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Does antenatal maternal administration of phenobarbital prevent exchange transfusion in neonates with alloimmune hemolytic disease?
S214 SMFM Abstracts Hilton Exhibition Center, New Orleans Hilton Riverside 564 WHAT IS THE ACCURACY OF PRENATAL ULTRASOUND DIAGNOSIS IN FETAL CYSTIC KIDNEY DISEASE? JULIO MATEUS1, SILVIA NARNE1, STUART WEINER1, JORGE TOLOSA1, ALEXA HERMAN1, BABU CHEKU1, BRUCE FILMER2, ERNESTO FIGUEROA2, VINCENZO BERGHELLA1, 1 Thomas Jefferson University, Department of Obstetrics and Gynecology, Philadelphia, PA 2Alfred I. du Pont Hospital for Children, Division of Pediatric Urology, Wilmington, DE OBJECTIVE: To assess the concordance between prenatal sonographic diagnosis and prognosis for fetal cystic kidney disease (FCKD) and definitive urologic postnatal or pathologic diagnosis. STUDY DESIGN: Cases of FCKD diagnosed in utero by ultrasound at our institution and subsequently evaluated by a urologist at Dupont Children’s Hospital or by a pathologist from 1991 to 2002 were retrospectively reviewed. Ultrasound diagnosis was established based on standard classification. Prenatal and postnatal prognosis was defined as good, fair, and poor. In pregnancy terminations, only diagnostic accuracy, and not prognosis, was considered. RESULTS: 28 cases were identified: 11 (39.3%) multicystic dysplastic kidney disease (MCDKD), 4 (14.3%) autosomal recessive polycystic kidney disease (ARPKD), 3 (11.7%) unilateral MCKD with contralateral urinary malformation, 4 (14.2%) cystic kidneys with obstructive uropathy, and 6 (14.3%) cystic kidneys associated with structural abnormalities and genetic syndromes. 12 (42.9%) had similar bilateral pathology, 5 (17.9%) had unilateral cystic disease with contralateral urologic malformation, and 11 (39.3%) were unilateral. Oligohydramnios in 5 cases and bilateral cystic disease in 6 were associated 100% and 83.3% with fetal loss. The accuracy of prenatal diagnosis confirmed by autopsy report in 10 cases and postnatal urologic diagnosis in 16 was 78%. Misdiagnoses were due to hyperechogenicity of MCDKD interpreted as ARPCKD in 2 cases and complex urologic malformations in 4. The prognosis established by the perinatologist was concordant in 19 cases (90.4%) with the urologic postnatal diagnosis. Fetal survival rate was 57.1%. CONCLUSION: The in utero diagnosis and clinical prognosis of FCKD made by the perinatologist had high accuracy and concordance with the postnatal diagnosis and prognosis made by pediatric urologists. Collaboration between pediatric urologists and perinatologists should be further developed to benefit the affected family.
565
DOES ANTENATAL MATERNAL ADMINISTRATION OF PHENOBARBITAL PREVENT EXCHANGE TRANSFUSION IN NEONATES WITH ALLOIMMUNE HEMOLYTIC DISEASE? THOMAS TREVETT JR1, KAREN DORMAN1, GEORGINE LAMVU2, KENNETH MOISE1, 1University of North Carolina at Chapel Hill, Obstetrics/Gynecology, Chapel Hill, NC 2University of North Carolina, Chapel Hill, Gynecology, Chapel Hill, NC OBJECTIVE: Neonatal alloimmune hemolytic disease is associated with kernicterus due to the inefficiency of the neonatal liver to conjugate bilirubin. Neonatal exchange transfusions (EXT) are performed to prevent kernicterus. We hypothesized that administration of phenobarbital (PB) to women with fetal red cell alloimmunization who required serial intrauterine transfusions (IUT) in the week prior to delivery would induce neonatal hepatic maturity and prevent the need for exchange transfusion. STUDY DESIGN: Cases of alloimmune hemolytic disease of the fetus treated with PUBS/IUT from January 1992 to June 2003 were reviewed. Variables studied were gestational age and hematocrit at first IUT, number of total IUTs, delivery hematocrit and bilirubin, peak neonatal bilirubin, hours of phototherapy, need for exchange transfusion, and maternal PB administration. Multivariable regression analysis was performed to evaluate the impact of maternal phenobarbital administration on the need for EXT. Relative risks and 95% confidence intervals were calculated. RESULTS: 106 patients met study criteria. The mean ( ± SD) gestational age and hematocrit at time of first transfusion were 25.9 ( ± 3.4) wks and 21.3% ( ± 8.1), respectively. The median number of IUTs was 3 (range: 1-8 ). 24% of the neonates underwent EXT. The use of antenatal PB significantly decreased the need for EXT, 9% vs 38% (P = 0.01). After controlling for confounding variables, there was an 84% reduction in the need for EXT with exposure to antenatal PB (RR: 0.16, 95% CI: 0.04-0.70). CONCLUSION: Maternal administration of phenobarbital late in gestation significantly reduces the need for neonatal exchange transfusions in hemolytic disease of the newborn. A prospective randomized trial should be undertaken to confirm these results.
December 2003 Am J Obstet Gynecol
566
THE GENDER DOES MATTER EYAL SHEINER1, AMALIA LEVY2, MIRIAM KATZ1, RELI HERSHKOVITZ1, ELAD LERON1, MOSHE MAZOR1, 1Soroka University Medical Center, Ob/Gyn, Beer-Sheva, Israel 2Ben-Gurion University of the Negev, Epidemiology and Health Services Evaluation, Beer-Sheva, Israel OBJECTIVE: To investigate complications and outcomes of pregnancies of male versus female fetuses. STUDY DESIGN: A population-based study comparing all singleton deliveries between the years 1988 and 1999 was performed. A comparison was done between pregnancies of male vs female neonates. Patients with a previous cesarean section (CS) were excluded from the study. Statistical analyses, using the Mantel-Haenszel technique, and multiple logistic regression models were performed to control for confounders. RESULTS: During the study period there were 55,891 deliveries of males and 53,104 deliveries of female neonates. Patients carrying male fetuses had higher rates of gestational diabetes mellitus (OR = 1.1; 95% CI 1.01-1.12; P = 0.012), fetal macrosomia (OR = 2.0; 95% CI 1.8-2.1; P < 0.001), failure to progress during the 1st and 2nd stages of labor (OR = 1.2; 95% CI 1.1-1.3; P < 0.001 and OR = 1.4; 95% CI 1.3-1.5; P < 0.001; respectively), cord prolapse (OR = 1.3; 95% CI 1.1-1.6; P = 0.014), nuchal cord (OR = 1.2; 95% CI 1.1-1.2; P < 0.001), and true knots of cord (OR = 1.5; 95% CI 1.3-1.7; P < 0.001). Higher rates of cesarean sections (CS) were found among males as compared to females (8.7% vs 7.9%, OR = 1.1; 95% CI 1.06-1.16; P < 0.001). Using 3 multivariate logistic regression models, controlling for birth weight and gestational age, male gender was significantly associated with non-reassuring FHR patterns (OR = 1.5; 95% CI 1.4-1.6; P < 0.001), low Apgar scores at 5 minutes (OR = 1.5; 95% CI 1.31.8; P < 0.001), and CS (OR = 1.2; 95% CI 1.2-1.3; P < 0.001). Controlling for possible confounders like gestational diabetes, cord prolapse, failed induction, non-progressive labor, fetal macrosomia, nuchal cord, and true knots of cord, using the Mantel-Haenszel technique, did not change the significant association between male gender and CS. CONCLUSION: Male gender is an independent risk factor for adverse pregnancy outcome.
567
FETAL INTERVENTION MAY BENEFIT FETUSES WITH SEVERE RIGHTSIDED CDH KUOJEN TSAO1, BENJAMIN WEI2, ROBERT BALL3, DIANA FARMER4, KERILYN NOBUHARA5, MICHAEL HARRISON6, HANMIN LEE7, 1University of California, San Francisco, Fetal Treatment Center, San Francisco, CA 2Harvard Medical School, Boston, MA 3University of California, San Francisco, Obstetrics, Gynecology & Reproductive Sciences, San Francisco, CA 4University of California, San Francisco, Surgery, OB GYN & Pediatrics, San Francisco, CA 5University of California, San Francisco, Surgery and Pediatrics, San Francisco, CA 6University of California, San Francisco, Surgery & Pediatrics, San Francisco, CA 7University of California, San Francisco, Surgery, Pediatrics, & OB/GYN, San Francisco, CA OBJECTIVE: Because most congenital diaphragmatic hernias (CDH) are unilateral and predominantly left-sided, current literature involving fetal therapy has been limited to left-sided defects. While right-sided defects comprise < 10% of prenatally diagnosed CDH, their prognosis with or without fetal intervention remains unclear. We have reviewed our experience with the management of fetuses with right-sided CDH. STUDY DESIGN: We retrospectively reviewed all CDH cases referred to our institution and evaluated prenatal evaluation, surgical intervention, and postnatal care for all fetuses with right-sided CDH. Fetuses who underwent intervention were compared to fetuses expectantly managed. Statistical analysis was performed with chi-square and Student’s t-test. RESULTS: From January 1994 to May 2002, 187 fetuses prenatally diagnosed with CDH were identified; 12 (6.4%) were identified with right-sided CDH. Two of the 12 fetuses were terminated, five with average LHR of 1.0 were expectantly managed, and five fetuses with average LHR of 0.6 underwent fetal tracheal occlusion. Mean gestational age (GA) of fetal intervention was 26 weeks. Mean GA at delivery was 38 weeks for the expectantly managed group versus 31 weeks for the fetal intervention group. No fetus who underwent fetal intervention required ECMO, while 3 of 5 expectantly managed neonates required ECMO. Two of five fetuses (40%) expectantly managed survived to discharge, while four of five fetuses (80%) who underwent intervention survived to discharge. CONCLUSION: Despite the relatively small group of fetuses with rightsided CDH, overall survival with fetal intervention was comparable to left-sided CDH. Based on prenatal prognostic factors such as LHR, fetuses in the fetal intervention group would have an equally poor prognosis compared to those expectantly managed. Thus, fetuses with severe right-sided CDH with otherwise dismal prognosis may benefit from fetal tracheal occlusion.
565
DOES ANTENATAL MATERNAL ADMINISTRATION OF PHENOBARBITAL PREVENT EXCHANGE TRANSFUSION IN NEONATES WITH ALLOIMMUNE HEMOLYTIC DISEASE? THOMAS TREVETT JR1, KAREN DORMAN1, GEORGINE LAMVU2, KENNETH MOISE1, 1University of North Carolina at Chapel Hill, Obstetrics/Gynecology, Chapel Hill, NC 2University of North Carolina, Chapel Hill, Gynecology, Chapel Hill, NC OBJECTIVE: Neonatal alloimmune hemolytic disease is associated with kernicterus due to the inefficiency of the neonatal liver to conjugate bilirubin. Neonatal exchange transfusions (EXT) are performed to prevent kernicterus. We hypothesized that administration of phenobarbital (PB) to women with fetal red cell alloimmunization who required serial intrauterine transfusions (IUT) in the week prior to delivery would induce neonatal hepatic maturity and prevent the need for exchange transfusion. STUDY DESIGN: Cases of alloimmune hemolytic disease of the fetus treated with PUBS/IUT from January 1992 to June 2003 were reviewed. Variables studied were gestational age and hematocrit at first IUT, number of total IUTs, delivery hematocrit and bilirubin, peak neonatal bilirubin, hours of phototherapy, need for exchange transfusion, and maternal PB administration. Multivariable regression analysis was performed to evaluate the impact of maternal phenobarbital administration on the need for EXT. Relative risks and 95% confidence intervals were calculated. RESULTS: 106 patients met study criteria. The mean ( ± SD) gestational age and hematocrit at time of first transfusion were 25.9 ( ± 3.4) wks and 21.3% ( ± 8.1), respectively. The median number of IUTs was 3 (range: 1-8 ). 24% of the neonates underwent EXT. The use of antenatal PB significantly decreased the need for EXT, 9% vs 38% (P = 0.01). After controlling for confounding variables, there was an 84% reduction in the need for EXT with exposure to antenatal PB (RR: 0.16, 95% CI: 0.04-0.70). CONCLUSION: Maternal administration of phenobarbital late in gestation significantly reduces the need for neonatal exchange transfusions in hemolytic disease of the newborn. A prospective randomized trial should be undertaken to confirm these results.
December 2003 Am J Obstet Gynecol
566
THE GENDER DOES MATTER EYAL SHEINER1, AMALIA LEVY2, MIRIAM KATZ1, RELI HERSHKOVITZ1, ELAD LERON1, MOSHE MAZOR1, 1Soroka University Medical Center, Ob/Gyn, Beer-Sheva, Israel 2Ben-Gurion University of the Negev, Epidemiology and Health Services Evaluation, Beer-Sheva, Israel OBJECTIVE: To investigate complications and outcomes of pregnancies of male versus female fetuses. STUDY DESIGN: A population-based study comparing all singleton deliveries between the years 1988 and 1999 was performed. A comparison was done between pregnancies of male vs female neonates. Patients with a previous cesarean section (CS) were excluded from the study. Statistical analyses, using the Mantel-Haenszel technique, and multiple logistic regression models were performed to control for confounders. RESULTS: During the study period there were 55,891 deliveries of males and 53,104 deliveries of female neonates. Patients carrying male fetuses had higher rates of gestational diabetes mellitus (OR = 1.1; 95% CI 1.01-1.12; P = 0.012), fetal macrosomia (OR = 2.0; 95% CI 1.8-2.1; P < 0.001), failure to progress during the 1st and 2nd stages of labor (OR = 1.2; 95% CI 1.1-1.3; P < 0.001 and OR = 1.4; 95% CI 1.3-1.5; P < 0.001; respectively), cord prolapse (OR = 1.3; 95% CI 1.1-1.6; P = 0.014), nuchal cord (OR = 1.2; 95% CI 1.1-1.2; P < 0.001), and true knots of cord (OR = 1.5; 95% CI 1.3-1.7; P < 0.001). Higher rates of cesarean sections (CS) were found among males as compared to females (8.7% vs 7.9%, OR = 1.1; 95% CI 1.06-1.16; P < 0.001). Using 3 multivariate logistic regression models, controlling for birth weight and gestational age, male gender was significantly associated with non-reassuring FHR patterns (OR = 1.5; 95% CI 1.4-1.6; P < 0.001), low Apgar scores at 5 minutes (OR = 1.5; 95% CI 1.31.8; P < 0.001), and CS (OR = 1.2; 95% CI 1.2-1.3; P < 0.001). Controlling for possible confounders like gestational diabetes, cord prolapse, failed induction, non-progressive labor, fetal macrosomia, nuchal cord, and true knots of cord, using the Mantel-Haenszel technique, did not change the significant association between male gender and CS. CONCLUSION: Male gender is an independent risk factor for adverse pregnancy outcome.
567
FETAL INTERVENTION MAY BENEFIT FETUSES WITH SEVERE RIGHTSIDED CDH KUOJEN TSAO1, BENJAMIN WEI2, ROBERT BALL3, DIANA FARMER4, KERILYN NOBUHARA5, MICHAEL HARRISON6, HANMIN LEE7, 1University of California, San Francisco, Fetal Treatment Center, San Francisco, CA 2Harvard Medical School, Boston, MA 3University of California, San Francisco, Obstetrics, Gynecology & Reproductive Sciences, San Francisco, CA 4University of California, San Francisco, Surgery, OB GYN & Pediatrics, San Francisco, CA 5University of California, San Francisco, Surgery and Pediatrics, San Francisco, CA 6University of California, San Francisco, Surgery & Pediatrics, San Francisco, CA 7University of California, San Francisco, Surgery, Pediatrics, & OB/GYN, San Francisco, CA OBJECTIVE: Because most congenital diaphragmatic hernias (CDH) are unilateral and predominantly left-sided, current literature involving fetal therapy has been limited to left-sided defects. While right-sided defects comprise < 10% of prenatally diagnosed CDH, their prognosis with or without fetal intervention remains unclear. We have reviewed our experience with the management of fetuses with right-sided CDH. STUDY DESIGN: We retrospectively reviewed all CDH cases referred to our institution and evaluated prenatal evaluation, surgical intervention, and postnatal care for all fetuses with right-sided CDH. Fetuses who underwent intervention were compared to fetuses expectantly managed. Statistical analysis was performed with chi-square and Student’s t-test. RESULTS: From January 1994 to May 2002, 187 fetuses prenatally diagnosed with CDH were identified; 12 (6.4%) were identified with right-sided CDH. Two of the 12 fetuses were terminated, five with average LHR of 1.0 were expectantly managed, and five fetuses with average LHR of 0.6 underwent fetal tracheal occlusion. Mean gestational age (GA) of fetal intervention was 26 weeks. Mean GA at delivery was 38 weeks for the expectantly managed group versus 31 weeks for the fetal intervention group. No fetus who underwent fetal intervention required ECMO, while 3 of 5 expectantly managed neonates required ECMO. Two of five fetuses (40%) expectantly managed survived to discharge, while four of five fetuses (80%) who underwent intervention survived to discharge. CONCLUSION: Despite the relatively small group of fetuses with rightsided CDH, overall survival with fetal intervention was comparable to left-sided CDH. Based on prenatal prognostic factors such as LHR, fetuses in the fetal intervention group would have an equally poor prognosis compared to those expectantly managed. Thus, fetuses with severe right-sided CDH with otherwise dismal prognosis may benefit from fetal tracheal occlusion.