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Volume 168 Number 1, Part 2

FACTORS AFFECTING SURVIVAL IN NEWBORNS 2J TO 2S WEEKS GESTATION. P, Holtrop" L, Ertzbischoff', R, Lorenz+, Depts, of Peds' and OB/GYN+, Wm, Beaumont Hospital, Royal Oak, MI. andWayneSt, Univ, OBJECTIVE: To detennine which prenatally known factors are associated with survival in 23 to 15 week gestation newborns, STUDY DESIGN: Charts of our inborn Iiveborns (n=82) of 23 to 15 weeks gestation from 1988 through 1991 were reviewed, Seventy-six had prenatal care, and all but 2 were resuscitated after delivery. Gestational age (GA) was determined by the obstetrician's best estimate (based on dates and/or early ultrasound). Prenatslly known variables -race, GA, maternal age, premature rupture of membranes, amnionitis, hypertension, presence and duration of labor, prenatal care, maternal transport, cervical dilation on admission, substance abuse, maternal steroids, fetal sex, presentation, delivery mode, vaginal bleeding, abruption, placenta previa, IU GR, and fetsI distress -were compared for survivors to hospital discharge (n =39) and non-survivors (n =43), using t-test, X' and Fisher's exact test. Variables with p value <.15 on univariate analysis were then analyzed by multiple logistic regression analysis. RESULTS: Survival rates at 23, 24, and 15 weeks GAwere 19%, 59%, and 65% respectively. Greater GA, female sex, and absence of maternal hypertension (MH) were significantly associated with survival.

Variable Coef. p Odds ratio 95% C.L.OR 24 weeks GA 1.6 .03 5.1 1.2,22.1 15 weeks GA 2.1 .004 8.5 2.0,37.2 MH -2.3.04.1 .01, .9 Female sex 1.2.04 3.4 1.1, 11.0 A 15 week GA female fetus, without MH, has an 81 % predicted chance of survival, versus 2% for a 23 week GA male fetus with MH. CONCLUSIONS: A multivariate model using the above 3 variables allows one to more accurately predict survival chances and better counsel parents than a single variable model, which may facilitate decision making about the degree of intervention.

NEONATAL MORBIDITY FOLLOWING PRETERM DELIVERY WITH DOCUMENTED PULMONARY MATURITY. TR Wigton, RK Tamura, EA Wickstrom, V Aikins", R Deddish', ML Socol. Division of Maternal-Fetal Medicine, Northwestern University Medical School, Chicago, Illinois. OBJECTIVE: To determine the incidence of significant neonatal morbidity in fetuses with documented puhnonary maturity delivered prior to 37 week's gestation. s-nrny DESIGN: A retrospective review of 213 women who delivered 240 neonates with documented lung maturity (US c< 2.0 or PG present) prior to 37 weeks from 4/88-8/91 was performed. Amniotic fluid was obtained by amniocentesis (n = 157) or by transvaginal aspiration of free flowing fluid (n =56). 101 patients had preterm premature rupture of membranes (PPROM). The incidences of neonatal respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), patent ductus arteriosus (PDA), and admission to the intensive care unit (NICU) were determined for the entire popUlation and separately for those pregnancies complicated by PPROM. RESULTS: The incidences of neonatal morbidity by gestational age are presented in the table. No cases of RDS, NEC, IVH, or PDA occurred after 35 weeks. When patients with PPROM were compared to those with intact membranes, a statistically significant difference existed for RDS (14 % vs 1.6%, ,,<0.001), but not for NEC, IVH, PDA, or admission to the NICU.

<30 30-31 32 33 34 35-36 n=9 n=14 n=14 n=38 n=44 n=121

RDS(%) 66.7 21.4 21.4 7.9 4.6 0

IVH(%) 22.2 7.1 14.3 0 2.3 0

NEC(%) 11.1 7.1 0 2.6 0 0

PDA(%) 22.2 14.3 0 5.3 2.3 0

NICU(%) 100.0 92.9 85.7 86.8 65.9 25.6

CONCLUSIONS: Despite fetal lung maturity, major neonatal morbidity was observed up to 34 week's gestation; after 34 weeks, 25.6% of the popUlation still required admission to the NICU. These data relating neonatal morbidities to gestational age arc important in the critical decision regarding the timing of delivery.

SPO Abstracts 373

270 A CXIIPARIlD or mAL LIlIG MA'l'IIRA'fI~ S!ODIES (SURPAC!AI'f/AImIII RA'fIOj }'Jl(JI SIIIIL'fADXISLY <mAIIID VAGIIAL AID AlllIOCI!II'fBSIS SPICIIIEIS.S. Schorr, D. Hurfor~, S. carlan, A. Penal. Arnold Palter Hospital for Children and lIoten, orlando, FL. <IIJBC'fIVE: To co~e the surfactant/albUIin ratios (S/A) in alDiotic fluid collected silUltaneously by aJl\iocentesis and vaginal pool sapling in pregnant woten with preten prelature rupture of the telbranes (PPRal). S'fUDY DESIGI: FrOI 11/1/91-6/1/92 all pregnant woten with PPROII were offered entry into the study. miotic fluid was collected silUltaneously frol vaginal pool aspiration and aJl\iocentesis and these paired saaples were processed iuediatel y using the standard S/A ratio assay kits. standard criteria were used to interpret the results with a ratio >69 indicating laturity. RBSOL'fS: Of 78 candidates, 19 study patients were enrolled at a tean gestational age of 32 ± 2.9 weeks (tean ± SD). Vaginal pool S/A satples (45.8 ± 28) were significantly lower than aJl\iocentesis salples (58.7 ± (0). This significant difference was present regardless of gestational age, tite frol telbrane rupture to satple collection, or the value of the S/A ratio itself. IIben vaginal pool satples were aature,alniocentesis satples were lature in each case. <XIICLIlSI~: Vaginal aJl\iotic fluid pool S/A specilen values are significantly lower than aJl\iocentesis results. iihen using the currently recouended levels for fetal IWlg laturation, a aature S/A in fluid collected frol the vagina indicates a true aature S/A ratio. However, if the vaginal salple results in an iuature S/A, the test lay need to be perfoned by aJl\iocentesis to establish the presence or absence of fetal IWlg aaturity. PresUlably, increased aIOunts of albUIin in the vaginal pool salple result in consistently lower ratios.

271 THE EFFECT OF GESTATIONAL AGE AND FETAL INDOMETHACIN LEVELS ON THE INCIDENCE OF CONSTRICTION OF THE FETAL DUcruS ARTERIOSUS. I Van den Vevver", K. Moise Jr., CoN. Oux, R. Carpenter Jr.,Depts ofOB/OYN and Pediatrics; Baylor College of Medicine; Houston, Texas. OBJECTIVE: To determine the effect of gestational age and fetal serum levels on constriction of the ductus arteriosus after maternal indomethacin administration. STUDY DESIGN: 25 pregnant patients received a 50 mg oral dose of indomethacin 6 hours before 50 intrauterine transfusions. Fetal serum indomethacin levels were determined on the initial fetal blood sample. The ductus arteriosus was evaluated with Doppler ultrasound immediately prior to 40 of the procedures. Constriction of the ductus arteriosus was defmed as a peak diastolic flow> 35 cm/sec. A least square fit regression line and Pearson's correlation coefficient were used for statistical analysis. RESULTS; The peak diastolic flow velocity through the fetal ductus arteriosus after maternal indomethacin ingestion is constant at 25 cm/sec prior to 27 weeks, increases between 27 and 30 weeks to a mean of 39 cm/sec and is stable thereafter (R'=0.35). Peak diastolic flow velocity and fetal serum indomethacin level were not correlated (r = 0.048, P = 0.77). CONCLUSIONS: I. The constrictive effect of maternal indomethacin ingestion on the fetal ductus arteriosus starts as early as 27 weeks. 2. Doppler ultrasound monitoring of the ductus arteriosus should be initiated at 27 weeks in patients treated with indomethacin. 3.Constriction of the ductus arteriosus is independent of fetal serum indomethacin levels.