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365 Ultrasound predication of shoulder dystocia in
low risk term singleton deliveries
alon sapir, Izzat Khayyat, Lior Drukker, Ron Rabinowitz,
Arnon Samueloff, Hen Y. Sela
Shaare Zedek medical center, jerusalem, Israel
OBJECTIVE: To evaluate the performance of various publish ultraso-
nographic (US) parameters in the prediction of shoulder dystocia
(SD) in low risk term singleton deliveries.
STUDY DESIGN: Retrospective study, 2010-2015, all patients with
viable singleton pregnancy, without history of shoulder dystocia or
diagnosis of gestational or pregestational diabetes mellitus, who
underwent US estimations of fetal weight within 7 days of vaginal
delivery at term (37-42 weeks of gestation) were included. De-
mographics, gestational and delivery characteristics and outcomes
noted. After reviewing the relevant literature the US parameters
assessed were abdominal diameter - biparietal diameter (AD-BPD)

26mm, estimated fetal weight (EFW)
4000g, EFW
4500g,
abdominal circumference (AC)
390mm and AC/BPD
4. Statis-
tics: c2 (p<0.05 signicant) and multivariate logistic regression (LR)
(OR, 95%CI, p value).
RESULTS: Out of 6214 deliveries who met inclusion criteria, 31
(0.5%) were complicated by SD. Median time from US to delivery
was 1.2 [0.55 - 2.73] days. SD was associated with operative vaginal
delivery (32.3% vs. 6.9%, p0.01), oxytocin use during labor
(61.3% vs. 38.7%, p<0.01) and prolonged second stage (16.1% vs.
4.5% p 0.01). On univariate analysis US parameters that were
associated with SD were: EFW
4000g (25.8% vs. 8.2%, p<0.01),
AC/BPD
4 (25.8% vs. 7.3%, p<0.01), AD-BPD
26mm (25.8%
vs. 5.6%, p<0.01), AC
390mm (6.5% vs. 0.6%, p<0.02), EFW

4500g (6.5% vs. 0.4%, p<0.01) and EFW
4000g + AD - BPD

26mm (9.7% vs. 2.4%, p<0.05).The sensitivity, specicity, positive
predictive value (PPV) and negative predictive value (NPV) of the
US parameters are summarized in table 1. Multivariate analysis
including US parameters, instrumental delivery and the use of
oxytocin during labor revealed OR of: 28.3, 14.1, 6.2, 5.2, 4.6, 4.2 for
EFW
4500g, AC
390mm, AD-BPD
26mm, EFW
4000g +
AD-BPD
26mm , AC/BPD
4, EFW
4000g respectively.
CONCLUSION: All publish US parameters for predicting SD are asso-
ciated with SD in low risk population at term, yet given the low
incidence of SD in this population, sensitivity and PPV of these
parameters are low while the specicity and NPV are high. When
using these various parameters to manage labor, a total of fourteen
Supplement to JANUARY 2017 American Journal of Obstetrics & Gynecology
Poster Session II
to seventy elective cesarean deliveries would be performed to prevent
one case of SD according to the different parameters.
366 Pulling the plug on first trimester placental
blood flow controversy; new insights from
contrast-enhanced ultrasound
Victoria H. Roberts1, Jamie O. Lo2, Terry K. Morgan2,
Antonio E. Frias2
1
Oregon Health & Science University, Beaverton, OR, 2Oregon Health &
Science University, Portland, OR
OBJECTIVE: Early vascular remodeling of the maternal spiral ar-
teries by trophoblast invasion is critical to pregnancy success.
There is conicting evidence as to whether the spiral arteries
remain plugged until 10-12 weeks of gestation (wks). Morpho-
logical studies demonstrate both spiral artery plugs, and red blood
cells in the intervillous space (IVS) <10 wks, suggesting only
partial plugging occurs. Yet in vivo placental Doppler ultrasound
studies have limited capability to detect blood ow in the rst
trimester making this a controversial issue. We recently utilized
contrast-enhanced ultrasound (CE-US) to visualize and quantify
perfusion in the IVS of the nonhuman primate placenta in the
second and third trimester. In the current study we used CE-US to
examine utero-placental blood ow in the rst trimester of hu-
man subjects.
STUDY DESIGN: Women (n35) were recruited in the rst trimester
(age range: 6 - 13+6 wks) under local IRB approval. All studies were
performed with maternal intravenous infusion of lipid-shelled
octouoropropane microbubbles with image acquisition using a
multipulse contrast-specic algorithm with destruction-replenish-
ment analysis of signal intensity for assessment of perfusion. The
ux rate (b) determines the rate constant of the post-destructive
vascular relling and reects the microvascular blood ux rate.
Perfusion was assessed in replicate analyses of the whole placenta
(not individual spiral artery sources) for each study.
RESULTS: Placental perfusion was visualized as early as 6 wks gesta-
tion with identication of individual spiral artery sources perfusing
the IVS at w8 wks [Fig. Placental perfusion at 8+4 wks; spiral artery
input (*) perfusing the IVS (insert), whole placenta outlined (dashed
line)]. Flux rate was not signicantly altered across 6 to 12 weeks but
may be increasing at 13+ wks [Graph: Data are mean+SEM, n values
given within individual bars].
CONCLUSION: These novel data provide the rst quantitative in vivo
evidence of maternal perfusion of the IVS earlier than previously
postulated. Use of a vascular contrast agent to visualize blood ow
overcomes prior limitations with D-US and challenges the notion
that there is no blood ow through the spiral arteries in early human
pregnancy; the concept of completely obstructed spiral arteries needs
to be re-examined in light of this nding.
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