408 SPO Abstracts

401 EVALUATION OF STILLBORN INFANTS OF DIABETIC MOTHERS IN A TERTIARY PRENATAL CARE SYSTEM: A FIVE YEAR REVIEW (1987-1991). Carolina ReyesX, Sirl Kjos. Dept. of ObiGyn, University of Southern California School of Medicine, Los Angeles, CA. OBJECTIVE: To determine possible causes and preventable factors contributing to stillbirths of diabetic mothers. STUDY DESIGN: Thirty-seven stillborn infants born to diabetic mothers during the study period 1987-1991 were identified. All hospital charts and autopsies (performed in 75 percent of cases) were reviewed. The adequacy of prenatal care and adherence to the protocol were evaluated. RESULTS: The Class Al and Class A2 stillbirth rate was 7.23 per 1000 and 6.46 per 1000. The Class B through R stillbirth rate was 33.03 _ 43.85 per 1000. Among the gestational diabetics (GDM), 75 percent were tested for GDM in the standard testing time. Fifty-nine percent had either a delay in the diagnosis or a delay in management. Six had undergone antepartum fetal surveillance between 2 to 24 days prior to the demise. Two were anomalous (Trisomy 18, encephalocele), two had obstetrical causes (abruptio, IUGR/HlN), 25 were of undetermined etiology. Among the pregestational diabetics, two had undergone antepartum fetal surveillance greater than one week prior to the demise. All but one was poorly compliant. One was anomalous (potter's syndrome), four had diabetic ketoacidosis, three were of undetermined etiology. CONCLUSION: Unexplained intrauterine death among diabetic mothers is an unusual event. The stillbirth rate among the Class A was lower than the hospital rate of 10.09 per 1000. The stillbirth rate among the Class B through R was substantially increased. Poor patient compliance was the primary factor.

402 THE PROGNOSTIC VALUE OF HEMOGLOBIN Ale (HhAle) IN PREDICTING FETAL HEART DISEASE IN DIABETIC PREGNANCY L.E. Shields EA Ganx , H.F. Murphy", OJ. Sahnx, T.R. Moore, Dept. Repro. Mod., Div. Perinatal Mod., Unv. Cal. San Diego OBJECTIVE: The purpose of this study was to evaluate the effectiveness of a protocol of detailed fetal echocardiography (ECHO) in predicting congenital heart disease (CHD) in overt diabetic pregnancies. STUDY DESIGN: A prospective protocol was initiated to identify fetuses with CHD. Overt diabetic patients with initial HbAlc ~ 8.5%, a family Hx of CHD, or fetal cardiac anomaly suspected on screening ultrasound were referred for detailed ECHO. After 7 years, the results of the protocol were reviewed. The sensitivity and specificity of initial HbA I c in predicting CHD were assessed. RESULTS: During the study period from 111185 to 4/30/92, 193 patients received care in the UCSD Diabetes and Pregnancy Service. Sixty-four patients were referred and 47 received fetal echocardiography secondary to initial HbAlc levels ~ 8.5%. Seventeen additional patients were referred for fetal ECHO for other indications. Twenty fetuses had major anomalies, of which 8 (40%) were cardiac. Of the cardiac anomalies, six received echocardiography and 4 were correctly diagnosed. The initial HbAlc was not different among pregnancies with major anomalies, cardiac anomalies, or no anomalies. No anomalies were seen in patients with normal initial HbAlc values. The overall sensitivity of the protocol in identifying CHD was 50%, specificity 64%. ECHO had a sensitivity of 75% and specificity of 100% for correctly identifying fetal CHD. CONCLUSIONS: No cases of CHD were observed in patients with a normal initial HbAlc value (6.%). Among patients with abnormal HbAlc values, no critical level of glycohemoglobin was identified which provided optimal predictive power for CHD screening. We recommend detailed fetal ECHO imaging in all patients with initial HbAlc levels above the normal range.

January 1993 Am J Obstet Gynecol

403 SUCCESS OF LABOR INDUCTION VARIES BY POST-RIPENING CERVICAL DILATION AND AGENT USED. 'J. KRAMMER, W. O'BRIEN, M. WILLIAMS, 'So SAWAI. Department of Obstetrics and Gynecology, University 01 South Florida, Tampa, FL. OBJECTIVE: To examine the possible interaction between post-ripening Bishop score (BS) and its components, and method of cervical ripening on successful labor induction (SLI). STUDY DESIGN: 194 singleton gestations of 3&44 weeks with Bishop score < 9 requiring labor induction were prospectively randomized to either intracervical Dilapan (DILAP) or 0.5 mg prostaglandin E2 gel (PGE2). Bishop scores were evaluated at 6 hours, and oxytocin inductions then performed per protocol. SLI was defined as entry into active phase labor within 6 hours of oxytocin infusion. RESULTS: The DILAP and PGE2 groups were demographically similar, as were all initial mean Bishop score components. Rates 01 SLI were similar for DILAP and PGE2. Initial analysis of data found that post­ripening cervical dilation (R=0.32, P<0.OOO1) and post-ripening BS (R=O.29, P<0.OOO1) similarly correlated with SLI. Forward stepwise logistic regression found dilation (DIL) and effacement (EFF) best predicted SLI. Cervical ripening agent was then added, and direct effects and interactions assessed, with initial and final models below. Initial Interaction Model Anal Interaction Model DIL R=0.32 P<0.OOO1 DIL R=0.31 P<0.OOO1 EFF R=0.21 P<O.OOO4 Agent x DIL R=0.15 P<O.OO63 Agent R=0.03 P<0.14 Not in model: Agent x DIL R=O P=NS EFF R=0.07 P<0.07 Agent x EFF R=O P=NS (74% cases correctly assigned)

SLI by Post-Ripening Cervical Dilation Category (cms) 0-1 1.1-2.0 2.1-3.0 >3.0

PGE2 9/48(19%) 9/24(38%) 10/14(71%) 6/8(75%) DILAP 5/27(19%) 4/35(11%) 12/30(40%) 5/9(56%) CONCLUSIONS: 1) DILAP and PGE2 are equally efficacious ripening agents 2) SLI varies relative to post-ripening DIL and agent used.

404 A PROSPECTIVE RANDOMIZED COMPARISON OF DILAPAN VS. PGE2 FOR PREINDUCTION CERVICAL RIPENING AND THEIR EFFECT ON LABOR KINETICS.'J KRAMMER, W. O'BRIEN, M. WILLIAMS, 'So SAWAI. Dept. Ob/Gyn, Univ. 01 South Florida, Tampa, FL. OBJECTIVE: To examine Induction and labor characteristics alter pre-induction ripening by Dilapan (DILA) and prostaglandin E2 GEL (PGE). STUDY DESIGN: 194 singleton gestations of 3&44 weeks with Bishop score < 9 requiring labor Induction were randomized to either Intracervical DILA or 0.5 mg PGE gel. Bishop scores were then evaluated at 6 hours, oxytocin inductions then performed per protocol. Successful induction was defined as entry into active phase labor within 6 hours 01 oxytocin infusion. RESULTS: There were 101 patients In the DILA and 93 in the PGE groups. The two groups were demographically similar. There was no difference in the mean pre (3.7 vS. 4.0) or post-ripening (6.1 vS. 6.1) Bishop scores. The effect of the two methods on components 01 the Bishop score. however differed:

tJ. DIL DIL EFF STA DILA 1.0 1.98 50% -2.4 PGE 0.62 1.68 57% -2.1 P <0.01 0.08 0.06 0.03 Additionally. the methods resulted in differerent labor kinetics:

Max Oxytocin Active Phase Success (mlu/min) (hours) (%)

DILA 19.3 4.7 27 PGE 15.7 3.6 37 P <0.003 <0.03 NS CONCLUSIONS: 1) Dilapan and PGE2 are equally efficacious ripening agents 2) Induction and labor characteristics vary by ripening method.