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82: A randomized study comparing subcuticular sutures versus staples for skin closure in cesarean sections
SMFM Abstracts 79
www.AJOG.org
OPTIMIZATION OF PLACENTAL MANAGEMENT IN SECOND TRIMESTER MEDICAL TERMINATION OF PREGNANCY JAN DICKINSON1, DOROTA DOHERTY1, 1University of Western Australia, Perth, Western Australia, Australia OBJECTIVE: To compare the efficacy of 3 regimens for the management of placental delivery in second trimester medical termination of pregnancy. STUDY DESIGN: Prospective randomized trial of women undergoing pregnancy termination with intravaginal misoprostol between 14 and 24 weeks in a single center. Three management strategies for placental delivery were compared: 10 units of intramuscular oxytocin after delivery of the fetus (Group 1), 600 mcg oral misoprostol after delivery of the fetus (Group 2), and no additional medication after delivery of the fetus (Group 3). The primary study outcome was the incidence of failure of placental expulsion within 60 minutes of fetal delivery with the requirement for manual removal of the placenta. RESULTS: 251 women were randomized: 83 to Group 1, 83 to Group 2 and 85 to Group 3. There was no difference in maternal age, race, parity or prior uterine surgery between the groups. There was no difference in the median gestation at recruitment: Group 1 19.4 weeks (IQR 17.5-20.6), Group 2 19.1 weeks (IQR 17.920.7), Group 3 19.4 weeks (IQR 17.2-20.7); p⫽0.988. Duration of termination did not differ between groups: Group 1 17.3 hours, Group 2 17.5 hours and Group 3 16.6 hours; p⫽0.655. There was a significant difference in the incidence of placental retention between the 3 groups: Group 1 8/83 (10%) vs Group 2 24/83 (29%) vs Group 3 26/85 (31%); p⫽0.002. Calculated blood loss was significantly lower in Group 1 100 mls (IQR 50-200) compared with Group 2 200 mls (IQR 100-370) and Group 3 200mls (IQR 100-375); p⬍0.001. There was no difference in the requirement for blood transfusion: Group 1 1/83 (1%) vs Group 2 1/83 (1%) vs Group 3 5/85 (6%); p⫽0.103. Readmission for curettage post-termination did not differ between groups: Group 1 3/83 (4%); Group 2 2/83 (2%) and Group 3 5/85 (6%); p⫽0.411. CONCLUSION: Intramuscular oxytocin administered after delivery of the fetus in second trimester medical termination of pregnancy significantly increases placental expulsion rates and decreases short-term postpartum blood loss.
81
Unknown Scar Labor Induction Prior Vaginal Delivery Interval ⱕ 2yrs Prior CD Indic: Dystocia Prior CD Indic: Malpresent Prior CD Indic: NRFHT Prior CD ⬍37 wks
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.105
80
NORMAL LABOR PATTERNS IN U.S. WOMEN JUN ZHANG1, PAUL VANVELDHUISEN2, JAMES TROENDLE3, UMA REDDY4, WARE BRANCH5, JENNIFER BAILIT6, MICHELLE KOMINIAREK7, MILDRED RAMIREZ8, VICTOR HUGO GONZALEZ QUINTERO9, MATTHEW HOFFMAN10, JUDITH HIBBARD11, JAMES FANNING12, RONALD BURKMAN13, SHOSHANA HABERMAN14, HELAIN LANDY15, KIMBERLY GREGORY16, 1National Institutes of Health (NIH), Bethesda, Maryland, 2EMMES Corp, Rockville, Maryland, 3National Institutes of Health (NIH), Maryland, 4University of Maryland at Baltimore, Bethesda, Maryland, 5Intermountain Healthcare, Utah, 6MetroHealth, Cleveland, Ohio, 7Indiana University, Indianapolis, Indiana, 8University of Texas Health Science Center at Houston, Houston, Texas, 9University of Miami, Dept of Ob/Gyn-MFM Division, Miami, Florida, 10Christiana Hospital, Newark, Delaware, 11University of Illinois at Chicago, Obstetrics and Gynecology, Chicago, Illinois, 12Summa Health System, Toledo, Ohio, 13Tufts University, Springfield, Massachusetts, 14Maimonides Medical Center, Brooklyn, New York, 15Georgetown University, Washington, District of Columbia, OBJECTIVE: To describe normal duration of labor and range of variation in a large contemporary U.S. population. STUDY DESIGN: The Consortium on Safe Labor consists of 12 institutions (19 hospitals) in 9 US ACOG Districts. Using 234,656 computerized delivery records from 2003-2007, data on maternal characteristics, reproductive and medical history, pregnancy complications, labor progression, delivery summary, newborn and NICU information were compiled. We restricted our analysis to singleton, term pregnancies with vertex presentation, no previous cesarean delivery and vaginal deliveries; the newborns had 5= Apgar score ⬎7 and no NICU admission. Interval censored regression was used to estimate labor duration. RESULTS: A total of 126,887 deliveries were included. The table presents the median duration of labor (hours) and 95th percentile by parity and cervical dilation (cm). In addition, among nulliparas, the median duration from 4-10 cm was 5.2 hours with 95th percentile at 21.6 hours. CONCLUSION: Labor curves currently in use (eg, Friedman=s) may not accurately reflect the current U.S. labor population, particularly before 6 cm. This information is important to take into account for labor management so that the likelihood of a safe spontaneous vaginal delivery is optimized. Duration of labor (h) by parity and dilation Cervical Dilation
Parity 0 (median, 95th%)
Parity 1 (median, 95th%)
Parity 2⫹ (median, 95th%)
4-5 5-6 6-7 7-8 8-9 9 - 10
1.2 (5.9) 0.7 (3.0) 0.6 (1.9) 0.5 (1.4) 0.4 (1.2) 0.5 (1.7)
1.2 (6.2) 0.7 (2.8) 0.5 (1.6) 0.4 (1.1) 0.3 (0.9) 0.3 (0.8)
1.1 (5.8) 0.6 (2.6) 0.4 (1.5) 0.3 (1.0) 0.3 (0.8) 0.3 (0.7)
Adjusted Odds Ratio
(95% CI) for uterine rupture
0.98 1.85 0.64 1.61 1.58 1.28 1.36 1.43
0.53-1.80 1.24-2.77 0.41-0.99 1.05-2.45 0.80-3.11 0.64-2.57 0.68-2.74 0.82-2.49
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.107
82
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.106
S36
THE MFMU CESAREAN REGISTRY: RISK OF UTERINE RUPTURE IN WOMEN ATTEMPTING VBAC WITH AN UNKNOWN UTERINE SCAR M. ASHLEY HICKMAN1, 1for the Eunice Kennedy Shriver National Institute of Child Health and Human Development MFMU Network, Bethesda, Maryland OBJECTIVE: To assess risk for uterine rupture in women with one prior cesarean delivery (CD) and an unknown scar, and to determine if clinical factors alter this risk. STUDY DESIGN: A secondary analysis of a prospective multicenter registry was performed on women attempting VBAC after one prior CD with unknown scar versus single prior low transverse cesarean delivery (LTCD). Among women with unknown scar, clinical factors, including indication for prior CD were assessed for their association with uterine rupture in the current pregnancy. RESULTS: 16,280 women met criteria for analysis including 13,766 (85%) with known prior LTCD and 2,514 (15%) with unknown scar. Indications for prior CD in the unknown scar group were: dystocia (34%), malpresentation (26%), NRFHT (19%), and other (including multiples, macrosomia, preeclampsia, previa) (20%); (14%) of these occurred before 37 wks, similar to preterm delivery rate in those with prior LTCD. Uterine rupture was similar between women with unknown scar and known prior LTCD (0.52% vs 0.70%, p⫽0.29), OR 0.73 (0.41 - 1.31). The final model to determine risk for rupture with an unknown scar is shown below. CONCLUSION: An unknown scar does not increase uterine rupture risk among women attempting VBAC. Women with an unknown scar who desire VBAC should be counseled on the increased risk of rupture with induction and interdelivery interval ⱕ 2years. Logistic Regression Model
American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2008
A RANDOMIZED STUDY COMPARING SUBCUTICULAR SUTURES VERSUS STAPLES FOR SKIN CLOSURE IN CESAREAN SECTIONS JULIE-ANNE ROUSSEAU1, KARINE GIRARD2, LUCILLE TURCOT-LEMAY3, NANCY THOMAS2, 1Laval University, Centre hospitalier universitaire de Québec / Centre Mère-Enfant, Québec, Quebec, Canada, 2Laval University, Centre hospitalier universitaire de Québec / Centre Mère-Enfant, Quebec, Quebec, Canada, 3Laval University, Centre hospitalier universitaire de Québec, Quebec OBJECTIVE: To compare post-operative (PO) pain according to the skin closure method: subcuticular sutures versus staples, following an elective cesarean section. Secondary objectives were to evaluate operative time, incidence of wound infection, incision appearance and general satisfaction of women. STUDY DESIGN: A randomized controlled trial of 101 women undergoing an elective term cesarean was performed. Women were randomly assigned to skin closure with subcuticular sutures using Monocryl 4-0 or staples. Operative technique and PO analgesia were standardized for both groups. Stratification was used for primary versus iterative cesareans. Analogue pain and satisfaction scales were completed at PO day one and three and, at six weeks PO. A digital picture of the incision was taken at six weeks PO and evaluated according to five objective criteria by three independent blinded observers. Statistical analysis was performed using bilateral Student T test and Fisher exact test when appropriate. RESULTS: Fifty-two women had a subcuticular closure and forty-nine received staples. Maternal characteristics (including body mass index) and pain at PO day one and three were similar in both groups. Pain at six weeks PO was significantly less in the staples group (0.17 vs 0.51 p⫽0.04). Operative time was also shorter in that group (24 vs 33 minutes p⬍0.0001). No significant differences were noted for incision appearance and women=s general satisfaction. One patient, from the subcuticular group, developed a wound infection. CONCLUSION: Staples are the method of choice for skin closure for elective term cesarean sections in our population. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.108
www.AJOG.org
OPTIMIZATION OF PLACENTAL MANAGEMENT IN SECOND TRIMESTER MEDICAL TERMINATION OF PREGNANCY JAN DICKINSON1, DOROTA DOHERTY1, 1University of Western Australia, Perth, Western Australia, Australia OBJECTIVE: To compare the efficacy of 3 regimens for the management of placental delivery in second trimester medical termination of pregnancy. STUDY DESIGN: Prospective randomized trial of women undergoing pregnancy termination with intravaginal misoprostol between 14 and 24 weeks in a single center. Three management strategies for placental delivery were compared: 10 units of intramuscular oxytocin after delivery of the fetus (Group 1), 600 mcg oral misoprostol after delivery of the fetus (Group 2), and no additional medication after delivery of the fetus (Group 3). The primary study outcome was the incidence of failure of placental expulsion within 60 minutes of fetal delivery with the requirement for manual removal of the placenta. RESULTS: 251 women were randomized: 83 to Group 1, 83 to Group 2 and 85 to Group 3. There was no difference in maternal age, race, parity or prior uterine surgery between the groups. There was no difference in the median gestation at recruitment: Group 1 19.4 weeks (IQR 17.5-20.6), Group 2 19.1 weeks (IQR 17.920.7), Group 3 19.4 weeks (IQR 17.2-20.7); p⫽0.988. Duration of termination did not differ between groups: Group 1 17.3 hours, Group 2 17.5 hours and Group 3 16.6 hours; p⫽0.655. There was a significant difference in the incidence of placental retention between the 3 groups: Group 1 8/83 (10%) vs Group 2 24/83 (29%) vs Group 3 26/85 (31%); p⫽0.002. Calculated blood loss was significantly lower in Group 1 100 mls (IQR 50-200) compared with Group 2 200 mls (IQR 100-370) and Group 3 200mls (IQR 100-375); p⬍0.001. There was no difference in the requirement for blood transfusion: Group 1 1/83 (1%) vs Group 2 1/83 (1%) vs Group 3 5/85 (6%); p⫽0.103. Readmission for curettage post-termination did not differ between groups: Group 1 3/83 (4%); Group 2 2/83 (2%) and Group 3 5/85 (6%); p⫽0.411. CONCLUSION: Intramuscular oxytocin administered after delivery of the fetus in second trimester medical termination of pregnancy significantly increases placental expulsion rates and decreases short-term postpartum blood loss.
81
Unknown Scar Labor Induction Prior Vaginal Delivery Interval ⱕ 2yrs Prior CD Indic: Dystocia Prior CD Indic: Malpresent Prior CD Indic: NRFHT Prior CD ⬍37 wks
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.105
80
NORMAL LABOR PATTERNS IN U.S. WOMEN JUN ZHANG1, PAUL VANVELDHUISEN2, JAMES TROENDLE3, UMA REDDY4, WARE BRANCH5, JENNIFER BAILIT6, MICHELLE KOMINIAREK7, MILDRED RAMIREZ8, VICTOR HUGO GONZALEZ QUINTERO9, MATTHEW HOFFMAN10, JUDITH HIBBARD11, JAMES FANNING12, RONALD BURKMAN13, SHOSHANA HABERMAN14, HELAIN LANDY15, KIMBERLY GREGORY16, 1National Institutes of Health (NIH), Bethesda, Maryland, 2EMMES Corp, Rockville, Maryland, 3National Institutes of Health (NIH), Maryland, 4University of Maryland at Baltimore, Bethesda, Maryland, 5Intermountain Healthcare, Utah, 6MetroHealth, Cleveland, Ohio, 7Indiana University, Indianapolis, Indiana, 8University of Texas Health Science Center at Houston, Houston, Texas, 9University of Miami, Dept of Ob/Gyn-MFM Division, Miami, Florida, 10Christiana Hospital, Newark, Delaware, 11University of Illinois at Chicago, Obstetrics and Gynecology, Chicago, Illinois, 12Summa Health System, Toledo, Ohio, 13Tufts University, Springfield, Massachusetts, 14Maimonides Medical Center, Brooklyn, New York, 15Georgetown University, Washington, District of Columbia, OBJECTIVE: To describe normal duration of labor and range of variation in a large contemporary U.S. population. STUDY DESIGN: The Consortium on Safe Labor consists of 12 institutions (19 hospitals) in 9 US ACOG Districts. Using 234,656 computerized delivery records from 2003-2007, data on maternal characteristics, reproductive and medical history, pregnancy complications, labor progression, delivery summary, newborn and NICU information were compiled. We restricted our analysis to singleton, term pregnancies with vertex presentation, no previous cesarean delivery and vaginal deliveries; the newborns had 5= Apgar score ⬎7 and no NICU admission. Interval censored regression was used to estimate labor duration. RESULTS: A total of 126,887 deliveries were included. The table presents the median duration of labor (hours) and 95th percentile by parity and cervical dilation (cm). In addition, among nulliparas, the median duration from 4-10 cm was 5.2 hours with 95th percentile at 21.6 hours. CONCLUSION: Labor curves currently in use (eg, Friedman=s) may not accurately reflect the current U.S. labor population, particularly before 6 cm. This information is important to take into account for labor management so that the likelihood of a safe spontaneous vaginal delivery is optimized. Duration of labor (h) by parity and dilation Cervical Dilation
Parity 0 (median, 95th%)
Parity 1 (median, 95th%)
Parity 2⫹ (median, 95th%)
4-5 5-6 6-7 7-8 8-9 9 - 10
1.2 (5.9) 0.7 (3.0) 0.6 (1.9) 0.5 (1.4) 0.4 (1.2) 0.5 (1.7)
1.2 (6.2) 0.7 (2.8) 0.5 (1.6) 0.4 (1.1) 0.3 (0.9) 0.3 (0.8)
1.1 (5.8) 0.6 (2.6) 0.4 (1.5) 0.3 (1.0) 0.3 (0.8) 0.3 (0.7)
Adjusted Odds Ratio
(95% CI) for uterine rupture
0.98 1.85 0.64 1.61 1.58 1.28 1.36 1.43
0.53-1.80 1.24-2.77 0.41-0.99 1.05-2.45 0.80-3.11 0.64-2.57 0.68-2.74 0.82-2.49
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.107
82
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.106
S36
THE MFMU CESAREAN REGISTRY: RISK OF UTERINE RUPTURE IN WOMEN ATTEMPTING VBAC WITH AN UNKNOWN UTERINE SCAR M. ASHLEY HICKMAN1, 1for the Eunice Kennedy Shriver National Institute of Child Health and Human Development MFMU Network, Bethesda, Maryland OBJECTIVE: To assess risk for uterine rupture in women with one prior cesarean delivery (CD) and an unknown scar, and to determine if clinical factors alter this risk. STUDY DESIGN: A secondary analysis of a prospective multicenter registry was performed on women attempting VBAC after one prior CD with unknown scar versus single prior low transverse cesarean delivery (LTCD). Among women with unknown scar, clinical factors, including indication for prior CD were assessed for their association with uterine rupture in the current pregnancy. RESULTS: 16,280 women met criteria for analysis including 13,766 (85%) with known prior LTCD and 2,514 (15%) with unknown scar. Indications for prior CD in the unknown scar group were: dystocia (34%), malpresentation (26%), NRFHT (19%), and other (including multiples, macrosomia, preeclampsia, previa) (20%); (14%) of these occurred before 37 wks, similar to preterm delivery rate in those with prior LTCD. Uterine rupture was similar between women with unknown scar and known prior LTCD (0.52% vs 0.70%, p⫽0.29), OR 0.73 (0.41 - 1.31). The final model to determine risk for rupture with an unknown scar is shown below. CONCLUSION: An unknown scar does not increase uterine rupture risk among women attempting VBAC. Women with an unknown scar who desire VBAC should be counseled on the increased risk of rupture with induction and interdelivery interval ⱕ 2years. Logistic Regression Model
American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2008
A RANDOMIZED STUDY COMPARING SUBCUTICULAR SUTURES VERSUS STAPLES FOR SKIN CLOSURE IN CESAREAN SECTIONS JULIE-ANNE ROUSSEAU1, KARINE GIRARD2, LUCILLE TURCOT-LEMAY3, NANCY THOMAS2, 1Laval University, Centre hospitalier universitaire de Québec / Centre Mère-Enfant, Québec, Quebec, Canada, 2Laval University, Centre hospitalier universitaire de Québec / Centre Mère-Enfant, Quebec, Quebec, Canada, 3Laval University, Centre hospitalier universitaire de Québec, Quebec OBJECTIVE: To compare post-operative (PO) pain according to the skin closure method: subcuticular sutures versus staples, following an elective cesarean section. Secondary objectives were to evaluate operative time, incidence of wound infection, incision appearance and general satisfaction of women. STUDY DESIGN: A randomized controlled trial of 101 women undergoing an elective term cesarean was performed. Women were randomly assigned to skin closure with subcuticular sutures using Monocryl 4-0 or staples. Operative technique and PO analgesia were standardized for both groups. Stratification was used for primary versus iterative cesareans. Analogue pain and satisfaction scales were completed at PO day one and three and, at six weeks PO. A digital picture of the incision was taken at six weeks PO and evaluated according to five objective criteria by three independent blinded observers. Statistical analysis was performed using bilateral Student T test and Fisher exact test when appropriate. RESULTS: Fifty-two women had a subcuticular closure and forty-nine received staples. Maternal characteristics (including body mass index) and pain at PO day one and three were similar in both groups. Pain at six weeks PO was significantly less in the staples group (0.17 vs 0.51 p⫽0.04). Operative time was also shorter in that group (24 vs 33 minutes p⬍0.0001). No significant differences were noted for incision appearance and women=s general satisfaction. One patient, from the subcuticular group, developed a wound infection. CONCLUSION: Staples are the method of choice for skin closure for elective term cesarean sections in our population. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.108