435 FETOMATERNAL HEMORRHAGE IN WOMEN UNDERGOING CESAREAN SECTIONDENISE PELIKAN1, HUMPHREY KANHAI1, GODELIEVE DE GROOT-SWINGS1,HANS TANKE2, SICCO SCHERJON1, 1Leiden University Medical Center, Obstet-rics, Leiden, Netherlands, 2Leiden University Medical Center, MolecularCell Biology, Leiden, Netherlands

OBJECTIVE: To investigate whether women undergoing Cesarean section(CS) are at risk for fetomaternal hemorrhage (FMH).

STUDY DESIGN: Blood samples of 57 women were collected before and 15-20 minutes after CS by phlebotomy. Fifty women had a planned CS forvarious indications and 7 underwent an emergency CS because of fetal distress.Quantification of fetal red cells using the Kleihauer-Betke technique andmeasurement of alpha-fetoprotein (AFP) was performed on all pre- and post-CS samples. FMH was defined as the proportion of fetal and maternal red cellsmultiplied by the assumed maternal red cell volume of 1800 ml.

RESULTS: The mean fetal red cell count per 400 microscopic fields beforeand after CS was 6.1 cells (range 0-130, 95%CI [0.9, 11.3]) and 27.9 cells (range0-540, 95%CI [7.0, 48.8]), respectively. This increase is significant (p = 0.036).The mean AFP concentration before and after CS was 144.5 microg/l (range13-542, 95%CI [116.8, 172.2]) and 132.1 microg/l (range 12-419, 95%CI[108.1, 156.0]), respectively. This decrease is significant (p = 0.028). The meandelta fetal red cells was 21.8 (range -8-533, 95%CI [1.5, 42.1]). The mean deltaAFP was -12.4 microg/l (range -123 -144, 95%CI [-23.4, -1.4). Correlationbetween the delta fetal red cells and delta AFP was poor (r2 = 0.244). AFMH!0.1 ml was found in 71.9% of the women. In 28.1% FMH rangedfrom 0.1 to 4.8 ml. Subgroup analyses for manual removal of the placentaversus controlled cord traction, singleton versus twin pregnancy, plannedversus emergency CS revealed no significant differences.

CONCLUSION: Our finding that fetal red cells are increased after CSindicates that in an unselected population undergoing CS the procedure itselfresults in a small but detectable FMH volume. The AFP decrease is most likelyexplained by intravenous fluid supply in combination with per-operative bloodloss resulting in dilution of maternal plasma.

436 CERVICAL CERCLAGE COMPARED TO EXPECTANT MANAGEMENT IN WOMENWITH A DILATED CERVIX IN THE 2ND TRIMESTER: RESULTS FROM THE GNPRHINTERNATIONAL COHORT STUDY LEONARDO PEREIRA1, AMANDA COTTER2,VINCENZO BERGHELLA3, RICARDO GOMEZ4, WITOON PRASERTCHAROENSUK5, JUHARASANEN6, SURASITH CHAITHONGWONGWATTHANA7, SUNEETA MITTAL8, JORGEE. TOLOSA1, 1Oregon Health & Science University, Obstetrics and Gynecology,Portland, Oregon, 2University of Miami, Obstetrics and Gynecology, Miami,Florida, 3Thomas Jefferson University, Obstetrics and Gynecology, Philadel-phia, Pennsylvania, 4CEDIP, Sotero del Rio Hospital, Puente Alto, Chile,5Khon Kaen University, Khon Kaen, Khon Kaen, Thailand, 6University ofOulu, Obstetrics and Gynecology, Oulu, Finland, 7Chulalongkorn University,Department of Obstetrics and Gynecology, Bangkok, Thailand, 8All IndiaInstitute of Medical Sciences, New Delhi, New Delhi, India

OBJECTIVE: To compare pregnancy outcomes of women with a dilatedcervix in the 2nd trimester who receive cerclage (CERC) versus expectant man-agement (EXP).

STUDY DESIGN: Multicentered cohort study conducted by the GlobalNetwork for Perinatal and Reproductive Health. Women between 14-256/7

weeks gestation presenting with threatened preterm birth or dilated cervixfrom 1998-2004 were identified retrospectively. Women with preterm prelaborrupture of membranes, labor, or vaginal bleeding at time of presentation, thosewith a closed cervix, or those opting for induction of labor or termination wereexcluded. The primary outcome was median number of weeks from presenta-tion until delivery. The secondary outcome was neonatal survival. c2 was usedto compare categorical variables, Mann-Whitney was used to compare non-evenly distributed continuous variables. Multivariate logistic regression wasused to assess the likelihood of neonatal survival in women undergoing cer-clage while controlling for confounders.

RESULTS: 409 women were identified. After exclusions (25 induction/termination, 26 no outcome data, 15 closed cervix, 117 clinical symptoms), 210women remained: 136 CERC and 74 EXP. Median cervical dilation (1.0 cm vs.2.0 cm, p .03) and gestational age at presentation (19.4 weeks vs. 23.3 weeks,p!.001) were lower in CERC compared to EXP respectively. Median weeksfrom presentation until delivery was significantly more in CERC than EXP(12.4 vs. 2.0 weeks, p!.001). Unadjusted neonatal survival was similar (65.4%CERC vs. 64.4% EXP, p NS), however in a multivariate logistic regressioncontrolling for gestational age and cervical dilation at presentation, fetalnumber, and maternal race, CERC was associated with greater neonatalsurvival than EXP (OR 2.53 [1.03, 6.17]).

CONCLUSION: In a strictly defined cohort of women with a dilated cervix inthe 2nd trimester cerclage appears to prolong gestation and is associated withhigher neonatal survival compared to expectant management. A randomizedcontrolled trial in this population is urgently needed.

437 NEONATAL AND MATERNAL MORBIDITIES ASSOCIATED WITH CERCLAGECOMPARED TO EXPECTANT MANAGEMENT IN PREGNANCIES WITH 2ND TRIMESTERCERVICAL DILATION: RESULTS FROM THE GNPRH INTERNATIONAL COHORTSTUDY LEONARDO PEREIRA1, JUHA RASANEN2, AMEN NESS3, WITOONPRASERTHCHAERONSUK4, SURASITH CHAITHONGWONGWATTHANA5, AMANDACOTTER6, RICARDO GOMEZ7, SUNEETA MITTAL8, KATHERINE GESTELAND9, PISAKELUMBIGANON4, JORGE E. TOLOSA1, 1Oregon Health & Science University, Obstet-rics and Gynecology, Portland, Oregon, 2University of Oulu, Obstetrics andGynecology, Oulu, Finland, 3Thomas Jefferson University, Obstetrics and Gy-necology, Philadelphia, Pennsylvania, 4Khon Kaen University, Khon Kaen,Khon Kaen, Thailand, 5Chulalongkorn University, Department of ObstetricsandGynecology, Bangkok, Thailand, 6University ofMiami, Obstetrics andGy-necology,Miami, Florida, 7CEDIP, Sotero del RioHospital, PuenteAlto, Chile,8All India Institute of Medical Sciences, New Delhi, New Delhi, India, 9OregonHealth & Science University, Obstetrics & Gynecology, Portland, Oregon

OBJECTIVE: To compare neonatal and maternal morbidities associatedwith cervical cerclage (CERC) versus expectant management (EXP) in preg-nancies complicated by 2nd trimester cervical dilation.

STUDY DESIGN: Historical multicentered cohort study conducted by theGlobal Network for Perinatal and Reproductive Health. Women between 14-256/7 weeks gestation presenting with threatened preterm birth or dilated cervixfrom 1998-2004 were identified. Women with preterm prelabor rupture ofmembranes, labor, or vaginal bleeding at time of presentation, those with aclosed cervix, or those opting for induction of labor or termination were ex-cluded. Main outcomes were composite neonatal morbidity (respiratory dis-tress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage,and necrotizing enterocolitis) and composite maternal infectious morbidity(chorioamnionitis, endometritis, and sepsis). c2 and Fishers Exact Test wereused to compare categorical variables as appropriate. Mann-Whitney Testwas used to compare non-evenly distributed continuous variables. Type 1 errorwas set at 0.05 (two-sided).

RESULTS: 409 women were identified. After exclusions (25 induction/termination, 26 no outcome data, 15 closed cervix, 117 clinical symptoms), 210women remained: 136 CERC and 74 EXP. Median gestational age at deliverywas greater in CERC than EXP (32.4 weeks vs. 26.1 weeks respectively, p .007).Among pregnancies delivering beyond 236/7 weeks gestation (97CERC, 55EXP)composite neonatal morbidity occurred less frequently in CERC than EXP(19.6%vs. 54.5%respectively, p!.001).Compositematernal infectiousmorbid-ity occurred in 14.5%of CERC vs. 5.3% of EXP, p!.046. The use of antibioticsdid not differ between CERC and EXP (54.2% vs. 52.7% respectively, p NS).

CONCLUSION: Compared to expectant management, cerclage in pregnanciescomplicated by 2nd trimester cervical dilationwas associatedwith lower compos-ite neonatal morbidity, but higher composite maternal infectious morbidity.

438 CLASSIFICATION OF CAESAREAN SECTIONS IN SPONTANEOUSLY LABOURING,SINGLE CEPHALIC, NULLIPAROUS WOMEN AT GREATER THEN 36 WEEKS (SCNT)NANDINI RAVIKUMAR1, CLIONA MURPHY1, ANN RATH1, MICHAEL ROBSON1,DECLAN KEANE1, 1National Maternity Hospital, Dublin, Ireland

OBJECTIVE: SCNT is the single most important group in the managementof women in labour. There is greater variation in the caesarean section rate inSCNT then in any other group of women. The group is a significantcontributor to the overall caesarean section (CS) rate. We present a classifi-cation system which allows the objective comparison of the indications of CSsin this group of women.

STUDY DESIGN: The classification system defines fetal distress and dystociaas the only 2 groups under which CSs could be classified. Fetal distressincludes only women not treated with oxytocin. Dystocia is subdivided into 5groups. The first 4 are all defined as ineffecient uterine action, but subdividedinto poor response (but full dose of oxytocin)(DPR), inability to treat (due toovercontracting or malpresentation)(DITTOCMP) inability to treat (due tofetal intolerance)(DITTFI) and lastly cases where no oxytocin has been usedDNO. The fifth sub group of dystocia, where inefficient uterine action has beenexcluded, consists of cases of cephalo pelvic disproportion or persistentoccipito posterior position (DCPDPOP). All these groups are mutuallyexclusive and totally inclusive. The classification was applied over a 6 monthperiod in a unit who has practised active management of labour (AML) for 40years. All consecutive SNCT irrespective of any other medical or obstetrichistory were included in the analysis.

RESULTS: The overall CS rate in SCNT was 7%. Even in a unit thatpractises AML inefficient uterine action remains the most common reason forcaesarean section. The most common subgroup was DITTOCMP. Truecephalo pelvic disproportion is rare. No woman was delivered by CS fordystocia without being treated with oxytocin.

CONCLUSION: A standard classification system, if used, will allow differentunits with different management protocols to compare in an objective mannerthe indications for caesarean sections in SCNT.

Classification of CSs in spontaneous labour 70/994 (7.0%)

FD DPR DITTOCMP DITTFI DCPDPOP DNO

n = 12 n = 15 n = 25 n = 11 n = 7 n = 0

S128 SMFM Abstracts