longer event to delivery intervals in this cohort.
760 Variation of fetal lung size in congenital diaphragmatic hernia - biology or measurement error? Rosa M. Polan, Dana Block-Abraham, Eric B. Jelin, Janine Bullard, Viola Seravalli, Sarah Millard, Cyrethia McShane, Jena L. Miller, Ahmet A. Baschat
759 Emergent cesarean deliveries for fetal bradycardia
Johns Hopkins University School of Medicine, Baltmore, MD
Bethany Sabol, Aaron Caughey
be prenatally assessed by normalizing measurements of the contralateral lung for the head circumference (HC, lung to head ratio¼LHR). Unlike the LHR, which increases with gestational age, the observed to expected (O/E) LHR is constant and expressed as a fixed percentage. This may detect variations in lung compression due to dynamic changes in organ herniation. We sought to determine variability of O/E LHR measurement, its potential impact on the accuracy of severity assessment and the ability to detect longitudinal variation in lung compression. STUDY DESIGN: CDH patients undergoing standard assessment from 2010-2015 were retrospectively studied. Anterior/posterior (A/P) dimensions of the contralateral lung were expressed as O/E LHR after correcting the observed LHR for gestational age (GA). Distributions of multiple O/E LHR measurements at a single and on serial
Oregon Health & Science University, Portland, OR
OBJECTIVE: Fetal bradycardia is one of the most common indications
for emergent cesarean deliveries (CD). We know from previous research that terminal bradycardia at the time of vaginal delivery is associated with increased rates of acidemia, with a predictable decrease in umbilical cord gas the longer the duration of the bradycardia. We sought to evaluate the relationship between umbilical artery pH in the setting of emergent cesarean deliveries performed for fetal bradycardia. STUDY DESIGN: This was a retrospective cohort study at Oregon Health & Science University from 2009-2016 of all women undergoing emergent CD for fetal bradycardia. Multiple gestations and
OBJECTIVE: The severity of congenital diaphragmatic hernia (CDH) can
S440 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2017