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Balloon-tip catheter occlusion of the hypogastric arteries for the management of placenta accreta
S128 SMFM Abstracts 236
December 2003 Am J Obstet Gynecol
INTRAPARTUM OUTCOMES ASSOCIATED WITH CHANGE IN BODY MASS INDEX CATEGORY DURING PREGNANCY WANJIKU KABIRU1, B. DENISE RAYNOR1, 1Emory University, OB/GYN, Atlanta, GA OBJECTIVE: To investigate the effect of change in body mass index (BMI) category on intrapartum outcomes. STUDY DESIGN: Retrospective cohort study conducted from 1999 to 2002. Women with term singleton pregnancies were included. BMI categories were defined as normal 25-29.9, overweight 30-34.5, obese 35-39.9, and morbid obesity $40. Change in BMI category was calculated by subtracting prepregnancy BMI category from BMI category at delivery. Analysis was performed with one-way ANOVA for continuous variables and chi-square test for trend for categorical variables. Multivariate analysis was performed to evaluate the relationship between outcomes, change in BMI categories, and other covariables. RESULTS: 10,880 singleton, term pregnancies were identified in the Grady Memorial Hospital database. Of these, 5802 had complete obstetric data. 3163 (29.1%) women remained in the same BMI category during pregnancy, 2330 (21.4%) increased by 1 BMI category, and 309 (2.8%) increased by 2 categories. Demographics and prenatal characteristics were similar. Change in BMI category was associated with decreased risk of intrauterine growth restriction (P < 0.001). Intrapartum outcomes differed between groups (Table). CONCLUSION: Change in BMI category is associated with failed induction, amnionitis, lacerations, and operative delivery.
238
BALLOON-TIP CATHETER OCCLUSION OF THE HYPOGASTRIC ARTERIES FOR THE MANAGEMENT OF PLACENTA ACCRETA NIKOLAOS ZACHARIAS1, ALFREDO GEI1, VICTOR SUAREZ, MD1, LUIS DIEGO PACHECO1, ANA VIDAL1, RAKESH VADHERA2, GEORGE SAADE1, GARY HANKINS1, 1University of Texas Medical Branch, Obstetrics & Gynecology, Galveston, TX 2University of Texas Medical Branch, Obstetrical Anesthesiology, Galveston, TX OBJECTIVE: To determine the role of preoperative placement of balloontip catheters in the hypogastric arteries in the control of obstetrical hemorrhage due to placenta accreta. STUDY DESIGN: Patients that underwent cesarean hysterectomies for placenta accreta (histologically confirmed) between 1992 and 2002 were identified. Complete records were available on 6 patients who had preoperative placement of balloon-tip catheters in the hypogastric arteries (cases) and 14 who did not (controls). Demographics, operative findings, and peripartum morbidity were compared using Mann-Whitney U test, t-test, and Fisher’s exact test as appropriate (significance: P < 0.05). RESULTS: Demographics were not significantly different between cases and controls. The cases had, on average, 45 minutes longer operative time (180 vs 135 min; NS). No significant differences were observed between the catheter and control groups with respect to estimated blood loss (3321 vs 3450 mL) or number of blood product units transfused (median: 3). Cases were twice as likely to require intensive care (33% vs 14%; NS), and on average, were discharged one day later than the control group (postoperative day 6 versus 5; NS). The neonatal outcomes were similar between the two groups. CONCLUSION: These findings suggest that the preoperative placement of hypogastric artery balloon-tip catheters does not improve the outcome of patients undergoing hysterectomy for placenta accreta. A prospective randomized trial is needed to validate these results.
239
EPIDURAL ANESTHESIA RESULTS IN SIGNIFICANTLY GREATER FORCE APPLIED TO THE FETUS DURING DELIVERY SARAH POGGI1, CATHERINE SPONG1, CHIRAG PATEL2, ALESSANDRO GHIDINI1, ROBERT ALLEN2, 1Georgetown University Hospital, Obstetrics and Gynecology, Washington, DC 2Johns Hopkins University, Biomedical Engineering, Baltimore, MD OBJECTIVE: The objective of this study was to evaluate if type of anesthesia affects the amount of force required for delivery of the fetus during vaginal delivery. STUDY DESIGN: After informed consent, multiparous patients with term, cephalic, singleton gestations were delivered by a single physician who wore a tactile sensing device (a thin glove equipped with small sensors on the fingertips) during each delivery to record the amount of clinician force exerted on the fetal head during the delivery. Patients receiving epidural anesthesia were compared to those who did not for the variables of peak delivery force, peak force rate, head to body interval, and birthweight using Student t test with P < 0.05 considered significant. RESULTS: The peak force (lbs) required for delivery was significantly greater in patients with epidural anesthesia (n = 27) than no regional anesthesia (n = 5) (7.72 ± .54 vs 3.88 ± .89, P = .006). The peak force for delivery of the anterior shoulder (7.06 ± .53 vs 4.32 ± .60, P = 0.034) and peak force rate (lbs/ sec) (30.59 ± 3.94 vs 13.26 ± 2.61, P = 0.056) were also greater in patients with epidural vs no anesthesia. Birthweight (gm) (3506 ± 63.20 vs 3311 ± 276, P = .30) and head to body delivery interval (sec) (14.89 ± 1.8 vs 12.4 ± 3.5, P = 0.59) were not different between the patients with epidural vs no regional anesthesia, respectively. Data presented as mean ± standard error. CONCLUSION: Epidural anesthesia resulted in a significantly greater clinician force required for delivery of the fetus during vaginal delivery in multiparous patients. This may be due to the anesthetic effect resulting in inadequate maternal expulsive efforts.
BMI category and intrapartum outcomes No Change Chorioamnionitis Failed Induction Perineal Lacerations Cesarean Section Operative Vaginal Deliveries
237
131 225 838 544 286
(4.1%) (7.1%) (26.5%) (17.2%) (9.0%)
1 Category increase 114 243 693 471 254
(4.9%) (10.4%) (29.7%) (20.2%) (10.9%)
2 Category increase
P value
25 46 95 78 40
0.006 < 0.001 < 0.001 < 0.001 0.016
(8.1%) (14.9%) (37.9%) (2502%) (12.9%)
IS PERIPARTUM HYSTERECTOMY MORE COMMON IN MULTIPLE GESTATIONS? KARRIE FRANCOIS1, JOSEPH ORTIZ2, CATHLEEN HARRIS1, 1Good Samaritan Regional Medical Center, Maternal-Fetal Medicine, Phoenix, AZ 2Good Samaritan Regional Medical Center, Obstetrics and Gynecology, Phoenix, AZ OBJECTIVE: To compare the occurrence of peripartum hysterectomy among singleton and multiple gestations. STUDY DESIGN: Historical cohort study comparing the occurrence of peripartum hysterectomy among singleton and multiple gestations at Good Samaritan Regional Medical Center, Phoenix, AZ, from January 1, 1996, to December 31, 2001. RESULTS: During the study years, 42,595 singleton, 1131 twin, 164 triplet, 35 quadruplet, and 2 quintuplet deliveries occurred. A total of 100 peripartum hysterectomies were performed. Of these hysterectomies, 88 occurred in singleton, 5 in twin, 6 in triplet, and 1 in quadruplet gestations. The overall occurrence of peripartum hysterectomy was 2.28 per 1000. Multiple gestations were significantly more likely to require emergent peripartum hysterectomy than singletons (OR 6.46, 95% CI 3.01-12.37; P < .001). This difference was further demonstrated upon stratification of the multiple gestations by twin (OR 3.16, 95% CI 1.12-8.18; P = .027), triplet (OR 27.00, 95% CI 10.38-65.94; P < .001), and quadruplet (OR 20.91, 95% CI 1.05-145.55; P = .043) gestations. When compared to singletons, higher-order multiple gestations had a 25-fold increased risk of peripartum hysterectomy (OR 25.66, 95% CI 10.62-58.98; P < .001). CONCLUSION: Multiple gestations have a significantly higher occurrence of peripartum hysterectomy than singletons. This finding is most pronounced among higher-order multiple gestations. This information has not been previously reported and should be used in counseling patients with such pregnancies.
December 2003 Am J Obstet Gynecol
INTRAPARTUM OUTCOMES ASSOCIATED WITH CHANGE IN BODY MASS INDEX CATEGORY DURING PREGNANCY WANJIKU KABIRU1, B. DENISE RAYNOR1, 1Emory University, OB/GYN, Atlanta, GA OBJECTIVE: To investigate the effect of change in body mass index (BMI) category on intrapartum outcomes. STUDY DESIGN: Retrospective cohort study conducted from 1999 to 2002. Women with term singleton pregnancies were included. BMI categories were defined as normal 25-29.9, overweight 30-34.5, obese 35-39.9, and morbid obesity $40. Change in BMI category was calculated by subtracting prepregnancy BMI category from BMI category at delivery. Analysis was performed with one-way ANOVA for continuous variables and chi-square test for trend for categorical variables. Multivariate analysis was performed to evaluate the relationship between outcomes, change in BMI categories, and other covariables. RESULTS: 10,880 singleton, term pregnancies were identified in the Grady Memorial Hospital database. Of these, 5802 had complete obstetric data. 3163 (29.1%) women remained in the same BMI category during pregnancy, 2330 (21.4%) increased by 1 BMI category, and 309 (2.8%) increased by 2 categories. Demographics and prenatal characteristics were similar. Change in BMI category was associated with decreased risk of intrauterine growth restriction (P < 0.001). Intrapartum outcomes differed between groups (Table). CONCLUSION: Change in BMI category is associated with failed induction, amnionitis, lacerations, and operative delivery.
238
BALLOON-TIP CATHETER OCCLUSION OF THE HYPOGASTRIC ARTERIES FOR THE MANAGEMENT OF PLACENTA ACCRETA NIKOLAOS ZACHARIAS1, ALFREDO GEI1, VICTOR SUAREZ, MD1, LUIS DIEGO PACHECO1, ANA VIDAL1, RAKESH VADHERA2, GEORGE SAADE1, GARY HANKINS1, 1University of Texas Medical Branch, Obstetrics & Gynecology, Galveston, TX 2University of Texas Medical Branch, Obstetrical Anesthesiology, Galveston, TX OBJECTIVE: To determine the role of preoperative placement of balloontip catheters in the hypogastric arteries in the control of obstetrical hemorrhage due to placenta accreta. STUDY DESIGN: Patients that underwent cesarean hysterectomies for placenta accreta (histologically confirmed) between 1992 and 2002 were identified. Complete records were available on 6 patients who had preoperative placement of balloon-tip catheters in the hypogastric arteries (cases) and 14 who did not (controls). Demographics, operative findings, and peripartum morbidity were compared using Mann-Whitney U test, t-test, and Fisher’s exact test as appropriate (significance: P < 0.05). RESULTS: Demographics were not significantly different between cases and controls. The cases had, on average, 45 minutes longer operative time (180 vs 135 min; NS). No significant differences were observed between the catheter and control groups with respect to estimated blood loss (3321 vs 3450 mL) or number of blood product units transfused (median: 3). Cases were twice as likely to require intensive care (33% vs 14%; NS), and on average, were discharged one day later than the control group (postoperative day 6 versus 5; NS). The neonatal outcomes were similar between the two groups. CONCLUSION: These findings suggest that the preoperative placement of hypogastric artery balloon-tip catheters does not improve the outcome of patients undergoing hysterectomy for placenta accreta. A prospective randomized trial is needed to validate these results.
239
EPIDURAL ANESTHESIA RESULTS IN SIGNIFICANTLY GREATER FORCE APPLIED TO THE FETUS DURING DELIVERY SARAH POGGI1, CATHERINE SPONG1, CHIRAG PATEL2, ALESSANDRO GHIDINI1, ROBERT ALLEN2, 1Georgetown University Hospital, Obstetrics and Gynecology, Washington, DC 2Johns Hopkins University, Biomedical Engineering, Baltimore, MD OBJECTIVE: The objective of this study was to evaluate if type of anesthesia affects the amount of force required for delivery of the fetus during vaginal delivery. STUDY DESIGN: After informed consent, multiparous patients with term, cephalic, singleton gestations were delivered by a single physician who wore a tactile sensing device (a thin glove equipped with small sensors on the fingertips) during each delivery to record the amount of clinician force exerted on the fetal head during the delivery. Patients receiving epidural anesthesia were compared to those who did not for the variables of peak delivery force, peak force rate, head to body interval, and birthweight using Student t test with P < 0.05 considered significant. RESULTS: The peak force (lbs) required for delivery was significantly greater in patients with epidural anesthesia (n = 27) than no regional anesthesia (n = 5) (7.72 ± .54 vs 3.88 ± .89, P = .006). The peak force for delivery of the anterior shoulder (7.06 ± .53 vs 4.32 ± .60, P = 0.034) and peak force rate (lbs/ sec) (30.59 ± 3.94 vs 13.26 ± 2.61, P = 0.056) were also greater in patients with epidural vs no anesthesia. Birthweight (gm) (3506 ± 63.20 vs 3311 ± 276, P = .30) and head to body delivery interval (sec) (14.89 ± 1.8 vs 12.4 ± 3.5, P = 0.59) were not different between the patients with epidural vs no regional anesthesia, respectively. Data presented as mean ± standard error. CONCLUSION: Epidural anesthesia resulted in a significantly greater clinician force required for delivery of the fetus during vaginal delivery in multiparous patients. This may be due to the anesthetic effect resulting in inadequate maternal expulsive efforts.
BMI category and intrapartum outcomes No Change Chorioamnionitis Failed Induction Perineal Lacerations Cesarean Section Operative Vaginal Deliveries
237
131 225 838 544 286
(4.1%) (7.1%) (26.5%) (17.2%) (9.0%)
1 Category increase 114 243 693 471 254
(4.9%) (10.4%) (29.7%) (20.2%) (10.9%)
2 Category increase
P value
25 46 95 78 40
0.006 < 0.001 < 0.001 < 0.001 0.016
(8.1%) (14.9%) (37.9%) (2502%) (12.9%)
IS PERIPARTUM HYSTERECTOMY MORE COMMON IN MULTIPLE GESTATIONS? KARRIE FRANCOIS1, JOSEPH ORTIZ2, CATHLEEN HARRIS1, 1Good Samaritan Regional Medical Center, Maternal-Fetal Medicine, Phoenix, AZ 2Good Samaritan Regional Medical Center, Obstetrics and Gynecology, Phoenix, AZ OBJECTIVE: To compare the occurrence of peripartum hysterectomy among singleton and multiple gestations. STUDY DESIGN: Historical cohort study comparing the occurrence of peripartum hysterectomy among singleton and multiple gestations at Good Samaritan Regional Medical Center, Phoenix, AZ, from January 1, 1996, to December 31, 2001. RESULTS: During the study years, 42,595 singleton, 1131 twin, 164 triplet, 35 quadruplet, and 2 quintuplet deliveries occurred. A total of 100 peripartum hysterectomies were performed. Of these hysterectomies, 88 occurred in singleton, 5 in twin, 6 in triplet, and 1 in quadruplet gestations. The overall occurrence of peripartum hysterectomy was 2.28 per 1000. Multiple gestations were significantly more likely to require emergent peripartum hysterectomy than singletons (OR 6.46, 95% CI 3.01-12.37; P < .001). This difference was further demonstrated upon stratification of the multiple gestations by twin (OR 3.16, 95% CI 1.12-8.18; P = .027), triplet (OR 27.00, 95% CI 10.38-65.94; P < .001), and quadruplet (OR 20.91, 95% CI 1.05-145.55; P = .043) gestations. When compared to singletons, higher-order multiple gestations had a 25-fold increased risk of peripartum hysterectomy (OR 25.66, 95% CI 10.62-58.98; P < .001). CONCLUSION: Multiple gestations have a significantly higher occurrence of peripartum hysterectomy than singletons. This finding is most pronounced among higher-order multiple gestations. This information has not been previously reported and should be used in counseling patients with such pregnancies.