progressive cervical changes after prophylactic cerclage: is a reinforcing cerclage beneficial?

560 A COMPARISON OF VERTICAL AND PFANNENSTEIL INCISIONS IN PATIENTSUNDERGOING CESAREAN DELIVERY WITH THE SYNDROME OF HEMOLYSIS,ELEVATED LIVER ENZYMES, AND LOW PLATELETS (HELLP) D. MICHAELARMSTRONG1, EUGENE CHANG1, CHRISTOPHER ROBINSON1, SCOTT SULLIVAN1,DONNA JOHNSON1, STEPHEN VERMILLION1, J. VAN DORSTEN1, 1Medical Universityof South Carolina, Obstetrics and Gynecology, Charleston, South Carolina

OBJECTIVE: To determine whether the use of a drain or midline incisionresulted in a lower wound hematoma rate in patients with HELLP syndromeundergoing cesarean delivery.

STUDY DESIGN: A retrospective chart review of patients diagnosed withHELLP syndrome that underwent Cesarean delivery at the Medical Universityof South Carolina from 1990-2002 was conducted. Medical records for thesepatients were examined for the type of incision and for the use of drains. Woundhematomas were analyzed with respect to the type of skin incision and whetheror not a drain was used. Data were analyzed by the Fisher exact test. Significancewas considered P ! .05.

RESULTS: A total of 135 patients with HELLP syndrome undergoingcesarean section were identified. There were 107 patients with Pfannensteilincision and 28 patients with a vertical midline incision. Sixty patients hada drain placed intraoperatively and 75 patients who had no drain. Complicationrates are listed in the chart below.

CONCLUSION: In women with HELLP syndrome, the incidence of woundhematomas is not influenced by the type of skin incision or drain placement.

Wound hematomas by incision

Type of incision Wound hematomas Significance

Pfannensteil 9/107 (8.4%)Vertical 2/28 (7.1%) P = 1.00

Wound hematomas by drain placement

Drain placement Wound hematomas Significance

Drain 3/60 (5.0%)No drain 8/75 (10.7%) P = .35

S158 SMFM Abstracts

561 PROGRESSIVE CERVICAL CHANGES AFTER PROPHYLACTIC CERCLAGE: ISA REINFORCING CERCLAGE BENEFICIAL? JASON BAXTER1, JAMES AIROLDI1,VINCENZO BERGHELLA1, 1Thomas Jefferson University, Department ofObstetrics and Gynecology, Philadelphia, Pennsylvania

OBJECTIVE: To determine if placement of an interval reinforcing cerclageimproves outcome in patients with a prophylactic cerclage who develop a shortcervix on ultrasound.

STUDY DESIGN: Patients who received a prophylactic transvaginal cerclageand subsequently developed a short cervix (cervical length !25 mm) ontransvaginal ultrasound (TVU) at !24 weeks between 1991 and 2001 at ourinstitution were retrospectively reviewed. Pregnancies that received a reinforcingcerclage (RC) because of cervical changes were compared to similar pregnancieswhich were followed without a reinforcing cerclage (NRC). The primaryoutcome was preterm birth (PTB) !35 weeks. Exclusion criteria includedmultiple gestation, concomitant pessary use, manual exam diagnosis of thecervical changes, or incomplete records. The Mann-Whitney U test and andFisher’s exact test were used to compare descriptive statistical data.

RESULTS: Twenty-four patients with prophylactic cerclage and subsequentcervical shortening by TVU were identified, of which 5 had RC and 19 hadNRC. There was no difference in patient demographics (age, race, smokingstatus and insurance status) and risk factors (parity, history of prior cerclage,failed cerclage, PTB, midtrimester loss, and cone biopsy) between the twogroups. RC was associated with a significantly earlier gestional age at delivery aswell as higher rates of both PTB !35 weeks and PTB !24 weeks (Table).

CONCLUSION: In patients with a prophylactic cerclage already in place andultrasonographically diagnosed cervical shortening before 24 weeks, placementof a reinforcing cerclage is associated with a worse outcome than expectantmanagement. None of the patients who received an interval reinforcing cerclageafter prior prophylactic cerclage achieved a gestational age greater than 25weeks. Reinforcing cerclages are not beneficial and should not be performed.

Reinforcing cerclage (RC) vs. no reinforcing cerclage (NRC)

RC (n = 5) NRC (n = 19) Significance

Mean GA del 20.8 wk 32.9 wks P = .002PTB !35 wk 5 (100%) 6 (31.6%) P = .011PTB !24wk 4 (80%) 3 (15.8%) P = .014