290 S P O Abs t rac ts J a n u a r y 1995 A m J Obs te t Gynecol

97 TRIAL OF LABOR IN PATIENTS WITH A DOCUMENTED LOWER UTERINE VERTICAL CESAREAN SECTION. C.D. Adair," L. Sanchez- Ramos, L. Farab," D. Whittaker," D McDyer," D. Briones*. University of Florida Health Science Center, Jacksonville, Division of Maternal-Fetal Medicine, Jacksonville, FL O ~ V E : To evaluate the effectiveness and safety of a trial of labor in women with a previous lower uterine vertical cesarean section. STUDY DESIGN: A review from January 1988 to December 1993 revealed 71 patients who had previous low vertical incision without extension above the round ligaments and who had undergone a trial of labor. These patients were compared to the next two patients with an unscarred uterus who appeared in the delivery log book. Maternal demographics, labor and delivery characteristics, and maternal and perinatal morbidity were evaluated. Data were analyzed by Student t test and significance was considered at p = < .05. RESULTS: Seventy-one patients were identified, of which 19 had labor induced. They were compared to 142 patients without a previous uterine incision. No significant differences between the two groups in regard to demographics were noted. The average number of prior vaginal deliveries was lower in the study group (1.0 versus 1.6, p = .0001).

CATEGORY STUDY GROUP CONTROL GROUP p (N = 71) (N = 142)

Cesarean Rate 12 (16.9%) 17 (11.9%) NS

Forceps Rate 12 (16.9%) 11 (7.7%) NS

Endometritis 8 (11.3 %) 13 (9.1%) NS

Uterine Rupture 1 (1.4%) 0 (0.0%) NS

A trial of labor in patients with a previous lower uterine vertical incision resulted in a VBAC rate of 83% and was not associated with adverse maternal and per)natal outcomes. The uterine rupture in the study group was associated with good maternal-fetal outcome after cesarean hysterectomy. CONCLUSIONS: This study suggests that a trial of labor in patients with a previous low vertical incision may be attempted without serious morbidity.

99 J igUIg.lXI~ ~ ' B H , I D ~ a ~ m i~1~n'm:mf

.T.szael t t :ep i ta l / t i~ '~zd t,'e:~ca]. Sd'~ol, B:~con, M~. t'~-,-'L,.~¢: ~ , , ~ 1 ~ # , ~ 1 ep~icCo,y has keen aho~n to , . ~ the ~nS~a~ce of 3rd a~d ¢h d~zee perL~al ~ ~n ~,11~*jus wm~n and cbring cFemtive deliw~M,

/s ~ w i t h a greatly bxxeaaed ride of rmjor ~aum~. Ne~_~le~, r~¢ A~rican dostmzicla~ favor

the ,B~an ~d~, feeJ_t~ that it ~,~ 1~s ~/n and dyst:vxexda. 1he - , ~ c£ thLs ~Cxty ~ to detenntx~ ~ a h e r

vain and c t y ~ a r e x ~ than nedian %~,a~-xxny. • -~ , ,~ : A p rwpec~ve , ~ ckxtfle b3And ana].yaia

of p s ~ e a t s ~ had ~ ' m d a ne~zm o r ~ .,~p~-~,~'.onF ms ~----~o=~d. Each par_~='s aralcjesic v=q,~ . . . . ~_ du=Lrq hours ]2-36 posti:aztxm vas zecoz~led. ~ wexe then im.e_wia,~l by t P - ~ at 3 ~ 6 ra3rehs l: ~ ~g[][,~g: During the 24 hour a~lcjesic ~ , = = , L p e ~ Uhe m~dian ~D~ctcmj g~qo ~-429) r~q,~ed an aum-~C~ ~ of 1.5 percooet amd 1.6 m:¢r/n ~ the l~rH~xa:al ~ (n-215) n=qH~ed 1.9 peroooet ~dl.7,ctrin. By3m:~ths~ 84%of thsmsdian group and 81% cf the ~ ~qo had zemxmd ~ . Using a pa/n scale from 0to 5, there ",,as an increase cf 2 cr cjzeater in zepoz~.ed d y ~ ~=m ~,=v=~'~c3, ~ , ~ in 25% of ~ e ~ cjzoup a~d 22t o f the m~Kolata=~l gzoap ~" 3 m:~.hs ~ a n d ~n 14% c¢ "the mad~ cj0aqp and ~n 12% c¢ ~he m ~ t % o ~ l , c~cup at: 6 ~ ~ I~,~.~c~1 ~ at the e ~ site at 6 rrnths ~ss r ~ in 14% Qf the msdian group and 18% cf the ms/iolatensl group. A multi~*~ ms~-~-~rn a~lysis, controlling for 20 mstemal, fetal and /abor %~u~- was perfonmd; none of the cutcu~e d/ff~ between the msdian and m~olatezal gz~ups ware found to he ~ y significant. ~ : ~here are no clinically s~nific~ differences in

and ms~/~lateral episiotc,y.

98 A PROSPECTIVE, RANDOMIZED EVALUATION OF INTENSIFIED THERAPY FOR SMOKING REDUCTION IN PREGNANCY. C. Cook, S. Ward', S. Myers ~, J. Spinanto. Depts. Ob/Gyn, Pharmacology, Univ. of Louisville, Louisville, KY. OBJECTIVE: Cigarette smoking in pregnancy has been associated with several dose-depandcotedverse fetal outcomes. The purpose of this study was to evaluate the efficacy of intensified (INT) therapy versus standard (STD) interventions for decreasing cigarette smoking in pregnancy. STUDY DESIGN: One hundred-fitly self-reported smokers presenting for prenatal cute at less than 24 weeks gestmion wore randomized to either STD or INT. STD consisted of discussion of smoking risks by a outritionist and again by the resident physician at the initial prenatal visit. INT consisted of regular meetings with a smoking counselor in addition to physician reinforcement at each prenatal visit. These woman also received biochemical feedback of their progress as demonstrated by an interval reduction in urine cotininc. All women submitted an entry and a term or delivery urine for cotinine evaluation. Reductions were defined as greater than 50% decrease at term from entry ootinines. Categoric variables were compared using X ~ analysis and Fisher exact test where appropriate. RESULTS: To date 43 patients (23-1NT, 20-STD) have delivered. In the STD group 2 patiants had antry cotinines consistent with a nonsmoking level. Of the remaining 18 patients, 4 (22%) demonstrated reductions in smoking with no eegmtions noted. In the 1NT group I patient never presented for prenatal care at~r randomization. Of the remaining 22 patients, 6 (27%) demonstrated reductions and 8 (36%) demonstrated cessation in smoking. The INT group showed significant improvemant in cessation rates (36% vs 0%, p < .005) as well as total response rates (64% vs 22 %, p < .025), RR 2.86 (1.14-7.19). Mean birthweights also showed an as yet nonsignificamt trend toward larger infants in the INT group (2961g) and the INT-rospondera (3019g) versus STD (2713g). CONCLUSIONS: INT with frequent counselor visits, regular physician reinforcement and biochemical feedback leads to greater cessation rates as well as overall response rates in an indigent population. These response rates also lead to a treed toward larger delivered infants.

10(] IS OBSERVATION OF SEVERE ACUTE ANEMIA IN WOMEN SAFE? S Inohs, L Stevens, I Udom-R ca, H Yun, FA Chervenak. Dept. Ob/Gyn, New York Hospital, NY, NY and Jersey City Mad Ctr, Jersey City, NJ. OBJECTIVE: Determine the risks of observation of severe acute anemia after hemorrhage rather then immediate blood transfusion. STUDY DESIGN: Sixty-eight healthy women with severe acute anemia after hemorrhage requested careful observation rather than undergo immediate blood transfusion. The incidence of major complications (cardiac or respicatory dysfunction), minor complications (fatigue end dizziness), subsequent blood transfusion and the number of additional hospital days were compared. The students T test, Fisher'e Exact test, and Chi square analyses were used when appropriate. RESULTS: Hematocrit Group

<18% 18-19.9% 20-21.9% AIIPetiants n=;~l n=31 n=16 n=68

Major Medical Complication 24% 16% 0% 18% Minor Medical Complication 48% 19% 0% 24% Major or Minor Medical Complication 62% 29% 0% 32% Blood Transfusion 48% 28% 0% 26% Additional Hosp Days 1.09 0.23 0.19 0.48 During observation, the incidence of major end minor complications and blood transfusion were directly proportional to the degree of anemia (p <0.01 and p <0.01 respectively). Additional hospital days were also associated with more profound anemia (p < 0.01). CONCLUSlOIM8: For women, the traditional "trigger point" for blood transfusion of Hgb < 8mg/dl is too high. Observation is reasonable in healthy women who era arable with hematocrits of 18-19.9% or 20-21.8%. Individualized treatment and patient involvement is important. Blood transfusion should be performed when medical illness exacerbated by severe anemia exists.