- Email: [email protected]
517: Trends in major neonatal and maternal morbidities accompanying the rise in the cesarean delivery rate
www.AJOG.org
Epidemiology, Ob Quality, Operative Obstetrics, Public Health, Infectious Disease, Academic Issues
between the respondents’ year in fellowship and self-reported knowledge level (P¼0.014). Accuracy on the proper indications for NIPT for trisomy 21 screening exhibited a non-statistically significant correlation with year of training (P¼0.162) and self-reported knowledge level (P¼0.066). CONCLUSION: MFM fellows are learning about NIPT through a variety of avenues. Formal education, review of scientific literature, and discussions with peers provided education more often than interactions with lab representatives. Fellows demonstrated appropriate knowledge levels regarding the use of fetal cell free DNA screening for trisomy 21. However, they did not show the same knowledge levels regarding the use of NIPT to screen for monosomy X and in twin pregnancies.
515 Perinatal outcomes among women with mood disorders: a retrospective population-based cohort study Elad Mei-Dan1, Joel Ray2, Simone Vigod3 1
Sunnybrook Health Sciences Centre, University of Toronto, Women and Babies Program, Toronto, ON, Canada, 2St. Michael’s Hospital, University of Toronto, Institute for Clinical Evaluative Sciences, Department of Medicine, Toronto, ON, Canada, 3Women’s College Hospital and Women’s College Research Institute, Institute for Clinical Evaluative Sciences, Department of Psychiatry, Toronto, ON, Canada
OBJECTIVE: To investigate whether the risks of adverse perinatal outcomes is elevated among pregnant women with mood disorders compared to women with no diagnosed mental illness. STUDY DESIGN: We completed a population-based cohort study of pregnant women in Ontario, between 2002 and 2011. Bipolar (n¼1859) and major depressive (n¼3724) disorders were identified among women with at least one inpatient diagnosis for the respective diagnoses within 5 years prior to conception. The reference group comprised 432,358 women with no documented mental illness during the same pre-pregnancy period. The main adverse perinatal outcomes included preterm birth < 37 weeks gestation, birth weight > 97th or < 3rd percentile for gestational age, stillbirth and early infant death within 28 days after birth. Outcomes were adjusted for maternal age, parity, pre-pregnancy medical morbidity and infant sex. Additional perinatal health outcome indicators were secondary outcomes. RESULTS: Relative to a rate of 6.2% in the referent, the risk of preterm was higher in women with bipolar disorder (adjusted odds ratio [AOR] 2.01, 95% confidence interval [CI] 1.73 to 2.33), and those with major depressive group (AOR 1.96, 95% CI 1.76 to 2.18). The AOR for small gestational age were 1.15 (95% CI 0.92 to 1.44) and 1.22 (95% CI 1.05 to 1.42), respectively. The AOR for large gestational age were 1.34 (95% CI 1.05 to 1.70) and 1.01 (95% CI 1.01 to 1.02), respectively. Neonatal mortality did not differ significantly between groups. Serious neonatal morbidity, malformations and neonatal re-admission rates were significantly increased in each mood disorder group, relative to women with no mental illness. CONCLUSION: Women with mood disorders are at an increased risk for multiple adverse perinatal outcomes. Adverse outcome rates in women with depressive and bipolar disorders were similar, suggesting that the commonalities to these disorders may be more important to maternal and child outcomes, than the differences.
516 In the dark of night: delivery during the night shift is a risk factor for maternal adverse outcome Roy Shalit1, Lena Novack1, Eyal Sheiner2 1 Ben-Gurion University of the Negev, Department of Epidemiology and Health Services Evaluation, Beer-Sheva, Israel, 2Soroka University Medical
Poster Session III
Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Department of Obstetrics and Gynecology, Beer-Sheva, Israel
OBJECTIVE: The study was aimed to determine whether the time and/ or the date of delivery are risk factors for adverse maternal outcome. STUDY DESIGN: A comprehensive review of all major adverse maternal outcomes was performed during a 24 year period (1988-2011). A composite adverse outcome was defined as one or more of the following: postpartum hemorrhage, perineal tear grade 3/4, cervical tear, uterine rupture, blood transfusions and peripartum hysterectomy. The events were evaluated in terms of time and date of the delivery, including night shifts, weekend or holiday shifts, delivery during the shift changes and delivery during the last hour of a shift. Multivariable generalized estimating equation (GEE) analyses were performed in order to control for confounders. RESULTS: The study group comprised of 263,827 deliveries; 2.15% (n¼5688) had one or more maternal adverse outcomes. Delivery during the night shift and delivery during the last hour of the night shift were found to be independent risk factors for maternal composite adverse outcome in a multivariable GEE model (adjusted odds ratio: 1.103; 95% confidence interval, 1.04-1.16; P ¼ .001 and, 1.134; 95% confidence interval, 1.03-1.24; P ¼ .011 matched to the above). The model controlled for confounders such as: gravidity, hypertensive disorders, placental pathologies, labor dystocia, instrumental or Cesarean delivery. Other factors such as delivery during the weekend or holiday shift, delivery during the shift changes were not found to be significant risk factors for adverse maternal outcomes (Table). CONCLUSION: Delivery during the night shift is an independent risk factor for maternal composite adverse outcome.
Maternal composite adverse outcome by time / date of the delivery
CI, confidence interval; OR, odds ratio. a
Generalized estimation equation models including: gravidity, hypertensive disorders, placental pathologies, labor dystocia, instrumental delivery and caesarian delivery.
517 Trends in major neonatal and maternal morbidities accompanying the rise in the cesarean delivery rate Sivan Zuarez-Easton1, Eliezer Shalev2, Raed Salim2 1 Emek Medical Center, Obstetrics and Gynecology, Afula, Israel, 2Technion, Rappaport Faculty of Medicine, Haifa, Israel
OBJECTIVE: The cesarean delivery rate (CDR) has increased consid-
erably over the past 20 years. However, the appropriate CDR of which beyond, major morbidity may outweigh the benefits of the procedure itself is still not determined. We aimed to explore the association between the trend of CDR during the last two decades and the occurrence of major neonatal and maternal morbidities. STUDY DESIGN: A population based cohort study conducted between the years 1993 to 2012 at a single university teaching hospital. Data
Supplement to JANUARY 2014 American Journal of Obstetrics & Gynecology
S255
Poster Session III
Epidemiology, Ob Quality, Operative Obstetrics, Public Health, Infectious Disease, Academic Issues
that included number of deliveries, CD, and major neonatal and maternal morbidities that included Erb’s palsy (EP), neonatal encephalopathy (NE), placenta accreta (PA) and cesarean hysterectomy (CH) for each year were extracted and plotted, and trends were assessed. Data was obtained from the hospital discharge register with ICD-9 codes, crosschecked with the labor electronic medical records, and individual cases were manually checked and validated. The Cochran-Armitage Trend Test was used in order to identify trends and correlations. RESULTS: Overall 83806 deliveries took place during the study period. CDR increased from 10.9% in 1993 to a maximum rate of 21.7% (p<.0001). This increase was accompanied with a significant decrease in the incidence of EP (p<.0001) and a significant decrease in the incidence of NE (p¼.006). At a CDR of 13.6% and 20%, there was no further significant decrease in the incidence of EP and NE, respectively (figure1). The increase in the CDR was accompanied with an increase in the incidence of PA, though the trend up to a maximum CDR of 21.7% was still not significant (p¼.06). There was no significant change in the incidence of CH (p¼.4) or CH due to a PA (p¼.06). CONCLUSION: The increase in the CDR was accompanied with a decrease in major neonatal morbidities. This advantage disappeared at a threshold of 20%. Additionally, up to this threshold, the incidence of major maternal morbidities increased though this increase was still not significant.
Annual rates of cesarean deliveries and major neonatal morbidities
518 Reproductive outcomes of women and men born very preterm and/or with a very low birth weight in 1983: a longitudinal cohort study in the Netherlands Arnout van Gendt2, Sylvia van der Pal1, Wietske Hermes3, Frans Walther2, Karin van der Pal - de Bruin1, Christianne de Groot3 1 TNO, Leiden, Netherlands, 2LUMC, Leiden, Netherlands, 3VUMC, Leiden, Netherlands
OBJECTIVE: To analyse reproductive outcomes of women and men
born very preterm or with a very low birth weight in 1983 in the Netherlands, and to compare their reproductive outcomes with the total population at similar age of 28 years.
www.AJOG.org
STUDY DESIGN: Young adults who were born after a pregnancy complicated by very preterm delivery (gestational age <32 weeks) or with a very low birth weight (<1500 grams) in the Netherlands in 1983 (POPS cohort) were invited to complete online questionnaire at the age of 28. In total, 293 POPS-28 participants (31.6%) completed the questionnaire including 185 female and 108 male participants. RESULTS: Female and male participants who were born very preterm or with a very low birth weight had significant reduced reproductive rates compared to total population at 28 years of age (female 23.2% vs 31.9% and male 7.4% vs 22.2%). Pregnancies of the female participants were in 14% complicated by preterm delivery in at least one pregnancy. CONCLUSION: This study indicates that women and men born very preterm or with a very low birth weight have reduced reproductive rates at the age of 28 compared to the total Dutch population. Women who were born themselves very preterm or with a very low birth weight have more often preterm offspring.
519 Qualitative outcomes of an in-patient art therapy program in high risk obstetrics Men-Jean Lee1, Martine Faist2, Lisa Rainey2, Juliet King2, Joani Rothenberg2, Jeffrey Rothenberg1 1
Indiana University School of Medicine, Obstetrics and Gynecology, Indianapolis, IN, 2Indiana University, Herron School of Art and Design, Graduate School of Art Therapy, Indianapolis, IN
OBJECTIVE: Art therapy is the therapeutic use of art making within a professional relationship by people who experience illness, trauma, or challenges in living. This study explored the therapeutic benefits of an art therapy program for hospitalized high risk pregnant women facing uncertain pregnancy outcomes. STUDY DESIGN: Art therapy was offered to women admitted to a high risk obstetrical unit in a tertiary care center for complicated pregnancies from 08/12 through 07/13. 49 patients were offered a choice of art mediums and given art directives by 2 registered art therapists experienced with adult, pediatric, and cancer patients. Each patient was initially asked to transform a pre-drawn circle on paper using colors, lines, shapes, and symbols to depict her current life experience, i.e. thoughts, feelings, and events. During the process, the patient was interviewed and asked to verbally share what her personal imagery symbolized. Progress notes were written after each art therapy session and recorded in the hospital medical record. Data including presenting diagnosis, history, verbalizations, affect, and other observations made by the art therapist were abstracted and summarized from the notes. The data was converted into therapeutic outcomes and categorized into themes for qualitative analysis. RESULTS: 14 themes emerged from the therapeutic outcome data, with the three most prevalent outcomes being: (1) stress management (reducing anxiety and fear, lowering BP, aiding in relaxation); (2) emotional expression (acknowledged emotions, shared tears and fears); (3) stimulated verbal communication (increased patient’s capacity to verbalize their experience, find meaning, process information, and debrief from traumatic events). CONCLUSION: Through analysis of themes, art therapy was found to be an effective therapeutic intervention for women hospitalized with high risk pregnancies. Art therapy gave them a creative way to cope with their stress, grieve loss, find meaning, and have a normalizing experience in an abnormal environment.
S256 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2014
Epidemiology, Ob Quality, Operative Obstetrics, Public Health, Infectious Disease, Academic Issues
between the respondents’ year in fellowship and self-reported knowledge level (P¼0.014). Accuracy on the proper indications for NIPT for trisomy 21 screening exhibited a non-statistically significant correlation with year of training (P¼0.162) and self-reported knowledge level (P¼0.066). CONCLUSION: MFM fellows are learning about NIPT through a variety of avenues. Formal education, review of scientific literature, and discussions with peers provided education more often than interactions with lab representatives. Fellows demonstrated appropriate knowledge levels regarding the use of fetal cell free DNA screening for trisomy 21. However, they did not show the same knowledge levels regarding the use of NIPT to screen for monosomy X and in twin pregnancies.
515 Perinatal outcomes among women with mood disorders: a retrospective population-based cohort study Elad Mei-Dan1, Joel Ray2, Simone Vigod3 1
Sunnybrook Health Sciences Centre, University of Toronto, Women and Babies Program, Toronto, ON, Canada, 2St. Michael’s Hospital, University of Toronto, Institute for Clinical Evaluative Sciences, Department of Medicine, Toronto, ON, Canada, 3Women’s College Hospital and Women’s College Research Institute, Institute for Clinical Evaluative Sciences, Department of Psychiatry, Toronto, ON, Canada
OBJECTIVE: To investigate whether the risks of adverse perinatal outcomes is elevated among pregnant women with mood disorders compared to women with no diagnosed mental illness. STUDY DESIGN: We completed a population-based cohort study of pregnant women in Ontario, between 2002 and 2011. Bipolar (n¼1859) and major depressive (n¼3724) disorders were identified among women with at least one inpatient diagnosis for the respective diagnoses within 5 years prior to conception. The reference group comprised 432,358 women with no documented mental illness during the same pre-pregnancy period. The main adverse perinatal outcomes included preterm birth < 37 weeks gestation, birth weight > 97th or < 3rd percentile for gestational age, stillbirth and early infant death within 28 days after birth. Outcomes were adjusted for maternal age, parity, pre-pregnancy medical morbidity and infant sex. Additional perinatal health outcome indicators were secondary outcomes. RESULTS: Relative to a rate of 6.2% in the referent, the risk of preterm was higher in women with bipolar disorder (adjusted odds ratio [AOR] 2.01, 95% confidence interval [CI] 1.73 to 2.33), and those with major depressive group (AOR 1.96, 95% CI 1.76 to 2.18). The AOR for small gestational age were 1.15 (95% CI 0.92 to 1.44) and 1.22 (95% CI 1.05 to 1.42), respectively. The AOR for large gestational age were 1.34 (95% CI 1.05 to 1.70) and 1.01 (95% CI 1.01 to 1.02), respectively. Neonatal mortality did not differ significantly between groups. Serious neonatal morbidity, malformations and neonatal re-admission rates were significantly increased in each mood disorder group, relative to women with no mental illness. CONCLUSION: Women with mood disorders are at an increased risk for multiple adverse perinatal outcomes. Adverse outcome rates in women with depressive and bipolar disorders were similar, suggesting that the commonalities to these disorders may be more important to maternal and child outcomes, than the differences.
516 In the dark of night: delivery during the night shift is a risk factor for maternal adverse outcome Roy Shalit1, Lena Novack1, Eyal Sheiner2 1 Ben-Gurion University of the Negev, Department of Epidemiology and Health Services Evaluation, Beer-Sheva, Israel, 2Soroka University Medical
Poster Session III
Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Department of Obstetrics and Gynecology, Beer-Sheva, Israel
OBJECTIVE: The study was aimed to determine whether the time and/ or the date of delivery are risk factors for adverse maternal outcome. STUDY DESIGN: A comprehensive review of all major adverse maternal outcomes was performed during a 24 year period (1988-2011). A composite adverse outcome was defined as one or more of the following: postpartum hemorrhage, perineal tear grade 3/4, cervical tear, uterine rupture, blood transfusions and peripartum hysterectomy. The events were evaluated in terms of time and date of the delivery, including night shifts, weekend or holiday shifts, delivery during the shift changes and delivery during the last hour of a shift. Multivariable generalized estimating equation (GEE) analyses were performed in order to control for confounders. RESULTS: The study group comprised of 263,827 deliveries; 2.15% (n¼5688) had one or more maternal adverse outcomes. Delivery during the night shift and delivery during the last hour of the night shift were found to be independent risk factors for maternal composite adverse outcome in a multivariable GEE model (adjusted odds ratio: 1.103; 95% confidence interval, 1.04-1.16; P ¼ .001 and, 1.134; 95% confidence interval, 1.03-1.24; P ¼ .011 matched to the above). The model controlled for confounders such as: gravidity, hypertensive disorders, placental pathologies, labor dystocia, instrumental or Cesarean delivery. Other factors such as delivery during the weekend or holiday shift, delivery during the shift changes were not found to be significant risk factors for adverse maternal outcomes (Table). CONCLUSION: Delivery during the night shift is an independent risk factor for maternal composite adverse outcome.
Maternal composite adverse outcome by time / date of the delivery
CI, confidence interval; OR, odds ratio. a
Generalized estimation equation models including: gravidity, hypertensive disorders, placental pathologies, labor dystocia, instrumental delivery and caesarian delivery.
517 Trends in major neonatal and maternal morbidities accompanying the rise in the cesarean delivery rate Sivan Zuarez-Easton1, Eliezer Shalev2, Raed Salim2 1 Emek Medical Center, Obstetrics and Gynecology, Afula, Israel, 2Technion, Rappaport Faculty of Medicine, Haifa, Israel
OBJECTIVE: The cesarean delivery rate (CDR) has increased consid-
erably over the past 20 years. However, the appropriate CDR of which beyond, major morbidity may outweigh the benefits of the procedure itself is still not determined. We aimed to explore the association between the trend of CDR during the last two decades and the occurrence of major neonatal and maternal morbidities. STUDY DESIGN: A population based cohort study conducted between the years 1993 to 2012 at a single university teaching hospital. Data
Supplement to JANUARY 2014 American Journal of Obstetrics & Gynecology
S255
Poster Session III
Epidemiology, Ob Quality, Operative Obstetrics, Public Health, Infectious Disease, Academic Issues
that included number of deliveries, CD, and major neonatal and maternal morbidities that included Erb’s palsy (EP), neonatal encephalopathy (NE), placenta accreta (PA) and cesarean hysterectomy (CH) for each year were extracted and plotted, and trends were assessed. Data was obtained from the hospital discharge register with ICD-9 codes, crosschecked with the labor electronic medical records, and individual cases were manually checked and validated. The Cochran-Armitage Trend Test was used in order to identify trends and correlations. RESULTS: Overall 83806 deliveries took place during the study period. CDR increased from 10.9% in 1993 to a maximum rate of 21.7% (p<.0001). This increase was accompanied with a significant decrease in the incidence of EP (p<.0001) and a significant decrease in the incidence of NE (p¼.006). At a CDR of 13.6% and 20%, there was no further significant decrease in the incidence of EP and NE, respectively (figure1). The increase in the CDR was accompanied with an increase in the incidence of PA, though the trend up to a maximum CDR of 21.7% was still not significant (p¼.06). There was no significant change in the incidence of CH (p¼.4) or CH due to a PA (p¼.06). CONCLUSION: The increase in the CDR was accompanied with a decrease in major neonatal morbidities. This advantage disappeared at a threshold of 20%. Additionally, up to this threshold, the incidence of major maternal morbidities increased though this increase was still not significant.
Annual rates of cesarean deliveries and major neonatal morbidities
518 Reproductive outcomes of women and men born very preterm and/or with a very low birth weight in 1983: a longitudinal cohort study in the Netherlands Arnout van Gendt2, Sylvia van der Pal1, Wietske Hermes3, Frans Walther2, Karin van der Pal - de Bruin1, Christianne de Groot3 1 TNO, Leiden, Netherlands, 2LUMC, Leiden, Netherlands, 3VUMC, Leiden, Netherlands
OBJECTIVE: To analyse reproductive outcomes of women and men
born very preterm or with a very low birth weight in 1983 in the Netherlands, and to compare their reproductive outcomes with the total population at similar age of 28 years.
www.AJOG.org
STUDY DESIGN: Young adults who were born after a pregnancy complicated by very preterm delivery (gestational age <32 weeks) or with a very low birth weight (<1500 grams) in the Netherlands in 1983 (POPS cohort) were invited to complete online questionnaire at the age of 28. In total, 293 POPS-28 participants (31.6%) completed the questionnaire including 185 female and 108 male participants. RESULTS: Female and male participants who were born very preterm or with a very low birth weight had significant reduced reproductive rates compared to total population at 28 years of age (female 23.2% vs 31.9% and male 7.4% vs 22.2%). Pregnancies of the female participants were in 14% complicated by preterm delivery in at least one pregnancy. CONCLUSION: This study indicates that women and men born very preterm or with a very low birth weight have reduced reproductive rates at the age of 28 compared to the total Dutch population. Women who were born themselves very preterm or with a very low birth weight have more often preterm offspring.
519 Qualitative outcomes of an in-patient art therapy program in high risk obstetrics Men-Jean Lee1, Martine Faist2, Lisa Rainey2, Juliet King2, Joani Rothenberg2, Jeffrey Rothenberg1 1
Indiana University School of Medicine, Obstetrics and Gynecology, Indianapolis, IN, 2Indiana University, Herron School of Art and Design, Graduate School of Art Therapy, Indianapolis, IN
OBJECTIVE: Art therapy is the therapeutic use of art making within a professional relationship by people who experience illness, trauma, or challenges in living. This study explored the therapeutic benefits of an art therapy program for hospitalized high risk pregnant women facing uncertain pregnancy outcomes. STUDY DESIGN: Art therapy was offered to women admitted to a high risk obstetrical unit in a tertiary care center for complicated pregnancies from 08/12 through 07/13. 49 patients were offered a choice of art mediums and given art directives by 2 registered art therapists experienced with adult, pediatric, and cancer patients. Each patient was initially asked to transform a pre-drawn circle on paper using colors, lines, shapes, and symbols to depict her current life experience, i.e. thoughts, feelings, and events. During the process, the patient was interviewed and asked to verbally share what her personal imagery symbolized. Progress notes were written after each art therapy session and recorded in the hospital medical record. Data including presenting diagnosis, history, verbalizations, affect, and other observations made by the art therapist were abstracted and summarized from the notes. The data was converted into therapeutic outcomes and categorized into themes for qualitative analysis. RESULTS: 14 themes emerged from the therapeutic outcome data, with the three most prevalent outcomes being: (1) stress management (reducing anxiety and fear, lowering BP, aiding in relaxation); (2) emotional expression (acknowledged emotions, shared tears and fears); (3) stimulated verbal communication (increased patient’s capacity to verbalize their experience, find meaning, process information, and debrief from traumatic events). CONCLUSION: Through analysis of themes, art therapy was found to be an effective therapeutic intervention for women hospitalized with high risk pregnancies. Art therapy gave them a creative way to cope with their stress, grieve loss, find meaning, and have a normalizing experience in an abnormal environment.
S256 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2014