Are post dates primigravid patients with an unengaged vertex at a higher risk of cesarean delivery
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662 PERSISTENT OCCUPIT POSTERIOR POSITION: PREDICTORS AND OUTCOMES YVONNE CHENG 1 , BRIAN SHAFFER 1 , AARON B. CAUGHEY 1 , 1 University of California, San Francisco, Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California OBJECTIVE: To examine predictors of persistent occiput posterior position at delivery and its associated obstetric outcomes. STUDY DESIGN: This is a retrospective cohort study of 28,884 term, cephalic, singleton births. Persistent occiput posterior (OP) position at delivery was compared to occiput anterior (OA) position. Potential confounders including maternal age, weight, ethnicity, parity, gestational age, anesthesia, induction and length of labor were controlled for using multivariate logistic regression. RESULTS: In the study population, the overall frequency of persistent OP position was 8.6%, 10.8% in nulliparas and 6.1% in multiparas (P ! .001). When compared to Caucasians, a higher rate of OP was observed in African- Americans (OR = 1.44, P ! .001), while no other ethnic differences were noted. Other positive predictors of OP included increased maternal age, gestational age, and birthweight, as well as nulliparity, artificial rupture of the membranes (AROM), and epidural anesthesia (P ! .001 for all predictors). OP is associated with higher rates of operative deliveries and other peripartum complications (Table). CONCLUSION: Positive predictors of persistent OP position include African- American ethnicity, nulliparity, increasing maternal age, gestational age, birth- weight, epidural and AROM. Persistent OP is associated with higher rates of perinatal complications. This information can be used to counsel patients in labor regarding these risks. *P ! .001 for OA/OP comparisons Outcomes OA position OP position Adjusted OR SVD 79.6 % 25.5 % d Op vag 15.7 % 25.6 % 3.7, P ! .001 CS 4.7 % 48.9 % 13.8, P ! .001 PPH 14.2 % 31.8 % 1.2, P = .01 3rd/4th lacs 10.2 % 23.7 % 1.4, P ! .001 Chorio 4.5 % 15.8 % 2.2, P ! .001 Endo 1.6 % 9.1 % 1.1, P = .37 663 EXCESSIVE WEIGHT GAIN AFFECTS VBAC SUCCESS GABOR JUHASZ 1 , CYNTHIA GYAMFI 2 , KRISTINA TOCCE 2 , JOANNE STONE 2 , 1 University of Debrecen, Medical and Health Science Center, Department of Obstetrics and Gynecology, Debrecen, Hungary, Hungary, 2 Mount Sinai School of Medicine, Dept. of Obstetrics, Gynecology and Reproductive Sciences, New York, New York OBJECTIVE: To determine if excessive weight gain in pregnancy is a risk factor affecting success for vaginal birth after cesarean (VBAC). STUDY DESIGN: Patients attempting VBAC were identified using the ICD-9 codes ‘‘VBAC’’ and ‘‘non-primary C-section’’ and by reviewing logbooks on Labor and Delivery. A chart review identified 1216 patients attempting VBAC, of which 877 were eligible for inclusion. Exclusion criteria included multiple gestation, more than one previous cesarean section, previous classical uterine scar, delivery at !36 weeks, and patients where information was incomplete. Patients were divided into the following categories: underweight (BMI !19.8), normal weight (BMI 19.8-26), overweight (BMI 26-29) and obese (BMI >29). Excessive weight gain was defined as >40 lbs for BMI !19.8; >35 lbs for BMI 19.8-26; >25 lbs for BMI 26-29; and >15 lbs for BMI >29. If BMI could not be calculated, excessive weight gain was defined as >40 pounds. Variables of interest included diabetes, previous successful vaginal delivery or VBAC, and presence of recurrent indication for C-section. RESULTS: The overall success rate for VBAC was 70.4%. As the BMI increased, the VBAC success rate decreased. For BMI !19.5, the VBAC success rate was 78% while it decreased to 58% if the BMI was >29 (P ! .001). VBAC success also decreased from 73% to 60% if a patient had excessive weight gain (P = .003). Patients with complications, diabetes, without a previous NSVD, with recurrent indications for cesarean section, or with infants weighing >4000 g were less likely to be successful. The overall uterine rupture rate of 1.6% was more common in the average weight patients. CONCLUSION: Excessive weight gain during pregnancy and obesity both decrease VBAC success. Other factors such as diabetes, birth weight, and indication for the previous cesarean section also influence VBAC outcomes. Proper patient selection will help to increase the likelihood of successful VBAC. 664 PROGESTERONE RECEPTOR ISOFORMS (A/B) RATIO OF HUMAN FETAL MEMBRANE INCREASES DURING TERM PARTURITION SOO-YOUNG OH 1 , IN-SOOK PARK 1 , CHONG JAI KIM 2 , ROBERTO ROMERO 1 , SOON-SUP SHIM 1 , YOO-KYUNG SOHN 1 , HEE CHUL SYN 1 , BO HYUN YOON 1 , 1 Seoul National University College of Medicine, Obstetrics and Gynecology, Seoul, Korea, South Korea, 2 Seoul National University College of Medicine, Pathology, Seoul, Korea, South Korea OBJECTIVE: The role of progesterone in the control of human parturition remains unsettled. Since there is no systemic progesterone withdrawal before the onset of labor, a ‘functional progesterone withdrawal’ has been proposed to be operative before human parturition. This could be accomplished by a change in the density of progesterone receptor (PR) isoforms in the myometrium and fetal membranes. An increase in PR-A near term could block the ‘pro-gestational’ properties of progesterone mediated through PR-B. The purpose of our study is to determine if spontaneous term labor is associated with changes in PR isoforms (PR-A and PR-B) in fetal membranes. STUDY DESIGN: Fetal membranes were obtained from women undergoing elective cesarean delivery at term (no labor group) and from women with a vaginal delivery (labor group). Amnion and chorion-decidua were separated. The expression of PR isoforms was assessed by Western blot analysis of amnion and chorion-decidua. Densitometric analysis of PR-A/PR-B ratio was per- formed. Non-parametric statistics were used for analysis. RESULTS: (1) The predominant isoform of PR was PR-B in no labor group and PR-A in labor group. The ratio of PR-A/PR-B in amnion was significantly higher in labor group than in no labor group (labor group: 11.6 G 8.0 [mean G SEM]; no labor group: 1.2 G 0.4 [mean G SEM]; P ! .05); (2) Human amnion expressed both types of PR. CONCLUSION: Human parturition at term is associated with changes of PR isoforms in the amnion and thus a local ‘functional progesterone withdrawal’ may operate in human parturition through this mechanism. 665 ARE POST DATES PRIMIGRAVID PATIENTS WITH AN UNENGAGED VERTEX AT A HIGHER RISK OF CESAREAN DELIVERY NAVEED KHAWAJA 1 , TOM WALSH 1 , PAUL BYRNE 1 , MICHAEL GEARY 1 , 1 Rotunda Hospital, Obstetrics and Gynaecology, Dublin, Ireland OBJECTIVE: The purpose of this study was to establish if an unengaged vertex increases the risk of cesarean delivery in primigravid patients whom are 41 weeks gestation or more. STUDY DESIGN: A retrospective observational study looking at primigravid patients, 41 weeks gestation or more, cephalic presntation with an unengaged vertex. Patients undergoing both spontaneous labor and induced labor were included. Any patients who had an caesarean section before labor were excluded from this study. Data collection was via a computerised database. Data was analysed using SPSS version 11. RESULTS: In 2003, seven hundred and seventeen primigravid patients were 41 weeks or greaterwere delivered at the Rotunda Hospital Dublin. 38% underwent induction of labor and 62% went into spontaneous labor. 54% of these patients with an unengaged vertex were induced compared with 23% with an engaged vertex (P = ! .001) . 41% with an unengaged vertex underwent a caserean section, whilst only 23% had a cesaerean section with an engaged vertex (P = ! .001). At station-1: 6.5%; station-2: 25%; station-3: 42%; station-4: 56%; and at station-5: the cesarean section rate was 66 % respectively. CONCLUSION: Primigravid patients at 41 weeks or more with an unengaged vertex are more likely to be induced and have an cesarean section than a patient with an engaged vertex. SMFM Abstracts S185
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Transcript of Are post dates primigravid patients with an unengaged vertex at a higher risk of cesarean delivery
662 PERSISTENT OCCUPIT POSTERIOR POSITION: PREDICTORS AND OUTCOMESYVONNE CHENG1, BRIAN SHAFFER1, AARON B. CAUGHEY1, 1University ofCalifornia, San Francisco, Department of Obstetrics, Gynecology andReproductive Sciences, San Francisco, California
OBJECTIVE: To examine predictors of persistent occiput posterior position atdelivery and its associated obstetric outcomes.
STUDY DESIGN: This is a retrospective cohort study of 28,884 term, cephalic,singleton births. Persistent occiput posterior (OP) position at delivery wascompared to occiput anterior (OA) position. Potential confounders includingmaternal age, weight, ethnicity, parity, gestational age, anesthesia, induction andlength of labor were controlled for using multivariate logistic regression.
RESULTS: In the study population, the overall frequency of persistent OPposition was 8.6%, 10.8% in nulliparas and 6.1% in multiparas (P ! .001).When compared to Caucasians, a higher rate of OP was observed in African-Americans (OR= 1.44, P ! .001), while no other ethnic differences were noted.Other positive predictors of OP included increased maternal age, gestational age,and birthweight, as well as nulliparity, artificial rupture of the membranes(AROM), and epidural anesthesia (P ! .001 for all predictors). OP is associatedwith higher rates of operative deliveries and other peripartum complications(Table).
CONCLUSION: Positive predictors of persistent OP position include African-American ethnicity, nulliparity, increasing maternal age, gestational age, birth-weight, epidural and AROM. Persistent OP is associated with higher rates ofperinatal complications. This information can be used to counsel patients inlabor regarding these risks.
*P ! .001 for OA/OP comparisons
Outcomes OA position OP position Adjusted OR
SVD 79.6 % 25.5 % d
Op vag 15.7 % 25.6 % 3.7, P ! .001
CS 4.7 % 48.9 % 13.8, P ! .001
PPH 14.2 % 31.8 % 1.2, P = .01
3rd/4th lacs 10.2 % 23.7 % 1.4, P ! .001
Chorio 4.5 % 15.8 % 2.2, P ! .001
Endo 1.6 % 9.1 % 1.1, P = .37
663 EXCESSIVE WEIGHT GAIN AFFECTS VBAC SUCCESS GABOR JUHASZ1,CYNTHIA GYAMFI2, KRISTINA TOCCE2, JOANNE STONE2, 1University of Debrecen,Medical and Health Science Center, Department of Obstetrics and Gynecology,Debrecen, Hungary, Hungary, 2Mount Sinai School of Medicine, Dept. ofObstetrics, Gynecology and Reproductive Sciences, New York, New York
OBJECTIVE: To determine if excessive weight gain in pregnancy is a riskfactor affecting success for vaginal birth after cesarean (VBAC).
STUDY DESIGN: Patients attempting VBAC were identified using the ICD-9codes ‘‘VBAC’’ and ‘‘non-primary C-section’’ and by reviewing logbooks onLabor and Delivery. A chart review identified 1216 patients attempting VBAC,of which 877 were eligible for inclusion. Exclusion criteria included multiplegestation, more than one previous cesarean section, previous classical uterinescar, delivery at !36 weeks, and patients where information was incomplete.Patients were divided into the following categories: underweight (BMI !19.8),normal weight (BMI 19.8-26), overweight (BMI 26-29) and obese (BMI >29).Excessive weight gain was defined as >40 lbs for BMI !19.8; >35 lbs for BMI19.8-26; >25 lbs for BMI 26-29; and >15 lbs for BMI>29. If BMI could not becalculated, excessive weight gain was defined as >40 pounds. Variables ofinterest included diabetes, previous successful vaginal delivery or VBAC, andpresence of recurrent indication for C-section.
RESULTS: The overall success rate for VBAC was 70.4%. As the BMIincreased, the VBAC success rate decreased. For BMI !19.5, the VBAC successrate was 78% while it decreased to 58% if the BMI was >29 (P ! .001). VBACsuccess also decreased from 73% to 60% if a patient had excessive weight gain(P = .003). Patients with complications, diabetes, without a previous NSVD,with recurrent indications for cesarean section, or with infants weighing >4000 gwere less likely to be successful. The overall uterine rupture rate of 1.6% wasmore common in the average weight patients.
CONCLUSION: Excessive weight gain during pregnancy and obesity bothdecrease VBAC success. Other factors such as diabetes, birth weight, andindication for the previous cesarean section also influence VBAC outcomes.Proper patient selection will help to increase the likelihood of successful VBAC.
664 PROGESTERONE RECEPTOR ISOFORMS (A/B) RATIO OF HUMAN FETAL MEMBRANEINCREASES DURING TERM PARTURITION SOO-YOUNG OH1, IN-SOOK PARK1, CHONGJAI KIM2, ROBERTO ROMERO1, SOON-SUP SHIM1, YOO-KYUNG SOHN1, HEE CHUL SYN1,BO HYUN YOON1, 1Seoul National University College of Medicine, Obstetrics andGynecology, Seoul, Korea, South Korea, 2Seoul National University College ofMedicine, Pathology, Seoul, Korea, South Korea
OBJECTIVE: The role of progesterone in the control of human parturitionremains unsettled. Since there is no systemic progesterone withdrawal before theonset of labor, a ‘functional progesterone withdrawal’ has been proposed to beoperative before human parturition. This could be accomplished by a change inthe density of progesterone receptor (PR) isoforms in the myometrium and fetalmembranes. An increase in PR-A near term could block the ‘pro-gestational’properties of progesterone mediated through PR-B. The purpose of our study isto determine if spontaneous term labor is associated with changes in PRisoforms (PR-A and PR-B) in fetal membranes.
STUDY DESIGN: Fetal membranes were obtained from women undergoingelective cesarean delivery at term (no labor group) and from women witha vaginal delivery (labor group). Amnion and chorion-decidua were separated.The expression of PR isoforms was assessed by Western blot analysis of amnionand chorion-decidua. Densitometric analysis of PR-A/PR-B ratio was per-formed. Non-parametric statistics were used for analysis.
RESULTS: (1) The predominant isoform of PR was PR-B in no labor groupand PR-A in labor group. The ratio of PR-A/PR-B in amnion was significantlyhigher in labor group than in no labor group (labor group: 11.6 G 8.0 [mean GSEM]; no labor group: 1.2 G 0.4 [mean G SEM]; P ! .05); (2) Human amnionexpressed both types of PR.
CONCLUSION: Human parturition at term is associated with changes of PRisoforms in the amnion and thus a local ‘functional progesterone withdrawal’may operate in human parturition through this mechanism.
SMFM Abstracts S185
665 ARE POST DATES PRIMIGRAVID PATIENTS WITH AN UNENGAGED VERTEX ATA HIGHER RISK OF CESAREAN DELIVERY NAVEED KHAWAJA1, TOM WALSH1,PAUL BYRNE1, MICHAEL GEARY1, 1Rotunda Hospital, Obstetrics andGynaecology, Dublin, Ireland
OBJECTIVE: The purpose of this study was to establish if an unengaged vertexincreases the risk of cesarean delivery in primigravid patients whom are 41 weeksgestation or more.
STUDY DESIGN: A retrospective observational study looking at primigravidpatients, 41 weeks gestation or more, cephalic presntation with an unengagedvertex. Patients undergoing both spontaneous labor and induced labor wereincluded. Any patients who had an caesarean section before labor were excludedfrom this study. Data collection was via a computerised database. Data wasanalysed using SPSS version 11.
RESULTS: In 2003, seven hundred and seventeen primigravid patients were 41weeks or greaterwere delivered at the Rotunda Hospital Dublin. 38% underwentinduction of labor and 62% went into spontaneous labor.
54% of these patients with an unengaged vertex were induced compared with23% with an engaged vertex (P = ! .001) . 41% with an unengaged vertexunderwent a caserean section, whilst only 23% had a cesaerean section with anengaged vertex (P = ! .001).
At station-1: 6.5%; station-2: 25%; station-3: 42%; station-4: 56%; and atstation-5: the cesarean section rate was 66 % respectively.
CONCLUSION: Primigravid patients at 41 weeks or more with an unengagedvertex are more likely to be induced and have an cesarean section than a patientwith an engaged vertex.
