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Volume 166 Number 1, Part 2

SUBSTANCE ABUSE IN PREGNANCY, A RURAL PERSPECTIVE. S. C. Fee, P. l1eier, Dept. Ob/Gyn, Marshfield Clinic, Marshfield, WI.

Substance abuse in pregnancy is a well docUl1l"nted problem and has been associated with nUl1l"rous perinatal problems. M:lst studies have noted a prevalence of 11-15%, but these studies have all relied on urban populations. We have attempted to address the problem of substance abuse in rural pregnant warEn by conducting urine toxicology screens on 714 pregnant patients in a rural obstetrical clinic. In the first 4 nnnths of this ongoing clinical study we obtained anonynnus urine toxicology screens fran 30 I consecutive warEn seen for their initial prenatal visit and fran 413 consecutive warEn admitted to the labor/delivery suite. All urines were screened for cocaine, cannabinoids, opiates, barbiturates, benzodiazepams and amphetamines. All positive screens underwent confirmatory testing. The presence of secobarbitol in labor/delivery patients (n=4) was considered iatrogenic and was not included in the calculations. The prevalence of positive urine screens was 1.7%. Of patients presenting for prenatal care, 1.3% were positive. Labor/delivery patients had a prevalence of 1.4%. The substances found were as follows: opiates 1.3%, barbiturates 0.1%, cocaine 0.3%, cannabinoids 0.3%, 3 screens were positive for nnre than one substance. No screens were positive for amphetamines or benzodiazepams. Our findings suggest that substance abuse in pregnancy may not be as wide spread as suggested by previous studies and that the concept of universal screening for substance abuse in pregnancy may not be a cost effective treasure in all populations.

POSTPARTUM MORBIOITY AFTER FOURTH OEGREE PERINEAL REPAIR. Kenneth G. Goldaber. x Paul J. Wendel. x George D. Wendel. Jr. Department of Obstetrics and Gynecology. University of Texas Southwestern Medical Center. Dallas. TX

Fourth degree extension of epiSiotomies and perineal lacerations can have serious sequelae. However, there ;s little data regarding the incidence of fourth degree repair morbidity: infection and dehiscence. We sought to investigate the frequency of puerperal complications in women with fourth degree perineal lacerations and episiotomy extensions. The hospital records of 389 women (2% of vaginal deliveries) in 1989 and 1990 who had fourth degree perineal repair were reviewed. The delivery room surg ica 1 techn ique invo lved layered closure with 00 and 000 chromic catgut suture. Twenty women (5.1%) had infection and/or dehiscence. Thirteen women (3.3%) had infected perineal repairs, and 10 of the repairs (77%) subsequently became dehiscences. Seven women {1.8%} had perineal dehiscence without infection. Overall. 17 dehiscences (4.4%) occurred. accounting for 85% of the postpartum morbidity. Seventeen of the women (85%) were primiparas, and 19 (95%) had episiotomy extensions. The mean birth weight in the group with morbidity was 3500 grams. When compared to the 369 women without repair complications, there were no significant differences between maternal age, race, parity, weight, smoking or human papilloma virus infection. Similarly there was no difference regarding duration of second stage of labor. occiput pOSitions, forceps delivery. blood loss. macrosomia, or birthweight. The only significant association was with shoulder dystocia which occurred in 19 of 369 women (5.1%) without morbidity and 4 of 20 women (20%) with morbidity (P= 0.D2). Conclusion: Postpartum morbidity after fourth degree perineal repair is an uncomnon event, usually accompanied by perineal dehiscence. Unfortunately, fourth degree complications are not predicted by readi ly preventab le antepartum or intrapartum factors.

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spa Abstracts 401

PERIPARTIJM HYSTERECTOMY: A RETROSPECTIVE REVIEW Lorraine StancoX, M.D., David Schrimmer, M.D. Richard Paul, M.D.

University of Southern California, Los Angeles, CA

From January I, 1985 to July 1, 1990 at LAC+USC Women's Hospital, there were 85,841 births (71,845 vaginal and 13,996 cesarean). Retrospective review of medical records and departmental statistics revealed 125 cases of either cesarean or immediate post partum hysterectomy, with 60 being total and 65 subtotal. The incidence of peripartum hysterectomy was 1.5/1000 births, with an incidence following vaginal delivery of .097/1000 whereas the incidence associated with cesarean birth was 8.4/1000 or one hundred times greater. Median parity was 2 and median gestational age was 38 weeks. In 81 cases (65%), there was a history of prior cesarean delivery. Delivery was by cesarean section in 118 pts., while 7 delivered vaginally. Placenta previa was the indication for cesarean in 58/118 (49%) pts. Of the 7 pts. delivered vaginally, the 4 with prior cesarean delivery had uterine rupture requiring hysterectomy, despite the fact that 3 of them had undergone prior successful VBAC. Indication for hysterectomy was the diagnosis of placenta accreta in 55 pts, uterine atony in 25 pts, unspecified uterine bleeding in 19 pts, uterine rupture in 14 pts, placenta percreta in 6 pts, fibroids in 5 pts and infection in 1 pt. The pathological diagnosis of accreta or percreta was confirmed in 26/61 cases (43%). In 108/125 cases (86.4%) estimated blood loss was at least 2000 cc (range 900-21000) and blood transfusion occurred in 102/125 pts (82%). Fifty-seven pts. were transfused more than 2 units and of these 27 received more than 10 units. There were no significant differences in blood loss or replacement products with respect to type or indication for hysterectomy. Maternal complications included 11 cases of infectious morbidity, 11 wound complications, 7 cases of coagulopathy, and 4 cases of profound hemorrhage with one resultant maternal death. Median birthweight was 3120 grams and 13/126 (10%) infants had a 5 minute Apgar score of less than 7. There were 2 intrapartum and 2 neonatal deaths, the latter being attributed to prematurity. Median discharge for mothers and infants was the fourth hospital day. Previous cesarean section, placenta previa and blood loss of 2000cc or more were identified risk factors leading to hysterectomy. For 37/125 (29.6%) pts., all three factors were identified.

INTRAPARTUM MANAGEMENT OF THE NONVERTEX SECOND T~IN. ~

Sherman, B.W. Kovacs, Dept. Ob/Gyn, University of Southern Cal ifornia School of Medicine, Los Angeles, CA

The intrapartun management of twin gestations in the vertex­

nonvertex presentation is controversial. The purpose of this study was to c""""re the foL Lowing deL ivery methods of the

nonvertex second twin with regard to neonatal outcome: assisted breech, breech extraction, external version, and cesarean section. From 1/89 to 1/90, 236 sets of twins were del ivered: 109 vertex-vertex, 67 vertex-nonvertex, 59 nonvertex, and 1

unspeci f i ed. Among the 67 vertex-nonvertex, the findings were:

Second Assisted Breech External Cesarean twin breech extraction version section

N (%) 13 (20%) 26 (39%) 3 (4%) 25 (37%)

Bi rth wei ght 2314g 2387g 3140g 2399g

Apgar

5 min 8.3 8.3 8.2 8.6

NICU

a<*nit 0% 17% 0% 18%

In conclusion, there is no statistically significant increased

neonataL morbidity for these specified methods of vaginaL

deL ivery of the nonvertex second twin cOl'r1JBred to del ivery by

cesarean sect ion.