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Re: Difficult case**36 week previas**From: Dr. John Provatopoulos B.Sc. M.D.C.M. F.R.S.C. (johnprov@sympatico.ca)Mon May 14 21:25:36 2007
WHEN SHOULD WOMEN WITH PLACENTA PREVIA BE DELIVERED?: A DECISION ANALYSIS: 59 [ORAL CONCURRENT SESSION 5: Operative Obstetrics/Clinical Obstetrics: Friday, February 9, 2007 1:15 pm – 3:30 pm: Continental Ballroom 5, Hilton San Francisco] ZLATNIK, MARYA1; LITTLE, SARAH1; KOHLI, PUJA1; STOTLAND, NAOMI1; KAIMAL, ANJALI1; CAUGHEY, AARON1 1University of California, San Francisco, Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California OBJECTIVE: To determine the optimal gestational age for delivery of women with placenta previa by accounting for both neonatal & maternal outcomes. STUDY DESIGN: A decision analytic model was designed in DATA TreeAge Pro comparing the total maternal and neonatal quality-adjusted life years for delivery of women with placenta previa at gestational ages ranging from 34 to 38 weeks. At each gestational age, we allowed for four different delivery strategies: (1) amniocentesis for fetal lung maturity (FLM) with expectant management and repeat testing in 1 week if negative; (2) amniocentesis with administration of steroids if negative, followed by delivery in 48 hours (3) administer steroids to all women, followed by delivery in 48 hours; (4) immediate delivery. Baseline assumptions included the probability of emergent bleeding ranging from 4.7% at 35 weeks to 28.7% at 38 weeks, 1.7% risk of hysterectomy for scheduled delivery, and 5.5% risk of hysterectomy for delivery after emergent bleeding. Univariate sensitivity analysis was performed to test for robustness. RESULTS: Immediate delivery at 36 weeks, without amniocentesis or steroids, was the optimal strategy. Table 1 describes the outcomes for immediate delivery at 35–37 weeks gestation. In sensitivity analysis, 36 weeks was the best strategy as long as the risk of emergent bleeding was at least 38% as likely as the baseline estimates, the risk of maternal outcomes was between 60% and 370% of baseline, and the risk of neonatal outcomes (CP and RDS) was less than 160% of baseline estimates.
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Take care, John
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