Delayed-interval delivery in twin pregnancies.

OBJECTIVE: To report on pregnancy outcome in six twin pregnancies with delayed-interval delivery in a single maternal-fetal medicine practice. STUDY DESIGN: All cases of attempted delayed-interval delivery from January 1988 to August 2000 in a single maternal-fetal medicine practice were retrospectively reviewed. Patients were managed with a treatment protocol that included rescue cerclage after delivery of the first born twin, antibiotics, corticosteroids and tocolysis. RESULTS: Five of the six twin gestations resulted in viable birth of the second-born twin. One pregnancy had loss of both fetuses before viability. All first-born twins were nonviable. The median pregnancy prolongation achieved following delivery of the first-born, nonviable twin was 93 days, with a range of 23-153. Three of the five viable, second-born twins had a neonatal intensive care nursery stay of 3, 4 and 35 days (mean, 8.4). No infant required a ventilator. CONCLUSION: Based on our analysis of these six cases, the pregnancy prolongation gained resulted in a clinically significant benefit to the second-born twin, without significant morbidity in the mother.

Consequences of nonindicated preterm delivery in singleton gestations.

OBJECTIVE: To determine the neonatal and economic consequences of nonindicated preterm delivery in singleton gestations. STUDY DESIGN: From a database of women with high-risk pregnancies enrolled for outpatient nursing services between October 1995 and February 2000, singleton gestations with induced labor or scheduled cesarean delivery and a gestational age at delivery of 34-36 weeks were identified. Excluded were women with preterm premature rupture of the membranes or medically indicated delivery. We compared infant neonatal intensive care unit (NICU) admission rates and ventilator use for consecutive weeks and applied a cost model to determine potential savings of delaying delivery. RESULTS: A total of 1,538 pregnancies were analyzed. Risk of NICU admission declined significantly with each advancing week (by > 50%, P <.05). NICU length of stay and total nursery costs decreased significantly between weeks 35 and 36 and weeks 34 and 35. Need for ventilatory assistance increased significantly for infants admitted to the NICU between weeks 34 and 35. The incidence of respiratory distress syndrome decreased 49% between 35 and 36 weeks. CONCLUSION: Prolonging gestation 1 week beyond weeks 34 and 35 has a significant impact on improving neonatal outcome and decreasing associated costs. These factors should be considered when electing to deliver at 34 and 35 weeks.

Managing perinatal outcomes: the clinical benefit and cost-effectiveness of pharmacologic treatment of recurrent preterm labor.

PURPOSE: To compare the clinical benefit and cost-effectiveness of utilizing continuous subcutaneous terbutaline versus oral tocolytics following recurrent preterm labor. DESIGN: Retrospective, 1:1 matched cohort. METHODOLOGY: From prospectively collected data in a nationwide, perinatal database of women receiving outpatient services, we identified singleton gestations having recurrent preterm labor, stabilized during hospitalization, and subsequently treated with oral tocolytics (PO group) or continuous subcutaneous terbutaline infusion (SQ group). Those without medically indicated delivery were eligible for inclusion. Each woman in the PO group was matched 1:1 by gestational age at recurrent preterm labor to a woman in the SQ group. A standardized cost model was applied to compare total antepartum hospital, nursery, and outpatient charges. Wilcoxon Signed Rank, paired t, and McNemar's C2 test statistics were used for comparisons. PRINCIPAL FINDINGS: 558 women were studied (279 per group). The PO group had less gestational gain following recurrent preterm labor than the SQ group (28.4 +/- 19.8 days vs. 33.9 +/- 19.0 days, respectively, P < .001). The SQ group had less per patient charges ($) for antepartum hospitalization (3,986 +/- 6,895 vs. 5,495 +/- 7,131, P = .009), and nursery (7,143 +/- 20,048 vs. 15,050 +/- 32,648, P < .001). Outpatient charges were less for the PO group (1,390 +/- 1,152 vs. 5,520 +/- 3,292, P < .001). Overall costs for those in the SQ group were $5,286 less per pregnancy compared to the PO group. CONCLUSION: In this population, continuous subcutaneous terbutaline infusion was both a clinically beneficial and cost-effective treatment following recurrent preterm labor.

Is 34 weeks an acceptable goal for a complicated singleton pregnancy?

PURPOSE: To examine neonatal risk and associated nursery costs for infants with delivery following untreated preterm labor at 34, 35, or 36 weeks' gestation, by assessing the incidence of neonatal intensive care unit (NICU) admission, respiratory distress syndrome (RDS), and need for ventilatory assistance. DESIGN: Infants with preterm birth at 34, 35, or 36 weeks were identified from a database of prospectively collected clinical information and pregnancy outcomes of women receiving outpatient preterm-labor management services, in addition to routine prenatal care. Cases of singleton gestations with delivery related to spontaneous preterm labor were analyzed. Data were divided into three groups by gestational week at delivery. METHODOLOGY: Descriptive and statistical methods were used to compare maternal demographics, pregnancy outcome, and nursery costs. A cost model was utilized. PRINCIPAL FINDINGS: 2849 infants were studied. Risk of NICU admission decreased by 47.4 percent from weeks 34 to 35 and 41.8 percent from weeks 35 to 36. Risk of RDS decreased by 25.4 percent from weeks 34 to 35, and 40.7 percent from weeks 35 to 36. Mean nursery costs per infant delivering at 34, 35, and 36 weeks were $11,439 +/- $19,774, $5,796 +/- $11,858, and $3,824 +/- $9,135, respectively (p < .001). CONCLUSION: Rates of NICU admission, RDS, ventilator use, and nursery-related costs decreased significantly with each week gained. The data indicate that benefit is derived in prolonging pregnancy beyond 34 weeks.