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Placenta previa is increasing, occurring in 1.3% of pregnancies, and is associated with maternal morbidity. Although the literature has focused on the morbidity associated with concurrent placenta accreta,
Placenta previa is increasing, occurring in 1.3% of pregnancies, and is associated with maternal morbidity. Although the literature has focused on the morbidity associated with concurrent placenta accreta,
Placenta previa is increasing, occurring in 1.3% of pregnancies, and is associated with maternal morbidity. Although the literature has focused on the morbidity associated with concurrent placenta accreta,
24 Twin birth study: 2-year follow-up of the randomized
trial comparing planned cesarean vs planned vaginal delivery for twin pregnancy Elizabeth Asztalos1, Mary Hannah1, Eileen Hutton2, Andrew Willan1, Alexander Allen3, Anthony Armson3, Amiram Gafni2, K. S. Joseph4, Arne Ohlsson1, Susan Ross5, Jon Barrett1 1 University of Toronto, Toronto, ON, Canada, 2McMaster University, Hamilton, ON, Canada, 3Dalhousie University, Halifax, NS, Canada, 4 University of British Columbia, Vancouver, BC, Canada, 5University of Alberta, Edmonton, AB, Canada
OBJECTIVE: The Twin Birth Study enrolled women with uncomplicated
twin pregnancies, between 32 and 38 weeks gestation where the rst twin was in cephalic presentation, who were randomized to a policy of either a planned caesarean or planned vaginal delivery. A planned caesarean delivery did not increase or decrease the risk of fetal or neonatal death or serious neonatal morbidity as compared with a planned vaginal delivery. A secondary outcome for the trial was a composite of death or neurodevelopmental delay at 2 years of age. This report presents the 2-year outcomes of the Twin Births Study. STUDY DESIGN: A total of 4603 children (83% of the 5565 fetuses eligible from the initial trial) contributed to the outcome of death or neuro-developmental delay at 2 years of age. Surviving children were screened using the Ages and Stages Questionnaire. Abnormal scores were validated by a Clinical Neuro-developmental Assessment to conrm the presence or absence of a delay. The outcome of death or neuro-developmental delay was compared between the treatment groups with a logistic model to control for stratication variables and using generalized estimating equations to account for the nonindependence of twin births. RESULTS: Baseline maternal, pregnancy, and infant characteristics were similar between the two groups. The mean age at assessment was between 25-26 months. There was no signicant difference in the outcome of death or neuro-developmental delay: 5.99% in the planned caesarean vs. 5.83% in the planned vaginal delivery group [OR 1.04, 95% CI 0.77, 1.41, p 0.79]. CONCLUSION: A policy of planned caesarean delivery provides no signicant benet in children at 2 years of age compared with a policy of planned vaginal delivery in uncomplicated twin pregnancies between 32 and 38 weeks gestation where the rst twin is in cephalic presentation.
25 Optimal evaluation for stillbirth: Stillbirth Collaborative
Research Network Jessica M. Page1, for the SCRN of the Eunice Kennedy Shriver NICHD2 1
University of Utah, Salt Lake City, UT, 2NICHD, Bethesda, MD
OBJECTIVE: The optimal evaluation for the determination of the
cause of stillbirth remains uncertain. The cost of extensive evaluation
has to be weighed against the diagnostic yield. Thus, our objective was to determine the usefulness for each diagnostic test in the work-up for potential causes of stillbirth.
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STUDY DESIGN: Secondary analysis of 483 stillbirths enrolled in the
Stillbirth Collaborative Research Network (SCRN) from 2006 - 2008. The SCRN was a prospective, multisite, geographically, racially and ethnically diverse, population-based study of stillbirth in the U.S. Cases underwent standard evaluation that included maternal interview, medical record abstraction, biospecimen collection, postmortem examination, and placental pathology. Also, a clinically recommended work-up was recommended that included karyotype, toxicology screen, syphilis serology, antibody screen, Kleihauer-Betke, and testing for antiphospholipid syndrome (APS). In addition, additional testing was performed on biospecimens for research purposes. Each case was assigned probable and possible causes of death using the INCODE classication system. Tests were considered useful if a positive result established (or helped to establish) a cause of death or a negative result excluded a cause of death that was suspected based on the clinical history or other results. RESULTS: Tests for possible causes of stillbirth were useful as follows: Placental pathology 55.9%, postmortem examination 34.4%, karyotype 5.2%, testing for APS 4.1%, Kleihauer-Betke 1.9%, syphilis 0.2%, antibody screen 0%, toxicology screen 0.2%, and parvovirus 0.4%. Based on cause of death some tests were more useful when performed in a reexive manner (i.e. based on ndings from placental pathology and postmortem exam) such as tests for antiphospholipid syndrome, Kleihauer-Betke, parvovirus, syphilis and toxicology screen. CONCLUSION: The most useful tests were placental pathology and postmortem examination, followed by karyotype and testing for APS.
26 Quantifying maternal morbidity associated with
placenta previa Karen J. Gibbins1, Michael W. Varner1, Robert M. Silver1 1
University of Utah Health Sciences and Intermountain Healthcare, Salt Lake
City, UT
OBJECTIVE: Placenta previa is increasing, occurring in 1.3% of
pregnancies, and is associated with maternal morbidity. Although
the literature has focused on the morbidity associated with concurrent placenta accreta, the morbidity of previa in the absence of accreta with contemporary management is not well described. Hence, our purpose was to characterize maternal morbidity associated with placenta previa. STUDY DESIGN: Secondary analysis of the Maternal-Fetal Medicine Units Network Cesarean Registry including women undergoing cesarean delivery. Cohorts were those with previa compared to those without previa. Women with placenta accreta were excluded. Maternal hemorrhagic morbidity included mortality, blood product transfusion, atony requiring uterotonics, uterine/hypogastric artery ligation, hysterectomy, coagulopathy, exploratory laparotomy, and ICU admission. Severe maternal morbidity was dened as ICU admission or receipt of 4 units of blood products. Cohorts were compared using Wilcoxon rank sum test, chi-square test, and risk ratios (RRs). RRs were adjusted with poisson multivariable regression determined by backwards-stepwise elimination. RESULTS: 501 women with previa were compared to 53,957 women without. Maternal hemorrhagic morbidity was higher with previa (19 vs 5%; aRR 2.9, 95% CI 2.2-3.9) (Table 1). Severe maternal morbidity was increased with previa (3 vs 1%) in univariate but not multivariable analysis. Women with previa had increased use of uterotonics (11 vs 4%, aRR 3.6), red blood cell transfusion (13 vs 2%, aRR 4.0), and hysterectomy (2 vs 0.2%, aRR 4.9). Women with previa also had a larger hemoglobin drop (2.3 g/dL vs 1.7 g/dL, p<0.001) and higher rate of 4 units red cells transfused (2.2 vs 0.6%, aRR 2.9 [1.1-8.0]). More women with previa had emergent delivery (24 vs 13%) but this did not persist after adjustment, aRR 1.2 (0.9-1.5).
S18 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2016
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CLINICAL OBSTETRICS
CONCLUSION: Almost 20% of women with previa but no accreta had
hemorrhagic morbidity. 3% had severe morbidity and 2% required hysterectomy. These data are useful in counseling women with placenta previa.
Oral Concurrent Session 2
among them, 36.7% of nulliparous and 57.4% of multiparous
delivered vaginally. Only 1.4% of nulliparas and 0.3% of multiparas remained in latent labor after 18+ hrs. Maternal morbidity increased regardless of parity with longer latent phase (Figure 2). Chorioamnionitis was signicantly higher in both nulliparas and multiparas after 6, 9, 12, and 18+ hrs. Endometritis was signicantly higher in nulliparas after 6, 9, and 12 hrs. PPH was signicantly higher in nulliparas after 6 and 9 hrs, and in multiparas after 12 hrs. Neonatal morbidity was not associated with duration of oxytocin and ROM in latent labor. CONCLUSION: After 18 hours of oxytocin and ROM, 98.6% of nulliparas and 99.7% of multiparas delivered. Although maternal morbidity was associated with duration, neonatal morbidity was not increased. Our data support oxytocin administration after ROM for at least 12-18 hrs before considering an induction as failed as long as maternal and fetal condition allows.
27 Evaluation of failed induction of labor
Tetsuya Kawakita1, Sara N. Iqbal1, Uma M. Reddy1, Helain J. Landy2, Chun-Chih Huang3, Matthew Hoffman4, Anthony C. Sciscione4, Katherine L. Grantz1 1
MedStar Washington Hospital Center, Washington, DC, 2MedStar
Georgetown University Hospital, Washington, DC, 3MedStar Health Research Institute, Hyattsville, MD, 4Christiana Care Health System, Newark, DE
OBJECTIVE: Data are limited for determining the denition of failed
induction. We evaluated maternal and neonatal morbidity according
to duration of oxytocin administration in latent labor after rupture of membranes (ROM). STUDY DESIGN: In the Consortium of Safe Labor study (2002-2008), we included 9,772 nulliparas and 8,698 multiparas with singleton deliveries 37 weeks undergoing induction with cervix 2 cm dilation. Latent labor was dened as last cervical examination <6 cm in nulliparas and <5 cm in multiparas. Vaginal delivery (VD) rates, maternal morbidity (chorioamnionitis, endometritis, and postpartum hemorrhage [PPH]) and neonatal morbidity (neonatal intensive care unit [NICU] admission, NICU stay longer than 72 hours (hrs), continuous positive airway pressure, and neonatal sepsis) were evaluated for women who were in latent labor after 6, 9, 12, and 18+ hrs of oxytocin and ROM. RESULTS: After 6 hrs, 54% of nulliparas and 85% of multiparas entered active labor. Duration of latent labor was associated with lower VD rates (Figure 1). Only 6.5% of nulliparas and 1.1% of multiparas remained in latent labor after 12 hrs;
28 Variation in primary cesarean delivery rates by
individual physicians within a single hospital laborist model Torri Metz1, Amanda A. Allshouse2, Sara Babcock3, Reina Doyle1, Angie Tong1, J. Christopher Carey1 1 Denver Health Medical Center, Denver, CO, 2Colorado School of Public Health, Aurora, CO, 3University of Colorado School of Medicine, Aurora, CO
OBJECTIVE: Laborist practice models are associated with lower ce-
sarean delivery (CD) rates than private practice models. Our
objective is to evaluate the degree of variation in primary CD rates by
Supplement to JANUARY 2016 American Journal of Obstetrics & Gynecology