- Email: [email protected]
Oral concurrent session F
ORAL CONCURRENT SESSION F Clinical Obstetrics Medical Complications of Pregnancy Saturday, February 7, 1998 8:00 am - 10:30 am
Moderators:
Valerie M. Parisi, MD, MPH Thomas J. Benedetti, MD
Judges:
Haywood L. Brown, MD Mark A. Morgan, MD Washington C. Hill, MD
Fontainebleau Ballroom C/D Abstract Numbers 67-76
$30 SPO Abstracts
January 1998 Am J Obstet Gynecol
67 PRELABOR RUPTURE OF THE MEMBRANES (PROM) AT TERM: EX-
69 MEMBRANE STRIPPING VS DINOPROSTONE VAGINAL INSERT IN
PECTANT MANAGEMENT AT HOME VS. IN HOSPITAL. Robert D i Cecco. -~Ma,'3' Hannah, Ellen Hodnetf, x Gary Foswr, ~Dan Farine, Michael Helen'a, Dept's of Ob/Gyn and Maternal infant and Reproductive HRU, CRWH. University of Toronto and Universffy of Manitoba, Canada. OBJECTIVES: We wished to assess whether women with PROM at term eared for partialIy or completely at home were at any increased risk of adverse maternal or neonatal outcomes. STUDY' DESIGN: Data obtained from women enrolled in the TermPROM Study randomized tc expectant care either in hospital or partially or completely at home were analyzed using univariate and multivariate analyses. Maternal outcomes assessed included: rate of clinical chorioamnionitis, induction of labor, use of maternal antibiotics, cesarean section, operative vaginal delivery, use of epidural anaesthetic, post-partum fever, and maternal satisfaction. Neonatal outcomes assessed included rates of neonatal infection (definite or probable), use of neonatal antibiotics, and NICU stay greater than 24 hours, RESULTS: Of 1670 women with PROM at term randomized to expectant care, 1017 women were eared for in hospital and 653 women were eared for pardally or completely at home. Women with PROM cared for at home were found on multivariate analysis to be at increased risk of cesarean section, use of intrapartum antibiotics, and neonatal infection [OR(95% CI): /.44 (1.04, 2.00), 1.63 (1.28, 2.10), 1.97 (1.00, 3.90), respectively]. A trend towards an increased risk of chorioarnnionltis, NICU stay greater than 24 hours, and use of neotratal antibintlcs was also observed. Care of women with PROM at home was not significantly associated with an increased rate of induction, use of epidural anaesthetic, or post-parturn fever. Women were more likely to be satisfied with their care if they had received their care partially or completely at home. CONCLUSIONS: Women with PROM at term eared for partially or completely at home may be at increased risk of some adverse maternal and neonatal outcomes including cesarean section, use of neonatal antibiotics, and increased NICU stay, hut may be more satisfied with their care.
THE MANAGEMENT OF PREGNANCIES BEYOND 41 WEEKS W I T H AN UNFAVORABLE CERVIX. E F Ma~ann~ n SP Chauhao, t, M F McNamara, c JD Bass, "~a CM Estes, ~c J C Morrison. a Dept. of Ob-Gyn, Univ. of Mississ[ppi, Jackson, MS,a Dept. ObO-yn. Medical College of Georgia, Augusta, GA.b Dept. of Ob-Gyn, NavaI Medlcal Center, San Diego, CA. ~ OBJECTIVE: To determine the best method of cervical ripening to prevent postdates inductions in women with an unfavorable cervix at 41 weeks' gestation. STUDY DESIGN: Women presenting to the antenatal testing unit at 41 weeks' gestation with a Bishop score <:4 and no contraindieation to cervical ripening were invited to participate in this study. They received daily dinoprostone (Cervldii| vaginal inserts or daily membrane stripping until spontaneous labor, rupture of membranes or a favorable cervix for induction occurred. All other patients who achieved 42 weeks of pregnancy were admitted to the hospital for induction. RESULTS: Onehundred and eighty-two women were entered into this prospecdve study with 91 women randomized in each artn. No significant differences were observed in the gestational age at the beginning of the study (P = 0.681 ) or at admission for delivery (P = 0.273). Bishop scores at the start of the study were similar (P = 0.245) although significantly greater in membrane stripping group on admission for delivery (P < 0.001). A greater number of women were admitted in labor (63191 or 69%) in the membrane stripping group versus the dinoprostone group (44/91 or 48%) (P = 0.006) resulting in less time elapsed from admission to delivery (P = 0.018) and fewer women with membrane stripping had an induction at 42 weeks (4/91 or 4%) versus tbe dlnoprostone group ( 13/91 or 14%) (P = 0.04). The mode of delivery (P = 0.362), birth weights (P = 0.268), cord blood gases < 7.1 (P = 0,18), and neonatal intensive care unit admission (P = 0.097) were similar between groups. The total cost of the cervical ripening agent and antenatal testing for the membrane stripping group was $15,i20 versus $59,540 for the dinoprostone group. CONCLUSIONS: Daily membrane stripping was more effective than dinoprostone administration in women with an unfavorable cervix as fewer inductions for postdates were required. The induction rate at 42 weeks in both groups (4 and 14%, respectively) in these actively managed patients is much lower than the 63% observed in an untreated group of similur women. Daily membrane stripping appears to be superior to dinoprnstone in ripening Ihe unripe the cervix and tit onefourth the cost.
68 CERVICAL RIPENING AND LABOR INDUCTION: MISOPROSTOL VS. DINOPROSTONE. A Cklrk, V Cook, P f'lill, "~J Spimuzto. Dept. of OB/GYN, University of Louisville, Louisville KY. OBJECTIVE: To compare the safety and efficacy of a 25 ml.tintravaginal application of misoprostol (EI) to intracervicaI dinoprostone (E2) gel for cervical ripening and induction of labor in patients with a Bishop Score (BS) a 5. STUDY DE.SIGN: 138 patients with a BS ~ 5 were randomized to receive either an intravaginal El tablet or imracervical E2 gel for cervical ripening. Inclusion criteria included 1) obstetric or medical indication for induction, 2) singleton pregnancy, 3) vertex presentation, and 4) reassuring fetal status. Exclusion criteria ineluded i) abnormal fetal heart rate pattern, 2) placenta previa, 3) active herpes infection, 4) history of asthma, glaucoma, cardiac or hepatic disease, 5) chorioamnionitis, 6) previous uterine scar and 7) parity > 5. Patients randomized to El received a 25 mbt tablet placed in the posterior fornix every four hours until an adequate contraction pattern was achieved or active labor ensued. A nraximum of four doses was allowed. Patients receiving E2 gel were given .5 mg of intracervical gel every four hours until an adequate contraction pattern was achieved or the BS was >5. A maximum four doses of E2 was allowed. Oxytocin augmentation was initiated if the maximum number of doses of ripening agent had been adninistered abd did not result in an adequate contraction pattern, active labor or if protracted labor ensued. Cominuous fetal heart rule and uterine contn~ction monitoring were perfomled in all patients. RESULTS: 72 patients were randomized to El and 66 to E2 gel. Demographic characteristics and BS upon admission did not differ between the two groups. All 66 patients (100%) randomized to E2 required pitocin atlgmentation. Only 44 of 72 patients (66%) receiving El required pitoein augmentation (p<0.05). The induction to delivery time was significantly longer in the E2 group, 1403 + 566 minutes vs l 1gl + 566 minutes in the EI group (p = 0.02). Patients in the El group were two tim~ more Iikely to require cesarean delivery (RR = 2.08, CI 1.09-3.98, p = 0.02), with a cesarean delivery rate of 15% and 31% in the E i and E2 groups respectively. Neonatal outcomes did not differ between the two groups. The rates of hyperstlmulation syndrome were not different between the two groups, 21% vs 18% (p > 0.05), in the E2 and El groups respectively. CONCLUSION: Intravaginal El is a safe and efficacious replacement for E2 for labor induction in patients with a BS < 5.
70 RANDOMIZED, DOUBLE-BLINDED T R I A L OF OXYTOCIN USE FOR INDUCTION OF LABOR, D..,..Me,r 3 J ~ E Zlamik. Department of Obstetrics and Gynecology, University of Iowa, Iowa City, [A. OBJECTIVE: We tested the hypothesis that high dose oxytocin use will result in shorter labors and reduced cesarean see.don rates. STUDY DESIGN: A total of 813 patients at >_24 weeks gestation undergoing induction of labor between 3/94 and 3/97 were enrolled. Patients were randomly assigned by random numbers table to receive oxytocin by either a low dose (1.5 mUhnin initial; increase by 1.5 mU/min q. 30 rain) or high dose (4.5 mUhnin initial; increase by 4.5 mU/min q. 30 min) protocol (low dose: n = 404, high dose: n = 392). Oxytocin solutions were prepared by a central pharmacy with either 5 or 15 units/500 ml. Infusion volumes (ml/hr) were identical, thus ensuring double blinding. Continuous variables were compared by one-way analysis of variance, and categoric variables were compared by Z2 analysis and Fisber's exact test when appropriate. RESULTS: Maternal demographics (gestational age, % nuniparity, indication for induction, epldural use, cervical dilation, Bishop's score, % receiving cervical ripening) Were not significantly different between groups. High dose oxytocln was associated with u significant reduction in oxytucin .-...*completedilatation (9,7 :t: 0.3 vs. 7.8 + 0,2 hours, p < .0001) and oxytocin -->delivery times (I1.0 + 0.3 vs. 8.8 • hours, p < .0001). Cesarean section rates also tended to be lower in the high dose group (16.1% vs. 11.7%, p = .095). No differences in neonatal outcomes (Apgar scores, cord gases, neonatal hospital days) were noted between groups. Farther; cesarean delivery for fetal distress was not increased with high dose oxytocin (low: 6.1%, high: 4.4%). CONCLUSIONS: When used in n blinded fashion, high dose oxytocin is associated with significantly shorter labors and a tendency for less need for cesarean delivery without any den~onstrahle adverse fetal/neonatM effects.
SPO Abstracts $3"1
Volume 178, N u m b e r 1, Part 2 A m J Obstet Gynecol 71 A RANDOMIZED CLINICAL TRIAL OF TWO SURGICAL TECHNIQUES F O R CESAREAN SECTION. M Franchi. .~ F Ghezzi, r D Bolestreri, x M Miglierina, .r F Zannboni, "~N Donadello,~ P F Bolis. x Dept Ob/Gyn, University of Varese, Varese, italy. OBJ-ECTIVE: The Joel-Cohen (JC) technique of opening the abdomen followed by non closure of pelvic/parietal peritoneum at cesarean section has been advocated as an alternative method to the Pfannestiel (Pfl] incision with peritonealizatlon (World J Surg 1994:18;292). A randomized trial was designed to compare intra- and post-operatlve morbidity between the two techniques. STUDY DESIGN: Wnmen to undergo a cesarean section were randomly allocated to have either the JC technique and the parietal and pelvic peritoneum left open or to have the Pfl incision and both peritoneal layers sutured. Exclusion criteria were: 2 previous CS, a previous htparotomy with an abdominal longitudinal incision or a gestational age < 30 weeks. All patients received prophylactic antibiotics. The myometrium was sutured with polyglactin 0 using a continuous single-layer nonlocking technique. Patients in the Pfl group had peritoneum sutured with polyglactin 00, The fascia was sutured with continuous pelygactin 1 in all cases. Postoperative infectious morbidity was defined as operative site infections, clussifled for abdominal wmmd infections with a six grade score (Go..s). Opening time was defined as the period comprise between skin incision and the opening of the uterine cavity. Febrile morbidity was defined as a temperature > 38* C on two occasion 4 hours apart. Puerperal endometrttls was defined as postpartum temperature >38* C on two occasions 4 hours apart excluding the day of delivery, with uterine tenderness andlor foul smelling Ioehla. Non parametric tests were used for statistics. RE,SULTS: 149 and 150 patients were allocated to theJC and to Ihe Pfl groop, respectively. The indications for the CS were similar in both groups except for a higher rate of placenta previn in the Pfl group (8/I50 vs, 1/149, p=0.04). A shorter median opening time [.4 rain (2-21) vs. 6 rain (2-19), respectively, p<0.01] and a shorter median operative time 1"30min (range 10-65) vs. 40 rain (range 20- 110), respectively, p<0.01] were observed in the JC than in the Pfl group. No diffareoce was found in term of inedlaa intraoperative blood loss, proportion of patients who required transfusion (21149 vs. 0/150), bladder injuries, wound dehiscence, endometritis, sepsis; febrile morbidity nnd urinary tract infections. Patients operated with the JC technique had a shorter median dur~Llionof hospitalization than those in the Pfl group [5 days (2-11) vs. 6 (2-32), respectively, p=0.052]. A higher rate of wound infection GI was found in the Pfl than in the JC group [14/150 (9.3%) vs 2/149(1.3%)], respectively, p<0.01 ]. CONCLUSIONS: The JC incision without peritoncalization resulted in a shorter opening time and total operative time than the Pfl incision with peritonezlization. This was acoomplised without an increase in the frequency of intra- and postoperative complications. Cosmetic issues, the reqttirement for rapid delivery nnd the potential complications need to be bahmced when choosiltg the JC incision or cesarean section.
73 TIMING OF DELIVERY AND NEONATAL OUTCOME IN PATIENTS WITH CLINICALLY OVERT UTERINE RUPTURE DURING VBAC, TF Porten SL Clark, MS Esplin, .T C Tooke-Mille~; x JR Scott. x Dept. Ob/Oyn, Univ. of Utah, SLC, Ut. OBJECTIVE: To examine neonatal outcome associated with utedne rupture during VBAC. STUDY DESIGN: All cases of uterine rapture occurring during VBAC between 1990 and 1996 were identified from the records of 6 large hospitals in a single metropolitan region, all of which had 24 hour in-house anesthesia services. Clinically overt rapture was defined as rupture resulting in a fetal heart rate pattern leading to emergency delivery. Medical records were abstracted of 66 variables including neonatal outcome, Fetal heart tracings were evaluated for the presence and time of onset of mild and severe variable decelerations, and persistent bradycardia in ~elation to the time of delivery, Adverse neonatal outcome was defined as death or neurologic sequelae at follow-up. The student t test was used where appropriate. RESULTS: 26 patients were attempting VBAC at the time of rupture. 23 had I prior cesarean and 3 had 2 prior cesareans. 8 (31%) [tad prior successful VBAC deliveries. 6 (23%) infants suffered either neonatal death or adverse neurologic sequelae as a result of the rapture. The mean (:t:SD) time from decision to deliver to delivery for patients with an adverse neonatal outcome was 19 (:t:12) minutes compared to 41 (• minutes for patients with good neonatal outcomes (P=0.20). For those palienls whose rapture was manifest by sustained bradycnrdia, the mean (+SD) time from onset to delivery was 16.7 (+7.4) minutes for those patients with poor neomttsl outcome and I8.6 (• minutes for those without adverse neonatal outcome (P---0.72).Poor neonatal outcome was seen in 31% of the htfants delivered within 30 minutes of either severe variables or bradycardia and in 33% of the Infants delivered within 20 mlmnes. CONCLUSIONS: I) A prior VBAC does not protect against uterine rttpture during VBAC. 2) Felal damage or death may occur even in hospitals with 24 hour in house anesthesia services, 3) Fuctors other than time to delivery are important in determining neonatal outcome after uterine rupture. 4) Neonatal death or damage is seen in a high percentage of patients with uterine rapture during VBAC despite delivery within the 30 minute ACOG guidelines for emergency intervention.
72 IS VBAC LESS EXPENSIVE THAN REPEAT CESAREAN? ~lark SL. McClellan V, Scott JR, Burton DA, Porter TE Intcrmountaltl Health Care and University of Utah, Salt Lake City. OBJECTIVE: To compare financial implications of trial of labor(TOL) with those of repeat cesarean when total maternal and child costs (not charges), are considered. STUDY DESIGN: For maternal and short-term neonatal care, system-specific DRG related costs in all branches of a CPT based clinical outcome algorithm for TOL after 1 or 2 cesareans were compared with those of repeat cesarean without TOL. Data included all births during 1996 in a regional health care system with an annual delivery volume of 26,000. For Iong term neonatal care, best and worst case cost estimates were calculated based upon previously established data. RESULTS: Depending upon which available estimates are accepted regarding long term neonatal outcome of infants with catastrophic uterine rupture, net financial loss/savings per VBAC attempt compared to elective repeat cesarean varies from +$320(best case assumptions) to -$11,950 (worst case assumptions.) For women with 2 prior cesareans, net loss per VBAC attempt using best case assumptions is -$312. COMMENT: Conclusions regarding potential financial savings of VBAC vs. repeat cesarean based upon general eharg_es for vaginal birth vs. cesarean section are flawed. When total medical ~ arc calculated, including increased morbidity for failed VBAC attempts and medical care of infants following catastrophic uterine rupture, there are, at best, lintited financial advantages to VBAC, and at worst, major financial disadvantages. In hospitals without it NICU, in-house anesthesia and obstetric services, and capable of rmttinely performing emergency cesarean section in <20 minutes, VBAC attempt appears to result in a financial loss using any assumptions. The same applies to TOL after two cesareans. Considerations other than financial should guide policy and decisions regarding VBAC.
74 300 TERM BRAIN DAMAGED INFANTS: TtlEIR FHR PATTERNS. JP MO Ahn. Department of Obstetrics and Gynecology, Pomona Valley Hospital Medical Center, Pomona, California and Cha Women's Hospital, Seoul, Korea, and the Childbirth Injury Prevention Foundation, Pasadena, California. OBJECTIVE: To describe the fetal heart rate (FHR) patterns of 300 term brain damaged infants. STUDY DESIGN: The fetal monitor strips of 300 singleton term neurologically impaired neonates were retrospectively analyzed. RESULTS: Of the 300 infants, the admission fetal heart rate (FHR) patterns were reactive152 (51%), nonreactive 135 (45%), bradycardia 9 (3%) or unclassifiable 4 (1%). In the reactive group, the FHR did the following: (1) remained reactive throughout labor [24 (16%)]; (2) developed an elevated baseline FHR ill association with repetitive PHR decelerations and generally a loss of variability [67 (22%)]; or (3) a sudden prolonged F'HR deceleration that lasted until delivery [61 (20%)]. The nonreactive admission group exhibited the following: (1) a pe~istent fixed baseline rate from admission (149 • 16 bpm) until the end of the strip (151 +166 bpm) [97 (72%)]; (2) a prolonged FHR deceleration that lasted until delivery 1.12 (9%)]; or (3) a stair steps to death pattern [26 (19%)]. CONCLUSIONS: While tem~ infants later found to be neurologically impaired do not manifest a uniform FHR pattern, these fetuses do manifest distiact FHR pattenxs intrapartum that can be easily categorized and identified on the basis of the fetal admission lest and subsequent changes in baseline rate. This distinction should prove helpful in the management of obstetrical patients in labor, Phelan.
$32 SPO Abstracts
January 1998 A m J Obstet GynecoI
75 T H E E F F E C T OF S E C O N D VAGINAL D E L I V E R Y O N A N O R E C T A L P H Y S I O L O G Y AND F E C A L CONTINENCE. M.Fynes. V. Donnelly, M.Behan, C. O'Herlihy, PR. O'Connell. Departments of Obstetrics, Gynaecology, Surgery and Radiology, University College Dublin, Ireland. O B J E C T I V E : To determine the effect of second vaginal delivery on anorectal physiology and fecal continence. STUDY DESIGN: A prospective observational study of 52 women was performed over two successive vaginal deliveries in previously nulliparous women using a bowel function questionnaire and anorectal physiology assessment anteparturn end six weeks postpartum. The main outcome measures in this representative cohort were altered fecal continence, abnormal anal vector manometry, abnomaal anal endosonography or prolonged pudendal nerve terminal motor latency. RESULTS: 9 (I7%) women had altered fecal continence following first vaginal delivery and 5 of these had persistent symptoms during second pregnancy which deteriorated following delivery. In 2 eases, symptoms recurred after second delivery and 4 women developed new symptoms of incontinence following second vaginal delivery, 3 of whom had occult anal sphincter injury following first vaginal delivery. A significant change in all anorectal physiological parameters was observed following first vaginal delivery and smaller, but still significant changes occurred following second delivery. While injury following first delivery was mechanical, neuropathic injury was observed following second delivery. C O N C L U S I O N : Women with persistent symptoms after first vaginal delivery experience deterioration in fecal continence after second vaginal delivery. 20% of those with occult anal sphincter injury become symptomatic after second vaginal delivery. First vaginal delivery is associated with mechanical anal sphincter injury whereas neuropathic Injury is more common after second vaginal delivery.
7 6 PROTEINURIA AND ADVERSE PREGNANCY O U T C O M E IN WOMEN W I T H C H R O N I C HYPERTENSION. 1]. M. Sibai for the NICHD MFMU Network, Bethesda, MD. OBJECTIVE: To identify risk factors for development of superimposed preeclampsia and adverse neonatal outcome in women with chronic hypertension enrolled in a multicenter trial comparing low-dose aspirin to a placebo. STUDY DESIGN: 763 women with chronic hypertension who were randomized between 13-26 wks' gestation and had outcome dale were studied. Preeelampsia w~s defined as new onset proteinuria (>300 rag/24 hr) in those without proteinuria at baseline (n=682) and according to strict clinical criteria specified prior to analysis in those who had proteinuria at baseline (n=81). RESULTS: Aspirin has no effect on pregnancy outcome. Overall incidence of preeclampsia was 25.3% and of abruptio was 1.5%. The incidence of prceelampsia was significantly increased in women who had hypertension for at least 4 years (30.5% vs. 21.9%, P=0.007) and in those with previous history of preeclampsia (32.0% vs. 23.2%. P=.017). However, the incidence of preeclampsia was similar between those with or without proteinuda at baseline (27.2% vs. 25.1%). The table below demonstrates that the incidence of adverse neonatal outcome was significantly increased in the presence of proteinuda at baseline.
Delivery
<37wks (%) <35wks (%) SGA(
Pro'.einuria Present Absent (n=81) (n--'682)
RR (95% CI)
53.1 35.8 [9.8 45.3 6.7
1.72 (1.36--2.17)* 2.24 (I.6---3.14)* 2.52 (1.51..--4.19)* 2.07 (1.55--2.76)* 3.62 (1.31--10.0)**
30.9 16 7.8 2t,9 1.8
*P
Moderators:
Valerie M. Parisi, MD, MPH Thomas J. Benedetti, MD
Judges:
Haywood L. Brown, MD Mark A. Morgan, MD Washington C. Hill, MD
Fontainebleau Ballroom C/D Abstract Numbers 67-76
$30 SPO Abstracts
January 1998 Am J Obstet Gynecol
67 PRELABOR RUPTURE OF THE MEMBRANES (PROM) AT TERM: EX-
69 MEMBRANE STRIPPING VS DINOPROSTONE VAGINAL INSERT IN
PECTANT MANAGEMENT AT HOME VS. IN HOSPITAL. Robert D i Cecco. -~Ma,'3' Hannah, Ellen Hodnetf, x Gary Foswr, ~Dan Farine, Michael Helen'a, Dept's of Ob/Gyn and Maternal infant and Reproductive HRU, CRWH. University of Toronto and Universffy of Manitoba, Canada. OBJECTIVES: We wished to assess whether women with PROM at term eared for partialIy or completely at home were at any increased risk of adverse maternal or neonatal outcomes. STUDY' DESIGN: Data obtained from women enrolled in the TermPROM Study randomized tc expectant care either in hospital or partially or completely at home were analyzed using univariate and multivariate analyses. Maternal outcomes assessed included: rate of clinical chorioamnionitis, induction of labor, use of maternal antibiotics, cesarean section, operative vaginal delivery, use of epidural anaesthetic, post-partum fever, and maternal satisfaction. Neonatal outcomes assessed included rates of neonatal infection (definite or probable), use of neonatal antibiotics, and NICU stay greater than 24 hours, RESULTS: Of 1670 women with PROM at term randomized to expectant care, 1017 women were eared for in hospital and 653 women were eared for pardally or completely at home. Women with PROM cared for at home were found on multivariate analysis to be at increased risk of cesarean section, use of intrapartum antibiotics, and neonatal infection [OR(95% CI): /.44 (1.04, 2.00), 1.63 (1.28, 2.10), 1.97 (1.00, 3.90), respectively]. A trend towards an increased risk of chorioarnnionltis, NICU stay greater than 24 hours, and use of neotratal antibintlcs was also observed. Care of women with PROM at home was not significantly associated with an increased rate of induction, use of epidural anaesthetic, or post-parturn fever. Women were more likely to be satisfied with their care if they had received their care partially or completely at home. CONCLUSIONS: Women with PROM at term eared for partially or completely at home may be at increased risk of some adverse maternal and neonatal outcomes including cesarean section, use of neonatal antibiotics, and increased NICU stay, hut may be more satisfied with their care.
THE MANAGEMENT OF PREGNANCIES BEYOND 41 WEEKS W I T H AN UNFAVORABLE CERVIX. E F Ma~ann~ n SP Chauhao, t, M F McNamara, c JD Bass, "~a CM Estes, ~c J C Morrison. a Dept. of Ob-Gyn, Univ. of Mississ[ppi, Jackson, MS,a Dept. ObO-yn. Medical College of Georgia, Augusta, GA.b Dept. of Ob-Gyn, NavaI Medlcal Center, San Diego, CA. ~ OBJECTIVE: To determine the best method of cervical ripening to prevent postdates inductions in women with an unfavorable cervix at 41 weeks' gestation. STUDY DESIGN: Women presenting to the antenatal testing unit at 41 weeks' gestation with a Bishop score <:4 and no contraindieation to cervical ripening were invited to participate in this study. They received daily dinoprostone (Cervldii| vaginal inserts or daily membrane stripping until spontaneous labor, rupture of membranes or a favorable cervix for induction occurred. All other patients who achieved 42 weeks of pregnancy were admitted to the hospital for induction. RESULTS: Onehundred and eighty-two women were entered into this prospecdve study with 91 women randomized in each artn. No significant differences were observed in the gestational age at the beginning of the study (P = 0.681 ) or at admission for delivery (P = 0.273). Bishop scores at the start of the study were similar (P = 0.245) although significantly greater in membrane stripping group on admission for delivery (P < 0.001). A greater number of women were admitted in labor (63191 or 69%) in the membrane stripping group versus the dinoprostone group (44/91 or 48%) (P = 0.006) resulting in less time elapsed from admission to delivery (P = 0.018) and fewer women with membrane stripping had an induction at 42 weeks (4/91 or 4%) versus tbe dlnoprostone group ( 13/91 or 14%) (P = 0.04). The mode of delivery (P = 0.362), birth weights (P = 0.268), cord blood gases < 7.1 (P = 0,18), and neonatal intensive care unit admission (P = 0.097) were similar between groups. The total cost of the cervical ripening agent and antenatal testing for the membrane stripping group was $15,i20 versus $59,540 for the dinoprostone group. CONCLUSIONS: Daily membrane stripping was more effective than dinoprostone administration in women with an unfavorable cervix as fewer inductions for postdates were required. The induction rate at 42 weeks in both groups (4 and 14%, respectively) in these actively managed patients is much lower than the 63% observed in an untreated group of similur women. Daily membrane stripping appears to be superior to dinoprnstone in ripening Ihe unripe the cervix and tit onefourth the cost.
68 CERVICAL RIPENING AND LABOR INDUCTION: MISOPROSTOL VS. DINOPROSTONE. A Cklrk, V Cook, P f'lill, "~J Spimuzto. Dept. of OB/GYN, University of Louisville, Louisville KY. OBJECTIVE: To compare the safety and efficacy of a 25 ml.tintravaginal application of misoprostol (EI) to intracervicaI dinoprostone (E2) gel for cervical ripening and induction of labor in patients with a Bishop Score (BS) a 5. STUDY DE.SIGN: 138 patients with a BS ~ 5 were randomized to receive either an intravaginal El tablet or imracervical E2 gel for cervical ripening. Inclusion criteria included 1) obstetric or medical indication for induction, 2) singleton pregnancy, 3) vertex presentation, and 4) reassuring fetal status. Exclusion criteria ineluded i) abnormal fetal heart rate pattern, 2) placenta previa, 3) active herpes infection, 4) history of asthma, glaucoma, cardiac or hepatic disease, 5) chorioamnionitis, 6) previous uterine scar and 7) parity > 5. Patients randomized to El received a 25 mbt tablet placed in the posterior fornix every four hours until an adequate contraction pattern was achieved or active labor ensued. A nraximum of four doses was allowed. Patients receiving E2 gel were given .5 mg of intracervical gel every four hours until an adequate contraction pattern was achieved or the BS was >5. A maximum four doses of E2 was allowed. Oxytocin augmentation was initiated if the maximum number of doses of ripening agent had been adninistered abd did not result in an adequate contraction pattern, active labor or if protracted labor ensued. Cominuous fetal heart rule and uterine contn~ction monitoring were perfomled in all patients. RESULTS: 72 patients were randomized to El and 66 to E2 gel. Demographic characteristics and BS upon admission did not differ between the two groups. All 66 patients (100%) randomized to E2 required pitocin atlgmentation. Only 44 of 72 patients (66%) receiving El required pitoein augmentation (p<0.05). The induction to delivery time was significantly longer in the E2 group, 1403 + 566 minutes vs l 1gl + 566 minutes in the EI group (p = 0.02). Patients in the El group were two tim~ more Iikely to require cesarean delivery (RR = 2.08, CI 1.09-3.98, p = 0.02), with a cesarean delivery rate of 15% and 31% in the E i and E2 groups respectively. Neonatal outcomes did not differ between the two groups. The rates of hyperstlmulation syndrome were not different between the two groups, 21% vs 18% (p > 0.05), in the E2 and El groups respectively. CONCLUSION: Intravaginal El is a safe and efficacious replacement for E2 for labor induction in patients with a BS < 5.
70 RANDOMIZED, DOUBLE-BLINDED T R I A L OF OXYTOCIN USE FOR INDUCTION OF LABOR, D..,..Me,r 3 J ~ E Zlamik. Department of Obstetrics and Gynecology, University of Iowa, Iowa City, [A. OBJECTIVE: We tested the hypothesis that high dose oxytocin use will result in shorter labors and reduced cesarean see.don rates. STUDY DESIGN: A total of 813 patients at >_24 weeks gestation undergoing induction of labor between 3/94 and 3/97 were enrolled. Patients were randomly assigned by random numbers table to receive oxytocin by either a low dose (1.5 mUhnin initial; increase by 1.5 mU/min q. 30 rain) or high dose (4.5 mUhnin initial; increase by 4.5 mU/min q. 30 min) protocol (low dose: n = 404, high dose: n = 392). Oxytocin solutions were prepared by a central pharmacy with either 5 or 15 units/500 ml. Infusion volumes (ml/hr) were identical, thus ensuring double blinding. Continuous variables were compared by one-way analysis of variance, and categoric variables were compared by Z2 analysis and Fisber's exact test when appropriate. RESULTS: Maternal demographics (gestational age, % nuniparity, indication for induction, epldural use, cervical dilation, Bishop's score, % receiving cervical ripening) Were not significantly different between groups. High dose oxytocln was associated with u significant reduction in oxytucin .-...*completedilatation (9,7 :t: 0.3 vs. 7.8 + 0,2 hours, p < .0001) and oxytocin -->delivery times (I1.0 + 0.3 vs. 8.8 • hours, p < .0001). Cesarean section rates also tended to be lower in the high dose group (16.1% vs. 11.7%, p = .095). No differences in neonatal outcomes (Apgar scores, cord gases, neonatal hospital days) were noted between groups. Farther; cesarean delivery for fetal distress was not increased with high dose oxytocin (low: 6.1%, high: 4.4%). CONCLUSIONS: When used in n blinded fashion, high dose oxytocin is associated with significantly shorter labors and a tendency for less need for cesarean delivery without any den~onstrahle adverse fetal/neonatM effects.
SPO Abstracts $3"1
Volume 178, N u m b e r 1, Part 2 A m J Obstet Gynecol 71 A RANDOMIZED CLINICAL TRIAL OF TWO SURGICAL TECHNIQUES F O R CESAREAN SECTION. M Franchi. .~ F Ghezzi, r D Bolestreri, x M Miglierina, .r F Zannboni, "~N Donadello,~ P F Bolis. x Dept Ob/Gyn, University of Varese, Varese, italy. OBJ-ECTIVE: The Joel-Cohen (JC) technique of opening the abdomen followed by non closure of pelvic/parietal peritoneum at cesarean section has been advocated as an alternative method to the Pfannestiel (Pfl] incision with peritonealizatlon (World J Surg 1994:18;292). A randomized trial was designed to compare intra- and post-operatlve morbidity between the two techniques. STUDY DESIGN: Wnmen to undergo a cesarean section were randomly allocated to have either the JC technique and the parietal and pelvic peritoneum left open or to have the Pfl incision and both peritoneal layers sutured. Exclusion criteria were: 2 previous CS, a previous htparotomy with an abdominal longitudinal incision or a gestational age < 30 weeks. All patients received prophylactic antibiotics. The myometrium was sutured with polyglactin 0 using a continuous single-layer nonlocking technique. Patients in the Pfl group had peritoneum sutured with polyglactin 00, The fascia was sutured with continuous pelygactin 1 in all cases. Postoperative infectious morbidity was defined as operative site infections, clussifled for abdominal wmmd infections with a six grade score (Go..s). Opening time was defined as the period comprise between skin incision and the opening of the uterine cavity. Febrile morbidity was defined as a temperature > 38* C on two occasion 4 hours apart. Puerperal endometrttls was defined as postpartum temperature >38* C on two occasions 4 hours apart excluding the day of delivery, with uterine tenderness andlor foul smelling Ioehla. Non parametric tests were used for statistics. RE,SULTS: 149 and 150 patients were allocated to theJC and to Ihe Pfl groop, respectively. The indications for the CS were similar in both groups except for a higher rate of placenta previn in the Pfl group (8/I50 vs, 1/149, p=0.04). A shorter median opening time [.4 rain (2-21) vs. 6 rain (2-19), respectively, p<0.01] and a shorter median operative time 1"30min (range 10-65) vs. 40 rain (range 20- 110), respectively, p<0.01] were observed in the JC than in the Pfl group. No diffareoce was found in term of inedlaa intraoperative blood loss, proportion of patients who required transfusion (21149 vs. 0/150), bladder injuries, wound dehiscence, endometritis, sepsis; febrile morbidity nnd urinary tract infections. Patients operated with the JC technique had a shorter median dur~Llionof hospitalization than those in the Pfl group [5 days (2-11) vs. 6 (2-32), respectively, p=0.052]. A higher rate of wound infection GI was found in the Pfl than in the JC group [14/150 (9.3%) vs 2/149(1.3%)], respectively, p<0.01 ]. CONCLUSIONS: The JC incision without peritoncalization resulted in a shorter opening time and total operative time than the Pfl incision with peritonezlization. This was acoomplised without an increase in the frequency of intra- and postoperative complications. Cosmetic issues, the reqttirement for rapid delivery nnd the potential complications need to be bahmced when choosiltg the JC incision or cesarean section.
73 TIMING OF DELIVERY AND NEONATAL OUTCOME IN PATIENTS WITH CLINICALLY OVERT UTERINE RUPTURE DURING VBAC, TF Porten SL Clark, MS Esplin, .T C Tooke-Mille~; x JR Scott. x Dept. Ob/Oyn, Univ. of Utah, SLC, Ut. OBJECTIVE: To examine neonatal outcome associated with utedne rupture during VBAC. STUDY DESIGN: All cases of uterine rapture occurring during VBAC between 1990 and 1996 were identified from the records of 6 large hospitals in a single metropolitan region, all of which had 24 hour in-house anesthesia services. Clinically overt rapture was defined as rupture resulting in a fetal heart rate pattern leading to emergency delivery. Medical records were abstracted of 66 variables including neonatal outcome, Fetal heart tracings were evaluated for the presence and time of onset of mild and severe variable decelerations, and persistent bradycardia in ~elation to the time of delivery, Adverse neonatal outcome was defined as death or neurologic sequelae at follow-up. The student t test was used where appropriate. RESULTS: 26 patients were attempting VBAC at the time of rupture. 23 had I prior cesarean and 3 had 2 prior cesareans. 8 (31%) [tad prior successful VBAC deliveries. 6 (23%) infants suffered either neonatal death or adverse neurologic sequelae as a result of the rapture. The mean (:t:SD) time from decision to deliver to delivery for patients with an adverse neonatal outcome was 19 (:t:12) minutes compared to 41 (• minutes for patients with good neonatal outcomes (P=0.20). For those palienls whose rapture was manifest by sustained bradycnrdia, the mean (+SD) time from onset to delivery was 16.7 (+7.4) minutes for those patients with poor neomttsl outcome and I8.6 (• minutes for those without adverse neonatal outcome (P---0.72).Poor neonatal outcome was seen in 31% of the htfants delivered within 30 minutes of either severe variables or bradycardia and in 33% of the Infants delivered within 20 mlmnes. CONCLUSIONS: I) A prior VBAC does not protect against uterine rttpture during VBAC. 2) Felal damage or death may occur even in hospitals with 24 hour in house anesthesia services, 3) Fuctors other than time to delivery are important in determining neonatal outcome after uterine rupture. 4) Neonatal death or damage is seen in a high percentage of patients with uterine rapture during VBAC despite delivery within the 30 minute ACOG guidelines for emergency intervention.
72 IS VBAC LESS EXPENSIVE THAN REPEAT CESAREAN? ~lark SL. McClellan V, Scott JR, Burton DA, Porter TE Intcrmountaltl Health Care and University of Utah, Salt Lake City. OBJECTIVE: To compare financial implications of trial of labor(TOL) with those of repeat cesarean when total maternal and child costs (not charges), are considered. STUDY DESIGN: For maternal and short-term neonatal care, system-specific DRG related costs in all branches of a CPT based clinical outcome algorithm for TOL after 1 or 2 cesareans were compared with those of repeat cesarean without TOL. Data included all births during 1996 in a regional health care system with an annual delivery volume of 26,000. For Iong term neonatal care, best and worst case cost estimates were calculated based upon previously established data. RESULTS: Depending upon which available estimates are accepted regarding long term neonatal outcome of infants with catastrophic uterine rupture, net financial loss/savings per VBAC attempt compared to elective repeat cesarean varies from +$320(best case assumptions) to -$11,950 (worst case assumptions.) For women with 2 prior cesareans, net loss per VBAC attempt using best case assumptions is -$312. COMMENT: Conclusions regarding potential financial savings of VBAC vs. repeat cesarean based upon general eharg_es for vaginal birth vs. cesarean section are flawed. When total medical ~ arc calculated, including increased morbidity for failed VBAC attempts and medical care of infants following catastrophic uterine rupture, there are, at best, lintited financial advantages to VBAC, and at worst, major financial disadvantages. In hospitals without it NICU, in-house anesthesia and obstetric services, and capable of rmttinely performing emergency cesarean section in <20 minutes, VBAC attempt appears to result in a financial loss using any assumptions. The same applies to TOL after two cesareans. Considerations other than financial should guide policy and decisions regarding VBAC.
74 300 TERM BRAIN DAMAGED INFANTS: TtlEIR FHR PATTERNS. JP MO Ahn. Department of Obstetrics and Gynecology, Pomona Valley Hospital Medical Center, Pomona, California and Cha Women's Hospital, Seoul, Korea, and the Childbirth Injury Prevention Foundation, Pasadena, California. OBJECTIVE: To describe the fetal heart rate (FHR) patterns of 300 term brain damaged infants. STUDY DESIGN: The fetal monitor strips of 300 singleton term neurologically impaired neonates were retrospectively analyzed. RESULTS: Of the 300 infants, the admission fetal heart rate (FHR) patterns were reactive152 (51%), nonreactive 135 (45%), bradycardia 9 (3%) or unclassifiable 4 (1%). In the reactive group, the FHR did the following: (1) remained reactive throughout labor [24 (16%)]; (2) developed an elevated baseline FHR ill association with repetitive PHR decelerations and generally a loss of variability [67 (22%)]; or (3) a sudden prolonged F'HR deceleration that lasted until delivery [61 (20%)]. The nonreactive admission group exhibited the following: (1) a pe~istent fixed baseline rate from admission (149 • 16 bpm) until the end of the strip (151 +166 bpm) [97 (72%)]; (2) a prolonged FHR deceleration that lasted until delivery 1.12 (9%)]; or (3) a stair steps to death pattern [26 (19%)]. CONCLUSIONS: While tem~ infants later found to be neurologically impaired do not manifest a uniform FHR pattern, these fetuses do manifest distiact FHR pattenxs intrapartum that can be easily categorized and identified on the basis of the fetal admission lest and subsequent changes in baseline rate. This distinction should prove helpful in the management of obstetrical patients in labor, Phelan.
$32 SPO Abstracts
January 1998 A m J Obstet GynecoI
75 T H E E F F E C T OF S E C O N D VAGINAL D E L I V E R Y O N A N O R E C T A L P H Y S I O L O G Y AND F E C A L CONTINENCE. M.Fynes. V. Donnelly, M.Behan, C. O'Herlihy, PR. O'Connell. Departments of Obstetrics, Gynaecology, Surgery and Radiology, University College Dublin, Ireland. O B J E C T I V E : To determine the effect of second vaginal delivery on anorectal physiology and fecal continence. STUDY DESIGN: A prospective observational study of 52 women was performed over two successive vaginal deliveries in previously nulliparous women using a bowel function questionnaire and anorectal physiology assessment anteparturn end six weeks postpartum. The main outcome measures in this representative cohort were altered fecal continence, abnormal anal vector manometry, abnomaal anal endosonography or prolonged pudendal nerve terminal motor latency. RESULTS: 9 (I7%) women had altered fecal continence following first vaginal delivery and 5 of these had persistent symptoms during second pregnancy which deteriorated following delivery. In 2 eases, symptoms recurred after second delivery and 4 women developed new symptoms of incontinence following second vaginal delivery, 3 of whom had occult anal sphincter injury following first vaginal delivery. A significant change in all anorectal physiological parameters was observed following first vaginal delivery and smaller, but still significant changes occurred following second delivery. While injury following first delivery was mechanical, neuropathic injury was observed following second delivery. C O N C L U S I O N : Women with persistent symptoms after first vaginal delivery experience deterioration in fecal continence after second vaginal delivery. 20% of those with occult anal sphincter injury become symptomatic after second vaginal delivery. First vaginal delivery is associated with mechanical anal sphincter injury whereas neuropathic Injury is more common after second vaginal delivery.
7 6 PROTEINURIA AND ADVERSE PREGNANCY O U T C O M E IN WOMEN W I T H C H R O N I C HYPERTENSION. 1]. M. Sibai for the NICHD MFMU Network, Bethesda, MD. OBJECTIVE: To identify risk factors for development of superimposed preeclampsia and adverse neonatal outcome in women with chronic hypertension enrolled in a multicenter trial comparing low-dose aspirin to a placebo. STUDY DESIGN: 763 women with chronic hypertension who were randomized between 13-26 wks' gestation and had outcome dale were studied. Preeelampsia w~s defined as new onset proteinuria (>300 rag/24 hr) in those without proteinuria at baseline (n=682) and according to strict clinical criteria specified prior to analysis in those who had proteinuria at baseline (n=81). RESULTS: Aspirin has no effect on pregnancy outcome. Overall incidence of preeclampsia was 25.3% and of abruptio was 1.5%. The incidence of prceelampsia was significantly increased in women who had hypertension for at least 4 years (30.5% vs. 21.9%, P=0.007) and in those with previous history of preeclampsia (32.0% vs. 23.2%. P=.017). However, the incidence of preeclampsia was similar between those with or without proteinuda at baseline (27.2% vs. 25.1%). The table below demonstrates that the incidence of adverse neonatal outcome was significantly increased in the presence of proteinuda at baseline.
Delivery
<37wks (%) <35wks (%) SGA(
Pro'.einuria Present Absent (n=81) (n--'682)
RR (95% CI)
53.1 35.8 [9.8 45.3 6.7
1.72 (1.36--2.17)* 2.24 (I.6---3.14)* 2.52 (1.51..--4.19)* 2.07 (1.55--2.76)* 3.62 (1.31--10.0)**
30.9 16 7.8 2t,9 1.8
*P