- Email: [email protected]
125: Increased maternal and neonatal morbidity associated with suspected fetal macrosomia
www.AJOG.org
Clinical Obstetrics, Medical-Surgical-Disease, Neonatology, Physiology-Endocrinology
RESULTS: There were 61 women evaluated for possible placental abruption with a mean GA (31.4⫹4.3wk) compared to the 58 controls (35.1⫹5.7wk; p⬍.01). Confirmed placental abruption (clinical and/or histological) occurred in 11.5% (7/61) in the study group and none in the controls. MSAFP decreased from 24-41 wk with a mean MSAFP significantly higher in the study group (221⫹139g/l) compared with controls (128⫹67g/l; p⬍.01). Using an ROC curve the MSAFP cutoff values for the best prediction of placental abruption was calculated and compared with KB results (Table 1). CONCLUSION: MSAFP has predictive value for placental abruption in the 3rd trimester and can be available for use in clinical management. MSAFP can be performed as a simple, inexpensive, rapid test.
123 Impact of maternal pre-pregnancy body mass index on pregnancy and infant outcomes in triplet gestations Elizabeth Moore1, James Sumners2 1
St. Vincent Women’s Hospital, Obstetrics and Gynecology, Indianapolis, IN, St. Vincent Women’s Hospital, Center for Prenatal Diagnosis, Indianapolis, IN
2
OBJECTIVE: Risks associated with maternal obesity on pregnancy and neonatal outcomes in singleton pregnancies is well-documented. However, little is known about the impact of maternal obesity on triplet pregnancy outcomes. STUDY DESIGN: This is a retrospective review of 158 triplet pregnancies. Pre-pregnancy body mass index (PP BMI) was characterized in the following categories: underweight (BMI 30.0). The following pregnancy-related adverse birth outcomes in relation to PP BMI were considered: survival, stillbirth (intrauterine fetal death ⬎20 weeks), pregnancy complications, extreme (⬍28 weeks) and very (⬍32 weeks) preterm delivery, small for gestational age (SGA) and neonatal morbidities. The distribution of selected maternal clinical and sociodemographic characteristics was compared across BMI groups to assess differences in baseline characteristics. RESULTS: 64 pregnancies (40.5%) had a normal PP BMI, 2 (1.3%) were underweight, 46 (29.1%) were overweight, and 46 (29.1%) were obese. There was no significant difference in maternal demographics between PP BMI groups. Women in the obese group gained significantly less weight than women in the normal or overweight categories (p⬍0.001). When compared to women in the overweight and obese categories, women with a normal PP BMI were significantly more likely to have preterm labor (p⫽0.018), but less likely to have premature rupture of membranes (p⫽0.009). PP BMI was not associated with gestational age at delivery or birth weight or an increased incidence of extreme or very preterm birth, stillbirth, or SGA. The incidence of intraventricular hemorrhage, grade III/IV was significantly higher in the overweight group (p⫽0.041), while infants born to mothers with pre-pregnancy obesity were significantly more likely to develop BPD (p⫽0.007). CONCLUSION: In triplet gestations, maternal pre-pregnancy obesity and overweight is associated with increased risk of serious neonatal complications, despite the overall lack of association between PP BMI and gestation at delivery.
Poster Session I
124 Maternal-fetal medicine specialists’ provision of second-trimester termination Jennifer Kerns1, Jody Steinauer2, Melissa Rosenstein3, Jema Turk2, Aaron Caughey4, Mary D’Alton5 1 University of California, San Francisco, San Francisco General Hospital, Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA, 2 University of California, San Francisco, Bixby Center for Global Reproductive Health, Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA, 3UCSF, Obstetrics, Gynecology & Reproductive Sciences, San Francisco, CA, 4Oregon Health & Science University, Department of Obstetrics and Gynecology, Portland, OR, 5Columbia University, Department of Obstetrics and Gynecology, New York, NY
OBJECTIVE: Most abortions for fetal or maternal indications occur in the second trimester. Despite a continued need for second-trimester termination services, the number of providers is low. Maternal-fetal medicine specialists (MFMs) care for women with pregnancy complications. The extent to which they include termination services in their scope of practice is unknown. STUDY DESIGN: We surveyed all 2010 members of SMFM by email and/or mail regarding background characteristics and training in and provision of second-trimester abortion. We conducted both unadjusted and adjusted analyses of 1) any versus no abortion provision, 2) induction only versus dilation and evacuation (D&E), 3) frequent versus infrequent D&E provision. Provision of D&E or induction termination was defined as providing or supervising at least one procedure within the past year. Frequent D&E provision was defined as providing or supervising ten or more D&Es in the past year. RESULTS: Of the 2,125 MFMs asked to participate, 689 (32.4%) responded, 438 by email and 251 by mail. MFMs invited by email were more likely than those invited by mail to respond (48.4% vs20.6%, p⬍0.001). Over two-thirds of MFMs provide second-trimester termination and 31% provide D&Es. MFMs trained in D&E were more likely to provide D&E, especially if they were trained during their fellowship. Compared to MFMs who only provide induction termination, D&E providers were more likely to be male and to perform more CVS procedures and were less likely to be at an institution with a Family Planning Fellowship. Non-provision of any second-trimester termination was associated with being male, living in the South/ Southeast and practicing in a non-academic setting. CONCLUSION: Many MFMs include D&E and induction termination services in their scope of practice. Supporting current D&E providers and expanding training options for MFMs will ensure that women receive optimal care when diagnosed with serious pregnancy complications.
125 Increased maternal and neonatal morbidity associated with suspected fetal macrosomia Jennifer King1, Lisa Korst2, David Miller3, Joseph Ouzounian3 1 Keck School of Medicine, University of Southern California, Maternal-Fetal Medicine, Los Angeles, CA, 2University of Southern California, Obstetrics & Gynecology, Los Angeles, CA, 3Keck School of Medicine, University of Southern California, Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Los Angeles, CA
OBJECTIVE: To assess the risk of maternal and neonatal morbidity in pregnancies with suspected fetal macrosomia. STUDY DESIGN: We conducted a retrospective study of laboring women without a prior cesarean delivering singleton, term, liveborn, neonates at the Los Angeles County ⫹ University of Southern California Medical Center. Macrosomia and suspected macrosomia were defined respectively as birth weight (BW) or estimated fetal weight (EFW) (by ultrasound) ⬎ 4,000 grams. Both macrosomia and suspected macrosomia were evaluated for association with obstetrical and neonatal complications, which were tested independently and as a composite outcome using multivariable logistic regression models (reference: BW or EFW 5 days, neonatal birth trauma, meconium aspiration syndrome, perinatal infection, and neonatal length of stay ⬎ 5 days.
Supplement to JANUARY 2012 American Journal of Obstetrics & Gynecology
S67
Poster Session I
Clinical Obstetrics, Medical-Surgical-Disease, Neonatology, Physiology-Endocrinology
www.AJOG.org
RESULTS: The study population included 14,406 deliveries; 8,843 (61.4%) had an EFW by ultrasound, and of these, 9.7% were diabetic. Birth weight categories 4000-4499 grams, 4500-4999 grams, and 5000⫹ grams were each associated with increased composite morbidity [OR (95%CI): 2.2 (1.9-2.5), 4.8 (3.5-6.7), and 4.6 (2.2-9.4), respectively]. For suspected macrosomia in diabetics, EFW categories of 4000-4499 and 4500⫹ were tested with respect to composite morbidity [OR (95%CI): 1.7 (1.1-2.7) and 1.5 (0.5-5.2), respectively]. For suspected macrosomia in non-diabetics, EFW categories of 40004499 and 4500⫹ were associated with increased composite morbidity [OR (95%CI): 2.0 (1.7-2.4) and 3.0 (1.7-5.3), respectively]. CONCLUSION: Suspected fetal macrosomia appears associated with increased risk for obstetrical and neonatal complications.
126 Pre-eclampsia increases the risk for postpartum haemorrhage: a nationwide cohort study among more than 340,000 deliveries Joost F. von Schmidt auf Altenstadt1, Chantal P.W.M. Hukkelhoven2, Jos van Roosmalen1, Kitty W.M. Bloemenkamp1 1 Leiden University Medical Center, Department of Obstetrics and Gynecology, Leiden, Netherlands, 2The Netherlands Perinatal Registry, Epidemiology, Utrecht, Netherlands
OBJECTIVE: To investigate the association between pre-eclampsia and
postpartum haemorrhage (PPH) in a large and recent nationwide cohort. STUDY DESIGN: A cohort study in which data were prospectively collected consisting of 343 311 deliveries including low and high risk pregnancies, home and hospital births between 1st August 2004 and 1st August 2006 in the Netherlands. Data were extracted from the Netherlands Perinatal Registry in which 95% of the midwife practices and 99% of the hospitals register. Pre-eclampsia was defined as a minimum diastolic blood pressure of 90 mmHg and proteinuria occurring after 20 weeks of gestation and postpartum hemorrhage, our main outcome measure, was defined as blood loss of 1000 ml or more in the 24 hours following delivery. The association between pre-eclampsia and PPH was investigated with uni- and multivariate logistic regression analyses, adjusting for potential confounders. Also possible maternal and obstetric risk indicators for PPH were identified. RESULTS: The prevalence of PPH in the studied population was 4.9%. From the 7 288 women with pre-eclampsia 634 (8.7%) developed PPH, compared to 14 348 (4.6%) from the women without preeclampsia. (OR 2.0 95% CI 1.8-2.1). After adjustment for maternal age, parity, socio-economic status, ethnicity, gestational age and multiple pregnancy the risk of PPH in women with pre-eclampsia remained increased as is shown in table 1 (OR 1.5 (95% CI 1.4-1.7). Other possible risk indicators identified for PPH were birth weight ⱖ4000g, small for gestational age, abnormal fetal presentation, prolonged ruptured membranes, a prolonged expulsive phase, augmentated labour, induction of labour, assisted delivery, primary cesarean section, episiotomy, rupture, use of anesthesia and manual placenta removal. CONCLUSION: Our study shows an association between the two most important causes of maternal mortality and morbidity pre-eclampsia and PPH; women with pre-eclampsia have a 1.5 fold increased risk of PPH in the Netherlands. Clinicians should be aware of this increased risk and use this knowledge in the management of the third stage of labour.
S68
127 Effectiveness of multidisciplinary team training in obstetric emergencies: a randomized controlled trial Joost van de Ven1 1 Dutch Consortium for Studies in Women’s Health and Reproductivity, Obstetrics and Gynaecology, Veldhoven, MI, Netherlands
OBJECTIVE: Obstetric team training is thought to improve the performance of multidisciplinary teams, thus preventing complications and improving the outcomes of pregnancy and delivery for mothers and their babies. Although there is evidence that obstetric team training improves the process of team performance, evidence that this approach improves clinical outcome is lacking. We assessed the effectiveness of team training in acute obstetrics in a cluster randomized clinical trial. STUDY DESIGN: We performed a cluster randomized study in 24 obstetric units in The Netherlands, including teaching hospitals and non-teaching hospitals. The units were randomly assigned to receive multidisciplinary team training or to a control arm without any team training. Team training was performed during a one-day course in a medical simulation center. For each unit, all teams with each one or two obstetricians, residents, midwives and nurses were trained in a 1 to 4 week period. We measured obstetric complications in the units in the first 12 months after randomization. Here we report on the number of neonates with perinatal asphyxia (Apgar five minutes ⬍7 and/or arterial umbilical pH ⬍7.05), number of women with eclampsia and number of women with postpartum hemorrhage. RESULTS: In total there were 27.630 deliveries in the 24 participating hospitals in the study period, 14.010 deliveries in the intervention group and 13.620 in the control group. There were 700 cases (5.0%) of postpartum hemorrhage in the intervention group versus 654 cases (4.8%) in the control group (RR 1.04 (95% CI .94 to 1.2)), 218 cases (1.6%) of perinatal asphyxia in the intervention group and 237 cases (1.7%) in the control group (RR .89 (95% CI .75 to 1.07)), and 1 case (0.01%) of eclampsia in the intervention group versus 6 cases (0.04%) in the control group (RR 0.16 (95% CI 0.02 to 1.41)). The relative risk for the composite measure of these outcomes was 1.0 (95% CI .91 to 1.09). CONCLUSION: A one-day team training in acute obstetrics using simulation did not improve clinical outcome.
American Journal of Obstetrics & Gynecology Supplement to JANUARY 2012
Clinical Obstetrics, Medical-Surgical-Disease, Neonatology, Physiology-Endocrinology
RESULTS: There were 61 women evaluated for possible placental abruption with a mean GA (31.4⫹4.3wk) compared to the 58 controls (35.1⫹5.7wk; p⬍.01). Confirmed placental abruption (clinical and/or histological) occurred in 11.5% (7/61) in the study group and none in the controls. MSAFP decreased from 24-41 wk with a mean MSAFP significantly higher in the study group (221⫹139g/l) compared with controls (128⫹67g/l; p⬍.01). Using an ROC curve the MSAFP cutoff values for the best prediction of placental abruption was calculated and compared with KB results (Table 1). CONCLUSION: MSAFP has predictive value for placental abruption in the 3rd trimester and can be available for use in clinical management. MSAFP can be performed as a simple, inexpensive, rapid test.
123 Impact of maternal pre-pregnancy body mass index on pregnancy and infant outcomes in triplet gestations Elizabeth Moore1, James Sumners2 1
St. Vincent Women’s Hospital, Obstetrics and Gynecology, Indianapolis, IN, St. Vincent Women’s Hospital, Center for Prenatal Diagnosis, Indianapolis, IN
2
OBJECTIVE: Risks associated with maternal obesity on pregnancy and neonatal outcomes in singleton pregnancies is well-documented. However, little is known about the impact of maternal obesity on triplet pregnancy outcomes. STUDY DESIGN: This is a retrospective review of 158 triplet pregnancies. Pre-pregnancy body mass index (PP BMI) was characterized in the following categories: underweight (BMI 30.0). The following pregnancy-related adverse birth outcomes in relation to PP BMI were considered: survival, stillbirth (intrauterine fetal death ⬎20 weeks), pregnancy complications, extreme (⬍28 weeks) and very (⬍32 weeks) preterm delivery, small for gestational age (SGA) and neonatal morbidities. The distribution of selected maternal clinical and sociodemographic characteristics was compared across BMI groups to assess differences in baseline characteristics. RESULTS: 64 pregnancies (40.5%) had a normal PP BMI, 2 (1.3%) were underweight, 46 (29.1%) were overweight, and 46 (29.1%) were obese. There was no significant difference in maternal demographics between PP BMI groups. Women in the obese group gained significantly less weight than women in the normal or overweight categories (p⬍0.001). When compared to women in the overweight and obese categories, women with a normal PP BMI were significantly more likely to have preterm labor (p⫽0.018), but less likely to have premature rupture of membranes (p⫽0.009). PP BMI was not associated with gestational age at delivery or birth weight or an increased incidence of extreme or very preterm birth, stillbirth, or SGA. The incidence of intraventricular hemorrhage, grade III/IV was significantly higher in the overweight group (p⫽0.041), while infants born to mothers with pre-pregnancy obesity were significantly more likely to develop BPD (p⫽0.007). CONCLUSION: In triplet gestations, maternal pre-pregnancy obesity and overweight is associated with increased risk of serious neonatal complications, despite the overall lack of association between PP BMI and gestation at delivery.
Poster Session I
124 Maternal-fetal medicine specialists’ provision of second-trimester termination Jennifer Kerns1, Jody Steinauer2, Melissa Rosenstein3, Jema Turk2, Aaron Caughey4, Mary D’Alton5 1 University of California, San Francisco, San Francisco General Hospital, Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA, 2 University of California, San Francisco, Bixby Center for Global Reproductive Health, Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA, 3UCSF, Obstetrics, Gynecology & Reproductive Sciences, San Francisco, CA, 4Oregon Health & Science University, Department of Obstetrics and Gynecology, Portland, OR, 5Columbia University, Department of Obstetrics and Gynecology, New York, NY
OBJECTIVE: Most abortions for fetal or maternal indications occur in the second trimester. Despite a continued need for second-trimester termination services, the number of providers is low. Maternal-fetal medicine specialists (MFMs) care for women with pregnancy complications. The extent to which they include termination services in their scope of practice is unknown. STUDY DESIGN: We surveyed all 2010 members of SMFM by email and/or mail regarding background characteristics and training in and provision of second-trimester abortion. We conducted both unadjusted and adjusted analyses of 1) any versus no abortion provision, 2) induction only versus dilation and evacuation (D&E), 3) frequent versus infrequent D&E provision. Provision of D&E or induction termination was defined as providing or supervising at least one procedure within the past year. Frequent D&E provision was defined as providing or supervising ten or more D&Es in the past year. RESULTS: Of the 2,125 MFMs asked to participate, 689 (32.4%) responded, 438 by email and 251 by mail. MFMs invited by email were more likely than those invited by mail to respond (48.4% vs20.6%, p⬍0.001). Over two-thirds of MFMs provide second-trimester termination and 31% provide D&Es. MFMs trained in D&E were more likely to provide D&E, especially if they were trained during their fellowship. Compared to MFMs who only provide induction termination, D&E providers were more likely to be male and to perform more CVS procedures and were less likely to be at an institution with a Family Planning Fellowship. Non-provision of any second-trimester termination was associated with being male, living in the South/ Southeast and practicing in a non-academic setting. CONCLUSION: Many MFMs include D&E and induction termination services in their scope of practice. Supporting current D&E providers and expanding training options for MFMs will ensure that women receive optimal care when diagnosed with serious pregnancy complications.
125 Increased maternal and neonatal morbidity associated with suspected fetal macrosomia Jennifer King1, Lisa Korst2, David Miller3, Joseph Ouzounian3 1 Keck School of Medicine, University of Southern California, Maternal-Fetal Medicine, Los Angeles, CA, 2University of Southern California, Obstetrics & Gynecology, Los Angeles, CA, 3Keck School of Medicine, University of Southern California, Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Los Angeles, CA
OBJECTIVE: To assess the risk of maternal and neonatal morbidity in pregnancies with suspected fetal macrosomia. STUDY DESIGN: We conducted a retrospective study of laboring women without a prior cesarean delivering singleton, term, liveborn, neonates at the Los Angeles County ⫹ University of Southern California Medical Center. Macrosomia and suspected macrosomia were defined respectively as birth weight (BW) or estimated fetal weight (EFW) (by ultrasound) ⬎ 4,000 grams. Both macrosomia and suspected macrosomia were evaluated for association with obstetrical and neonatal complications, which were tested independently and as a composite outcome using multivariable logistic regression models (reference: BW or EFW 5 days, neonatal birth trauma, meconium aspiration syndrome, perinatal infection, and neonatal length of stay ⬎ 5 days.
Supplement to JANUARY 2012 American Journal of Obstetrics & Gynecology
S67
Poster Session I
Clinical Obstetrics, Medical-Surgical-Disease, Neonatology, Physiology-Endocrinology
www.AJOG.org
RESULTS: The study population included 14,406 deliveries; 8,843 (61.4%) had an EFW by ultrasound, and of these, 9.7% were diabetic. Birth weight categories 4000-4499 grams, 4500-4999 grams, and 5000⫹ grams were each associated with increased composite morbidity [OR (95%CI): 2.2 (1.9-2.5), 4.8 (3.5-6.7), and 4.6 (2.2-9.4), respectively]. For suspected macrosomia in diabetics, EFW categories of 4000-4499 and 4500⫹ were tested with respect to composite morbidity [OR (95%CI): 1.7 (1.1-2.7) and 1.5 (0.5-5.2), respectively]. For suspected macrosomia in non-diabetics, EFW categories of 40004499 and 4500⫹ were associated with increased composite morbidity [OR (95%CI): 2.0 (1.7-2.4) and 3.0 (1.7-5.3), respectively]. CONCLUSION: Suspected fetal macrosomia appears associated with increased risk for obstetrical and neonatal complications.
126 Pre-eclampsia increases the risk for postpartum haemorrhage: a nationwide cohort study among more than 340,000 deliveries Joost F. von Schmidt auf Altenstadt1, Chantal P.W.M. Hukkelhoven2, Jos van Roosmalen1, Kitty W.M. Bloemenkamp1 1 Leiden University Medical Center, Department of Obstetrics and Gynecology, Leiden, Netherlands, 2The Netherlands Perinatal Registry, Epidemiology, Utrecht, Netherlands
OBJECTIVE: To investigate the association between pre-eclampsia and
postpartum haemorrhage (PPH) in a large and recent nationwide cohort. STUDY DESIGN: A cohort study in which data were prospectively collected consisting of 343 311 deliveries including low and high risk pregnancies, home and hospital births between 1st August 2004 and 1st August 2006 in the Netherlands. Data were extracted from the Netherlands Perinatal Registry in which 95% of the midwife practices and 99% of the hospitals register. Pre-eclampsia was defined as a minimum diastolic blood pressure of 90 mmHg and proteinuria occurring after 20 weeks of gestation and postpartum hemorrhage, our main outcome measure, was defined as blood loss of 1000 ml or more in the 24 hours following delivery. The association between pre-eclampsia and PPH was investigated with uni- and multivariate logistic regression analyses, adjusting for potential confounders. Also possible maternal and obstetric risk indicators for PPH were identified. RESULTS: The prevalence of PPH in the studied population was 4.9%. From the 7 288 women with pre-eclampsia 634 (8.7%) developed PPH, compared to 14 348 (4.6%) from the women without preeclampsia. (OR 2.0 95% CI 1.8-2.1). After adjustment for maternal age, parity, socio-economic status, ethnicity, gestational age and multiple pregnancy the risk of PPH in women with pre-eclampsia remained increased as is shown in table 1 (OR 1.5 (95% CI 1.4-1.7). Other possible risk indicators identified for PPH were birth weight ⱖ4000g, small for gestational age, abnormal fetal presentation, prolonged ruptured membranes, a prolonged expulsive phase, augmentated labour, induction of labour, assisted delivery, primary cesarean section, episiotomy, rupture, use of anesthesia and manual placenta removal. CONCLUSION: Our study shows an association between the two most important causes of maternal mortality and morbidity pre-eclampsia and PPH; women with pre-eclampsia have a 1.5 fold increased risk of PPH in the Netherlands. Clinicians should be aware of this increased risk and use this knowledge in the management of the third stage of labour.
S68
127 Effectiveness of multidisciplinary team training in obstetric emergencies: a randomized controlled trial Joost van de Ven1 1 Dutch Consortium for Studies in Women’s Health and Reproductivity, Obstetrics and Gynaecology, Veldhoven, MI, Netherlands
OBJECTIVE: Obstetric team training is thought to improve the performance of multidisciplinary teams, thus preventing complications and improving the outcomes of pregnancy and delivery for mothers and their babies. Although there is evidence that obstetric team training improves the process of team performance, evidence that this approach improves clinical outcome is lacking. We assessed the effectiveness of team training in acute obstetrics in a cluster randomized clinical trial. STUDY DESIGN: We performed a cluster randomized study in 24 obstetric units in The Netherlands, including teaching hospitals and non-teaching hospitals. The units were randomly assigned to receive multidisciplinary team training or to a control arm without any team training. Team training was performed during a one-day course in a medical simulation center. For each unit, all teams with each one or two obstetricians, residents, midwives and nurses were trained in a 1 to 4 week period. We measured obstetric complications in the units in the first 12 months after randomization. Here we report on the number of neonates with perinatal asphyxia (Apgar five minutes ⬍7 and/or arterial umbilical pH ⬍7.05), number of women with eclampsia and number of women with postpartum hemorrhage. RESULTS: In total there were 27.630 deliveries in the 24 participating hospitals in the study period, 14.010 deliveries in the intervention group and 13.620 in the control group. There were 700 cases (5.0%) of postpartum hemorrhage in the intervention group versus 654 cases (4.8%) in the control group (RR 1.04 (95% CI .94 to 1.2)), 218 cases (1.6%) of perinatal asphyxia in the intervention group and 237 cases (1.7%) in the control group (RR .89 (95% CI .75 to 1.07)), and 1 case (0.01%) of eclampsia in the intervention group versus 6 cases (0.04%) in the control group (RR 0.16 (95% CI 0.02 to 1.41)). The relative risk for the composite measure of these outcomes was 1.0 (95% CI .91 to 1.09). CONCLUSION: A one-day team training in acute obstetrics using simulation did not improve clinical outcome.
American Journal of Obstetrics & Gynecology Supplement to JANUARY 2012