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www.AJOG.org Clinical Obstetrics, Neonatology, Physiology-Endocrinology Poster Session I

maternal care and length of stay (LOS). Median values were comparedusing the Kruskal-Wallis test.RESULTS: The median neonatal costs increase with each gestation, the

ost striking difference seen between twin and triplet pregnanciesTable). There was a 2-fold increase in cost from singleton to twins, a6.9-fold increase from twins to triplets, and only a 1.2-fold increaserom triplets to quadruplets. This correlates well with neonatal lengthf stay which was 2-fold greater from singleton to twins, 4-fold greaterrom twins to triplets and 1.25 times greater from triplets to quads.he maternal cost increases follows similar patterns and appear toorrelate with maternal LOS.

CONCLUSIONS: The median cost of neonatal and maternal care andength of hospital stay for both neonates and antepartum patientsncreases markedly with each additional gestation. These costs are

ost likely primarily due to decreasing gestational age at delivery.uch findings underscore the importance of minimizing the rates ofultiple gestations while optimizing their outcomes.

Neonatal Costs Maternal CostsNeonatalLOS

Mat LOSantepartum

Singleton $1,044-2,677 $5,123-11,443 1-3 days 0-1 days..........................................................................................................................................................................................

Twins $1,991-22,669 $8,993-17,862 3-8 days 0-1 days..........................................................................................................................................................................................

Triplets $19,657-136,767 $12,317-37,646 7-33 days 0-6 days..........................................................................................................................................................................................

Quads $53,121-177,548 $13,206-108,069 11-48 days 0-19 days..........................................................................................................................................................................................

p-value 0.0001 0.001 0.001 0.0001..........................................................................................................................................................................................

134 Ultrasound-indicated cerclage: do adjunctiventibiotics and tocolytics prolong gestation?

John Owen1, Jeff Szychowski1, for the Vaginalltrasound Trial Consortium2

1University of Alabama at Birmingham, Birmingham, AL, 2MulticenterOBJECTIVE: To assess the use of perioperative antibiotics (Abx) or to-olytics (Toco) in women at risk for recurrent preterm birth (PTB).

STUDY DESIGN: Planned secondary analysis of the NICHD-sponsorederclage trial. Women with prior spontaneous PTB at 17-336/7 wksnderwent cerclage for cervical length (CL) �25 mm. The use oferioperative agents was recorded. The primary outcome was cer-lage-to-birth interval

RESULTS: Of 142 women who received cerclage, 82 (58%) received ateast 1 (max 2) Abx, while 61 (43%) received at least 1 (max 2) Tocogent (57 prophylaxis; 4 prophylaxis�therapeutic). Abx included:ephalosporin (60), clindamycin (6), ampicillin (31), metronidazole8) or others (6). Toco included: non-steroidal (53), beta-mimetic1), and magnesium (25). Linear regression demonstrated a signifi-ant interaction between Abx and Toco on the cerclage-to-birth in-erval (p�0.02). In analyses stratified by Abx use, Toco was signifi-antly associated with a mean gain of 3.2 weeks in women whoeceived Abx (p�0.01); in multivariable regression, including GA aterclage, presence of U-funnel, and CL as covariates, Toco continuedo be associated with a mean 3.1 week gain (p�0.01). Conversely, inomen not receiving Abx, Toco was not associated with longer gesta-

ions (p�0.18). For women receiving Abx there was no difference inhe median cerclage-to-birth interval by class of Toco agent (p�0.24);

likewise, no specific Abx class was superior (p�0.13) in women re-ceiving Toco. ANCOVA was used to model the effect of Toco�Abx,Abx alone, Toco alone, versus no treatment, on cerclage-to-birth in-terval, adjusting for covariates. We observed a significant effect(p�0.03) on mean cerclage-to-birth interval: Abx�Toco - 16.8 wks,Abx alone - 13.9 wks, Toco - 11.4 wks; however, no treatment-15.3wks was statistically similiar to the other 3 groups.CONCLUSIONS: Compared to use of only Toco or Abx, dual treatment

rolongs gestation in women undergoing ultrasound-indicated cer-lage, but it was not superior to no treatment. In women receiving

oco�Abx, no single class of either agent appeared to be superior. w

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135 Effectivity and implementation of teamraining in managing shoulder dystocia

Joost van de Ven1, Frank van Deursen1,Guid Oei2, Ben Willem Mol31Maxima Medical Centre, Veldhoven, 2Maxima Medical Centre/

indhoven University of Technology, Veldhoven/Eindhoven,3Academic Medical Center, AmsterdamOBJECTIVE: Shoulder dystocia is an obstetric emergency with serious

otential risks for both fetus and mother. It is thought that poor fetalutcome is commonly a result of inappropriate management. Once

dentified, multiple manoeuvres can be applied in an attempt to alle-iate the dystocia. Training might therefore be the most effectiveethod to reduce morbidity and mortality related to shoulder dysto-

ia.STUDY DESIGN: To evaluate the effectiveness of simulation team train-ing for shoulder dystocia management, a retrospective study was per-formed at the Máxima Medical Centre in the Netherlands. In 2005simulation team training in acute obstetrics started, using the fullbodychildbirth simulator NoelleTM. We analysed a 36 months during pe-riod before start and after completion of these team trainings. Primaryoutcome is the number of fetal and maternal complications caused byshoulder dystocia. These complications are perinatal asphyxia anddamage caused by excessive traction. Secondary outcome was the as-sessment of the manoeuvre used to manage shoulder dystocia.RESULTS: In the period before obstetric team training started, there

ere 51 cases of shoulder dystocia reported on a total of 5,658 deliv-ries. After team training there were 90 cases of shoulder dystocia ontotal of 5,845 deliveries. Perinatal asphyxia and/or damage was re-orted in 11 cases (0.2%) in the period before training and in 8 cases0.1%) in the period after training (p�0.05). Persistent damage afterhoulder dystocia was present in 4 cases (0.1%) in the period beforehe team training and in none of the cases (0%) in the period after theeam training was performed (p�0.05). The all-fours technique wasever used in the period before team training, after team training this

echnique was used in 36 of the 90 cases (40%) to manage shoulderystocia.

CONCLUSIONS: After introduction of team training in managing shoul-er dystocia no significant differences in transient and persistent dam-ge occurred. Simulation team training in acute obstetrics is an effec-ive method to incorporate a technique to manage shoulder dystocia.

136 Screening for placenta accreta by transvaginalltrasound examination in the first trimester ofregnancy in women with prior caesarean delivery

Julien Stirnemann1, Silvana Forner1, Eve Mousty1, Gihadhaloui1, Laurent Salomon1, Jean-Pierre Bernard1, Yves Ville1

1Universite Paris Descartes, ParisOBJECTIVE: Identification of patients at-risk of placenta accreta (PA)enerally relies upon risk factors including prior caesarean deliveryCS), age and low-lying placenta. The timing of trophoblastic inva-ion, however suggests that this condition could be identified in therst trimester of pregnancy. To describe the potential value of first

rimester transvaginal ultrasound (TVUS) assessment of uterine scarsor risk-stratification regarding PA.

STUDY DESIGN: All patients with a history of CS underwent TVUSetween 11 and 13�6 weeks. A standard plane was defined as mid-agittal view through the cervical canal showing the isthmus and theestational sac. The performance and reproducibility of TVUS wasnvestigated by assessing the sensitivity and specificity of 14 operatorsncluding 6 FM specialists, 5 junior physicians and 3 midwives, usingweb database containing 110 images with a 50% prevalence of scars.perators were blinded to the existence of a scar as well as the artificialrevalence used in the database. The relationship between the scar andhe trophoblast led to 2 groups. Group A: Trophoblast not overlyinghe scar and Group B: Trophoblast overlying the scar. All patients

ere followed until delivery.

ent to JANUARY 2011 American Journal of Obstetrics & Gynecology S67