Oral Concurrent Session 2

CLINICAL OBSTETRICS

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.

ajog.org

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).

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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

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