SMFM Abstracts S109 359 DO WE NEED ROUTINE COMPLETE BLOOD COUNT EXAMINATION POST PARTUM? SHIR DAR1, EYAL SHEINER2, GERSHON HOLCBERG3, MIRIAM KATZ2, HAIM REUVENI4, RONIT YERUSHALMI5, ILANA SHOHAM- VARDI6, 1Ben-Gurion University Soroka Medical Center, Beer-Sheva, Israel, 2Soroka University Medical Center, BeerSheva, Israel, 3Ben-Gurion University of the Negev, Beer-Sheva, Israel, 4Ben Gurion University, Beer-Sheva, Israel, 5Soroka University Medical Center, Hematology, Beer-Sheva, Israel, 6Ben Gurion University, Epidemiology, Beer-Sheva, Israel OBJECTIVE: Routine post partum complete blood count examination (CBC) is customary at several medical centers. The main purpose of the CBC is to estimate delivery blood loss and to identify patients who need blood transfusion. The present study was aimed to determine the necessity of routine post-partum CBC following vaginal delivery. STUDY DESIGN: A retrospective cohort study, including all consecutive patients who received blood transfusion following vaginal delivery between January 2003 and November 2004, was performed. Indications for blood transfusions were reviewed in birth-files, including obstetric risk factors such as post-partum hemorrhage (PPH) and symptoms of anemia. RESULTS: Out of 20694 vaginal deliveries, 0.7% (n=138) received blood transfusions. All patients had at least one risk factor of PPH or symptomatic anemia (see Table; several patients had more than one risk factor). None of these patients received the blood transfusion based on the post partum hemoglobin level alone. CONCLUSION: Routine post-partum CBC is not warranted in order to identify patient requiring blood transfusions, and may represent old practice based on non evidence-base medicine. Post partum CBC should probably be taken as indicated by risk factors or patients´ complains. This step will save many unnecessary exams.
361 EXTERNAL CEPHALIC VERSION FOR GRAND MULTIPARAS TAMAR ELRAM1, ASSAF BEN-MEIR1, URIEL ELCHALAL1, YOSSEF EZRA1, 1Hadassah University Hospital, Obstetrics & Gynecology, Jerusalem, Israel OBJECTIVE: ECV is considered to be a procedure which is relatively contraindicated in grand-multiparas fearing damage to the worn uterus. We sought to assess the efficacy and risk of external cephalic version for grandmultiparas. STUDY DESIGN: From our database of 603 versions from breech to cephalic presentation, we identified 42 grand-multiparas (at least five prior deliveries). Four women had undergone a previous cesarean section. We summarized the data regarding rate of success and complications during the procedure. Logistic regression analysis was performed looking for a correlation between number of delivery (O1) and success of ECV. RESULTS: Success rate of ECV for grand-multiparas was 69%, no different from the success rate for all multiparas (68%). One woman following a successful version underwent emergent cesarean section due to severe fetal heart-beat decelerations. No other major complications were noted. Twentyfive (87%) of women delivered vaginally following a successful version. Two women delivered vaginally despite failing a trial of ECV. No correlation was found between the number of delivery and success rates of ECV as long women have undergone at least one prior delivery. CONCLUSION: We conclude that external cephalic version is probably not contraindicated for grand-multiparas Distribution of parity amongst ECV patients No. of delivery No. of cases
13 1
12 0
11 1
10 1
9 2
8 6
7 7
6 24
Characteristics of patients who received blood transfusion following vaginal delivery Risk factor
Number
%
Revision of uterine cavity General anesthesia Symptomatic and chronic anemia Post partum hemorrhage Retained placenta Lack of prenatal care Hypertensive disorder Placental abruption Multiple pregnancy Severe perineal tears
52 39 35 34 23 19 13 7 4 3
37.7 27.9 25.4 24.3 16.4 13.6 9.4 5.1 2.9 2.1
360 INDIVIDUALIZED GROWTH POTENTIAL IN TWINS VERSUS SINGLETON MURIEL DORET1, JEAN-CHARLES PASQUIER2, MONICA LONGO3, GEORGE SAADE3, PASCAL GAUCHERAND4, 1University Claude Bernard Lyon, Lyon, France, 2Universite de Sherbrooke, Obstetrics/Gynecology, Sherbrooke, Quebec, Canada, 3 University of Texas Medical Branch at Galveston, Obstetrics and Gynecology, Galveston, Texas, 4Universite Claude Bernard Lyon 1, Obstetrics, Lyon, France OBJECTIVE: Percentile of the Growth Potential (GP) is a proportion of the optimal weight each fetus ought to achieve in the absence of pathological conditions, as compared to its individually-calculated norm rather than population birthweight norms. In singletons, GP has been shown to be a better predictor of neonatal outcomes compared with population norms. Our objective was to compare GP of twins and singletons born at different gestational ages, as well as determine adverse neonatal outcomes in relation to twins´ GP versus population birthweight standards. STUDY DESIGN: Data from 335 consecutive twin pregnancies and 350 gestational age matched singletons were analyzed. Analysis was blocked by gestational age at delivery (!30, 30-34, 34-37, R37 weeks). GP was calculated using the GROW v.5.3 by Gardosi et al. In twins, adverse neonatal outcomes (NICU transfer, death, assisted ventilation, hyaline membrane disease, severe necrotising enterocolitis, severe cerebral damage) were compared between normally grown newborns and those small for gestational age (!10%ile) by GP versus population birthweight standards (AUDIPOG). Univariate and multivariable analysis were used. RESULTS: Twins GP was significantly lower than singleton (24G0.99 vs 46.76G1.66 %; p!0.05), and more twins than singletons had GP!10%ile (adjOR: 4.8; 95%CI 3.3-6.8). The differences in overall GP and GP!10%ile between twins and singletons increased with gestational age at birth but did not reach statistical significance until the 30-34 weeks period. Compared with appropriately grown fetuses, adverse neonatal outcomes of twins were significantly more frequent in the small for gestational age by GP (adjOR: 6.44; 95%CI 3.35-12.37) but not by population standards. CONCLUSION: Growth of twins does not deviate from that of singletons until the 30 to 34 weeks’ gestational period. Compared with population birthweight standards, individualized growth potential increased identification of neonates at risk for adverse outcomes.
362 COMBINED VAGINAL-CESAREAN DELIVERY OF TWIN GESTATIONS: INCIDENCE AND ASSOCIATED CLINICAL FACTORS DEBORAH FELDMAN1, ADAM BORGIDA1, HELENA GRABO1, CHARLES INGARDIA1, 1Hartford Hospital, Obstetrics and Gynecology, Hartford, Connecticut OBJECTIVE: We sought to evaluate the incidence of combined vaginalcesarean delivery of twin pregnancies and to determine whether any clinical factors may help predict the risk for cesarean delivery of twin B after vaginal delivery of twin A. STUDY DESIGN: We reviewed our computerized perinatal database and identified all twin gestations delivered at our institution from 1999-2004. Antepartum fetal deaths and cases where either fetus weighed less than 500 grams were excluded. Review of medical and delivery records was performed. The maternal and obstetrical characteristics of twin pregnancies for women who had a combined vaginal-cesarean were compared to those having only vaginal or cesarean births for both twins. Data were analyzed using Student t-test and Chi-square with Fisher exact test where appropriate. RESULTS: There were 466 sets of twins delivered during the study period. We excluded 5 cases due to fetal death and 4 cases where birth weights were less than 500 grams. Of the remaining, 142 (32%) sets of twins delivered vaginally, 276 (62%) sets delivered by cesarean and 28 (6%) sets with combined vaginal and cesarean birth. The indications for these combined deliveries were: malpresentation of twin B with failed version attempt (14 cases), fetal distress of twin B (7 cases), cord prolapse (5 cases), and dystocia (1 case). The mean gestational age, median parity and incidence of nulliparity were not different between the groups. The rates of preterm birth and birth weight discordance more than 20% were also similar for the groups. Women who had a vaginal delivery for both were significantly younger (30 yrs vs 32 yrs, P=.006). CONCLUSION: The incidence of combined vaginal-cesarean birth for twins was only 6% in our population. We were unable to identify antepartum clinical factors that predicted the need for combined vaginal-cesarean delivery. This may explain recent increases in the primary elective cesarean rate among twin gestations.
