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Factors associated with a non reassuring fetal heart rate immediately following epidural anesthesia
SMFM Abstracts S201
Volume 189, Number 6 Am J Obstet Gynecol 519
REVIEW OF FOUR HUNDRED WOMEN PRESENTING AFTER A THIRDDEGREE TEAR RHONA MAHONY1, MYRA FITZPATRICK1, CAITRIONA KIRWAN2, P. RONAN O’CONNELL2, COLM O’HERLIHY1, 1University College Dublin, Obstetrics and Gynaecology, Dublin 2 2University College Dublin, Surgery, Dublin 7, Ireland OBJECTIVE: Third-degree tears occur after approximately 3% of vaginal deliveries and represent the most important risk factor for the development of fecal incontinence in women. Up to 50% women who have sustained a thirddegree tear will experience alteration in fecal continence. The aim of this study was to review the outcome in 400 women after third-degree tear. STUDY DESIGN: This was a prospective review of 400 women who presented to a dedicated perineal clinic three months following primary repair of a recognized third-degree tear. Data recorded included age, parity, mode of delivery continence score, anal manometry pressures and the results of endoanal ultrasound examination. RESULTS: The median age was 31 (range 18-44) years and median parity was 1 (range 1-8). 290 (72%) women had a spontaneous vaginal delivery, 73 (18%) a forceps delivery and 38 (10%) a vacuum delivery. The median continence score was 2 (range 0-20); 56% of patients were symptomatic but only 7% of patients had contience scores >10. The median anal canal squeeze pressure was 65mmHg (range 18-164) and median resting pressure was 41mmHg (range 3-108). Five percent of patients had a normal endoanal ultrasound, while 93% had a defect of the external anal sphincter and 63% had a defect of the internal anal sphincter. There was a strong relationship between age and parity and the presence of incontinence symptoms. CONCLUSION: While the majority of women following third-degree tear were symptomatic, most had minor alteration in continence. The prsence of symptoms was influenced by age and parity.
521
ACTIVE MANAGEMENT FOR DELIVERY OF A SECOND TWIN WITH AN ESTIMATED BIRTH WEIGHT OF > 1500 G IS SAFE AND ASSOCIATED WITH A LOW RATE OF CESAREAN SECTION, EXPERIENCE FROM 663 DELIVERIES DORON KREISER1, MICHAL ZAJICEK1, YAEL BARKAI1, DANIEL SEIDMAN1, EYAL SIVAN1, EYAL SCHIFF1, 1Sheba Medical Center, Gynecology and Obstetrics, Tel Hashomer, Israel OBJECTIVE: The aim of this study was to examine the safety of active management for delivery of second twins weighing >1500 g at birth and to determine the rate of cesarean section (CS) for second twins. STUDY DESIGN: Data was obtained for the intrapartum management and delivery outcome of all twin deliveries during the period 1997-2002. We excluded pregnancies with a nonvretex (NVX) first twin, elective CS, IUFD and birth weigh of < 1500 g. Our active management for delivery of the second twin included rupture of membranes and oxytocin infusion for engaged vertex (VX) or internal podalic version followed by total breech extraction for non-engaged VX. For NVX second twins we applied assisted breech delivery for engaged frank breech or total breech extraction for all others. We compared the following parameters in VX/VX and VX/ NVX pairs. The maternal and fetal parameters included parity, gestational age, birth weight, suspected discordancy (>15%) and suspected IUGR ( < 10th percentile). Clinical parameters that were compared included, use of epidural anesthesia, oxytocin augmentation, and non reassuring fetal monitoring during 2nd stage of labor. Delivery outcome was assessed by the mode of delivery of the second twin, Apgar score < 6 at 5 min and intrapartum death. RESULTS: Of the 1740 twin pregnancies delivered in our center during the study period 663 pairs matched the inclusion criteria’s (379 VX/VX and 284 VX/NVX). Maternal and fetal variables did not differ between the two groups. The difference in the rate of CS, for second twin, between VX/VX and the VX/ NVX groups did not reach statistical significance, (2.4% vs. 4.9% respectively). Fetal outcome was excellent, with no intrapartum deaths and only 2 second twins with an Apgar score < 6 at 5 min. CONCLUSION: Active management for delivery of a second twin weighing >1500 g at birth is safe and associated with a low rate of emergency CS.
520
FACTORS ASSOCIATED WITH A NON REASSURING FETAL HEART RATE IMMEDIATELY FOLLOWING EPIDURAL ANESTHESIA DORON KREISER1, ARIELLA JAKOBSON SETTON1, DANIEL SEIDMAN1, ABBA ETCHINE2, EYAL SCHIFF1, 1Sheba Medical Center, Gynecology and Obstetrics, Tel Hashomer, Israel 2Sheba Medical Center, Anastasia, Tel Hashomer, Israel OBJECTIVE: Non reassuring fetal heart rate (FHR) tracing is a frequent occurrence during the first 30 minutes after epidural anesthesia. The aim of this study was to examine the factors that influence the risk for non reassuring FHR immediately following epidural anesthesia. STUDY DESIGN: We prospectively studied 98 sequential term singleton deliveries where epidural anesthesia was performed. Fetal heart rate (FHR) tracing was evaluated for 20 min. before and 40 min. after initiating continuous epidural anesthesia. FHR tracing was interpreted as non reassuring when severe variable decelerations, prolonged deceleration or bradycardia occurred. We compared among delieveries with and without non reassuring FHR, the maternal and fetal parameters, including maternal age, gravidity, parity, gestational age and birth weight. Clinical parameters that were compared included cervical dilatation and fetal head station, time to delivery, maternal blood pressure, use of oxytocin during epidural, frequecy of uterine contractions and presence of meconium stained amniotic fluid. Delivery outcome was assessed by the mode of delivery and Apgar score < 7 at 5 min. RESULTS: There were 13 (13%) non reassuring FHR traces during the 20 minutes immediately following epidural anesthesia. Maternal and fetal parameters, as well as the mode of delivery, were similar in both groups. However, the number of uterine contractions during this period was significantly higher among women with non reassuring FHR traces, 3.5 +/ 1.1 vs. 2.6 +/ 1.6 contractions per 10 minutes (p < 0.04). Oxytocin administration and maternal hemodynamic changes could not account for these differences. CONCLUSION: Non reassuring FHR traces, commonly observed immediately after epidural anesthesia, could be attributed in part to an increase in the frequency of uterine contractions during that period.
522
EPIDURAL ANALGESIA, EPIDURAL FEVER AND PLACENTAL CYTOKINE PRODUCTION ISRAEL ZIGHELBOIM1, JOSE RIVERS2, MARY ANN MASTRANGELO3, DAVID J. TWEARDY3, LAURA GOETZL1, 1Baylor College of Medicine, Obstetrics&Gynecology, Houston, TX 2Baylor College of Medicine, Anesthesiology, Houston, TX 3Baylor College of Medicine, Medicine, Houston, TX OBJECTIVE: Epidural fever is associated with elevated maternal and fetal serum interleukin 6 (IL-6) levels; the placenta is a potential source of increased IL-6 production. STUDY DESIGN: We enrolled a prospective cohort of low risk afebrile ( < 99.58F) nulliparas with (n = 39) and without (n = 10) epidural analgesia. IL-6 levels were determined from maternal serum, placental tissue and cord blood collected at delivery. Kruskal-Wallis, Mann-Whitney U and Pearson correlation coefficients were used as appropriate. RESULTS: In women with epidural analgesia, placental IL-6 levels were significantly higher in the subset of women (26%) who developed intrapartum fever >100.48F (Figure 1, p = 0.01). However, in the absence of fever, epidural analgesia was not associated with higher placental IL-6 (p = 0.65). Further, placental cytokine IL-6 levels did not correlate with either maternal serum (r = 0.20, p = 021) nor cord blood IL-6 (r = 0.06, p = 0.74). CONCLUSION: Altough placental levels of IL-6 are elevated with epidural fever, placental cytokine production does not appear to be the primary etiology for maternal or fetal inflammatory activation.
Placental I6 Levels by Analgesia Choice and Presence of Intrapartum Fever (Overall Kruskal-Wallis, p = 0.04)
Volume 189, Number 6 Am J Obstet Gynecol 519
REVIEW OF FOUR HUNDRED WOMEN PRESENTING AFTER A THIRDDEGREE TEAR RHONA MAHONY1, MYRA FITZPATRICK1, CAITRIONA KIRWAN2, P. RONAN O’CONNELL2, COLM O’HERLIHY1, 1University College Dublin, Obstetrics and Gynaecology, Dublin 2 2University College Dublin, Surgery, Dublin 7, Ireland OBJECTIVE: Third-degree tears occur after approximately 3% of vaginal deliveries and represent the most important risk factor for the development of fecal incontinence in women. Up to 50% women who have sustained a thirddegree tear will experience alteration in fecal continence. The aim of this study was to review the outcome in 400 women after third-degree tear. STUDY DESIGN: This was a prospective review of 400 women who presented to a dedicated perineal clinic three months following primary repair of a recognized third-degree tear. Data recorded included age, parity, mode of delivery continence score, anal manometry pressures and the results of endoanal ultrasound examination. RESULTS: The median age was 31 (range 18-44) years and median parity was 1 (range 1-8). 290 (72%) women had a spontaneous vaginal delivery, 73 (18%) a forceps delivery and 38 (10%) a vacuum delivery. The median continence score was 2 (range 0-20); 56% of patients were symptomatic but only 7% of patients had contience scores >10. The median anal canal squeeze pressure was 65mmHg (range 18-164) and median resting pressure was 41mmHg (range 3-108). Five percent of patients had a normal endoanal ultrasound, while 93% had a defect of the external anal sphincter and 63% had a defect of the internal anal sphincter. There was a strong relationship between age and parity and the presence of incontinence symptoms. CONCLUSION: While the majority of women following third-degree tear were symptomatic, most had minor alteration in continence. The prsence of symptoms was influenced by age and parity.
521
ACTIVE MANAGEMENT FOR DELIVERY OF A SECOND TWIN WITH AN ESTIMATED BIRTH WEIGHT OF > 1500 G IS SAFE AND ASSOCIATED WITH A LOW RATE OF CESAREAN SECTION, EXPERIENCE FROM 663 DELIVERIES DORON KREISER1, MICHAL ZAJICEK1, YAEL BARKAI1, DANIEL SEIDMAN1, EYAL SIVAN1, EYAL SCHIFF1, 1Sheba Medical Center, Gynecology and Obstetrics, Tel Hashomer, Israel OBJECTIVE: The aim of this study was to examine the safety of active management for delivery of second twins weighing >1500 g at birth and to determine the rate of cesarean section (CS) for second twins. STUDY DESIGN: Data was obtained for the intrapartum management and delivery outcome of all twin deliveries during the period 1997-2002. We excluded pregnancies with a nonvretex (NVX) first twin, elective CS, IUFD and birth weigh of < 1500 g. Our active management for delivery of the second twin included rupture of membranes and oxytocin infusion for engaged vertex (VX) or internal podalic version followed by total breech extraction for non-engaged VX. For NVX second twins we applied assisted breech delivery for engaged frank breech or total breech extraction for all others. We compared the following parameters in VX/VX and VX/ NVX pairs. The maternal and fetal parameters included parity, gestational age, birth weight, suspected discordancy (>15%) and suspected IUGR ( < 10th percentile). Clinical parameters that were compared included, use of epidural anesthesia, oxytocin augmentation, and non reassuring fetal monitoring during 2nd stage of labor. Delivery outcome was assessed by the mode of delivery of the second twin, Apgar score < 6 at 5 min and intrapartum death. RESULTS: Of the 1740 twin pregnancies delivered in our center during the study period 663 pairs matched the inclusion criteria’s (379 VX/VX and 284 VX/NVX). Maternal and fetal variables did not differ between the two groups. The difference in the rate of CS, for second twin, between VX/VX and the VX/ NVX groups did not reach statistical significance, (2.4% vs. 4.9% respectively). Fetal outcome was excellent, with no intrapartum deaths and only 2 second twins with an Apgar score < 6 at 5 min. CONCLUSION: Active management for delivery of a second twin weighing >1500 g at birth is safe and associated with a low rate of emergency CS.
520
FACTORS ASSOCIATED WITH A NON REASSURING FETAL HEART RATE IMMEDIATELY FOLLOWING EPIDURAL ANESTHESIA DORON KREISER1, ARIELLA JAKOBSON SETTON1, DANIEL SEIDMAN1, ABBA ETCHINE2, EYAL SCHIFF1, 1Sheba Medical Center, Gynecology and Obstetrics, Tel Hashomer, Israel 2Sheba Medical Center, Anastasia, Tel Hashomer, Israel OBJECTIVE: Non reassuring fetal heart rate (FHR) tracing is a frequent occurrence during the first 30 minutes after epidural anesthesia. The aim of this study was to examine the factors that influence the risk for non reassuring FHR immediately following epidural anesthesia. STUDY DESIGN: We prospectively studied 98 sequential term singleton deliveries where epidural anesthesia was performed. Fetal heart rate (FHR) tracing was evaluated for 20 min. before and 40 min. after initiating continuous epidural anesthesia. FHR tracing was interpreted as non reassuring when severe variable decelerations, prolonged deceleration or bradycardia occurred. We compared among delieveries with and without non reassuring FHR, the maternal and fetal parameters, including maternal age, gravidity, parity, gestational age and birth weight. Clinical parameters that were compared included cervical dilatation and fetal head station, time to delivery, maternal blood pressure, use of oxytocin during epidural, frequecy of uterine contractions and presence of meconium stained amniotic fluid. Delivery outcome was assessed by the mode of delivery and Apgar score < 7 at 5 min. RESULTS: There were 13 (13%) non reassuring FHR traces during the 20 minutes immediately following epidural anesthesia. Maternal and fetal parameters, as well as the mode of delivery, were similar in both groups. However, the number of uterine contractions during this period was significantly higher among women with non reassuring FHR traces, 3.5 +/ 1.1 vs. 2.6 +/ 1.6 contractions per 10 minutes (p < 0.04). Oxytocin administration and maternal hemodynamic changes could not account for these differences. CONCLUSION: Non reassuring FHR traces, commonly observed immediately after epidural anesthesia, could be attributed in part to an increase in the frequency of uterine contractions during that period.
522
EPIDURAL ANALGESIA, EPIDURAL FEVER AND PLACENTAL CYTOKINE PRODUCTION ISRAEL ZIGHELBOIM1, JOSE RIVERS2, MARY ANN MASTRANGELO3, DAVID J. TWEARDY3, LAURA GOETZL1, 1Baylor College of Medicine, Obstetrics&Gynecology, Houston, TX 2Baylor College of Medicine, Anesthesiology, Houston, TX 3Baylor College of Medicine, Medicine, Houston, TX OBJECTIVE: Epidural fever is associated with elevated maternal and fetal serum interleukin 6 (IL-6) levels; the placenta is a potential source of increased IL-6 production. STUDY DESIGN: We enrolled a prospective cohort of low risk afebrile ( < 99.58F) nulliparas with (n = 39) and without (n = 10) epidural analgesia. IL-6 levels were determined from maternal serum, placental tissue and cord blood collected at delivery. Kruskal-Wallis, Mann-Whitney U and Pearson correlation coefficients were used as appropriate. RESULTS: In women with epidural analgesia, placental IL-6 levels were significantly higher in the subset of women (26%) who developed intrapartum fever >100.48F (Figure 1, p = 0.01). However, in the absence of fever, epidural analgesia was not associated with higher placental IL-6 (p = 0.65). Further, placental cytokine IL-6 levels did not correlate with either maternal serum (r = 0.20, p = 021) nor cord blood IL-6 (r = 0.06, p = 0.74). CONCLUSION: Altough placental levels of IL-6 are elevated with epidural fever, placental cytokine production does not appear to be the primary etiology for maternal or fetal inflammatory activation.
Placental I6 Levels by Analgesia Choice and Presence of Intrapartum Fever (Overall Kruskal-Wallis, p = 0.04)