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Effectiveness of the selective arterial embolization in the management of obstetrical hemorrhage
S122 SMFM Abstracts
December 2003 Am J Obstet Gynecol
212
PLACENTAL PATHOLOGY AND PREGNANCY OUTCOMES IN DONOR AND NON-DONOR OOCYTE IN VITRO FERTILIZATION PREGNANCIES SRIRAM C. PERNI1, JENNIFER E. CHO1, REBECCA N. BAERGEN2, 1Weill Medical College of Cornell University, Obstetrics & Gynecology, New York, NY 2Weill Medical College of Cornell University, Pathology, New York, NY OBJECTIVE: Intrinsically poor maternal adaptation to pregnancy and dysregulated processes have been postulated to occur as a consequence of an immune response to the feto-placental unit as a ‘‘foreign’’ material. The aim of our study was to compare the placental pathology and outcomes in pregnancies conceived via donor oocyte in vitro fertilization (IVF) with non-donor oocyte IVF gestations. STUDY DESIGN: We conducted a retrospective, case-control study on 91 placentas from IVF pregnancies (36 from donor oocytes and 55 from non-donor cycles). All the placentas were examined by a single pathologist (R.N.B.) for pathology indicative of an immune response including chronic villitis (CV), chronic deciduitis (CD), increased perivillous fibrin (IPF), ischemic change/ infarction (INF), decidual vasculopathy (DV), increased syncytial knots (ISK), intervillous thrombi (IVT), and retroplacental hematomas (RPH). Statistical analysis was performed with chi-square, Fisher’s exact, and Mann-Whitney U tests where appropriate. A P value < 0.05 was considered statistically significant. RESULTS: Placentas from donor cycles were significantly more likely to demonstrate certain pathologic findings: CV (P < 0.001), CD (P = 0.034), IPF (P = 0.001), INF (P = 0.001), and IVT (P = 0.008). There was no statistical significance with respect to DV, ISK, or RPH. When analyzing the donor and non-donor groups separately, maternal age alone was not significantly associated with any placental histopathology. The patient populations did not differ in neonatal gender, preeclampsia, meconium, PPROM, 5-minute Apgar, or delivery method. However, the non-donor pregnancies were significant for lower birth weight (P = 0.010), lower 1-minute Apgar (P = 0.031), and earlier gestational age at delivery (P < 0.001). CONCLUSION: Pathologic evidence of an immune-mediated process is much more pronounced in donor oocyte IVF pregnancies compared to nondonor oocyte pregnancies. Clinical implications of these findings have yet to be determined.
214
TEACHING SIGNIFICANTLY IMPROVES VISUAL ESTIMATION OF BLOOD LOSS ARCHANA PAINE1, NATALIE GEORGE1, CRUZ VELASCO2, GARY DILDY1, 1Louisiana State University Health Sciences Center, Obstetrics & Gynecology, New Orleans, LA 2Louisiana State University Health Sciences Center, School of Public Health, New Orleans, LA OBJECTIVE: Postpartum hemorrhage is one of the three leading causes of maternal mortality. Visual estimated blood loss (EBL) has long been known to be imprecise, inaccurate, and often underestimated, which may lead to delayed diagnosis and treatment. Our purpose is to determine if a brief didactic course can improve visual EBL. STUDY DESIGN: Reconstituted whole blood (Hct ;40%) was obtained from the blood bank, and simulated scenarios with known measured blood loss (MBL) were created using common surgical materials (lap pads, surgical sponges, plastic collection drapes, perineal pads). Visual EBL was performed by medical personnel (medical students, residents, attendings) before and after a 20-minute didactic session. Percent errors of EBL were calculated and comparisons were made with the Wilcoxon signed-rank test, McNemar’s test, and Bowker’s test of symmetry. RESULTS: 53 participants assessed 7 scenarios. There were significant reductions in EBL error for all scenarios. For example, in scenario 1, an underbuttocks drape containing 350 mL of MBL was estimated (median ± SD_MAD) to contain 250 ± 148 mL before and 355 ± 67 mL after lecture, with an improvement of percent error in EBL from -29% ± 42% to 1% ± 19% after lecture (P < 0.0001). In scenario 4, 12 laparotomy sponges with MBL of 1200 mL were underestimated by at least 20% of MBL in 33/53 cases before lecture and only 1/53 cases after lecture (P < 0.001). CONCLUSION: EBL tends to be overestimated at low volumes and underestimated at high volumes. A simple and brief didactic session improves visual EBL and reduces both underestimation and overestimation. This educational process may assist clinicians in everyday practice to more accurately estimate blood loss and recognize patients at risk for hemorrhage-related complications.
213
ROUTINE CERVICAL ULTRASOUND IN TWIN GESTATIONS: IS PRETERM DELIVERY DECREASED? LISA SAUL1, MICHAEL HAYDON1, JUDITH CHUNG2, MARK GHAMSARY3, JAMES KURTZMAN1, TAMEROU ASRAT1, 1University of California, Irvine, Obstetrics & Gynecology, Orange, CA 2Long Beach Memorial Medical Center, Obstetrics & Gynecology, Long Beach, CA 3Loma Linda University, Epidemiology & Biostatistics, Loma Linda, CA OBJECTIVE: To determine if routine cervical length measurement in twin gestations enables the clinician to decrease preterm delivery. STUDY DESIGN: This is a retrospective chart review of 175 twin pregnancies delivering at Long Beach Memorial Medical Center between January 1999 and March 2001. In 53 twin pregnancies, cervical length surveillance (CL) was routinely used. These were compared to 122 pregnancies in which CL was not performed (non-CL). The primary outcome was gestational age (GA) at delivery. An a priori sample size calculation was performed, indicating that 49 patients were required in each group to detect a 2-week difference (a = 0.05, b = 0.20). RESULTS: In the CL group, the mean number of cervical length exams was 3.7 (median = 2.0, range = 1.0-17.0). The mean GA at initial cervical ultrasound was 21.2 ± 4.8 weeks. There was no difference in the mean gestational age at delivery between groups (CL = 34.8 ± 3.9; non-CL = 34.5 ± 4.8; P = 0.70). Adjustment for parity and prior preterm birth did not significantly alter these results (P = 0.39). CONCLUSION: The routine use of cervical length ultrasound in twin pregnancies does not appear to enable the clinician to decrease preterm delivery.
215
EFFECTIVENESS OF THE SELECTIVE ARTERIAL EMBOLIZATION IN THE MANAGEMENT OF OBSTETRICAL HEMORRHAGE JAE-YOON SHIM1, CHEUN-SIC KANG1, SUN-KWON KIM1, HYE-SUNG WON1, DAESHIK SUH1, PIL-RYANG LEE1, AHM KIM1, 1Asan Medical Center, Ulsan University, Obstetrics and Gynecology, Seoul, South Korea OBJECTIVE: To describe the selective arterial embolization as a treatment in the management of obstetrical hemorrhage and in preserving fertility. STUDY DESIGN: Between March 1999 and May 2003, 43 patients at Asan Medical Center underwent selective arterial embolization because of obstetrical hemorrhage unresponsive to conservative management or prophylaxis for obstetrical hemorrhage. Medical records were reviewed and detailed to collect clinical data such as clinical status, transfusion, embolization procedure, complications associated with embolization, hospital stay, and the success rate. Patients were contacted by telephone to obtain long-term outcome for menstruation, desire for conception, and subsequent pregnancies. RESULTS: We have experienced the successful embolization in 37 (86.0%) of 43 patients with obstetrical hemorrhage resulting from various causes. The main cause of hemorrhage was atony of uterus (n = 17), followed by abnormal placentation (n = 6), genital tract laceration (n = 5). The average amount of blood transfusion was 7.0 units (range, 0-36). The average length of the time for the procedure was 68.2 minutes (range, 30-150). The average duration of hospitalization was 6.4 days (range, 3-20). The main complication after embolization was numbness and pain on right lower extremities in 5 cases, and vessel dissection occurred in 1 case. But there was no major complication related to the procedure. We were able to follow up 28 patients. In all patients menses resumed spontaneously soon after the procedure. Eight patients expressed a desire for pregnancy and 7 patients became pregnant among them (1 undesired pregnancy included). Among 7 pregnancies, 3 cases completed gestations giving birth to healthy babies, 2 cases with ongoing pregnancy, 2 cases with early miscarriage. CONCLUSION: Selective arterial embolization is a relatively noninvasive and highly effective method for the management of obstetrical hemorrhage and a useful technique for preserving fertility.
Gestational age at delivery in CL and non-CL patients
Unadjusted Adjusted (Nulliparity, PTD)
CL
non-CL
P value
34.8 ± 3.9 wks 34.7 wks
34.5 ± 4.8 wks 34.0 wks
0.70 0.39
December 2003 Am J Obstet Gynecol
212
PLACENTAL PATHOLOGY AND PREGNANCY OUTCOMES IN DONOR AND NON-DONOR OOCYTE IN VITRO FERTILIZATION PREGNANCIES SRIRAM C. PERNI1, JENNIFER E. CHO1, REBECCA N. BAERGEN2, 1Weill Medical College of Cornell University, Obstetrics & Gynecology, New York, NY 2Weill Medical College of Cornell University, Pathology, New York, NY OBJECTIVE: Intrinsically poor maternal adaptation to pregnancy and dysregulated processes have been postulated to occur as a consequence of an immune response to the feto-placental unit as a ‘‘foreign’’ material. The aim of our study was to compare the placental pathology and outcomes in pregnancies conceived via donor oocyte in vitro fertilization (IVF) with non-donor oocyte IVF gestations. STUDY DESIGN: We conducted a retrospective, case-control study on 91 placentas from IVF pregnancies (36 from donor oocytes and 55 from non-donor cycles). All the placentas were examined by a single pathologist (R.N.B.) for pathology indicative of an immune response including chronic villitis (CV), chronic deciduitis (CD), increased perivillous fibrin (IPF), ischemic change/ infarction (INF), decidual vasculopathy (DV), increased syncytial knots (ISK), intervillous thrombi (IVT), and retroplacental hematomas (RPH). Statistical analysis was performed with chi-square, Fisher’s exact, and Mann-Whitney U tests where appropriate. A P value < 0.05 was considered statistically significant. RESULTS: Placentas from donor cycles were significantly more likely to demonstrate certain pathologic findings: CV (P < 0.001), CD (P = 0.034), IPF (P = 0.001), INF (P = 0.001), and IVT (P = 0.008). There was no statistical significance with respect to DV, ISK, or RPH. When analyzing the donor and non-donor groups separately, maternal age alone was not significantly associated with any placental histopathology. The patient populations did not differ in neonatal gender, preeclampsia, meconium, PPROM, 5-minute Apgar, or delivery method. However, the non-donor pregnancies were significant for lower birth weight (P = 0.010), lower 1-minute Apgar (P = 0.031), and earlier gestational age at delivery (P < 0.001). CONCLUSION: Pathologic evidence of an immune-mediated process is much more pronounced in donor oocyte IVF pregnancies compared to nondonor oocyte pregnancies. Clinical implications of these findings have yet to be determined.
214
TEACHING SIGNIFICANTLY IMPROVES VISUAL ESTIMATION OF BLOOD LOSS ARCHANA PAINE1, NATALIE GEORGE1, CRUZ VELASCO2, GARY DILDY1, 1Louisiana State University Health Sciences Center, Obstetrics & Gynecology, New Orleans, LA 2Louisiana State University Health Sciences Center, School of Public Health, New Orleans, LA OBJECTIVE: Postpartum hemorrhage is one of the three leading causes of maternal mortality. Visual estimated blood loss (EBL) has long been known to be imprecise, inaccurate, and often underestimated, which may lead to delayed diagnosis and treatment. Our purpose is to determine if a brief didactic course can improve visual EBL. STUDY DESIGN: Reconstituted whole blood (Hct ;40%) was obtained from the blood bank, and simulated scenarios with known measured blood loss (MBL) were created using common surgical materials (lap pads, surgical sponges, plastic collection drapes, perineal pads). Visual EBL was performed by medical personnel (medical students, residents, attendings) before and after a 20-minute didactic session. Percent errors of EBL were calculated and comparisons were made with the Wilcoxon signed-rank test, McNemar’s test, and Bowker’s test of symmetry. RESULTS: 53 participants assessed 7 scenarios. There were significant reductions in EBL error for all scenarios. For example, in scenario 1, an underbuttocks drape containing 350 mL of MBL was estimated (median ± SD_MAD) to contain 250 ± 148 mL before and 355 ± 67 mL after lecture, with an improvement of percent error in EBL from -29% ± 42% to 1% ± 19% after lecture (P < 0.0001). In scenario 4, 12 laparotomy sponges with MBL of 1200 mL were underestimated by at least 20% of MBL in 33/53 cases before lecture and only 1/53 cases after lecture (P < 0.001). CONCLUSION: EBL tends to be overestimated at low volumes and underestimated at high volumes. A simple and brief didactic session improves visual EBL and reduces both underestimation and overestimation. This educational process may assist clinicians in everyday practice to more accurately estimate blood loss and recognize patients at risk for hemorrhage-related complications.
213
ROUTINE CERVICAL ULTRASOUND IN TWIN GESTATIONS: IS PRETERM DELIVERY DECREASED? LISA SAUL1, MICHAEL HAYDON1, JUDITH CHUNG2, MARK GHAMSARY3, JAMES KURTZMAN1, TAMEROU ASRAT1, 1University of California, Irvine, Obstetrics & Gynecology, Orange, CA 2Long Beach Memorial Medical Center, Obstetrics & Gynecology, Long Beach, CA 3Loma Linda University, Epidemiology & Biostatistics, Loma Linda, CA OBJECTIVE: To determine if routine cervical length measurement in twin gestations enables the clinician to decrease preterm delivery. STUDY DESIGN: This is a retrospective chart review of 175 twin pregnancies delivering at Long Beach Memorial Medical Center between January 1999 and March 2001. In 53 twin pregnancies, cervical length surveillance (CL) was routinely used. These were compared to 122 pregnancies in which CL was not performed (non-CL). The primary outcome was gestational age (GA) at delivery. An a priori sample size calculation was performed, indicating that 49 patients were required in each group to detect a 2-week difference (a = 0.05, b = 0.20). RESULTS: In the CL group, the mean number of cervical length exams was 3.7 (median = 2.0, range = 1.0-17.0). The mean GA at initial cervical ultrasound was 21.2 ± 4.8 weeks. There was no difference in the mean gestational age at delivery between groups (CL = 34.8 ± 3.9; non-CL = 34.5 ± 4.8; P = 0.70). Adjustment for parity and prior preterm birth did not significantly alter these results (P = 0.39). CONCLUSION: The routine use of cervical length ultrasound in twin pregnancies does not appear to enable the clinician to decrease preterm delivery.
215
EFFECTIVENESS OF THE SELECTIVE ARTERIAL EMBOLIZATION IN THE MANAGEMENT OF OBSTETRICAL HEMORRHAGE JAE-YOON SHIM1, CHEUN-SIC KANG1, SUN-KWON KIM1, HYE-SUNG WON1, DAESHIK SUH1, PIL-RYANG LEE1, AHM KIM1, 1Asan Medical Center, Ulsan University, Obstetrics and Gynecology, Seoul, South Korea OBJECTIVE: To describe the selective arterial embolization as a treatment in the management of obstetrical hemorrhage and in preserving fertility. STUDY DESIGN: Between March 1999 and May 2003, 43 patients at Asan Medical Center underwent selective arterial embolization because of obstetrical hemorrhage unresponsive to conservative management or prophylaxis for obstetrical hemorrhage. Medical records were reviewed and detailed to collect clinical data such as clinical status, transfusion, embolization procedure, complications associated with embolization, hospital stay, and the success rate. Patients were contacted by telephone to obtain long-term outcome for menstruation, desire for conception, and subsequent pregnancies. RESULTS: We have experienced the successful embolization in 37 (86.0%) of 43 patients with obstetrical hemorrhage resulting from various causes. The main cause of hemorrhage was atony of uterus (n = 17), followed by abnormal placentation (n = 6), genital tract laceration (n = 5). The average amount of blood transfusion was 7.0 units (range, 0-36). The average length of the time for the procedure was 68.2 minutes (range, 30-150). The average duration of hospitalization was 6.4 days (range, 3-20). The main complication after embolization was numbness and pain on right lower extremities in 5 cases, and vessel dissection occurred in 1 case. But there was no major complication related to the procedure. We were able to follow up 28 patients. In all patients menses resumed spontaneously soon after the procedure. Eight patients expressed a desire for pregnancy and 7 patients became pregnant among them (1 undesired pregnancy included). Among 7 pregnancies, 3 cases completed gestations giving birth to healthy babies, 2 cases with ongoing pregnancy, 2 cases with early miscarriage. CONCLUSION: Selective arterial embolization is a relatively noninvasive and highly effective method for the management of obstetrical hemorrhage and a useful technique for preserving fertility.
Gestational age at delivery in CL and non-CL patients
Unadjusted Adjusted (Nulliparity, PTD)
CL
non-CL
P value
34.8 ± 3.9 wks 34.7 wks
34.5 ± 4.8 wks 34.0 wks
0.70 0.39