ton preganancies between 14-25 6/7 weeks gestation with suspected preterm ... RESULTS: Among 275 patients, 80 had a cerclage placed, (37 twins, 36 ... CONCLUSION: Maternal race, longer cervical length and a past history of PTD help.
SMFM Abstracts
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PREDICTORS OF OUTCOME WITH EXPECTANT MANAGEMENT OF THREATENED PRETERM DELIVERY IN THE 2ND TRIMESTER: RESULTS FROM THE GLOBAL NETWORK FOR PERINATAL AND REPRODUCTIVE HEALTH (GNPRH) INTERNATIONAL COHORT STUDY AMEN NESS1, LEONARDO PEREIRA2, AMANDA COTTER3, VINCENZO BERGHELLA4, RICARDO GOMEZ5, WITOON PRASERTCHAROENSUK6, JUHA RASANEN7, S CHAITHONGWONG-WATTHANA8, S. MITTAL9, SEAN DALY10, JORGE E. TOLOSA11, 1Stanford University Medical Center, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Palo Alto, California, 2OHSU, Portland, Oregon, 3University of Miami, Miami, Florida, 4Thomas Jefferson University, Philadelphia, Pennsylvania, 5Center for Perinatal Diagnosis and Research (CEDIP), Sotero del Rio Hospital, Puente Alto, Chile, 6Khon Kaen University, Khon Kaen, Thailand, 7 University of Oulu, Oulu, Finland, 8Chulalongkorn University, Bangkok, Thailand, 9All India Institute of Medical Sciences, New Delhi, Delhi, India, 10Coombe Women’s Hospital, Dublin, Ireland, 11Oregon Health & Science University, Obstetrics and Gynecology, Portland, Oregon OBJECTIVE: To evaluate predictors of pregnancy and neonatal outcomes of expectantly managed women with 2nd trimester suspected preterm labor and/or dilated cervix STUDY DESIGN: Retrospective multicenter cohort study of women with singleton preganancies between 14-25 6/7 weeks gestation with suspected preterm labor or dilated cervix between 1998-2004. Women with PPROM, cerclage or who terminated pregnancy were excluded. Women were divided into those with visible membranes (VIS) and non-visible membranes (NoVIS) and cervical dilatation (CD) more or less than 4cm. Outcomes studied: median interval from presentation until delivery (ITD) and neonatal survival. 2 and Mann-Whitney, multivariate linear and logistic regression were used. RESULTS: Of 449 women identified, 107 remained after exclusions (97 PPROM, 225 cerclage, 17 termination, 3 no outcome data). Median CD was 2cm and median gestational age (GA) at presentation was 23.3 weeks. Unadjusted median ITD was significantly longer and neonatal survival higher for NoVIS vs VIS [4.4 (0-17.7) vs 0.4 weeks (0-11.7) p⫽.000 and 61.4% vs. 33.3% p⫽.007, respectively]. After controlling for GA, race, tocolytics, steroids and prior PTB, NoVIS p⫽.015 and CD p⫽.003 were independently associated with greater ITD. CD⬍4cm, regardless of membrane status (OR 12.1 95%CI 2.8-51.6), GA at presentation (OR 1.8, 95%CI 1.2-2.7), and black race (OR 3.8 95%CI 1.2-12.7) were all predictive of neonatal survival. CONCLUSION: In a strictly defined cohort of women, non-visible membranes and less cervical dilatation were predictive of a longer ITD. CD was the strongest predictor of neonatal survival regardless of membrane status. This analysis provides data upon which to counsel women with 2nd trimester threatened preterm delivery about their anticipated outcomes with expectant management.
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CLINICAL PREDICTION MODELS FOR CERVICAL CERCLAGE SUCCESS IN MULTIPLE GESTATIONS KATHERINE GOETZINGER1, DAVID STAMILIO2, MICHAEL PAUL2, GEORGE MACONES2, ANTHONY ODIBO2, 1Washington University in St. Louis, Obstetrics and Gynecology, St. Louis, Missouri, 2Washington University in St. Louis, St. Louis, Missouri OBJECTIVE: To determine if cerclage success can be predicted in women with multiple gestations using maternal sociodemographic characteristics, obstetrical history and cervical length (CL). STUDY DESIGN: This is a retrospective cohort study of women with multiple gestations evaluated with transvaginal ultrasound prior to a potential cerclage procedure over a 5-year period. A successful cerclage was defined as delivery after 32 weeks. Bivariate and logistic regression analyses were used to identify predictive variables. The effectiveness of the models was compared using the area under the ROC curves (AUC). RESULTS: Among 275 patients, 80 had a cerclage placed, (37 twins, 36 triplets and 7 quadruplets). Although cerclage did not signifcantly prevent delivery ⬍ 32 weeks compared with those who had no cerclage (RR 1.5, 95% CI, 0.9-2.4), 51/80 (71%) receiving a cerclage delivered ⬎32 weeks. Neonatal mortality was lower in the successful cerclage group (2/147, 2.7%) compared with those without a successful cerclage (16/63, 25%), RR 0.10, 95% CI, 0.03-0.31. The variables in the final predictive model for successful cerclage included white race, CL⬎30mm and past history of PTD (AUC⫽ 0.67). Sub-group analysis restricted to twins or triplets showed similar findings.
WOMEN WITH PREVIOUS PHYSICAL EXAM INDICATED CERCLAGE: WHAT HAPPENS IN THE SUBSEQUENT PREGNANCY? NORIDELLE GILO1, NISHA VYAS1, KIMBERLY HICKEY1, YESMEAN WAHDAN1, ALESSANDRO GHIDINI2, HELAIN LANDY1, SARAH POGGI2, 1 Georgetown University, Washington, District of Columbia, 2Inova Alexandria Hospital, Brock Perinatal Diagnostic Center, Alexandria, Virginia OBJECTIVE: Physical exam (PE) indicated cerclage significantly lowers the risk of severe prematurity in patients with incompetent cervix. The objective of this study was to see how patients with prior PE indicated cerclage fared with prophylactic cerclage in a subsequent pregnancy. STUDY DESIGN: We accessed a prospectively gathered database of patients presenting for cervical cerclage and identified patients with one pregnancy treated with PE indicated cerclage (placed for dilated cervix with visible membranes following amniocentesis to exclude infection) followed by a subsequent pregnancy managed with prophylactic cerclage (placed in early midtrimester prior to cervical dilation). Each woman (N⫽27) served as her own control, and outcomes were compared between the two pregnancies. RESULTS: Not surprisingly, the mean ⫾ SD gestational age (GA) of cerclage placement in the pregnancy requiring PE indicated cerclage was later than that with prophylactic cerclage (20.0 ⫾ 1.5 vs. 14.5 ⫾ 2.3 weeks, P⬍0.001). Rate of PTD ⬍35 weeks in the earlier delivery was significantly higher than in the subsequent pregnancy (63 vs. 26%, P⫽0.006), whereas GA at delivery (29.5 ⫾ 7.6 vs. 34.8 ⫾ 6.6 weeks, P⫽0.008) and birth weight (1691 ⫾ 1270 vs. 2633 ⫾ 1178 grams, P⫽0.007) were lower. GA at the initial delivery (24.6 ⫾ 6.5 vs. 31.2 ⫾ 7.4 weeks, P⫽0.05) but not at initial cerclage placement (19.6 ⫾ 1.4 vs. 20.3 ⫾ 1.7 weeks, P⫽0.36) was associated with subsequent delivery at ⬍35 weeks after prophylactic cerclage. CONCLUSION: Women presenting for prophylactic cerclage following a history of PE indicated cerclage tend to have better obstetric outcomes in the latter pregnancy. The subgroup of patients with PTD ⬍35 weeks despite prophylactic cerclage was more likely to have had a midtrimester delivery with their prior PE indicated cerclage.
DOSE-RESPONSE RELATIONSHIP BETWEEN MATERNAL METHADONE DOSE AND DECREASED NEONATAL HEAD CIRCUMFERENCE EDWARD HAYES1, NEIL SELIGMAN2, KARI HOROWITZ2, MARIE O’NEILL1, BENJAMIN LEIBY3, KEVIN DYSART4, JASON BAXTER1, 1 Thomas Jefferson University, Obstetrics & Gynecology/Maternal Fetal Medicine, Philadelphia, Pennsylvania, 2Thomas Jefferson University, Obstetrics & Gynecology, Philadelphia, Pennsylvania, 3Thomas Jefferson University, Philadelphia, Pennsylvania, 4Thomas Jefferson University/Nemours Foundation, Neonatology, Philadelphia, Pennsylvania OBJECTIVE: To determine if maternal methadone dose is correlated with changes in neonatal head circumference. STUDY DESIGN: Retrospective cohort study of neonates born from 2000-2006 exposed to methadone in utero. Maternal methadone dose was defined by the maintenance dose at time of delivery. Head circumference was measured at birth. A mixed effects linear regression was used to model the association between head circumference and gestational age at delivery, adjusting for those variables found to be significant, and stratified separately by dose at delivery. The adjusted mean head circumference was calculated for each range of methadone levels at gestational ages 28, 32, 36, and 40 weeks, and compared with the mean population head circumference. P-values for these tests were adjusted for multiple comparisons using Bonferroni’s method. RESULTS: 259 neonates were examined (Maternal dose 1-50mg (n⫽17); 51100mg (n⫽76); 101-150mg (n⫽98); 151-200mg (n⫽46); ⬎200mg (n⫽22)) After adjusting for those variables which were found to be significant (race, cocaine, and age),a significant decrease in neonatal head circumference was demonstrated with increased methadone dose in a dose-response relationship (p⫽0.01). See graph. CONCLUSION: Higher maternal methadone dose is associated with a significant decrease in neonatal head circumference.
Maternal methadone dose and neonatal head circumference
Final prediction model for successful cerclage CONCLUSION: Maternal race, longer cervical length and a past history of PTD help predict cerclage success in multiple gestations, but the prediction models had only modest ability to discriminate between those destined for cerclage success or failure.
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.266
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.264
Supplement to DECEMBER 2007 American Journal of Obstetrics & Gynecology
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