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Institutional differences in twin placental pathologic assessment
S PO Abstracts
V o l u m e 1 7 6 , N u m b e r 1, Part 2 A m J O b s t e t Gynecol 451
PREGNANCY O U T C O M E F O L L O W I N G OOCYTE D O N A T I O N . /_. Hendler, x M. Dulitzky, ~ D. Soriano,~ D. Lev~an,~ ~ Dor,~ & Mashiach, ~ E. Schiff: Sheba Medical center, Tel-Aviv University, Israel. OBJECTIVE: To investigate the obstetrical and perinatal outconm of pregnancies following oocyte donation. STUDY DESIGN: Review of 74 pregnancies conceived following oocyte donation (OD) at one reproductive center, and who achieved 24 weeks of gestation or more. Delivery occurred between 1988 and 1996. All oocyte donors were ~<35 years old, and were under 1VF procedures. Furthermore, the outcome of 35 of the singleton pregnancies in the group, achieved in women aged 41 years or older was compared to the outconm of 95 other singleton pregnancies in women with advanced maternal age, delivered within the santo study period. RESULTS: Median maternal age was 40.0 years (range 24-52). Fifty-nine were singleton and 15 twins. Maternal complications included: hypertensive disorders 31.1%, vAth severe preeclampsia 8.1%, diabetes 16.2% (80.3% of whom gestational), placenta previa 2.7%, and placental abruption 0%. Premature labor prior to 34 wks occurred in five (8.4%) singleton and six (40%) twins. 79.7% delivered abdominally (45.8% by elective procedure). The majority of the scheduled cesareans were due to physician or patient distress, with no clear medical indication. O f the 20.3% vaginal deliveries, 13.5% required instrumental deliveries and only 6.8% delivered spontaneously. The rate of small-for-gestational age a m o n g the singleton neonates was 15.3%, and the perinatal mortality rate was 1.1% (one case of neonatal death of 30 wks newborn). The table presents the ontconm variables of pregnancies at advanced maternal age with and without OD.
Median age (y) Hypertensive disorders (%) Diabetes (%) Preterm delivery < 34 Wks (%) C / S (%) Mean birth weight (g) Small for age (%)
OD
CONTROL
46.5 25.7 22.9 11.4 80.0 2893 14.2
44.0 4.2* 13.7 2.1 31.0" 3294* 10.0
$133
458
O U T C O M E O F LIVEBORN M O N O A M N I O N I C , M O N O C H O R I O N I C TWINS. ]~M. Alexander, ~ L.C Gilstrap, S.M. Cox, f Dax, ~ Dept. Ob/Gyn, Unix:. T X Southwestern Medical Center, Dallas, T X OBJECTIVE: To examine the morbidity and inortality of liveborn sets of monoamnionic monochorionic twins as compared to a cohort of diananionic twins. STUDY DESIGN: A chart review of all twin deliveries between 1991 and 1994 was done revealing 680 pairs of twins in which the zygosity was known. 21 of these were inonoamnionic monochorionic with 19 identified at the time of birth and two diagnosed antenatally. Diagnosis was established by examination of the placenta at birth and by the pathologist. These 21 twins were compared to a cohort of 659 dianmionic twins. RESULTS: Maternal demographics, gestational age at birth (35.5 wks), birthweight (2200 gin), and route of delivery (C/S = 60%) were sinrilar between the two groups. Antepartmn complications were the same including incidence of diabetes, twin-twin transfusion syndrome and amniotic fluid disturbances. The incidence of P1H was greater in the monoamnionic group (48% vs 24%, p - .04) as was postpartum hemorrhage (19 vs. 6%; P - .03). There was no difference in cord pH, Apgar scores, or neonatal outcolne (RDS, NEC, 1VH, sepsis, hospital days). CONCLUSION: Liveborn monoamnionic twins have stinilar birthweight, gestational age at birth and neonatal outcomes to other twins. The incidence of PIH and PPH is higher in monoamnionic twins than in dianmionic twins.
454
I N S T I T U T I O N A L DIFFERENCES IN TWIN PLACENTAL P A T H O ASSESSMENT. T. Westover, 1L Peny, T. Dinh, R. Fischer, Dept OB/GYN, Cooper Hosp, UMDNJ/RWJ Med School, Camden, NJ. OBJECTIVE: Although standardized guidelines have been proposed for placental exantination, the ability" of individual hospitals and pathologists to accurately describe placental findings has not been described. The purpose of this study was to retrospectively review the variation in quality and accuracy of twin placental examination f n d i n g s in three hospital settings; tertia D, care hospital with dedicated placental pathologist (Hosp A), tertiary care hospital without dedicated placental pathologist (Hosp B), and comnmnity hospital (Hosp C). STUDY DESIGN: The placental exam reports from all twin placentas at three different institutions were reviewed (only monochorionic placentas were reviewed from the placental pathologist data base). The time fi'ame reviewed at each hospital was dependent on the availability of computerized records ranging fi-om two to six years. The actual reports were reviewed to determine the (1) n u m b e r of cord vessels in each cord, (2) type of cord insertion (velamentous, marginal, eccentric), (3) accuracy of amnionicity classification. Fisher's exact test was performed. RESULTS:
*p < 0.005 CONCLUSIONS: The overall perinatal outcome in pregnancies following oocyte donation is favorable, despite high rate of maternal complications. The extremely high rate of abdominal deliveries in this population is due to non-medical indications and might be preventable.
452
GLUCOSE CHARACTERISTICS O F PATIENTS W I T H LESSER DEGREES O F HYPERGLYCEMIA D U R I N G PREGNANCY. M. Berkus, O. Langer, T. Siler-Ktwdr,~ Dept. Ob/Gyn, UTHSC, San Antonio, TX. OBJECTIVE: It has been shown that gravidas having lesser degrees of hyperglycemia (non-GDM but GTT values greater than Coustan, Sacks or I-abnormal criteria) are associated with outcome comparable to standard (ACOG) GDM patients. However, the pathophysiology of these patients has not been examined. Therefore, we sought to determine the insulin resistance/secretion profiles of gravidas with lesser degrees of hyperglycemia. Ante
mrtum
Insulin
i',
+ --
Secretion
v s S~
+
, ~ '~ "~ 4"
Losser Degrees "1"
,~,, ', " . +
(Mien
9
Normafs
~b-
Insulin
Corv*
+05~ Cl)
Sensitivity
. __ - -
---
LOGIC
(Si)
[~o "~n'llmmell L)
METHODS: 36 patients with lesser degrees of hyperglycemia pm-ticipated in the study. Insulin sensitivity and secretion were examined using the insulin-modified, Minimal Model (20 sanrples per subject). They were compared to a control group of 20 gravidas normal by all criteria (GTT values below Coustan, Sacks and 1-abnormal) and to 50 patients with 2 or nmre GTT values abnormal (GDM). RESULTS: 62% of the lesser degree wmnen had both Si and insulin response below the normal curve (figure), i.e. values in the lower left corner of the graph. Additionally, there were no significant differences between study vs GDM gravidas in: (1) area under glucose cmwe - 6642 vs 7393 m g / d L * m i n , p - .09; (2) 1st phase insulin response - 2.2 vs 2.4 m U / mL*min, p = .38; (3) insulin sensitivity - 0.39 vs 0.46 10 4 rain ] / p m o l / L , p = .26. CONCLUSION: The decreased sensitivity and insulin secretion found in gravidas with lesser degrees of hyperglycemia is similar to standard GDM gravidas. These c o m m o n abnormalities form the core of their pathophysiology, and confirm the need to treat them as GDM.
Absent description of cord vessel # Absent description of insertion Inaccurate anmionicity
Hosp A
P value (A vs B)
Hosp B
P value (B vs C)
Hosp C
0/70
NS
1/43
.02
15/90
0/70
.02
4/43
NS
12/90
0/70
.02
4/43
NS
4/90
The misidemified placentas were characterized pathologically as monoamniotic due to disruption of the anmions when in fact both sonographic and delivep/room assessment had characterized them as diamniotic. C O N C L U S I O N : This study suggested that significant variation exists among pathologists regarding the quality and accuracy of their gross placental examinations of twin placenta. Adherence to the standardized guidelines will improve this performance.
V o l u m e 1 7 6 , N u m b e r 1, Part 2 A m J O b s t e t Gynecol 451
PREGNANCY O U T C O M E F O L L O W I N G OOCYTE D O N A T I O N . /_. Hendler, x M. Dulitzky, ~ D. Soriano,~ D. Lev~an,~ ~ Dor,~ & Mashiach, ~ E. Schiff: Sheba Medical center, Tel-Aviv University, Israel. OBJECTIVE: To investigate the obstetrical and perinatal outconm of pregnancies following oocyte donation. STUDY DESIGN: Review of 74 pregnancies conceived following oocyte donation (OD) at one reproductive center, and who achieved 24 weeks of gestation or more. Delivery occurred between 1988 and 1996. All oocyte donors were ~<35 years old, and were under 1VF procedures. Furthermore, the outcome of 35 of the singleton pregnancies in the group, achieved in women aged 41 years or older was compared to the outconm of 95 other singleton pregnancies in women with advanced maternal age, delivered within the santo study period. RESULTS: Median maternal age was 40.0 years (range 24-52). Fifty-nine were singleton and 15 twins. Maternal complications included: hypertensive disorders 31.1%, vAth severe preeclampsia 8.1%, diabetes 16.2% (80.3% of whom gestational), placenta previa 2.7%, and placental abruption 0%. Premature labor prior to 34 wks occurred in five (8.4%) singleton and six (40%) twins. 79.7% delivered abdominally (45.8% by elective procedure). The majority of the scheduled cesareans were due to physician or patient distress, with no clear medical indication. O f the 20.3% vaginal deliveries, 13.5% required instrumental deliveries and only 6.8% delivered spontaneously. The rate of small-for-gestational age a m o n g the singleton neonates was 15.3%, and the perinatal mortality rate was 1.1% (one case of neonatal death of 30 wks newborn). The table presents the ontconm variables of pregnancies at advanced maternal age with and without OD.
Median age (y) Hypertensive disorders (%) Diabetes (%) Preterm delivery < 34 Wks (%) C / S (%) Mean birth weight (g) Small for age (%)
OD
CONTROL
46.5 25.7 22.9 11.4 80.0 2893 14.2
44.0 4.2* 13.7 2.1 31.0" 3294* 10.0
$133
458
O U T C O M E O F LIVEBORN M O N O A M N I O N I C , M O N O C H O R I O N I C TWINS. ]~M. Alexander, ~ L.C Gilstrap, S.M. Cox, f Dax, ~ Dept. Ob/Gyn, Unix:. T X Southwestern Medical Center, Dallas, T X OBJECTIVE: To examine the morbidity and inortality of liveborn sets of monoamnionic monochorionic twins as compared to a cohort of diananionic twins. STUDY DESIGN: A chart review of all twin deliveries between 1991 and 1994 was done revealing 680 pairs of twins in which the zygosity was known. 21 of these were inonoamnionic monochorionic with 19 identified at the time of birth and two diagnosed antenatally. Diagnosis was established by examination of the placenta at birth and by the pathologist. These 21 twins were compared to a cohort of 659 dianmionic twins. RESULTS: Maternal demographics, gestational age at birth (35.5 wks), birthweight (2200 gin), and route of delivery (C/S = 60%) were sinrilar between the two groups. Antepartmn complications were the same including incidence of diabetes, twin-twin transfusion syndrome and amniotic fluid disturbances. The incidence of P1H was greater in the monoamnionic group (48% vs 24%, p - .04) as was postpartum hemorrhage (19 vs. 6%; P - .03). There was no difference in cord pH, Apgar scores, or neonatal outcolne (RDS, NEC, 1VH, sepsis, hospital days). CONCLUSION: Liveborn monoamnionic twins have stinilar birthweight, gestational age at birth and neonatal outcomes to other twins. The incidence of PIH and PPH is higher in monoamnionic twins than in dianmionic twins.
454
I N S T I T U T I O N A L DIFFERENCES IN TWIN PLACENTAL P A T H O ASSESSMENT. T. Westover, 1L Peny, T. Dinh, R. Fischer, Dept OB/GYN, Cooper Hosp, UMDNJ/RWJ Med School, Camden, NJ. OBJECTIVE: Although standardized guidelines have been proposed for placental exantination, the ability" of individual hospitals and pathologists to accurately describe placental findings has not been described. The purpose of this study was to retrospectively review the variation in quality and accuracy of twin placental examination f n d i n g s in three hospital settings; tertia D, care hospital with dedicated placental pathologist (Hosp A), tertiary care hospital without dedicated placental pathologist (Hosp B), and comnmnity hospital (Hosp C). STUDY DESIGN: The placental exam reports from all twin placentas at three different institutions were reviewed (only monochorionic placentas were reviewed from the placental pathologist data base). The time fi'ame reviewed at each hospital was dependent on the availability of computerized records ranging fi-om two to six years. The actual reports were reviewed to determine the (1) n u m b e r of cord vessels in each cord, (2) type of cord insertion (velamentous, marginal, eccentric), (3) accuracy of amnionicity classification. Fisher's exact test was performed. RESULTS:
*p < 0.005 CONCLUSIONS: The overall perinatal outcome in pregnancies following oocyte donation is favorable, despite high rate of maternal complications. The extremely high rate of abdominal deliveries in this population is due to non-medical indications and might be preventable.
452
GLUCOSE CHARACTERISTICS O F PATIENTS W I T H LESSER DEGREES O F HYPERGLYCEMIA D U R I N G PREGNANCY. M. Berkus, O. Langer, T. Siler-Ktwdr,~ Dept. Ob/Gyn, UTHSC, San Antonio, TX. OBJECTIVE: It has been shown that gravidas having lesser degrees of hyperglycemia (non-GDM but GTT values greater than Coustan, Sacks or I-abnormal criteria) are associated with outcome comparable to standard (ACOG) GDM patients. However, the pathophysiology of these patients has not been examined. Therefore, we sought to determine the insulin resistance/secretion profiles of gravidas with lesser degrees of hyperglycemia. Ante
mrtum
Insulin
i',
+ --
Secretion
v s S~
+
, ~ '~ "~ 4"
Losser Degrees "1"
,~,, ', " . +
(Mien
9
Normafs
~b-
Insulin
Corv*
+05~ Cl)
Sensitivity
. __ - -
---
LOGIC
(Si)
[~o "~n'llmmell L)
METHODS: 36 patients with lesser degrees of hyperglycemia pm-ticipated in the study. Insulin sensitivity and secretion were examined using the insulin-modified, Minimal Model (20 sanrples per subject). They were compared to a control group of 20 gravidas normal by all criteria (GTT values below Coustan, Sacks and 1-abnormal) and to 50 patients with 2 or nmre GTT values abnormal (GDM). RESULTS: 62% of the lesser degree wmnen had both Si and insulin response below the normal curve (figure), i.e. values in the lower left corner of the graph. Additionally, there were no significant differences between study vs GDM gravidas in: (1) area under glucose cmwe - 6642 vs 7393 m g / d L * m i n , p - .09; (2) 1st phase insulin response - 2.2 vs 2.4 m U / mL*min, p = .38; (3) insulin sensitivity - 0.39 vs 0.46 10 4 rain ] / p m o l / L , p = .26. CONCLUSION: The decreased sensitivity and insulin secretion found in gravidas with lesser degrees of hyperglycemia is similar to standard GDM gravidas. These c o m m o n abnormalities form the core of their pathophysiology, and confirm the need to treat them as GDM.
Absent description of cord vessel # Absent description of insertion Inaccurate anmionicity
Hosp A
P value (A vs B)
Hosp B
P value (B vs C)
Hosp C
0/70
NS
1/43
.02
15/90
0/70
.02
4/43
NS
12/90
0/70
.02
4/43
NS
4/90
The misidemified placentas were characterized pathologically as monoamniotic due to disruption of the anmions when in fact both sonographic and delivep/room assessment had characterized them as diamniotic. C O N C L U S I O N : This study suggested that significant variation exists among pathologists regarding the quality and accuracy of their gross placental examinations of twin placenta. Adherence to the standardized guidelines will improve this performance.