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Hypogastric artery ligation is an effective and safe alternative to hysterectomy in patients with severe postpartum hemorrhage
SPO Abstracts 291
Volume 172, N u m b e r 1, Part 2 Am J Obstet Gynecol
101
HYPOGASTRICARTERYLIGATIONIS AN EFFECTIVEAND SAFEALTERNATIVETO HYSTERECTOMYIN PATIENTSWITH SEVEREPOSTPARTUMHEMORRHAGE. L. Montoomerv.~ M. BeUort/ M. Alien,' K. Moise, Jr. Department of Obstetrics and Gynecology,Baylor College of Medicine, Houston, Texas. OBJECTIVE: It has been suggestedthat hypogestric artery ligetien may not be a safe end effective nlternative to hysterectomy in the management of the postpartum patient with intractable hemorrhage. At our institution, hypogestric artery ligatien is used prier tn resorting to hysterectomy in patients in whom future fertility is desired, end who have obstetrical bomerrhage unresponsive to conservntive measures. We evaluated our data in order to more clearly define the role of hypogastric artery ligatinn in the management of obstetrical hemorrhage. STUDYDESIGN: Retrospectivechart review of 18 patients undergoinghypogastric artery ligetion for intractable obstetric hemorrhagebetween January 1, 1989 and June 30, 1994. Variables evaluated included: etielogy of hemorrhage, interventions attempted prior to hypogestric artery ligatien, operative time (minutes), peri- and post-operative complications, blood products used and estimated blood loss, and length of hospital stay. We also compared the outcomes of 3 patients in whom hypogestrin artery ligetion failed to control bleeding, and in whom hysterectomy was ultimately required, with those patients in whom hypogestric artery ligetien was successful. Analysis: Unpaired Student's t-test, Mann Whitney U test and Fisher's Exact test; significance p < 0.05 RESULTS: Hypogastric artery ligatine was effective in controlling bleeding in 15/18 (83%) patients. In 3/18 (16%) hysterectomy was required after hypogastric artery ligetion, and 2 of these patients had severe coagulepethy. Etiology of bleeding included: atony (n 10), placenta eccreta (n-3), extension of uterine incision (n-3), uterine rupture (n- 1), and retained products of conception (n-1). None of the patients who had hypogastric artery ligetien experienced serious postoperative complications. Operative time was significantly greater for patients who neededhysterectomy (157_.+32vs 228+17 minutes), as was the estimated blood loss (2611_+1467 vs 5100_+ 854 ml). Length of hospital stay did not differ (6 days). CONCLUSION: For postpartum patients with intractable bleeding who are bemodynomically stable, have no evidenceof coagelepatby,and who desire future fertility, hypogastric artery ligetion is a safe alternative to hysterectomy.
102 VELAMENTOUS INSERTION OF THE CORD IN
POLYHYDRAMNIOS-OLIGOHYDRAMNIOS TWINS. (3. Marl, x B. Uerpalrojkitx, A. Abuhamad, E. Martinezx, J. Copel. Yale University, New Haven, CT and Eastern Virginia Medical School, Norfolk, VA. OBJECTIVE: Velamentous insertion (VI) of the cord is characterized by umbilical vessels which radiate toward the placental sarface and are thus not protected by Wharton's jelly. Intrauterine growth restriction (IUGR) is a common association with VI of the cord probably as a result of chronic compression. Fetal hypertension is a physiologic adaptation to hypoxia, which may result from umbilical vessel compression. In twin gestations with placental vascular anastomosis, the presence of VI of the cord in one member of the twins may alter fetal hemodynamics in such a way to increase the incidence of twin-twin transfusion. Our hypothesis was that VI of the cord is more frequently seen in monochorionlc-diamnionie (MoDi) twins with polyhydramnios-oligohydramnios syndrome (POS) than in uncomplicated MoDi twins. STUDY DESIGN: Case control study of nineteen consecutive MoDi twin gestations with diagnosis of POS were compared to 23 consecutive uncomplicated MoDi twin gestations. All the placental pathologic reports were reviewed. RESULTS: There were 9/19 (47%) VI of the cord in the POS group and 2/23 (8.6%) in the other group (p<0.01) (odds ratio = 9.45). In the POS group VI of the cord in the smaller twin was found in 8/9 (89%) of the cases. CONCLUSION: 1) Velamentous insertion of the cord is frequently seen in POS; 2) VI of the cord may play an important role in the pathogenesis of this syndrome.
103 THE CLINICAL SIGNIFICANCE OF T H E FINDING OF STUCK TWIN. l.Chyu', P.Cherouny, Dept. Ob/Gyn, Penn State Univ.~ Hershey, PA OBJCETIVE: To study our population of stuck twins (ST) for 1)etiology, 2)outcome, and 3)prognostic indicators. STUDY DESIGN: We reviewed retrospec6vely the records of 1~; patients with pregnancies complicated by ST. RESULTS: The survival rate was 4796. 5096 of cases met antenatal criteria for twin tran fosion syndrome (YI'S) and 3196 of cases were associated with anomalies. Placental abnormalities were present in 94% of cases. Abnormal cord insertion was present in 7 cases and 6 of these were associated with nonsurvival. Among cases with no survivors the average gestational age (GA) when discordancy and fluid discrepancies were first noted was 21 and 24 weeks (wk) respectively and was 24 and 26 wk respectively among cases resulting in survivors. Survival in cases where ST developed early in the second trimester was 3196, was 5096 when ST developed from 24-29 wk, and was 8396 when diagnosed from 30-34 wk. Survival was 43% when ST appeared concurrently as an initial finding with growth and fluid abnormalities, but was fi7% in cases where ST developed after an initial finding of abnormal growth or fluid. Among nonsurvivors the average discordancy was 46% and was 3896 among survivors. CONCLUSIONS: ST is not pathognomonic for severe TYS. There is no single pathophysiologic process that leads to the finding of ST. Abnormal placenta is the most common etiologic factor associated with ST and abnormal cord insertion is the single most common finding assodated with nonsurvival. The mortality for pregnancies complicated hy ST in our series is less than that previously published. These pregnandes may be predicted to result in a poor vs a more favorable outcome based upon prognostic indicators such as GA at development of discordancy, fluid discrepancies and ST, GA at delivery, degree of discordancy, and time interval from the finding of fluid or growth discrepandes to the development of ST. Interventiorml procedures may then he reserved for those pregnancies predicted to result in an otherwise poor outcome.
104 THE I~FF~TS OF M A ~ A L
AGE GREATER THAN 35 ON PERINATAL OUTCOME IN TWIN O~ffrATIONS. D.~lwgrdJx, L.C. Carom, L.D. RmL Dept. Ob/Oyu, Cedm'~inai Mod Or, LA, CA. OBJECTIVE: Provlon. u ~ d ~ ovdun~g the effoc~ of ms.riM age on pregnancyoutcome have beea limited to singleton ipmatinns. The pmpons of this study was to ovMun~ the d f ~ of metamd sgn great~ than 35 on pednml outeame ia twin Smatinn.. STUDY DESIGN," In thb prospective study we compm'afpr,~suncy outcomn. in sil uullil~ron, womun with twin gestations beOveea the ages of 20-29 to those with maternal a g u g r a z e flum 35, who ~ i v c r c d after 24 w e d ~ geU.stion. All womea deliveredat Cedm's-SinsiMedlc~ Cunt~ from Iununty
1, 1985mDonemb~31, 1992. Dmawetc eampsr~lusingXZ mudysis. RESULTS: ~ w ~ a total of 143 twln l~azslon, with a men~md ang bctwum ~0-29 (mn.n age 26~2.7) und 49 wlth a mat~rnsiage ~ than 35 (mean q e 37+1.9). Thas~ were no significantdiffmznc~ h a w s e olderand
youagor women in g~tatioeal ago (35.7"4-4 vs 35.8+3.8) und bitch weight (2215sm.+_69Qva22761pm + ~ 5 ) a t d e l l v ~ y , TIm~we~nodsnlfmmt diffem~.4m in rates of very low bii~h ~ (14.3% ve 13.8%), low birth w~ight(~.3% vs 59.8%) and inure-urn'leo ~ r~dgtlon(46% va 39%). The d i . c e r d ~7 r - ' - (imes-p~ birth weigk > 20%) wns .ignlr~a~'y higher inthaadvunczdmstarn.ls~group (27.1% va 12.4%; p<0.05). T h e ~ v ~ no significant diffet,m e ~ in 1 sad 5 minute AtPgnr Scores. The p~dn~si mortality rato (10,2% vs 3.3%; p<0.Ol) was signiflcunGy hlgh~ in the sdvunced maternal ~ group. ~ wet'e no signifin.nt diffss'uncns in the numbe~ of congenital unomalins betwnsa the two groups. Thwe significantly more ~ section, in the advanced matet,unl age group 014% vs 61%;p<0.02). When specific indications for ea~u,nsn sectina were examiaed, woman ilrut~ than 35 had signif'w.,untlyIres n . n . n m metlon, for the indication of fetal distrm~ (9.~ 9~vs 27.6%) but significuntly more for labor sbaormsiitln. (26.2% vs 17.1%). CONCLUSIONS: The~ fiadingn ~ g p a t that womm old~ thaa 3~ with twin gestations are at inct'n.m~d ~ of having a pragnsa~ mmplkatcd by discorduncy, perinatsi death sad eemuean section whea competed to younger womee with twin gestation..
Volume 172, N u m b e r 1, Part 2 Am J Obstet Gynecol
101
HYPOGASTRICARTERYLIGATIONIS AN EFFECTIVEAND SAFEALTERNATIVETO HYSTERECTOMYIN PATIENTSWITH SEVEREPOSTPARTUMHEMORRHAGE. L. Montoomerv.~ M. BeUort/ M. Alien,' K. Moise, Jr. Department of Obstetrics and Gynecology,Baylor College of Medicine, Houston, Texas. OBJECTIVE: It has been suggestedthat hypogestric artery ligetien may not be a safe end effective nlternative to hysterectomy in the management of the postpartum patient with intractable hemorrhage. At our institution, hypogestric artery ligatien is used prier tn resorting to hysterectomy in patients in whom future fertility is desired, end who have obstetrical bomerrhage unresponsive to conservntive measures. We evaluated our data in order to more clearly define the role of hypogastric artery ligatinn in the management of obstetrical hemorrhage. STUDYDESIGN: Retrospectivechart review of 18 patients undergoinghypogastric artery ligetion for intractable obstetric hemorrhagebetween January 1, 1989 and June 30, 1994. Variables evaluated included: etielogy of hemorrhage, interventions attempted prior to hypogestric artery ligatien, operative time (minutes), peri- and post-operative complications, blood products used and estimated blood loss, and length of hospital stay. We also compared the outcomes of 3 patients in whom hypogestrin artery ligetion failed to control bleeding, and in whom hysterectomy was ultimately required, with those patients in whom hypogestric artery ligetien was successful. Analysis: Unpaired Student's t-test, Mann Whitney U test and Fisher's Exact test; significance p < 0.05 RESULTS: Hypogastric artery ligatine was effective in controlling bleeding in 15/18 (83%) patients. In 3/18 (16%) hysterectomy was required after hypogastric artery ligetion, and 2 of these patients had severe coagulepethy. Etiology of bleeding included: atony (n 10), placenta eccreta (n-3), extension of uterine incision (n-3), uterine rupture (n- 1), and retained products of conception (n-1). None of the patients who had hypogastric artery ligetien experienced serious postoperative complications. Operative time was significantly greater for patients who neededhysterectomy (157_.+32vs 228+17 minutes), as was the estimated blood loss (2611_+1467 vs 5100_+ 854 ml). Length of hospital stay did not differ (6 days). CONCLUSION: For postpartum patients with intractable bleeding who are bemodynomically stable, have no evidenceof coagelepatby,and who desire future fertility, hypogastric artery ligetion is a safe alternative to hysterectomy.
102 VELAMENTOUS INSERTION OF THE CORD IN
POLYHYDRAMNIOS-OLIGOHYDRAMNIOS TWINS. (3. Marl, x B. Uerpalrojkitx, A. Abuhamad, E. Martinezx, J. Copel. Yale University, New Haven, CT and Eastern Virginia Medical School, Norfolk, VA. OBJECTIVE: Velamentous insertion (VI) of the cord is characterized by umbilical vessels which radiate toward the placental sarface and are thus not protected by Wharton's jelly. Intrauterine growth restriction (IUGR) is a common association with VI of the cord probably as a result of chronic compression. Fetal hypertension is a physiologic adaptation to hypoxia, which may result from umbilical vessel compression. In twin gestations with placental vascular anastomosis, the presence of VI of the cord in one member of the twins may alter fetal hemodynamics in such a way to increase the incidence of twin-twin transfusion. Our hypothesis was that VI of the cord is more frequently seen in monochorionlc-diamnionie (MoDi) twins with polyhydramnios-oligohydramnios syndrome (POS) than in uncomplicated MoDi twins. STUDY DESIGN: Case control study of nineteen consecutive MoDi twin gestations with diagnosis of POS were compared to 23 consecutive uncomplicated MoDi twin gestations. All the placental pathologic reports were reviewed. RESULTS: There were 9/19 (47%) VI of the cord in the POS group and 2/23 (8.6%) in the other group (p<0.01) (odds ratio = 9.45). In the POS group VI of the cord in the smaller twin was found in 8/9 (89%) of the cases. CONCLUSION: 1) Velamentous insertion of the cord is frequently seen in POS; 2) VI of the cord may play an important role in the pathogenesis of this syndrome.
103 THE CLINICAL SIGNIFICANCE OF T H E FINDING OF STUCK TWIN. l.Chyu', P.Cherouny, Dept. Ob/Gyn, Penn State Univ.~ Hershey, PA OBJCETIVE: To study our population of stuck twins (ST) for 1)etiology, 2)outcome, and 3)prognostic indicators. STUDY DESIGN: We reviewed retrospec6vely the records of 1~; patients with pregnancies complicated by ST. RESULTS: The survival rate was 4796. 5096 of cases met antenatal criteria for twin tran fosion syndrome (YI'S) and 3196 of cases were associated with anomalies. Placental abnormalities were present in 94% of cases. Abnormal cord insertion was present in 7 cases and 6 of these were associated with nonsurvival. Among cases with no survivors the average gestational age (GA) when discordancy and fluid discrepancies were first noted was 21 and 24 weeks (wk) respectively and was 24 and 26 wk respectively among cases resulting in survivors. Survival in cases where ST developed early in the second trimester was 3196, was 5096 when ST developed from 24-29 wk, and was 8396 when diagnosed from 30-34 wk. Survival was 43% when ST appeared concurrently as an initial finding with growth and fluid abnormalities, but was fi7% in cases where ST developed after an initial finding of abnormal growth or fluid. Among nonsurvivors the average discordancy was 46% and was 3896 among survivors. CONCLUSIONS: ST is not pathognomonic for severe TYS. There is no single pathophysiologic process that leads to the finding of ST. Abnormal placenta is the most common etiologic factor associated with ST and abnormal cord insertion is the single most common finding assodated with nonsurvival. The mortality for pregnancies complicated hy ST in our series is less than that previously published. These pregnandes may be predicted to result in a poor vs a more favorable outcome based upon prognostic indicators such as GA at development of discordancy, fluid discrepancies and ST, GA at delivery, degree of discordancy, and time interval from the finding of fluid or growth discrepandes to the development of ST. Interventiorml procedures may then he reserved for those pregnancies predicted to result in an otherwise poor outcome.
104 THE I~FF~TS OF M A ~ A L
AGE GREATER THAN 35 ON PERINATAL OUTCOME IN TWIN O~ffrATIONS. D.~lwgrdJx, L.C. Carom, L.D. RmL Dept. Ob/Oyu, Cedm'~inai Mod Or, LA, CA. OBJECTIVE: Provlon. u ~ d ~ ovdun~g the effoc~ of ms.riM age on pregnancyoutcome have beea limited to singleton ipmatinns. The pmpons of this study was to ovMun~ the d f ~ of metamd sgn great~ than 35 on pednml outeame ia twin Smatinn.. STUDY DESIGN," In thb prospective study we compm'afpr,~suncy outcomn. in sil uullil~ron, womun with twin gestations beOveea the ages of 20-29 to those with maternal a g u g r a z e flum 35, who ~ i v c r c d after 24 w e d ~ geU.stion. All womea deliveredat Cedm's-SinsiMedlc~ Cunt~ from Iununty
1, 1985mDonemb~31, 1992. Dmawetc eampsr~lusingXZ mudysis. RESULTS: ~ w ~ a total of 143 twln l~azslon, with a men~md ang bctwum ~0-29 (mn.n age 26~2.7) und 49 wlth a mat~rnsiage ~ than 35 (mean q e 37+1.9). Thas~ were no significantdiffmznc~ h a w s e olderand
youagor women in g~tatioeal ago (35.7"4-4 vs 35.8+3.8) und bitch weight (2215sm.+_69Qva22761pm + ~ 5 ) a t d e l l v ~ y , TIm~we~nodsnlfmmt diffem~.4m in rates of very low bii~h ~ (14.3% ve 13.8%), low birth w~ight(~.3% vs 59.8%) and inure-urn'leo ~ r~dgtlon(46% va 39%). The d i . c e r d ~7 r - ' - (imes-p~ birth weigk > 20%) wns .ignlr~a~'y higher inthaadvunczdmstarn.ls~group (27.1% va 12.4%; p<0.05). T h e ~ v ~ no significant diffet,m e ~ in 1 sad 5 minute AtPgnr Scores. The p~dn~si mortality rato (10,2% vs 3.3%; p<0.Ol) was signiflcunGy hlgh~ in the sdvunced maternal ~ group. ~ wet'e no signifin.nt diffss'uncns in the numbe~ of congenital unomalins betwnsa the two groups. Thwe significantly more ~ section, in the advanced matet,unl age group 014% vs 61%;p<0.02). When specific indications for ea~u,nsn sectina were examiaed, woman ilrut~ than 35 had signif'w.,untlyIres n . n . n m metlon, for the indication of fetal distrm~ (9.~ 9~vs 27.6%) but significuntly more for labor sbaormsiitln. (26.2% vs 17.1%). CONCLUSIONS: The~ fiadingn ~ g p a t that womm old~ thaa 3~ with twin gestations are at inct'n.m~d ~ of having a pragnsa~ mmplkatcd by discorduncy, perinatsi death sad eemuean section whea competed to younger womee with twin gestation..