- Email: [email protected]
Utility of amniocentesis in afebrile women with preterm labor
PRETERM LABOR Clinical and Economic Outcomes of Continuous Subcutaneous Tocolysis Steven Ambrose, MD Christ Hospital, Oak Lawn, IL
Debbie Jacques, MPH, and Gary Stanziano, MD Objective: To compare pregnancy and economic outcomes in women receiving inpatient (IP) versus outpatient (OP) tocolysis with subcutaneous terbutaline infusion (STI) following IP stabilization of preterm labor (PTL). Study design: The following inclusion criteria were applied to a database of women participating in a PTL identification program: 24 –33.9 weeks gestational age (GA) and documented cervical exam (CX) at start of STI. Exclusion criteria were CX at the start of STI ⱖ 3 cm or maternal or fetal instability requiring IP care or both. Inpatient STI patients were matched 1:1 to OP STI patients by CX, GA at the start of STI, and fetal number. Pregnancy and cost outcomes were examined with matched-pairs statistical analysis. Results: Ninety matched pairs (180 patients) were analyzed. Twin gestations accounted for 42.2%. Data are presented in the table; all P ⬍0.004.
GA delivery (weeks) Costs ($)—Antenatal IP days —OP days Costs ($)—NICU days Total costs ($) per pregnancy
IP (n ⫽ 90)
OP (n ⫽ 90)
34.1 ⫾ 2.9 1,162 ⫾ 12,889 0 23,688 ⫾ 33,836 54,851 ⫾ 48,720
35.8 ⫾ 1.9 3,780 ⫾ 4,690 9,432 ⫾ 4,761 8,884 ⫾ 16,564 25,279 ⫾ 26,319
Conclusion: Women receiving OP STI had fewer preterm deliveries, fewer low-birth-weight and very-low-birth-weight infants, and significantly lower total costs than those receiving IP STI. Outpatient-administered STI appears to be a costeffective and viable alternative in this select patient population.
Magnesium Sulfate Tocolysis Prolongs QT Interval Sandra C. Thomas, DO St. Luke’s Hospital, Bethlehem, PA
Albert Sarno, MD, and James Anasti, MD Objective: Magnesium sulfate (MgSO4) tocolysis causes maternal ionized calcium (Ca⫹⫹) to fall precipitously. Changes in Ca⫹⫹ levels are known to alter electrical conduction in the
VOL. 97, NO 4 (SUPPLEMENT), APRIL 2001
heart, possibly resulting in arrhythmias. The goal of this study was to determine the effects on maternal QT interval when intravenous MgSO4 is used for tocolysis in preterm labor. Methods: All patients admitted for MgSO4 tocolysis were considered for the study. Patients with any underlying medical conditions were excluded. Levels of ionized calcium, calcium, potassium, phosphate, magnesium (Mg⫹⫹), and albumin, and an electrocardiogram (ECG) were obtained before initiation of MgSO4. These labs and ECG were repeated after 12 hours of tocolysis and again after 24 hours. Magnesium sulfate was given as a 4-g bolus and continued as a 2–3 g/hour infusion. Results: In the initial six patients, the QTc was prolonged in all patients by 12 hours. At 24 hours, the QTc further lengthened in two out of six patients. In the other four women, the QTc remained longer than the initial measurement but did not continue to be prolonged. During the initial 12 hours, the average Mg⫹⫹ level was 6.2 mg/dL and the Ca⫹⫹ had declined an average of 19 % for five of the six patients. Conclusion: In this preliminary study, intravenous MgSO4 tocolysis had an effect on the level of ionized calcium and the length of the QTc. This effect occurred within 12 hours of tocolysis. Whether this results in an adverse effect in certain individuals remains to be determined.
Utility of Amniocentesis in Afebrile Women with Preterm Labor Debra Guinn, MD University of Colorado Health Sciences Center, Denver, CO
A. King, MD, M. Wheeler, MD, and L. Sullivan, PhD Objectives: To determine 1) the rate of positive markers of intraamniotic infection (IAI) in women with preterm labor (PTL) undergoing amniocentesis (AMNIO), 2) the outcomes of pregnancies with positive markers of IAI, 3) whether management was altered based on results, and 4) the rate of rupture of membranes (ROM) following AMNIO. Study design: Our policy was to perform AMNIO on afebrile women with PTL if there was 1) no response to tocolysis, 2) maternal/fetal signs of IAI, or 3) advanced cervical dilation (⬎ 3 cm, ACD), or if fetal lung maturity (FLM) needed to be checked. Cases were identified from 1998 to 1999 by ICD-9 codes. Cases were excluded for fever or ROM before AMNIO. Results: Of the 65 women who were included, 63% received antibiotics before the AMNIO. The mean gestational age (GA)
Tuesday Posters 47S
at AMNIO was 33.1 weks, and the mean GA at delivery was 34.1 weeks. The primary indications for AMNIO were FLM (52%), no response to tocolysis (26%), maternal signs (18%), and ACD (1.5%). There were 2 positive cultures (3%), 2 positive Gram stains (3%), 8 patients with white blood cell count of more than 50/uL (12%), 13 patients with glucose less than 15 (20%), and 24 patients with glucose less than 20 (37%). Only glucose less than 15 was associated with positive cultures (P ⫽ 0.04). No positive marker of IAI was associated with abruption, meconium, clinical chorioamnionitis, respiratory distress syndrome, or sepsis. Management was changed based
on AMNIO results in 25 cases (39%). ROM followed AMNIO in 14% (mean 1.7 days, maximum 4 days). If ROM occurred, 66% delivered within 48 hours. Conclusions: The rate of IAI was low, and no marker of IAI was associated with neonatal morbidity. These findings may be a result of our use of antibiotics before AMNIO, our culture technique, or changes in obstetric management based on our findings. The 14% risk of ROM was higher than expected. The role of AMNIO in PTL is unclear. A randomized controlled trial is needed to address efficacy and safety of AMNIO in PTL in afebrile women.
UROGYNECOLOGY
Are Women With Urogenital Atrophy Symptomatic?
An Alternative Approach to the Repair of Cystoceles and Rectoceles
G. Willy Davila, MD
Elizabeth Graul, MD
Cleveland Clinic Florida, Fort Lauderdale, FL
Ifi Karapanagiotou, MD, Sherry Woodhouse, MD, Anita Singh, Karen Huber, Steven Zimberg, MD, and Jeffrey Seiler, MD
Phase II Center for Women’s Health, Salt Lake City, UT
Barbara Hurst, MD Purpose: We present an alternative approach to repair severe or recurrent central anterior wall defects and high posterior wall defects. Background: Pelvic prolapse is one of the most common problems with which a gynecologist deals. One in nine women in the United States suffers from prolapse. Of those who undergo surgery, 25–30% will have a recurrence. It long has been recognized that the patient tissue available for repair often is less than optimal. Implantable material was used as early as 1955 in an attempt to improve the strength and longevity of the repair. Unfortunately, these materials often resulted in infection, sinus formation, or erosion. A better understanding of anatomy has improved our ability to recognize and repair these defects, especially paravaginal defects in the anterior compartment and site-specific defects in the posterior compartment. However, severe or recurrent central anterior defects and high posterior (Level I) defects have little or no supportive tissue to use in the repair. Results and Conclusions: Fifty women have undergone this alternative procedure to repair cystocele and rectocele from January through October 2000, using donor collagen. The use of donor collagen in the repair of these defects has resulted in no infections or erosions, and there has been no evidence of recurrence during our initial follow-up.
48S Tuesday Posters
Objective: To correlate the physical findings of urogenital atrophy, an inevitable consequence of menopause, with symptoms suggestive of atrophic vaginitis. Methods: Women presenting for routine outpatient gynecologic care were asked to complete a five-item questionnaire regarding the presence and severity (0 –3) of vaginal atrophy symptoms. They underwent a pelvic examination recording vaginal mucosal changes and severity (0 –3), including pH. Symptoms and physical findings were averaged for an overall score of 0 –3. A vaginal sidewall cytologic maturation index (MI) was performed (range 0 –100). Symptoms were correlated with mucosal changes, pH, and MI, using Spearman rank correlation. Results: Sixty-nine women, mean age 66 (range 23– 89) were enrolled. Symptom scores were surprisingly low, mean 0.36 (range 0 –2.6). Symptom scores were poorly correlated with age (0.35) and physical findings (0.35) but not with MI (– 0.04). There was a moderate correlation between physical examination and MI (– 0.49). Low pH correlated well with high MI. Women on estrogen therapy had higher symptom (P ⫽ 0.0097) and physical finding (P ⫽ 0.0311) scores. Conclusions: Although urogenital atrophy occurs universally after menopause, most elderly women are minimally symptomatic. Symptoms alone should not guide initiation of therapy.
Obstetrics & Gynecology
Debbie Jacques, MPH, and Gary Stanziano, MD Objective: To compare pregnancy and economic outcomes in women receiving inpatient (IP) versus outpatient (OP) tocolysis with subcutaneous terbutaline infusion (STI) following IP stabilization of preterm labor (PTL). Study design: The following inclusion criteria were applied to a database of women participating in a PTL identification program: 24 –33.9 weeks gestational age (GA) and documented cervical exam (CX) at start of STI. Exclusion criteria were CX at the start of STI ⱖ 3 cm or maternal or fetal instability requiring IP care or both. Inpatient STI patients were matched 1:1 to OP STI patients by CX, GA at the start of STI, and fetal number. Pregnancy and cost outcomes were examined with matched-pairs statistical analysis. Results: Ninety matched pairs (180 patients) were analyzed. Twin gestations accounted for 42.2%. Data are presented in the table; all P ⬍0.004.
GA delivery (weeks) Costs ($)—Antenatal IP days —OP days Costs ($)—NICU days Total costs ($) per pregnancy
IP (n ⫽ 90)
OP (n ⫽ 90)
34.1 ⫾ 2.9 1,162 ⫾ 12,889 0 23,688 ⫾ 33,836 54,851 ⫾ 48,720
35.8 ⫾ 1.9 3,780 ⫾ 4,690 9,432 ⫾ 4,761 8,884 ⫾ 16,564 25,279 ⫾ 26,319
Conclusion: Women receiving OP STI had fewer preterm deliveries, fewer low-birth-weight and very-low-birth-weight infants, and significantly lower total costs than those receiving IP STI. Outpatient-administered STI appears to be a costeffective and viable alternative in this select patient population.
Magnesium Sulfate Tocolysis Prolongs QT Interval Sandra C. Thomas, DO St. Luke’s Hospital, Bethlehem, PA
Albert Sarno, MD, and James Anasti, MD Objective: Magnesium sulfate (MgSO4) tocolysis causes maternal ionized calcium (Ca⫹⫹) to fall precipitously. Changes in Ca⫹⫹ levels are known to alter electrical conduction in the
VOL. 97, NO 4 (SUPPLEMENT), APRIL 2001
heart, possibly resulting in arrhythmias. The goal of this study was to determine the effects on maternal QT interval when intravenous MgSO4 is used for tocolysis in preterm labor. Methods: All patients admitted for MgSO4 tocolysis were considered for the study. Patients with any underlying medical conditions were excluded. Levels of ionized calcium, calcium, potassium, phosphate, magnesium (Mg⫹⫹), and albumin, and an electrocardiogram (ECG) were obtained before initiation of MgSO4. These labs and ECG were repeated after 12 hours of tocolysis and again after 24 hours. Magnesium sulfate was given as a 4-g bolus and continued as a 2–3 g/hour infusion. Results: In the initial six patients, the QTc was prolonged in all patients by 12 hours. At 24 hours, the QTc further lengthened in two out of six patients. In the other four women, the QTc remained longer than the initial measurement but did not continue to be prolonged. During the initial 12 hours, the average Mg⫹⫹ level was 6.2 mg/dL and the Ca⫹⫹ had declined an average of 19 % for five of the six patients. Conclusion: In this preliminary study, intravenous MgSO4 tocolysis had an effect on the level of ionized calcium and the length of the QTc. This effect occurred within 12 hours of tocolysis. Whether this results in an adverse effect in certain individuals remains to be determined.
Utility of Amniocentesis in Afebrile Women with Preterm Labor Debra Guinn, MD University of Colorado Health Sciences Center, Denver, CO
A. King, MD, M. Wheeler, MD, and L. Sullivan, PhD Objectives: To determine 1) the rate of positive markers of intraamniotic infection (IAI) in women with preterm labor (PTL) undergoing amniocentesis (AMNIO), 2) the outcomes of pregnancies with positive markers of IAI, 3) whether management was altered based on results, and 4) the rate of rupture of membranes (ROM) following AMNIO. Study design: Our policy was to perform AMNIO on afebrile women with PTL if there was 1) no response to tocolysis, 2) maternal/fetal signs of IAI, or 3) advanced cervical dilation (⬎ 3 cm, ACD), or if fetal lung maturity (FLM) needed to be checked. Cases were identified from 1998 to 1999 by ICD-9 codes. Cases were excluded for fever or ROM before AMNIO. Results: Of the 65 women who were included, 63% received antibiotics before the AMNIO. The mean gestational age (GA)
Tuesday Posters 47S
at AMNIO was 33.1 weks, and the mean GA at delivery was 34.1 weeks. The primary indications for AMNIO were FLM (52%), no response to tocolysis (26%), maternal signs (18%), and ACD (1.5%). There were 2 positive cultures (3%), 2 positive Gram stains (3%), 8 patients with white blood cell count of more than 50/uL (12%), 13 patients with glucose less than 15 (20%), and 24 patients with glucose less than 20 (37%). Only glucose less than 15 was associated with positive cultures (P ⫽ 0.04). No positive marker of IAI was associated with abruption, meconium, clinical chorioamnionitis, respiratory distress syndrome, or sepsis. Management was changed based
on AMNIO results in 25 cases (39%). ROM followed AMNIO in 14% (mean 1.7 days, maximum 4 days). If ROM occurred, 66% delivered within 48 hours. Conclusions: The rate of IAI was low, and no marker of IAI was associated with neonatal morbidity. These findings may be a result of our use of antibiotics before AMNIO, our culture technique, or changes in obstetric management based on our findings. The 14% risk of ROM was higher than expected. The role of AMNIO in PTL is unclear. A randomized controlled trial is needed to address efficacy and safety of AMNIO in PTL in afebrile women.
UROGYNECOLOGY
Are Women With Urogenital Atrophy Symptomatic?
An Alternative Approach to the Repair of Cystoceles and Rectoceles
G. Willy Davila, MD
Elizabeth Graul, MD
Cleveland Clinic Florida, Fort Lauderdale, FL
Ifi Karapanagiotou, MD, Sherry Woodhouse, MD, Anita Singh, Karen Huber, Steven Zimberg, MD, and Jeffrey Seiler, MD
Phase II Center for Women’s Health, Salt Lake City, UT
Barbara Hurst, MD Purpose: We present an alternative approach to repair severe or recurrent central anterior wall defects and high posterior wall defects. Background: Pelvic prolapse is one of the most common problems with which a gynecologist deals. One in nine women in the United States suffers from prolapse. Of those who undergo surgery, 25–30% will have a recurrence. It long has been recognized that the patient tissue available for repair often is less than optimal. Implantable material was used as early as 1955 in an attempt to improve the strength and longevity of the repair. Unfortunately, these materials often resulted in infection, sinus formation, or erosion. A better understanding of anatomy has improved our ability to recognize and repair these defects, especially paravaginal defects in the anterior compartment and site-specific defects in the posterior compartment. However, severe or recurrent central anterior defects and high posterior (Level I) defects have little or no supportive tissue to use in the repair. Results and Conclusions: Fifty women have undergone this alternative procedure to repair cystocele and rectocele from January through October 2000, using donor collagen. The use of donor collagen in the repair of these defects has resulted in no infections or erosions, and there has been no evidence of recurrence during our initial follow-up.
48S Tuesday Posters
Objective: To correlate the physical findings of urogenital atrophy, an inevitable consequence of menopause, with symptoms suggestive of atrophic vaginitis. Methods: Women presenting for routine outpatient gynecologic care were asked to complete a five-item questionnaire regarding the presence and severity (0 –3) of vaginal atrophy symptoms. They underwent a pelvic examination recording vaginal mucosal changes and severity (0 –3), including pH. Symptoms and physical findings were averaged for an overall score of 0 –3. A vaginal sidewall cytologic maturation index (MI) was performed (range 0 –100). Symptoms were correlated with mucosal changes, pH, and MI, using Spearman rank correlation. Results: Sixty-nine women, mean age 66 (range 23– 89) were enrolled. Symptom scores were surprisingly low, mean 0.36 (range 0 –2.6). Symptom scores were poorly correlated with age (0.35) and physical findings (0.35) but not with MI (– 0.04). There was a moderate correlation between physical examination and MI (– 0.49). Low pH correlated well with high MI. Women on estrogen therapy had higher symptom (P ⫽ 0.0097) and physical finding (P ⫽ 0.0311) scores. Conclusions: Although urogenital atrophy occurs universally after menopause, most elderly women are minimally symptomatic. Symptoms alone should not guide initiation of therapy.
Obstetrics & Gynecology