encing access and utilization of Trial of Labor After Cesarean delivery. (TOLAC) and Vaginal Birth After Cesarean (VBAC). As the largest. VBAC center in ...
Poster Session IV
Epidemiology, Global Maternal-Fetal Public Health, Infectious Disease, Intrapartum Fetal Assessment, Operative Obstetrics
673 Inadvertent hysterotomy extension at cesarean delivery and risk of uterine rupture in the next pregnancy Ilona Goldfarb1, Dana Henry1, Olivia Dumont1, William Barth1 1
Massachusetts General Hospital/Harvard Medical School, Boston, MA
OBJECTIVE: We sought to determine the risk of uterine rupture in a
subsequent pregnancy when the previous cesarean section was complicated by an inadvertent extension of the uterine incision STUDY DESIGN: Retrospective cohort study of all women whose primary lower segment cesarean and next delivery both occurred at our hospital between 1994 and 2009. We evaluated the impact of a uterine extension during cesarean delivery on the risk of uterine rupture in the next pregnancy. By definition, an extension had to require additional repair beyond usual closure of the incision and be described as an extension in the medical record. We defined uterine rupture as disruption of the uterine muscle and visceral peritoneum or a separation of the uterine muscle with extension to the bladder or broad ligament or extrusion of placenta, blood or fetal parts. Incidental discovery of dehiscence or uterine window was not considered a uterine rupture. RESULTS: Among 2385 subjects, 271 (11.4%) had an extension of the initial cesarean incision. Among all subjects, the risk of rupture with a prior extension was 5/271 (1.8%) vs 10/2114 (0.48%) without an extension (OR ⫽ 4.0, 95% CI 1.3 – 11.7, p ⫽ 0.01). Adjusted for prior vaginal delivery, puerperal infection at the first cesarean, inter-pregnancy interval and induction or augmentation, a prior extension remained significantly associated with subsequent rupture (OR ⫽ 4.5, 95% CI 1.5 – 13.8). Among those attempting a trial of labor, the risk of uterine rupture with a prior extension was 4/67 (6.0%) compared to 9/599 (1.5%) without extension (OR ⫽ 4.2, 95% CI 1.3 – 14.1, p ⫽ 0.01). Adjusted as above, a prior extension remained significantly associated with uterine rupture during a trial of labor (OR ⫽ 4.1, 95% CI 1.2 – 14.6) CONCLUSIONS: Inadvertent extension of the uterine incision at the time of primary cesarean section is a significant risk factor for uterine rupture during the next pregnancy, especially among those who attempt a trial of labor. Prior hysterotomy extension should be considered when counseling patients about the risks of a trial of labor.
674 Vaginal birth after cesarean: access and safety following quality improvement initiatives Luchin Wong1, James Byrne1, Andrea Jelks1, Anita Sit1, Laura McClellan1, Carolyn Cruz1 1
Santa Clara Valley Medical Center, San Jose, CA
OBJECTIVE: Recent patient safety efforts have focused on factors influ-
encing access and utilization of Trial of Labor After Cesarean delivery (TOLAC) and Vaginal Birth After Cesarean (VBAC). As the largest VBAC center in California, we report TOLAC/VBAC performance after a collaborative quality improvement (QI) effort that included evidence based standardized management and process improvement. STUDY DESIGN: A multidisciplinary QI initiative was implemented in early 2004 with ongoing evaluation that resulted in additional process improvements in May 2007. Using best practice resources from both medical and risk management literature, the initiative targeted medical and non-medical factors contributing to access and safety. Examples of processes improved in 2007 include standardized informed consent, standardized guidelines for management of labor (including induction and use of oxytocin augmentation), and guidelines for physician documentation. Any case of uterine rupture had expedited QA review within 24 hours. Provider education was offered by lectures and electronic communications. System resources for anesthesia and nursing were addressed. Using 2010 NIH definitions, outcomes data was obtained from ICD9 codes, QA records, and chart abstracting and then compared for the 30 month periods both prior to and following the 2007 QI enhancement. RESULTS: Comparing 30-months of base data (Jan ’05-June ’07) to 30-months of data (July ’07-Dec ’09) following QI process refinements in May 2007, we demonstrate high acceptance of TOLAC
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among patients and providers with significantly increased rates for electing TOLAC over time. Safety measures remained within national benchmarks including rates for successful VBAC and for uterine rupture. After May 2007, there were no cases of uterine rupture leading to NICU admission. CONCLUSIONS: An integrated TOLAC/VBAC QI initiative with standardized management and processes was associated with high access and utilization of TOLAC combined with stable/improved safety measures. This supports ongoing QI initiatives that faciliate access to TOLAC for appropriate candidates. TOLAC/VBAC Performance
Total Births
Baseline Jan ’05-June ’07
After Process Improvement Jan ’05-June ’07
14,054
13,262
p
.................................................................................................................................................................................
Eligible for TOLAC 1,428 1,495 NS ................................................................................................................................................................................. Elected TOLAC n (%) 794 (55.6) 903 (60.4) ⬍0.01 ................................................................................................................................................................................. VBAC Success n (%) 642 (80.9) 712 (78.8) .33 ................................................................................................................................................................................. Uterine Rupture n (%)
6 (0.8)
8 (0.9)
NS
..........................................................................................................................................................................................
NICU Admission w/ Uterine 3 (50) 0 (0) ⬍0.01 Rupture n (%) ..........................................................................................................................................................................................
675 Cervical cerclage: one stitch or two? Jennifer McNamara1, Methodius Tuuli1, Jeanine Carbone1, Mahmoud Ismail2, George Macones1, Anthony Odibo1 1 Washington University in St. Louis, St. Louis, MO, 2University of Chicago, Chicago, IL
OBJECTIVE: While multiple trials have assessed the efficacy of cerclage, there is little information regarding technical aspects of the procedure. We sought to determine whether routine placement of a second stitch at the time of cervical cerclage improves its efficacy. STUDY DESIGN: This is a retrospective cohort study of patients who had cervical cerclage placement between Jan 2003 and Dec 2009 at a single institution. Operative reports were examined for indication and number of stitches placed. Ultrasound images were reviewed for pre-cerclage cervical length and post-cerclage cerclage height (defined as distance from external os to the most superior cerclage stitch). The primary outcome was spontaneous preterm delivery ⬍35wks. Secondary outcomes were spontaneous preterm delivery ⬍37wks and 24wks, cerclage height, chorioamnionitis, premature rupture of membranes (PROM), and perinatal death. Univariable, multivariable and Kaplan-Meier survival analysis were used to compare pregnancy outcomes among women with one stitch and two stitches. A priori power analysis showed that 59 patients were needed in each group for 80% power to detect a 3-fold decrease in preterm delivery ⬍ 35 weeks from a baseline rate of 30% (␣ ⫽ 0.05). RESULTS: Of 146 patients identified, 63 had two stitches while 83 had one stitch placed. Baseline characteristics and indications for cerclage in the two groups were similar except for differences in history of prior cerclage and multiple gestation. Over the study period, there was a trend in favor of the two stitch approach (2 for trend, p⬍0.005). The two-stitch approach was associated with a greater cerclage height despite similar pre-cerclage cervical length, but there was no difference in spontaneous preterm delivery ⬍35wks (47.6% vs 41.0 %, aOR 0.99 95% CI 0.48 – 2.02). There were also no differences in the survival curves for the two groups (log-rank p⫽0.57) and no differences in any of the other secondary outcomes (Table). CONCLUSIONS: A two-stitch approach to cervical cerclage increases cerclage height, but does not improve efficacy.
American Journal of Obstetrics & Gynecology Supplement to JANUARY 2011
www.AJOG.org
Epidemiology, Global Maternal-Fetal Public Health, Infectious Disease, Intrapartum Fetal Assessment, Operative Obstetrics
Two Stitch
One Stitch
aOR (95% CI)
p-value
Primary outcome
..........................................................................................................................................................................................
Spontaneous Delivery 30 (47.6%) 34 (41.0%) 0.99 (0.48-2.02) 0.973 ⬍35weeks .......................................................................................................................................................................................... Secondary outcomes
..........................................................................................................................................................................................
Spontaneous Delivery 38 (60.3%) 39 (47%) 1.15 (0.55-2.39) 0.703 ⬍37weeks .......................................................................................................................................................................................... Spontaneous Delivery 7 (11.1%) 7 (8.43%) 1.14 (0.37-3.52) 0.808 ⬍24weeks .......................................................................................................................................................................................... Chorioamnionitis 9 (14.2%) 17 (20.5%) 0.59 (0.20-1.45) 0.248 .......................................................................................................................................................................................... PPROM 37 (58.7%) 39 (47%) 1.07 (0.52-2.22) 0.160 .......................................................................................................................................................................................... Perinatal Death 10 (15.9%) 8 (9.6%) 1.44 (0.56-4.31) 0.386 .......................................................................................................................................................................................... Cerclage Height (mm) 20.4 ⴞ 0.72 18 ⴞ 0.54 0.007 .......................................................................................................................................................................................... Mean cerclage-to118 ⫾ 6.78 123 ⫾ 0.59 0.609 delivery Interval (days) ..........................................................................................................................................................................................
676 Robotic-assisted laparoscopic transabdominal cerclage in the non-pregnant patient Katherine McHugh1, Elizabeth Moore2, James Sumners2 1 Indiana University School of Medicine, Indianapolis, IN, 2St. Vincent Women’s Hospital, Indianapolis, IN
OBJECTIVE: To present our experience with robotic-assisted laparoscopic transabdominal cerclage (RA-LTAC) in the non-pregnant patient. STUDY DESIGN: All RA-LTAC procedures performed on non-pregnant patients, by one maternal-fetal medicine specialist are included in this case series. The procedure was offered to women based on their medical and obstetrical history, desire for future pregnancy, and clinical and ultrasound evaluation of the cervix. RESULTS: Nine patients underwent the procedure and had a mean age of 33 years and body mass index of 30.5 kg/m2. All had at least one pregnancy loss with evidence of cervical insufficiency as a probable cause. Two patients had a failed vaginal cerclage before the placement of the RA-LTAC, while one patient had a damaged cervix from a previously successful transvaginal cerclage. The only surgical complication was an intraoperative decision to convert to laparotomy due to inability to adequately insufflate the peritoneal cavity. The remaining eight procedures were uncomplicated and all recovered well. The median estimated blood loss was 100 mL (range: 25-150 mL). Anesthesia time, surgeon console time, and total procedure times were consistent across the eight completed cases. The mean times were 165⫾17 minutes, 59⫾5 minutes, and 70⫾5 minutes, respectively. Two patients were discharged at their request on the day of surgery with the remainder discharged the next day. All patients reported satisfactory postop-
Poster Session IV
erative pain control, with many not filling their post-surgery analgesic prescription. As of this writing, two patients achieved pregnancy and have not experienced any complications. CONCLUSIONS: Based on our experience, the RA-LTAC holds promise for women with incompetent cervix and/or a history of previous pregnancy loss. Anesthetic and operative times do not appear to be excessive. However, there remains much research to be done on the benefit of robotic assistance in transabdominal cerclage placement in order to determine if the benefits outweigh the costs and potentially increased anesthesia time of the robot, especially for the pregnant patient.
677 Techniques for wound closure at caesarean section: a randomized controlled trial Irene de Graaf1, Katrien Oude Rengerink2, Irene Wiersma1, Marielle Donker1, Eva Pajkrt3, Ben Willem Mol2 1
Spaarne Hospital, Hoofddorp, 2Academic Medical Center, Amsterdam, 3Academic Medical Centre, Amsterdam
OBJECTIVE: Caesarean section (CS) is the most common operation in obstetrics. It is unclear which technique for skin closure results in the best long term cosmetic outcome. We assessed the cosmetic outcome of different techniques for skin closure after CS. STUDY DESIGN: We performed a two centre randomized controlled trial among women undergoing their first CS. In a factorial design, women were randomly allocated to (I) closure versus non-closure of the fat layer, and (II) stitches or staples for skin closure. The primary outcome was the cosmetic result six months after CS, assessed by both a blinded observer and the patient using the Patient and Observer Scar Assessment Scale (PSAS and OSAS). Secondary outcomes were postoperative pain, wound complications and operation time. RESULTS: We included 136 women. As there was no interaction between type of closure of the fat layer and type of skin closure, we report their effects independently. When the skin had been closed with stitches 39 (63%) women judged the scar as satisfactory, versus 38 (63%) when closed with staples (RR 1.0 95% CI 0.64 to 1.6). The OSAS did also not differ between the groups (RR 0.94; 95% CI 0.38 to 2.3). When the fat layer had been closed subcutaneously, 33 (52%) patients scored the scar as satisfactory, versus 44 (75%) in the nonclosure group (RR 0.53; 95% CI 0.32-0.89). There was no significant difference between the groups as scored by the observers (RR 1.3, 95% CI 0.53 to 3.3). Thickness of the subcutaneous fat layer did not affect the outcome (⬎3/ⱕ3 cm, p-value for interaction 0.64). Wound complications (N⫽3, 2.4%) and general complications (N⫽8, 6.3%) were not different between the groups. Subcutaneous closure resulted in slightly longer hospital admission time than no closure (median 4 days, IQR 3-5 versus median 3 days, IQR 3-5; p⫽0.023). There were no differences in pain scores. CONCLUSIONS: The use of staples or stitches does not affect the long term cosmetic result after a caesarean section. Since we did not find any benefit of closing the subcutaneous fat layer, we recommend it should be not closed.
678 Do adhesions at repeat cesarean delay delivery of the newborn? Mara Greenberg1, Kay Daniels1, Yair Blumenfeld1, Aaron Caughey2, Deirdre Lyell1 1 Stanford University School of Medicine/Lucile Salter Packard Children’s Hospital, Stanford, CA, 2Oregon Health & Science University, Portland, OR
OBJECTIVE: To determine whether adhesions at first repeat cesarean delivery predicts skin incision to neonatal delivery times. STUDY DESIGN: This is a secondary analysis of a prospective cohort study of women who underwent a first repeat CD. Immediately following a first repeat cesarean delivery, surgeons scored the severity and location of adhesions. Surgeons were asked to categorize adhesions as none, filmy, or dense, and to identify their presence among specified locations including uterus, fascia, omentum, bowel, and “other”. We then summed weighted scores for each patient based on the presence and type of adhesions at each site: 0 (no adhesions),
Supplement to JANUARY 2011 American Journal of Obstetrics & Gynecology
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