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Maturity cutoffs for lamellar body counts
SMFM Abstracts S83 271
IMPACT OF PRIOR PERITONEAL CLOSURE AT CESAREAN SECTION ON SIGNIFICANT ADHESION YOSHIKO KOMOTO1, TAKSHI SHIMIZU2, KOICHIRO SHIMOYA1, KENSHI WASADA1, HIROTSUGU FUKUDA1, ON FUKUI1, SHUSAKU HAYASHI1, HIROAKI TSUBOUCHI1, MITSUNORI SHIOJI1, NAO OKISHIRO-OURA1, YUJI MURATA1, 1Osaka University Graduate School of Medicine, Suita, Osaka, Japan, 2Shimizu Women’s Clinic, Takarazuka, Hyogo, Japan OBJECTIVE: The importance of peritoneal closure at cesarean section is still controversial. To evaluate the incidence of adhesion formation following cesarean section and the association between adhesion formation and peritoneal closure, we examined the relationship between adhesion form and peritoneal closure. STUDY DESIGN: First cesarean sections were randomly performed with or without peritoneal closure between January 1999 and December 2002. When next repeated cesarean sections were performed, we determined the adhesion formation in the peritoneal cavity. The association between previous peritoneal closure and levels of adhesion, operation time, and complications were examined. RESULTS: There is no significant difference between patient characteristics of peritoneal closure group (C-group: n = 27) and non-closure group (NC-group: n = 23), such as maternal age, gestational weeks, and neonatal body weight. There is no difference between the rates of complications of both groups, such as fever, anemia, endometritis, wound infection, urinary tract infection, pneumonia, and ileus. The total blood loss of C-group is not different from that of NCgroup. The incidence of adhesion of C-group (10/27) is significantly higher than that of NC-group (2/23) (P ! .05). The incidence of severe adhesion (adhesiolysis before delivery) of C-group (6/27) is also significantly higher than that of NC-group (0/23) (P = .05). The mean of interval time of skin incision to delivery (I-D time) of C-group is 11.1 minutes and that of NC-group is 7.6 minutes. There is a significant difference between the I-D time of both groups (P ! .001). The mean of total operation time of C-group (46.7 minutes) is significantly longer than that of NC-group (39.7 minutes) (P ! .05). CONCLUSION: The present study demonstrates that surgical peritoneal closure results more advanced adhesion formation. The practice of non-closure of peritoneum should be performed at cesarean section.
273
MATURITY CUTOFFS FOR LAMELLAR BODY COUNTS MARK NEERHOF1, ELAINE HANEY2, JAMES DOHNAL3, NICHOLAS HOBART1, 1Evanston Northwestern Healthcare, Obstetrics and Gynecology, Evanston, Illinois, 2Evanston Northwestern Healthcare, Evanston, Illinois, 3Evanston Northwestern Healthcare, Pathology, Evanston, Illinois OBJECTIVE: To evaluate potential cut-off values for fetal lung maturity for Lamellar body counts. STUDY DESIGN: Amniotic fluid analysis was performed on 222 samples obatined using Abbott’s CellDyne systems cell counters. Only those analyses performed within 72 hours of delivery were included. Lamellar Body Count was reported as a value with an interpretation of immature(*15,000), mature(*50,000), or transitional(>15,000 to !50,000). Infant charts were reviewed for neonatal outcomes, with RDS being diagnosed in infants with presence of (1) positive radiographic findings; (2) supplemental oxygen requirement of >24 hours; and (3) presence of physical signs of RDS (nasal flaring, grunting, retractions, or tachypnea). RESULTS: The average gestational age of the group was 35.6 G 2.2 weeks. A total of 13 infants of the 222 tested developed RDS. The average gestational age of this group was 33.9 G 2.5 weeks. Two of these infants had immature counts, 8 had transitional, and 3 had mature counts. 50 infants had counts in the transitional zone, and 8 of these infants developed RDS. Of the 8, 7 had additional testing for Lecithin/Syhphingomyelin ratio and were determined to be in the mature range, with L/S ratios of 3. All 7 infants were lacking Phosphatidyl Glycerol. Only 4 infants received surfactant, all had a diagnosis of RDS. A cutoff of 40 changed the interpretation for 19 infants. An additional 13 infants were affected by changing the cutoff to 30. CONCLUSION: (1) Lamellar body count remains an excellent test to determine fetal lung maturity. (2) 40,000 may be a better cut-off for maturity. More data are needed to confirm this. (3) A mature L/S ratio in the setting of a transitional LBC is associated with a substantial risk for RDS. Comparison of LBC cutoffs
True pos True neg False pos False neg PPV NPV Specificity Sensitivity
272
WHEN HAS AN INDUCTION FAILED?: A COHORT ANALYSIS CHARLA SIMON1, WILLIAM GROBMAN1, 1Northwestern University, Obstetrics and Gynecology, Chicago, Illinois OBJECTIVE: To evaluate the length of the latent phase that, during labor inductions in nulliparous women, is associated with significantly decreased chance of vaginal delivery and increased risk of maternal and neonatal morbidity. STUDY DESIGN: All inductions of labor during a six-month period were prospectively identified. Only those women who were nulliparous with a pregnancy of 36 weeks of gestation underwent further data analysis. Demographic data, intrapartum course, and maternal and neonatal outcomes were abstracted from the medical record. The latent phase was defined as beginning at amniotomy and continuing until either 4 cm cervical dilation and 80% effacement or 5 cm cervical dilation was achieved. RESULTS: 397 nulliparous women, 32% of whom had cervical ripening, presented during the study period. Only 8 women (2%) never achieved active labor prior to cesarean and the overall cesarean rate was 26.0%. A longer latent phase was associated with a greater rate of cesarean, although only after 18 hours did a majority of induced labors result in cesarean (Table). Chorioamnionitis and postpartum hemorrhage were more frequent with latent phases greater than 18 hours (16% and 26%, respectively), although these diagnoses did not translate into greater risk of transfusion, hysterectomy, or prolonged hospitalization. Adverse neonatal outcomes (meconium passage, fetal acidemia, NICU admission, mechanical ventilation, seizures) did not increase in conjunction with longer latent phases. CONCLUSION: A latent phase of up to 18 hours during nulliparous inductions allows the majority of women to achieve a vaginal delivery without a significantly increased risk of maternal or neonatal morbidity. Risk of cesarean stratified by length of latent labor Time (h)
N (%)
Cesarean delivery
0-3 3.1-6 6.1-9 9.1-12 12.1-15 15.1-18 18.1-21 21.1-24
63 111 106 49 35 14 13 6
10 15 35 15 10 5 9 4
(16%) (28%) (27%) (12%) (8%) (4%) (3%) (2%)
(16%) (14%) (33%) (31%) (29%) (36%) (69%) (67%)
274
50,000
40,000
30,000
9 164 45 4 16.6% 97.6% 78.5% 69.2%
8 182 27 5 22.9% 97.3% 87.1% 61.5%
5 192 17 8 22.7% 96.0% 91.9% 38.5%
CLINICAL AND SONOGRAPHIC ESTIMATION OF FETAL WEIGHT PERFORMED BY RESIDENTS DURING THE ACTIVE PHASE OF LABOR GEORGE NOUMI1, JORGE VENEGAS1, ALLAN BOMBARD1, ZEEV WEINER1, 1Lutheran Medical Center, Brooklyn, New York OBJECTIVE: To assess the accuracy of both clinical and sonographic estimation of fetal weight (EFW) performed by residents during the active phase of labor and to evaluate potential variables that may affect the accuracy of fetal weight estimation during labor. STUDY DESIGN: Between December 2003 and May 2004 we prospectively evaluated fetal weight assessments on all service patients who presented in the active phase of labor at term. The study protocol consisted of achieving clinical, followed by sonographic, estimation of fetal weight by the admitting resident during the active phase of labor. Clinical EFW was by Leopold maneuver and fundal height measurement. Sonographic EFW was performed by using the Hadlock reference tables assessing the BPD, AC, and FL. In addition, we examined the effect of the following variables on the accuracy of the EFW: maternal weight and basal metabolic index (BMI), parity, the Bishop score prior to FW estimation, gestational age, birth weight, and the post graduate year of the examiner. Correlation between the birth weight and the clinical and sonographic EFW was collected independently after the delivery. The statistical analysis used was Pearson correlation, Chi-square test, and student t-test. RESULTS: 192 patients participated in this study. The coefficient of correlation between the clinical and sonographic estimation of the FW and the birth weight were 0.59 (P ! .0001) and 0.65 (P ! .0001), respectively. Clinical estimation of FW was correct in 75% of the cases (within + 10%) and the sonographic estimation of fetal weight was correct in 79% of the cases (within + 10%). However, the sensitivity of predicting birth weight of 4 kg or more was only 46% with 94% specificity for both clinical and sonographic EFW. None of the clinical variables that were tested was significantly associated with the accuracy of the EFW. CONCLUSION: Although both clinical and sonographic EFW performed by residents during the active phase of labor correlate with the actual birth weight, the sensitivity in detecting macrosomic fetuses remains poor.
IMPACT OF PRIOR PERITONEAL CLOSURE AT CESAREAN SECTION ON SIGNIFICANT ADHESION YOSHIKO KOMOTO1, TAKSHI SHIMIZU2, KOICHIRO SHIMOYA1, KENSHI WASADA1, HIROTSUGU FUKUDA1, ON FUKUI1, SHUSAKU HAYASHI1, HIROAKI TSUBOUCHI1, MITSUNORI SHIOJI1, NAO OKISHIRO-OURA1, YUJI MURATA1, 1Osaka University Graduate School of Medicine, Suita, Osaka, Japan, 2Shimizu Women’s Clinic, Takarazuka, Hyogo, Japan OBJECTIVE: The importance of peritoneal closure at cesarean section is still controversial. To evaluate the incidence of adhesion formation following cesarean section and the association between adhesion formation and peritoneal closure, we examined the relationship between adhesion form and peritoneal closure. STUDY DESIGN: First cesarean sections were randomly performed with or without peritoneal closure between January 1999 and December 2002. When next repeated cesarean sections were performed, we determined the adhesion formation in the peritoneal cavity. The association between previous peritoneal closure and levels of adhesion, operation time, and complications were examined. RESULTS: There is no significant difference between patient characteristics of peritoneal closure group (C-group: n = 27) and non-closure group (NC-group: n = 23), such as maternal age, gestational weeks, and neonatal body weight. There is no difference between the rates of complications of both groups, such as fever, anemia, endometritis, wound infection, urinary tract infection, pneumonia, and ileus. The total blood loss of C-group is not different from that of NCgroup. The incidence of adhesion of C-group (10/27) is significantly higher than that of NC-group (2/23) (P ! .05). The incidence of severe adhesion (adhesiolysis before delivery) of C-group (6/27) is also significantly higher than that of NC-group (0/23) (P = .05). The mean of interval time of skin incision to delivery (I-D time) of C-group is 11.1 minutes and that of NC-group is 7.6 minutes. There is a significant difference between the I-D time of both groups (P ! .001). The mean of total operation time of C-group (46.7 minutes) is significantly longer than that of NC-group (39.7 minutes) (P ! .05). CONCLUSION: The present study demonstrates that surgical peritoneal closure results more advanced adhesion formation. The practice of non-closure of peritoneum should be performed at cesarean section.
273
MATURITY CUTOFFS FOR LAMELLAR BODY COUNTS MARK NEERHOF1, ELAINE HANEY2, JAMES DOHNAL3, NICHOLAS HOBART1, 1Evanston Northwestern Healthcare, Obstetrics and Gynecology, Evanston, Illinois, 2Evanston Northwestern Healthcare, Evanston, Illinois, 3Evanston Northwestern Healthcare, Pathology, Evanston, Illinois OBJECTIVE: To evaluate potential cut-off values for fetal lung maturity for Lamellar body counts. STUDY DESIGN: Amniotic fluid analysis was performed on 222 samples obatined using Abbott’s CellDyne systems cell counters. Only those analyses performed within 72 hours of delivery were included. Lamellar Body Count was reported as a value with an interpretation of immature(*15,000), mature(*50,000), or transitional(>15,000 to !50,000). Infant charts were reviewed for neonatal outcomes, with RDS being diagnosed in infants with presence of (1) positive radiographic findings; (2) supplemental oxygen requirement of >24 hours; and (3) presence of physical signs of RDS (nasal flaring, grunting, retractions, or tachypnea). RESULTS: The average gestational age of the group was 35.6 G 2.2 weeks. A total of 13 infants of the 222 tested developed RDS. The average gestational age of this group was 33.9 G 2.5 weeks. Two of these infants had immature counts, 8 had transitional, and 3 had mature counts. 50 infants had counts in the transitional zone, and 8 of these infants developed RDS. Of the 8, 7 had additional testing for Lecithin/Syhphingomyelin ratio and were determined to be in the mature range, with L/S ratios of 3. All 7 infants were lacking Phosphatidyl Glycerol. Only 4 infants received surfactant, all had a diagnosis of RDS. A cutoff of 40 changed the interpretation for 19 infants. An additional 13 infants were affected by changing the cutoff to 30. CONCLUSION: (1) Lamellar body count remains an excellent test to determine fetal lung maturity. (2) 40,000 may be a better cut-off for maturity. More data are needed to confirm this. (3) A mature L/S ratio in the setting of a transitional LBC is associated with a substantial risk for RDS. Comparison of LBC cutoffs
True pos True neg False pos False neg PPV NPV Specificity Sensitivity
272
WHEN HAS AN INDUCTION FAILED?: A COHORT ANALYSIS CHARLA SIMON1, WILLIAM GROBMAN1, 1Northwestern University, Obstetrics and Gynecology, Chicago, Illinois OBJECTIVE: To evaluate the length of the latent phase that, during labor inductions in nulliparous women, is associated with significantly decreased chance of vaginal delivery and increased risk of maternal and neonatal morbidity. STUDY DESIGN: All inductions of labor during a six-month period were prospectively identified. Only those women who were nulliparous with a pregnancy of 36 weeks of gestation underwent further data analysis. Demographic data, intrapartum course, and maternal and neonatal outcomes were abstracted from the medical record. The latent phase was defined as beginning at amniotomy and continuing until either 4 cm cervical dilation and 80% effacement or 5 cm cervical dilation was achieved. RESULTS: 397 nulliparous women, 32% of whom had cervical ripening, presented during the study period. Only 8 women (2%) never achieved active labor prior to cesarean and the overall cesarean rate was 26.0%. A longer latent phase was associated with a greater rate of cesarean, although only after 18 hours did a majority of induced labors result in cesarean (Table). Chorioamnionitis and postpartum hemorrhage were more frequent with latent phases greater than 18 hours (16% and 26%, respectively), although these diagnoses did not translate into greater risk of transfusion, hysterectomy, or prolonged hospitalization. Adverse neonatal outcomes (meconium passage, fetal acidemia, NICU admission, mechanical ventilation, seizures) did not increase in conjunction with longer latent phases. CONCLUSION: A latent phase of up to 18 hours during nulliparous inductions allows the majority of women to achieve a vaginal delivery without a significantly increased risk of maternal or neonatal morbidity. Risk of cesarean stratified by length of latent labor Time (h)
N (%)
Cesarean delivery
0-3 3.1-6 6.1-9 9.1-12 12.1-15 15.1-18 18.1-21 21.1-24
63 111 106 49 35 14 13 6
10 15 35 15 10 5 9 4
(16%) (28%) (27%) (12%) (8%) (4%) (3%) (2%)
(16%) (14%) (33%) (31%) (29%) (36%) (69%) (67%)
274
50,000
40,000
30,000
9 164 45 4 16.6% 97.6% 78.5% 69.2%
8 182 27 5 22.9% 97.3% 87.1% 61.5%
5 192 17 8 22.7% 96.0% 91.9% 38.5%
CLINICAL AND SONOGRAPHIC ESTIMATION OF FETAL WEIGHT PERFORMED BY RESIDENTS DURING THE ACTIVE PHASE OF LABOR GEORGE NOUMI1, JORGE VENEGAS1, ALLAN BOMBARD1, ZEEV WEINER1, 1Lutheran Medical Center, Brooklyn, New York OBJECTIVE: To assess the accuracy of both clinical and sonographic estimation of fetal weight (EFW) performed by residents during the active phase of labor and to evaluate potential variables that may affect the accuracy of fetal weight estimation during labor. STUDY DESIGN: Between December 2003 and May 2004 we prospectively evaluated fetal weight assessments on all service patients who presented in the active phase of labor at term. The study protocol consisted of achieving clinical, followed by sonographic, estimation of fetal weight by the admitting resident during the active phase of labor. Clinical EFW was by Leopold maneuver and fundal height measurement. Sonographic EFW was performed by using the Hadlock reference tables assessing the BPD, AC, and FL. In addition, we examined the effect of the following variables on the accuracy of the EFW: maternal weight and basal metabolic index (BMI), parity, the Bishop score prior to FW estimation, gestational age, birth weight, and the post graduate year of the examiner. Correlation between the birth weight and the clinical and sonographic EFW was collected independently after the delivery. The statistical analysis used was Pearson correlation, Chi-square test, and student t-test. RESULTS: 192 patients participated in this study. The coefficient of correlation between the clinical and sonographic estimation of the FW and the birth weight were 0.59 (P ! .0001) and 0.65 (P ! .0001), respectively. Clinical estimation of FW was correct in 75% of the cases (within + 10%) and the sonographic estimation of fetal weight was correct in 79% of the cases (within + 10%). However, the sensitivity of predicting birth weight of 4 kg or more was only 46% with 94% specificity for both clinical and sonographic EFW. None of the clinical variables that were tested was significantly associated with the accuracy of the EFW. CONCLUSION: Although both clinical and sonographic EFW performed by residents during the active phase of labor correlate with the actual birth weight, the sensitivity in detecting macrosomic fetuses remains poor.