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Second-born twins have more fetal distress and low apgars than their co-twins
SMFM Abstracts S121
Volume 189, Number 6 Am J Obstet Gynecol 208
EPIDURAL-ASSOCIATED HYPERTHERMIA IS INCREASED IN TWIN COMPARED TO SINGLETON GESTATIONS BRIAN BROST1, JAMES DUNN2, 1Mayo Clinic, Obstetrics and Gynecology, Rochester, MN 2Keesler USAF Medical Center, Obstetrics and Gynecology, Biloxi, MS OBJECTIVE: Epidural-induced temperature increases have been documented in singleton gestations. We hypothesize that the greater fetal/placental mass of twin gestations would lead to a greater increase in maternal temperature intrapartum with epidural analgesia. We evaluated the effects of epidural analgesia–associated hyperthermia in twin compared to singleton gestations. STUDY DESIGN: All twin deliveries receiving epidural analgesia at a tertiary medical center were evaluated over a 7-year period. Singleton controls were selected by finding the singleton gestation having epidural analgesia before and after each study twin pregnancy. Controls were matched within 1 week of gestation. Exclusion criteria were no labor, no epidural analgesia, insufficient temperature readings prior to delivery, or the clinical diagnosis of chorioamnionitis. Hourly temperature readings were obtained after epidural placement and analyzed using linear regression. Statistical significance was set a P < 0.05. RESULTS: Of the 67 twin gestations delivered during the study period, 37 met the inclusion criteria. Maternal demographics were similar between the groups except for parity (P = .03). The average time from epidural placement to delivery was similar for twins at 302.4 minutes compared to singleton gestations at 256.6 minutes (P = 0.08). The increase in temperature for singletons was 0.06 degrees Celsius/hour compared to 0.1 degrees Celsius/hour. This temperature increase during labor with epidural analgesia is 1.65 times higher for twin compared to singleton gestations (P = 0.002). CONCLUSION: Epidural use in singleton and twin gestations is associated with an increase in maternal temperature during labor. Twin gestations have a higher increase in the rate of maternal temperature rise. This finding places neonates of multifetal gestations at higher risk of fever workup during the postpartum period.
210
SECOND-BORN TWINS HAVE MORE FETAL DISTRESS AND LOW APGARS THAN THEIR CO-TWINS REBECCA HARTLEY1, JANE HITTI2, 1 Seattle University, Biology, Seattle, WA 2University of Washington, Obstetrics and Gynecology, Seattle, WA OBJECTIVE: To determine whether second-born (B) twins have higher morbidity and mortality than first-born (A) twins. STUDY DESIGN: We conducted a retrospective analysis of birth certificates and fetal and infant death certificates. Our linked twins file contained 9326 pairs born at 24-42 weeks’ gestation, with neither malformations nor size discordance ($20%), from 1989-2001 in Washington State. The adverse outcomes were fetal death, neonatal death, perinatal death, fetal distress, low 5-min Apgar score ( < 7), assisted ventilation > 30 min, and respiratory distress syndrome (RDS). McNemar’s test was used. RESULTS: Second-born twins had significantly higher rates of fetal death, perinatal death, and RDS than their co-twins in M/M pairs, and significantly higher rates of distress and low Apgars than their co-twins in M/M, M/F, F/M, and F/F pairs. The A/B differences in fetal distress and low Apgars were significant when A was delivered vaginally (P = 0.001 and 0.001, respectively), but not when both infants were delivered by cesarean (P = 0.063 and 0.815). When A was delivered vaginally, the A/B differences in fetal distress and low Apgars were significant for all gestational ages (24-31, 32-36, and 37-42 wks) at three delivery intervals (1-15, 16-30, and 31-359 min) and in both vertex/vertex (V/V) and vertex/breech (V/N) pairs (Table). CONCLUSION: Second-born twins face higher risks of fetal distress and low Apgar scores than their co-twins, even in dichorionic pairs. When A twins are delivered vaginally, B twins have higher rates of distress and low Apgars than A twins, regardless of gestational age or delivery interval, and even when both infants are vertex.
Number of pairs with specified outcome in 0-2 infants, when A was delivered vaginally Presentation
Neither
Both
Only A
Only B
P value
V/V V/N V/V V/N
3955 849 3923 841
57 7 39 15
27 7 64 20
141 64 130 48
0.001 0.001 0.001 0.001
Fetal distress Low Apgar
209
EVALUATION OF CLINICAL RISK FACTORS FOR DELIVERING A MACROSOMIC INFANT BRIAN BROST1, BYRON CALHOUN2, CURT MISKO2, 1 Mayo Clinic, Obstetrics and Gynecology, Rochester, MN 2Madigan Army Medical Center, Obstetrics and Gynecology, Tacoma, WA OBJECTIVE: To evaluate maternal variables thought to increase the risk of delivering a macrosomic infant. STUDY DESIGN: Maternal and fetal demographics were obtained on 113 consecutive macrosomic infant (>4500 grams) delivered to non-diabetic mothers over a 4 1/2-year period at two tertiary medical centers. Data for control infants were obtained by matching the next infant in the delivery log weighing < 3500 grams with similar maternal age ( ± 2 years) and estimated gestational age ± 1 week. Clinical variables between the two groups were compared using logistic regression and chi-square testing as appropriate with statistical significance set at P < 0.05. RESULTS: Body mass index, Leopold estimated fetal weight (>8 pounds), and intrapartum fundal height > 38 cm were associated with an increased risk of fetal macrosomia (P = 0.01, 0.03, and 0.009, respectively). Total pregnancy weight gain and third-trimester weight gain were not associated with delivery of a macrosomic infant (P = 0.45 and 0.08, respectively). Fundal heights > 38 cm were associated with a 20 times greater risk of delivering a macrosomic infant, while Leopold estimated weight > 8 pounds is associated with a 6-fold increased risk. CONCLUSION: While no single maternal variable is a consistent predictor of delivering a macrosomic infant, maternal body mass index, Leopold estimated fetal weight, and intrapartum fundal height appear to be the best predictors.
211
ORAL AMBROXOL SUPPLEMENT IN PREGNANT WOMEN INDUCES FETAL LUNG MATURATION AS MEASURED BY LAMELLAR BODIES IN AMNIOTIC FLUID ESTEBAN HOLGUIN1, MUNIM SAEED1, ENRIQUE TERAN2, GUSTAVO MOLINA2, 1Hospital Metropilitano, Medicine, Quito, Ecuador 2Biomedical Center, Central University of Ecuador, Medicine, Quito, Ecuador OBJECTIVE: Infant respiratory distress syndrome (IRDS) is an important cause of neonatal morbidity and mortality in developing countries and is due to reduced surfactant production by underdeveloped lungs in premature infants. The lamellar body count of equal to or greater than 32,000 lL is 98% specific for biochemical lung maturity. This study explores the use of oral ambroxol on fetal lung maturation in pregnant women in their third trimester. STUDY DESIGN: We conducted a randomized controlled study in pregnant women in their third trimester. Ambroxol was given orally, 30-mg dose every 8 hours, from week 28 until 32 ± 1 week to group A. Group B received no drug. A sample of 3 to 4 cc of amniotic fluid was taken in 10-cc tubes by ultrasound-guided amniocentesis at 32 ± 1 week. The procedure consisted of centrifuging the sample for 5 minutes to 276 turns per minute and then measuring lamellar body concentration with automatic account machine of hematological cells in both groups. P value was obtained by Mann-Whitney U test and was considered significant if P < 0.05. RESULTS: The results of lamellar body concentration in 20 women are shown in the Table. Group A had 37.2% increase of lamellar body concentration as compared to group B (P = 0.0102). There were no side effects attributable to the drug. CONCLUSION: Oral ambroxol plays an important role in fetal lung maturation. The study highlights the option of oral ambroxol, which causes an increase of lamellar body concentration, as a supplement in the third trimester with fetus at risk of prematurity and IRDS.
Comparative values of lamellar bodies in intervention Measurements
Intervention
Control
Total patients Maximum value Mean Standard deviation Standard error Median
10 40,000 26,455 8,744.9 2,636.7 27,000
10 21,000 16,600 2,796.8 884.43 17,000
Volume 189, Number 6 Am J Obstet Gynecol 208
EPIDURAL-ASSOCIATED HYPERTHERMIA IS INCREASED IN TWIN COMPARED TO SINGLETON GESTATIONS BRIAN BROST1, JAMES DUNN2, 1Mayo Clinic, Obstetrics and Gynecology, Rochester, MN 2Keesler USAF Medical Center, Obstetrics and Gynecology, Biloxi, MS OBJECTIVE: Epidural-induced temperature increases have been documented in singleton gestations. We hypothesize that the greater fetal/placental mass of twin gestations would lead to a greater increase in maternal temperature intrapartum with epidural analgesia. We evaluated the effects of epidural analgesia–associated hyperthermia in twin compared to singleton gestations. STUDY DESIGN: All twin deliveries receiving epidural analgesia at a tertiary medical center were evaluated over a 7-year period. Singleton controls were selected by finding the singleton gestation having epidural analgesia before and after each study twin pregnancy. Controls were matched within 1 week of gestation. Exclusion criteria were no labor, no epidural analgesia, insufficient temperature readings prior to delivery, or the clinical diagnosis of chorioamnionitis. Hourly temperature readings were obtained after epidural placement and analyzed using linear regression. Statistical significance was set a P < 0.05. RESULTS: Of the 67 twin gestations delivered during the study period, 37 met the inclusion criteria. Maternal demographics were similar between the groups except for parity (P = .03). The average time from epidural placement to delivery was similar for twins at 302.4 minutes compared to singleton gestations at 256.6 minutes (P = 0.08). The increase in temperature for singletons was 0.06 degrees Celsius/hour compared to 0.1 degrees Celsius/hour. This temperature increase during labor with epidural analgesia is 1.65 times higher for twin compared to singleton gestations (P = 0.002). CONCLUSION: Epidural use in singleton and twin gestations is associated with an increase in maternal temperature during labor. Twin gestations have a higher increase in the rate of maternal temperature rise. This finding places neonates of multifetal gestations at higher risk of fever workup during the postpartum period.
210
SECOND-BORN TWINS HAVE MORE FETAL DISTRESS AND LOW APGARS THAN THEIR CO-TWINS REBECCA HARTLEY1, JANE HITTI2, 1 Seattle University, Biology, Seattle, WA 2University of Washington, Obstetrics and Gynecology, Seattle, WA OBJECTIVE: To determine whether second-born (B) twins have higher morbidity and mortality than first-born (A) twins. STUDY DESIGN: We conducted a retrospective analysis of birth certificates and fetal and infant death certificates. Our linked twins file contained 9326 pairs born at 24-42 weeks’ gestation, with neither malformations nor size discordance ($20%), from 1989-2001 in Washington State. The adverse outcomes were fetal death, neonatal death, perinatal death, fetal distress, low 5-min Apgar score ( < 7), assisted ventilation > 30 min, and respiratory distress syndrome (RDS). McNemar’s test was used. RESULTS: Second-born twins had significantly higher rates of fetal death, perinatal death, and RDS than their co-twins in M/M pairs, and significantly higher rates of distress and low Apgars than their co-twins in M/M, M/F, F/M, and F/F pairs. The A/B differences in fetal distress and low Apgars were significant when A was delivered vaginally (P = 0.001 and 0.001, respectively), but not when both infants were delivered by cesarean (P = 0.063 and 0.815). When A was delivered vaginally, the A/B differences in fetal distress and low Apgars were significant for all gestational ages (24-31, 32-36, and 37-42 wks) at three delivery intervals (1-15, 16-30, and 31-359 min) and in both vertex/vertex (V/V) and vertex/breech (V/N) pairs (Table). CONCLUSION: Second-born twins face higher risks of fetal distress and low Apgar scores than their co-twins, even in dichorionic pairs. When A twins are delivered vaginally, B twins have higher rates of distress and low Apgars than A twins, regardless of gestational age or delivery interval, and even when both infants are vertex.
Number of pairs with specified outcome in 0-2 infants, when A was delivered vaginally Presentation
Neither
Both
Only A
Only B
P value
V/V V/N V/V V/N
3955 849 3923 841
57 7 39 15
27 7 64 20
141 64 130 48
0.001 0.001 0.001 0.001
Fetal distress Low Apgar
209
EVALUATION OF CLINICAL RISK FACTORS FOR DELIVERING A MACROSOMIC INFANT BRIAN BROST1, BYRON CALHOUN2, CURT MISKO2, 1 Mayo Clinic, Obstetrics and Gynecology, Rochester, MN 2Madigan Army Medical Center, Obstetrics and Gynecology, Tacoma, WA OBJECTIVE: To evaluate maternal variables thought to increase the risk of delivering a macrosomic infant. STUDY DESIGN: Maternal and fetal demographics were obtained on 113 consecutive macrosomic infant (>4500 grams) delivered to non-diabetic mothers over a 4 1/2-year period at two tertiary medical centers. Data for control infants were obtained by matching the next infant in the delivery log weighing < 3500 grams with similar maternal age ( ± 2 years) and estimated gestational age ± 1 week. Clinical variables between the two groups were compared using logistic regression and chi-square testing as appropriate with statistical significance set at P < 0.05. RESULTS: Body mass index, Leopold estimated fetal weight (>8 pounds), and intrapartum fundal height > 38 cm were associated with an increased risk of fetal macrosomia (P = 0.01, 0.03, and 0.009, respectively). Total pregnancy weight gain and third-trimester weight gain were not associated with delivery of a macrosomic infant (P = 0.45 and 0.08, respectively). Fundal heights > 38 cm were associated with a 20 times greater risk of delivering a macrosomic infant, while Leopold estimated weight > 8 pounds is associated with a 6-fold increased risk. CONCLUSION: While no single maternal variable is a consistent predictor of delivering a macrosomic infant, maternal body mass index, Leopold estimated fetal weight, and intrapartum fundal height appear to be the best predictors.
211
ORAL AMBROXOL SUPPLEMENT IN PREGNANT WOMEN INDUCES FETAL LUNG MATURATION AS MEASURED BY LAMELLAR BODIES IN AMNIOTIC FLUID ESTEBAN HOLGUIN1, MUNIM SAEED1, ENRIQUE TERAN2, GUSTAVO MOLINA2, 1Hospital Metropilitano, Medicine, Quito, Ecuador 2Biomedical Center, Central University of Ecuador, Medicine, Quito, Ecuador OBJECTIVE: Infant respiratory distress syndrome (IRDS) is an important cause of neonatal morbidity and mortality in developing countries and is due to reduced surfactant production by underdeveloped lungs in premature infants. The lamellar body count of equal to or greater than 32,000 lL is 98% specific for biochemical lung maturity. This study explores the use of oral ambroxol on fetal lung maturation in pregnant women in their third trimester. STUDY DESIGN: We conducted a randomized controlled study in pregnant women in their third trimester. Ambroxol was given orally, 30-mg dose every 8 hours, from week 28 until 32 ± 1 week to group A. Group B received no drug. A sample of 3 to 4 cc of amniotic fluid was taken in 10-cc tubes by ultrasound-guided amniocentesis at 32 ± 1 week. The procedure consisted of centrifuging the sample for 5 minutes to 276 turns per minute and then measuring lamellar body concentration with automatic account machine of hematological cells in both groups. P value was obtained by Mann-Whitney U test and was considered significant if P < 0.05. RESULTS: The results of lamellar body concentration in 20 women are shown in the Table. Group A had 37.2% increase of lamellar body concentration as compared to group B (P = 0.0102). There were no side effects attributable to the drug. CONCLUSION: Oral ambroxol plays an important role in fetal lung maturation. The study highlights the option of oral ambroxol, which causes an increase of lamellar body concentration, as a supplement in the third trimester with fetus at risk of prematurity and IRDS.
Comparative values of lamellar bodies in intervention Measurements
Intervention
Control
Total patients Maximum value Mean Standard deviation Standard error Median
10 40,000 26,455 8,744.9 2,636.7 27,000
10 21,000 16,600 2,796.8 884.43 17,000