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Future death and bowel complications in undelivered fetuses with gastroschisis by week of gestation
S144 SMFM Abstracts 495 FUTURE DEATH AND BOWEL COMPLICATIONS IN UNDELIVERED FETUSES WITH GASTROSCHISIS BY WEEK OF GESTATION DENA TOWNER1, 1University of California, Davis, Obstetrics & Gynecology, Sacramento, California OBJECTIVE: To determine the chance of future death and adverse bowel outcomes by gestational week in undelivered pregnancies with gastroschisis. STUDY DESIGN: Using linked data from maternal and infant hospital discharge records and from birth and death certificates from acute care civilian hospitals in California during the years 1992-1997, we identified infants that survived to gastroschisis repair. In the population of undelivered fetuses, the chance of future neonatal death, bowel atresia and need for major bowel surgery (resections and ostomies) were calculated at 24 weeks and weekly from 34 through 41 weeks. The statistic utilized was the chi square for linear trend. RESULTS: There were 577 infants at risk for atresia and major bowel surgery and 387 at risk for death as data on death was only available through 1995. There was a significant trend for decreased chance of future bowel atresia (p=0.002) and bowel surgery (p=0.023) with increasing gestational age but no trend found for death (Table1). CONCLUSION: Fetuses with bowel atresia and those with major bowel surgery tend to be delivered earlier in gestation, but there remains a constant risk for death in the undelivered population of fetuses with gastroschisis. Percent of undelivered infants with these future complications by completed gestational week Gestational week
Bowel atresia
Major bowel surgery
Death
24 34 35 36 37 38 39 40 41
7.8% 7.8% 7.2% 6.1% 5.4% 5.5% 3.4% 1.5% 0%
14.6% 13.8% 13.2% 12.5% 11.8% 11.9% 10.3% 9.2% 3.6%
6.7% 5.8% 5.1% 5.0% 5.7% 5.4% 4.4% 5.9% 10.0%
496 MODERATE OR THICK MECONIUM-STAINED AMNIOTIC FLUID IS ASSOCIATED WITH HIGHER RATES OF NEONATAL MORBIDITY SUSAN H. TRAN (F)1, J. T. PARER1, THOMAS J. MUSCI2, AARON B. CAUGHEY1, 1University of California, San Francisco, Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California, 2California Pacific Medical Center (CPMC), Obstetrics and Gynecology, San Francisco, California OBJECTIVE: The purpose of this study was to determine the relationship between moderate or thick meconium-stained amniotic fluid (MSAF) and short-term neonatal outcomes. STUDY DESIGN: We designed a retrospective cohort study of all deliveries beyond 37 weeks gestational age affected by MSAF from 1981 to 2001 at a single university hospital. Data was collected on quality of MSAF; umbilical arterial pH (ua pH) and base excess (ua BE); rates of neonatal sepsis, respiratory distress syndrome (RDS), pneumothorax, jaundice, and chorioamnionitis; and analyzed with bivariate and multivariate analyses. RESULTS: There were 27,437 women who met the inclusion criteria. The neonates with moderate/thick MSAF had higher rates of neonatal morbidity when compared to those with no meconium (Table). Moderate/thick MSAF was associated with chorioamnionitis in 10.24% of pregnancies, as compared to 4.26% of pregnancies with clear or thin MSAF (p!0.001). Controlling for ethnicity, maternal age, gestational age, birthweight, and parity, moderatethick MSAF was still associated with increased risks of the above neonatal outcomes. CONCLUSION: We found that moderate/thick MSAF is associated with adverse neonatal outcomes, even when controlling for potential confounding variables. Whether MSAF acts as an indicator for high risk pregnancies or there are interventions that may improve the outcomes in these patients requires further investigation.
ua pH ! 7.0 ua BE ! ÿ12 Sepsis RDS Pneumothorax
Moderate/thick MSAF
Clear amniotic fluid
p-value
1.09% 3.09% 0.62% 1.91% 0.60%
0.52% 1.66% 0.20% 0.73% 0.24%
p!0.001 p!0.001 p!0.001 p!0.001 p!0.001
497 LONG-TERM NEURODEVELOPMENTAL AND NEUROPSYCHOLOGICAL OUTCOMES AFTER TREATMENT FOR IMMUNE HYDROPS FETALIS BY INTRAVASCULAR TRANSFUSION (IVT) DENNIS HARPER1, HANES SWINGLE1, JOHN WIDNESS1, DANIEL BONTHIUS1, GLEN AYLWARD2, CARL P. WEINER3, 1University of Iowa, Pediatrics, Iowa City, Iowa, 2Southern Illinois University, Pediatrics, Springfield, Illinois, 3University of Maryland at Baltimore, Physiology and Obstetrics, Gynecology and Reproductive Sciences, Baltimore, Maryland OBJECTIVE: We tested the hypothesis that long-term neurodevelopmental / neuropsychological outcomes of IVT treated immune hydrops (IH) fetuses are similar to unaffected siblings using of a specific IVT protocol that addresses the underlying pathophysiology of IH. STUDY DESIGN: Eighteen consecutive IH fetuses were treated by one physician from July 1985 to October 1995; 16 (89%) survived. Because IH reflects cardiac dysfunction secondary to inadequate oxygen carrying capacity characterized by increased UV pressure (UVP), the IVT protocol utilized a 2step HCT deficit correction (final target HCT 50%) over a 2-4d interval combined with UVP measurement to avoid over transfusion and bicarbonate administration to assure a post transfusion UVpHO7.30. All survivors participated in the follow-up at a mean age of 10y. Unaffected older siblings served as controls. Physical and neurological exams and comprehensive neuropsychological evaluations were performed. The neuropsychological tests were a balance of tasks to identify general and subtle neurocognitive deficits. They included a comprehensive neuropsychological battery measuring verbal and nonverbal language, spatial tasks, multiple measures of memory, visual motor coordination and perception, and a computerized measure of attention. RESULTS: Two (12%) had major neurological sequelae associated with either procedural (post IVT bradycardia after umbilical artery transfusion) or neonatal (kernicterus) complications. Each occurred early in the learning curve. IH children had physical, neurological, and neuropsychological, including cognitive, outcomes statistically similar to their siblings, except for lower scores on a computerized measure of attention. Fourteen IH children had a normal head CT scan and two minor abnormalities (NS from unrelated controls). All 16 children had normal brain volumes. CONCLUSION: This, the most comprehensive and longest follow-up of IH, is good news for fetal medicine. IVT for IH is associated with a high likelihood of survival and favorable neurological and neuropsychological long-term outcomes.
498 DOES A MYELOMENINGOCELE SAC COMPARED TO NO SAC INCREASE MORBIDITY? ROBERT WILSON1, M. P. JOHNSON2, M. W. BEBBINGTON2, A. W. FLAKE2, H. L. HEDRICK2, L. N. SUTTON3, N. S. ADZICK2, 1University of Pennsylvania, Surgery/ OBGYN, Philadelphia, Pennsylvania, 2Children’s Hospital of Philadelphia, Surgery, Philadelphia, Pennsylvania, 3Children’s Hospital of Philadelphia, Neurosurgery, Philadelphia, Pennsylvania OBJECTIVE: A recent fetus with a large sac S1 myelomeningocele (MMC) but bilateral talipes prompted the question’ does the presence or size of a MMC sac affect postnatal leg function’? STUDY DESIGN: A MMC database with prenatal, birth and a minimum of one year follow-up evaluations was reviewed (IRB 2002-2354) . All fetuses had undergone in-utero MMC repair (prior to NICHD MOMS trial) at 20C0 to 25C6 weeks at a single institution . Fifty-four fetuses had prenatal evaluation with 48 children completing a birth and one year evaluation of leg neurofunction. Sac presence and volume were calculated from presurgical ultrasound imaging. Pearson statistical analysis was used to compare functional outcome differences between MMC sac and MMC no sac. RESULTS: A MMC sac was present in 38/54 (70%) of fetuses evaluated inutero and had been present in 35/48 (73%) of children evaluated at one year of age. Sac volume was !5cc, 5-10cc (5.3,6.9,7.0,7.4), and O10cc (10.6,11.1,11.3, 12.6,26.3,55.5) in 28, 4, and 6 fetuses respectively. Leg functional levels were 2 or more levels higher (worse) than the bony level when a sac was present in 23% and 17% compared to no sac in 0% and 0% at birth and one year evaluation respectively (p = 0.0951) . At one year, MMC sac fetuses had leg neurofunctional exams that were better (17%), equal to (66%) or worse (17%) than predicted by bony lesion levels while fetuses without sacs were better (30%) and equal to (70%) predicted level . Spinal level was a signficant factor for function but it was presence or absence of a MMC sac not the size that was the added factor to affect function. CONCLUSION: The presence of a MMC sac may cause spinal nerve damage at a higher level than the bony level due to traction on the cord or nerve roots . Sac size/volume or spinal level did not appear to contribute to this observation but this may be due to small patient population.
Bowel atresia
Major bowel surgery
Death
24 34 35 36 37 38 39 40 41
7.8% 7.8% 7.2% 6.1% 5.4% 5.5% 3.4% 1.5% 0%
14.6% 13.8% 13.2% 12.5% 11.8% 11.9% 10.3% 9.2% 3.6%
6.7% 5.8% 5.1% 5.0% 5.7% 5.4% 4.4% 5.9% 10.0%
496 MODERATE OR THICK MECONIUM-STAINED AMNIOTIC FLUID IS ASSOCIATED WITH HIGHER RATES OF NEONATAL MORBIDITY SUSAN H. TRAN (F)1, J. T. PARER1, THOMAS J. MUSCI2, AARON B. CAUGHEY1, 1University of California, San Francisco, Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California, 2California Pacific Medical Center (CPMC), Obstetrics and Gynecology, San Francisco, California OBJECTIVE: The purpose of this study was to determine the relationship between moderate or thick meconium-stained amniotic fluid (MSAF) and short-term neonatal outcomes. STUDY DESIGN: We designed a retrospective cohort study of all deliveries beyond 37 weeks gestational age affected by MSAF from 1981 to 2001 at a single university hospital. Data was collected on quality of MSAF; umbilical arterial pH (ua pH) and base excess (ua BE); rates of neonatal sepsis, respiratory distress syndrome (RDS), pneumothorax, jaundice, and chorioamnionitis; and analyzed with bivariate and multivariate analyses. RESULTS: There were 27,437 women who met the inclusion criteria. The neonates with moderate/thick MSAF had higher rates of neonatal morbidity when compared to those with no meconium (Table). Moderate/thick MSAF was associated with chorioamnionitis in 10.24% of pregnancies, as compared to 4.26% of pregnancies with clear or thin MSAF (p!0.001). Controlling for ethnicity, maternal age, gestational age, birthweight, and parity, moderatethick MSAF was still associated with increased risks of the above neonatal outcomes. CONCLUSION: We found that moderate/thick MSAF is associated with adverse neonatal outcomes, even when controlling for potential confounding variables. Whether MSAF acts as an indicator for high risk pregnancies or there are interventions that may improve the outcomes in these patients requires further investigation.
ua pH ! 7.0 ua BE ! ÿ12 Sepsis RDS Pneumothorax
Moderate/thick MSAF
Clear amniotic fluid
p-value
1.09% 3.09% 0.62% 1.91% 0.60%
0.52% 1.66% 0.20% 0.73% 0.24%
p!0.001 p!0.001 p!0.001 p!0.001 p!0.001
497 LONG-TERM NEURODEVELOPMENTAL AND NEUROPSYCHOLOGICAL OUTCOMES AFTER TREATMENT FOR IMMUNE HYDROPS FETALIS BY INTRAVASCULAR TRANSFUSION (IVT) DENNIS HARPER1, HANES SWINGLE1, JOHN WIDNESS1, DANIEL BONTHIUS1, GLEN AYLWARD2, CARL P. WEINER3, 1University of Iowa, Pediatrics, Iowa City, Iowa, 2Southern Illinois University, Pediatrics, Springfield, Illinois, 3University of Maryland at Baltimore, Physiology and Obstetrics, Gynecology and Reproductive Sciences, Baltimore, Maryland OBJECTIVE: We tested the hypothesis that long-term neurodevelopmental / neuropsychological outcomes of IVT treated immune hydrops (IH) fetuses are similar to unaffected siblings using of a specific IVT protocol that addresses the underlying pathophysiology of IH. STUDY DESIGN: Eighteen consecutive IH fetuses were treated by one physician from July 1985 to October 1995; 16 (89%) survived. Because IH reflects cardiac dysfunction secondary to inadequate oxygen carrying capacity characterized by increased UV pressure (UVP), the IVT protocol utilized a 2step HCT deficit correction (final target HCT 50%) over a 2-4d interval combined with UVP measurement to avoid over transfusion and bicarbonate administration to assure a post transfusion UVpHO7.30. All survivors participated in the follow-up at a mean age of 10y. Unaffected older siblings served as controls. Physical and neurological exams and comprehensive neuropsychological evaluations were performed. The neuropsychological tests were a balance of tasks to identify general and subtle neurocognitive deficits. They included a comprehensive neuropsychological battery measuring verbal and nonverbal language, spatial tasks, multiple measures of memory, visual motor coordination and perception, and a computerized measure of attention. RESULTS: Two (12%) had major neurological sequelae associated with either procedural (post IVT bradycardia after umbilical artery transfusion) or neonatal (kernicterus) complications. Each occurred early in the learning curve. IH children had physical, neurological, and neuropsychological, including cognitive, outcomes statistically similar to their siblings, except for lower scores on a computerized measure of attention. Fourteen IH children had a normal head CT scan and two minor abnormalities (NS from unrelated controls). All 16 children had normal brain volumes. CONCLUSION: This, the most comprehensive and longest follow-up of IH, is good news for fetal medicine. IVT for IH is associated with a high likelihood of survival and favorable neurological and neuropsychological long-term outcomes.
498 DOES A MYELOMENINGOCELE SAC COMPARED TO NO SAC INCREASE MORBIDITY? ROBERT WILSON1, M. P. JOHNSON2, M. W. BEBBINGTON2, A. W. FLAKE2, H. L. HEDRICK2, L. N. SUTTON3, N. S. ADZICK2, 1University of Pennsylvania, Surgery/ OBGYN, Philadelphia, Pennsylvania, 2Children’s Hospital of Philadelphia, Surgery, Philadelphia, Pennsylvania, 3Children’s Hospital of Philadelphia, Neurosurgery, Philadelphia, Pennsylvania OBJECTIVE: A recent fetus with a large sac S1 myelomeningocele (MMC) but bilateral talipes prompted the question’ does the presence or size of a MMC sac affect postnatal leg function’? STUDY DESIGN: A MMC database with prenatal, birth and a minimum of one year follow-up evaluations was reviewed (IRB 2002-2354) . All fetuses had undergone in-utero MMC repair (prior to NICHD MOMS trial) at 20C0 to 25C6 weeks at a single institution . Fifty-four fetuses had prenatal evaluation with 48 children completing a birth and one year evaluation of leg neurofunction. Sac presence and volume were calculated from presurgical ultrasound imaging. Pearson statistical analysis was used to compare functional outcome differences between MMC sac and MMC no sac. RESULTS: A MMC sac was present in 38/54 (70%) of fetuses evaluated inutero and had been present in 35/48 (73%) of children evaluated at one year of age. Sac volume was !5cc, 5-10cc (5.3,6.9,7.0,7.4), and O10cc (10.6,11.1,11.3, 12.6,26.3,55.5) in 28, 4, and 6 fetuses respectively. Leg functional levels were 2 or more levels higher (worse) than the bony level when a sac was present in 23% and 17% compared to no sac in 0% and 0% at birth and one year evaluation respectively (p = 0.0951) . At one year, MMC sac fetuses had leg neurofunctional exams that were better (17%), equal to (66%) or worse (17%) than predicted by bony lesion levels while fetuses without sacs were better (30%) and equal to (70%) predicted level . Spinal level was a signficant factor for function but it was presence or absence of a MMC sac not the size that was the added factor to affect function. CONCLUSION: The presence of a MMC sac may cause spinal nerve damage at a higher level than the bony level due to traction on the cord or nerve roots . Sac size/volume or spinal level did not appear to contribute to this observation but this may be due to small patient population.