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230 PERINATAL OUTCOME IN TWINS ACCORDING TO CHORIONICITYLINE LEDUC1, DENYSE RINFRET1, 1Sainte-Justine Hospital, U. de Mon-treal, Dept. Obstetrics & Gynecology, Montreal, Quebec, Canada

OBJECTIVE: To document the perinatal outcome of twins in relation tochorionicity in a tertiary care center.

STUDY DESIGN: Data were prospectively collected in all twins followed atSte-Justine hospital between 1994 and 2002. Twin-twin transfusion syndromeand monoamniotic twins were excluded. Antepartum care was the same in allpatients from 20 weeks of gestation to delivery with clinical visits q 2 weeks,ultrasound q 4 weeks in presence of normal fetal growth and q 2 weeks whenfetal growth restriction (FGR) was suspected. Doppler studies were performedin cases with FGR. All women had a work leave from 24 weeks of gestation untildelivery.

RESULTS: Five hundred three women with twins were studied including378 (75%) dichorionic (DC) and 125 (25%) monochorionic (MC). MC wasassociated with a mortality rate twice as high as DC with 7.2% vs 3.2% and anincreased perinatal morbidity. The mean gest. age at delivery was 34.7 +/� 2.8weeks in MC vs 35.7 +/� 2.9 in DC. Delivery before 34 weeks occurred in 34% ofMC vs 22.5% of DC. Birthweight (BW) discordance (25%) was present in 20.8%of MC vs 10.3% of DC. BW less than the 10th perc. was found in 15.6% of MC vs7.6% of DC and less than 1500 g in 16.8% of MC vs 9.7% of DC. Morbidity at theNICU: endotracheal intubation was required in 9.2% of MC and 6.2% of DC.IVH occurred in 1.6% of MC vs 0.4% of DC.

CONCLUSION: MC is definitely associated with increased perinatalmorbidity and mortality. Prematurity and fetal growth restriction are the twomain factors responsible for this morbidity. Antenatal diagnosis of chorionicitybecomes essential to offer appropriate intervention in a timely fashion.

December 2003Am J Obstet Gynecol

S126 SMFM Abstracts

ACCURACY OF VISUAL ASSESSMENT OF THE CERVIX COMPARED TODIGITAL EXAMINATION LEONARDO PEREIRA1, REBECCA GOULD2,JACQUELYN PELHAM1, 1Thomas Jefferson University, Department ofObstetrics and Gynecology, Philadelphia, PA 2Drexel University College ofMedicine, Department of Obstetrics and Gynecology, Philadelphia, PA

OBJECTIVE: To prospectively determine the accuracy of visual assessmentof the cervix (VIS) compared to digital cervical examination (DIG).

STUDY DESIGN: Prospective study of 100 patients presenting to Labor andDelivery from April to June 2003. Patients requiring both a sterile speculumexam (SSE) andDIG examination were eligible. Exclusion criteria were pretermrupturedmembranes (PPROM) or other contraindication to DIG examination.VIS assessment was made and recorded during SSE. Following SSE, the samephysician performed DIG examination. Variables measured included cervicaldilation (DIL), effacement (EFF), position (POS), and station of fetalpresenting part (STA). A modified Bishop score (BIS) was calculated.Correlation between VIS assessment and DIG examination was measured usingSpearman’s correlation coefficient (COR). Type I error was set at 0.05 (two-sided).

RESULTS:Mean gestational age (GA) at examwas 32.4 weeks (w) (range 17-41). 84% of patients had intact membranes; 55% were multiparous. VISassessment correlated with DIG examination for all parameters measured. Thiscorrelation remained significant after controlling for DIL, parity, GA < 34 w, andruptured membranes (SROM) in term patients with 2 exceptions: EFF inpatients < 34 w GA (N = 46, COR .284, P .056), and STA in SROM patients(N = 7, COR .722, P .067).

CONCLUSION: Visual assessment correlates with digital examination ofthe cervix. This correlation remains significant in preterm patients with intactmembranes and patients with term SROM and may be applicable to patientswith PPROM.

Correlation between visual and digital cervical examination

NSpearman’s correlation

coefficient P value

Dilation 100 0.723 < .001Effacement 100 0.674 < .001Station 100 0.640 < .001Position 73 0.619 < .001Modified Bishop score 100 0.652 < .001

MORBID OBESITY ADVERSELY IMPACTS CESAREAN DELIVERY MI-CHELLE KUSH1, AHMET BASCHAT1, GARY COKE2, MICHAELMUENCH3, HUGH MIGHTY4, ANDREW MALINOW5, JEROME KOPEL-MAN6, CHRISTOPHER HARMAN1, CARL WEINER7, 1University of Mary-land at Baltimore, Obstetrics, Gynecology and Reproductive Sciences,Baltimore, MD 2University of Maryland, Anesthesiology, Baltimore, MD3University of Maryland at Baltimore, Obstetrics and Gynecology, Baltimore,MD 4University of Maryland Medicine, Obstetrics, Gynecology, and Re-productive Sciences, Baltimore, MD 5University of Maryland at Baltimore,Anesthesiology, Baltimore, MD 6University of Maryland at Baltimore,Obstetrics, Gynecology & Repro Sciences, Baltimore, MD 7University ofMaryland at Baltimore, Physiology, Baltimore, MD

OBJECTIVE: There is an epidemic of obesity in the U.S. We tested thehypothesis that excess bodymass index (BMI) adversely impacts the outcomes ofcesarean delivery.

STUDY DESIGN: In a case-control study of 233 consecutive cesareandeliveries, time from skin incision to uterus, from uterine incision to delivery,and total operating time, estimated blood loss (EBL), and need for transfusionwere determined. Umbilical artery blood gases were measured. Calculated BMI(kg/m2) was analyzed by WHO obesity categories (normal < 30), (obese 30-39),and (morbidly obese > 39). Statistical methods included Mann-Whitney U, chi-square, for categorical variables and logistic regression for continuous variables.

RESULTS: There were 33 normal (mean BMI = 29), 70 obese (meanBMI = 34.6), and 130 morbidly obese (mean BMI = 51.3) women. Any obesitypredicted greater EBL, lower cord pH, and higher cord base deficit compared tonormal-weight women (P < 0.05). Obese and morbidly obese women did notdiffer from each other in these categories. Morbidly obese women had longertotal operating time, skin to uterus, and uterus to delivery times compared tonormal and obese women (each P < 0.05). As the BMI rose, there was anexponential increase in EBL and OR time (R2 0.03, P = 0.009 and R2 0.13,P < 0.001), a linear increase in skin incision to uterus time (R2 0.09; P < 0.001),and a linear decline in umbilical artery pH (R2 0.006; P < 0.002).

CONCLUSION: This is one of the largest series of morbidly obese womenundergoing cesarean delivery. It demonstrates that cesarean delivery is notspared from the adverse consequences of obesity. Morbid obesity increases alloperating times, associated with increased EBL. The lower neonatal fetal pHmeasurements likely reflect the great difficulty positioning and ventilating obesewomen.

231 CLINICAL SIGNIFICANCE OF FIRST-TRIMESTER GROWTH DISCOR-DANCE IN TWIN GESTATIONS ROBIN B. KALISH1, MERUKA GUPTA1,SRIRAM C. PERNI1, SETH BERMAN1, GEETA SHARMA1, STEPHEN T.CHASEN1, 1Weill Medical College of Cornell University, Obstetrics andGynecology, New York, NY

OBJECTIVE: To determine the clinical significance of first-trimester growthdiscordance in twin gestations.

STUDY DESIGN: Ultrasound examinations of dichorionic twin pregnan-cies between 11 and 14 weeks’ gestation performed at New York Weill CornellMedical Center from 2000-2002 were evaluated for growth discordance usingcrown rump length (CRL) measurements. Discordance was determined by theinter-twin disparity in CRL inmillimeters, as well as the percentage difference inrelation to the larger fetus. Medical records were reviewed for antenatalcomplications including spontaneous abortion, fetal demise, fetal structural orchromosomal anomalies, and preterm delivery. Fisher’s exact and Mann-Whitney U tests were used for statistical analysis with P < 0.05 consideredstatistically significant.

RESULTS: Of 159 twin pregnancies that underwent first-trimesterultrasound examination, 6 had fetal structural anomalies, 2 had fetalchromosomal anomalies, 6 had a second-trimester spontaneous abortion, 3had a second-trimester fetal demise, and 1 had a third-trimester fetal demise.Overall, the median CRL discordance was 2.1 mm (range 0-15 mm) or 4.0%(range 0%-21.7%). Pregnancies complicated by fetal structural or chromosomalanomalies had significantly greater median CRL discordance than pregnancieswithout fetal anomalies (6.0 mm vs 2.0 mm, P = .02). CRL discordance > 10%,the 90th percentile for inter-twinCRLdisparity in our population, was associatedwith significantly higher incidence of fetal anomalies (22.2% vs 2.8%, P = .01).In pregnancies resulting in two live births, birth weight discordance > 20% wasassociated with increased median CRL discordance compared to twins withconcordant birth weights (4.9 mm vs 2.0 mm, P = .001). CRL discordance wasnot predictive of preterm delivery.

CONCLUSION: First-trimester CRL discordance in twin gestations may beassociated with an increased risk of antenatal complications including fetalstructural and chromosomal anomalies, as well as subsequent birth weightdiscordance.