417: Fetoscopic entry technique affects the rate of preterm membrane rupture and preterm birth...
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intervention and delivery of the fetus from an unfavourable intrauter- ine environment. N (%) adjOR 95% CI PAR FGR 6865 (13.9) 9.46 7.27-12.3 54.1 .......................................................................................................................................................................................... Afr Amer 10174 (20.6) 2.11 1.61-2.77 18.6 .......................................................................................................................................................................................... BMI >30 11359 (23.0) 1.38 1.05-1.82 8.1 .......................................................................................................................................................................................... PROM 1136 (2.3) 4.35 2.86-6.63 7.0 .......................................................................................................................................................................................... PTL 4050 (8.2) 1.92 1.34-2.76 7.0 .......................................................................................................................................................................................... Abrupt 3457 (0.7) 8.72 5.20-14.61 5.1 .......................................................................................................................................................................................... HTN disease 3704 (7.5) 0.53 0.32-0.87 3.7 .......................................................................................................................................................................................... 0002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.581 416 Predictors of need for extracorporeal membrane oxygenation (ECMO) and survival in congenital diaphragmatic hernia (CDH): a centers’ 10-year experience Anthony Odibo 1 , Tasnim Najaf 2 , Akshaya Vachharajani 2 , Barbara Warner 2 , Amit Mathur 2 , Brad Warner 2 1 Washington University in St. Louis, St. Louis, Missouri, 2 St Louis Children’s Hospital, St. Louis, Missouri OBJECTIVE: To determine prenatal factors associated with a need for ECMO and neonatal survival in CDH. STUDY DESIGN: A retrospective cohort study of all cases of CDH seen in our Center between 1998 and 2008. Prenatal ultrasound and neonatal records were reviewed. Both univariable and logistic regression anal- yses were performed to determine significant factors associated with the need for ECMO and survival. RESULTS: Among 107 live born infants with CDH seen during the study period, 62 were evaluated prenatally in our Center and 49 had information on all variables evaluated. The overall rate of ECMO use was 27/107 (25%) and survival rate 53/107 (49.5%). Significant fac- tors* associated with ECMO use and survival are shown (Table). The lung area to head circumference ratio (LHR) and gestational age (GA) at delivery were the only significant factors associated with ECMO use, and the LHR and absence of liver herniation were significantly asso- ciated with survival. LHR values under 1.0 were associated with a 57% need for ECMO and 100% neonatal death. Although overall the Ob- served:Expected LHR (O:E LHR) was not significantly associated with the need for ECMO or survival, levels below 65% was associated with 58% need for ECMO (p0.004) and 100% neonatal death (p0.002). CONCLUSION: The study confirms the LHR, GA at delivery and liver herniation as significant prenatal predictors of the need for ECMO or survival in cases with CDH. This information is helpful for counseling women with fetuses complicated by CDH. ECMO (adjOR, 95% CI) Survival (adjOR, 95% CI) LHR 0.25 (0.07-0.95)* 2.5 (1.1-6.1)* .......................................................................................................................................................................................... O:E LHR 0.98 (0.95-1.00) 1.01 (0.9-1.04) .......................................................................................................................................................................................... Right sided defect 0.33 (0.04-2.99) 1.3 (0.3-6.0) .......................................................................................................................................................................................... No Liver Herniation 1.71 (0.4-6.8) 5.1 (1.2-22)* .......................................................................................................................................................................................... Isolated CDH 1.3 (0.2-8.4) 1.1 (0.2-6.7) .......................................................................................................................................................................................... GA at Diagnosis 0.9(0.88-1.1) 1.1 (0.9-1.2) .......................................................................................................................................................................................... GA at delivery 1.3 (1.0-1.6)* 0.8 (0.6-1.2) .......................................................................................................................................................................................... 0002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.582 417 Fetoscopic entry technique affects the rate of preterm membrane rupture and preterm birth before 32 weeks Scott Petersen 1 , Paul Lewi 2 , Anke Diemert 3 , Liesbeth Lewi 4 , Jan Dickinson 5 , Craig Pennell 6 , Francois Luks 7 , Kurt Hecher 8 , Glenn Gardener 9 , Jan Deprest 4 1 Catholic University of Leuven, Center for Surgical Technologies, Leuven, Belgium, 2 Catholic University Leuven, Department Woman and Child, Leuven, Vlaams Brabant, Belgium, 3 University Medical Centre Hamburg- Eppendorf, Obstetrics, Hamburg, Germany, 4 University Hospital Leuven, Department Woman and Child, Leuven, Belgium, 5 University of Western Australia, Crawley, Western Australia, Australia, 6 University of Western Australia, Perth, Western Australia, Australia, 7 Brown University, Department of Pediatric Surgery, Providence, Rhode Island, 8 University Medical centre Hamburg-Eppendorf, Hamburg, Germany, 9 Mater Mother’s Hospital, Maternal Fetal Medicine, Brisbane, Queensland, Australia OBJECTIVE: Different entry techniques are used at laser coagulation for twin-to-twin transfusion syndrome (TTTS): Access - percutaneous or via laparotomy; Instrument insertion - stabbing trocar in the feto- scopic sheath or cannula, or a guide wire and dilator (Seldinger tech- nique) within cannula. We assessed the impact of entry technique on preterm membrane rupture (PPROM32) and preterm birth before 32 wks (PTB32). STUDY DESIGN: Retrospective study of 513 consecutive fetoscopic laser procedures performed at 5 centres using different entry techniques. We collected data regarding maternal, TTTS disease and procedural characteristics, and pregnancy outcomes. Univariate and multivariate logistic regression analysis were performed. Repeat invasive proce- dures (n46), termination of pregnancy or cases with double IUFD (n 39) were excluded. RESULTS: Three fetoscopic entry techniques were assessed:stabbing trocar in a cannula or fetoscopic sheath, and mini-laparotomy with Seldinger technique sealing of the defect with collagen (Table 1). PTB 32 occurred in 200 cases (39.0%) with associated PROM in 72 cases (36%). The Likelihood Ratio (LR) of PTB 32 after PROM was 73 (p0.0001). Entry technique but not access diameter was associ- ated with PPROM32 (p0.0006; LR 15.0) and PTB32 wks (p0.004; LR 8.3). PPROM32 was also independently affected by the number of ports used (55.1% vs 17.2%; p 0.030; LR 4.7). Cervi- cal length at fetoscopy independently affects PTB32 (LR 8.6). CONCLUSION: Fetoscopic entry technique affects the rate of PPROM and PTB32 weeks. 0002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.583 Poster Session III Fetus, Prematurity www.AJOG.org S160 American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2009
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Poster Session III Fetus, Prematurity www.AJOG.org
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ntervention and delivery of the fetus from an unfavourable intrauter-ne environment.
N (%) adjOR 95% CI PAR
GR 6865 (13.9) 9.46 7.27-12.3 54.1.........................................................................................................................................................................................
fr Amer 10174 (20.6) 2.11 1.61-2.77 18.6.........................................................................................................................................................................................
MI >30 11359 (23.0) 1.38 1.05-1.82 8.1.........................................................................................................................................................................................
ROM 1136 (2.3) 4.35 2.86-6.63 7.0.........................................................................................................................................................................................
TL 4050 (8.2) 1.92 1.34-2.76 7.0.........................................................................................................................................................................................
brupt 3457 (0.7) 8.72 5.20-14.61 5.1.........................................................................................................................................................................................
TN disease 3704 (7.5) 0.53 0.32-0.87 �3.7.........................................................................................................................................................................................
002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.581
416 Predictors of need for extracorporeal membranexygenation (ECMO) and survival in congenitaliaphragmatic hernia (CDH): a centers’ 10-year experiencenthony Odibo1, Tasnim Najaf2, Akshaya Vachharajani2,arbara Warner2, Amit Mathur2, Brad Warner2
Washington University in St. Louis, St. Louis, Missouri,2St Louis Children’s Hospital, St. Louis, MissouriBJECTIVE: To determine prenatal factors associated with a need forCMO and neonatal survival in CDH.TUDY DESIGN: A retrospective cohort study of all cases of CDH seen inur Center between 1998 and 2008. Prenatal ultrasound and neonatalecords were reviewed. Both univariable and logistic regression anal-ses were performed to determine significant factors associated withhe need for ECMO and survival.ESULTS: Among 107 live born infants with CDH seen during thetudy period, 62 were evaluated prenatally in our Center and 49 hadnformation on all variables evaluated. The overall rate of ECMO useas 27/107 (25%) and survival rate 53/107 (49.5%). Significant fac-
ors* associated with ECMO use and survival are shown (Table). Theung area to head circumference ratio (LHR) and gestational age (GA)t delivery were the only significant factors associated with ECMO use,nd the LHR and absence of liver herniation were significantly asso-iated with survival. LHR values under 1.0 were associated with a 57%eed for ECMO and 100% neonatal death. Although overall the Ob-erved:Expected LHR (O:E LHR) was not significantly associated withhe need for ECMO or survival, levels below 65% was associated with8% need for ECMO (p�0.004) and 100% neonatal death (p�0.002).ONCLUSION: The study confirms the LHR, GA at delivery and livererniation as significant prenatal predictors of the need for ECMO orurvival in cases with CDH. This information is helpful for counselingomen with fetuses complicated by CDH.
ECMO (adjOR, 95% CI) Survival (adjOR, 95% CI)
HR 0.25 (0.07-0.95)* 2.5 (1.1-6.1)*.........................................................................................................................................................................................
:E LHR 0.98 (0.95-1.00) 1.01 (0.9-1.04).........................................................................................................................................................................................
ight sided defect 0.33 (0.04-2.99) 1.3 (0.3-6.0).........................................................................................................................................................................................
o Liver Herniation 1.71 (0.4-6.8) 5.1 (1.2-22)*.........................................................................................................................................................................................
solated CDH 1.3 (0.2-8.4) 1.1 (0.2-6.7).........................................................................................................................................................................................
A at Diagnosis 0.9(0.88-1.1) 1.1 (0.9-1.2).........................................................................................................................................................................................
A at delivery 1.3 (1.0-1.6)* 0.8 (0.6-1.2).........................................................................................................................................................................................
002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.582
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160 American Journal of Obstetrics & Gynecology Supplement to DECEMBER
417 Fetoscopic entry technique affects the rate of pretermembrane rupture and preterm birth before 32 weeks
cott Petersen1, Paul Lewi2, Anke Diemert3, Liesbethewi4, Jan Dickinson5, Craig Pennell6, Francois Luks7,urt Hecher8, Glenn Gardener9, Jan Deprest4
Catholic University of Leuven, Center for Surgical Technologies, Leuven,elgium, 2Catholic University Leuven, Department Woman and Child,euven, Vlaams Brabant, Belgium, 3University Medical Centre Hamburg-ppendorf, Obstetrics, Hamburg, Germany, 4University Hospital Leuven,epartment Woman and Child, Leuven, Belgium, 5University of Westernustralia, Crawley, Western Australia, Australia, 6University of Westernustralia, Perth, Western Australia, Australia, 7Brown University,epartment of Pediatric Surgery, Providence, Rhode Island, 8Universityedical centre Hamburg-Eppendorf, Hamburg, Germany, 9Mater Mother’sospital, Maternal Fetal Medicine, Brisbane, Queensland, AustraliaBJECTIVE: Different entry techniques are used at laser coagulation forwin-to-twin transfusion syndrome (TTTS): Access - percutaneous oria laparotomy; Instrument insertion - stabbing trocar in the feto-copic sheath or cannula, or a guide wire and dilator (Seldinger tech-ique) within cannula. We assessed the impact of entry technique onreterm membrane rupture (PPROM�32) and preterm birth before2 wks (PTB�32).TUDY DESIGN: Retrospective study of 513 consecutive fetoscopic laserrocedures performed at 5 centres using different entry techniques.e collected data regarding maternal, TTTS disease and procedural
haracteristics, and pregnancy outcomes. Univariate and multivariateogistic regression analysis were performed. Repeat invasive proce-ures (n�46), termination of pregnancy or cases with double IUFDn� 39) were excluded.ESULTS: Three fetoscopic entry techniques were assessed:stabbingrocar in a cannula or fetoscopic sheath, and mini-laparotomy witheldinger technique � sealing of the defect with collagen (Table 1).TB � 32 occurred in 200 cases (39.0%) with associated PROM in 72ases (36%). The Likelihood Ratio (LR) of PTB � 32 after PROM was3 (p�0.0001). Entry technique but not access diameter was associ-ted with PPROM�32 (p�0.0006; LR 15.0) and PTB�32 wksp�0.004; LR 8.3). PPROM�32 was also independently affected byhe number of ports used (55.1% vs 17.2%; p� 0.030; LR 4.7). Cervi-al length at fetoscopy independently affects PTB�32 (LR 8.6).
ONCLUSION: Fetoscopic entry technique affects the rate of PPROMnd PTB�32 weeks.
002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.5832009
