- Email: [email protected]
142: Does timing of 17-Hydroxyprogesterone caproate initiation influence risk of preterm birth?
Poster Session I both a negative quad screen and fetal EIF identified on screening US. This was stratified by maternal age above and below 35. T21 sensitivities for US and cfDNA were assumed at 69% and 99% and examined in sensitivity analysis. Outcomes of interest were t21 diagnosis, procedure related loss, termination, spontaneous abortion and t21 live births. Strategies were then compared to generate an incremental cost-effectiveness ratio, with a threshold set to $100,000 per QALY. RESULTS: The US followed by cfDNA strategy in women <35 with an EIF and negative quad screen resulted in 13 fewer t21 births and 33 additional QALYS with cost savings of $8,940,591 per 10,000 pregnancies when compared to targeted US alone, a dominant strategy in cost-effectiveness analysis. In women >35, the US/cfDNA strategy resulted in 10 fewer t21 births and 25 additional QALYs with cost savings of $5,843,871 per 10,000 pregnancies, also a dominant strategy. CONCLUSION: Our results indicate in a population with prior negative aneuploidy screening, it still remains cost effective to offer targeted US followed by cfDNA as compared to targeted US alone when an EIF is visualized. This result was observed in pregnancies across all maternal ages but was more cost-effective in women<35, likely secondary to decreased t21 quad screening sensitivity in this group.
141 Prediction of shoulder dystocia in a contemporary birth cohort Sean C. Blackwell for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network, Bethesda, MD
OBJECTIVE: Shoulder dystocia has historically been an unpredictable
and unpreventable complication of childbirth. Over the last 20 years patient characteristics, labor progress, and intrapartum management have dramatically changed. The objective of this study was to evaluate the association of traditional risk factors for shoulder dystocia in a contemporary labor cohort. STUDY DESIGN: This is a secondary analysis of a multi-center randomized clinical trial (RCT) of fetal monitoring with adjunctive ST segment analysis performed from 2010 to 2014 across 26 different hospitals in the US. Eligibility criteria were singleton gestation, GA 36 weeks, planned labor attempt, and cervical exam 2-7 cm. The RCT reported no difference in the rates of cesarean delivery (CD) or adverse neonatal outcomes. The clinical characteristics and intrapartum outcomes of women with vaginal deliveries who developed shoulder dystocia were compared to those who did not. Data was collected by trained research nurses and shoulder dystocia was defined as the need to
ajog.org perform additional obstetrical maneuvers to effect vaginal delivery. Logistic regression analyses were performed to evaluate known clinical risk factors. RESULTS: There were 11,108 women in the study; 1,835 underwent cesarean delivery (16.5%) and 3.2% of the remainder developed shoulder dystocia (297/9,273). The table describes the frequency of shoulder dystocia in those with and without the various risk factors, and presents adjusted OR’s when all factors are considered simultaneously. The most parsimonious model included DM, macrosomia, prolonged 2nd stage, and operative vaginal delivery, which had an Area Under the Curve of 0.67, (95% CI 0.64-0.70). Of the cohort 21.5% of women had 1 or more of these risk factors (n¼1,984) but only 50.3% of shoulder dystocia cases occurred in this group (149/296). CONCLUSION: In this contemporary birth cohort, the strongest combination of risk factors for shoulder dystocia has not changed. In addition, predictive models for shoulder dystocia remain limited to adequately guide clinical practice.
142 Does timing of 17-Hydroxyprogesterone caproate initiation influence risk of preterm birth? Ebony B. Carter, George A. Macones, Dustin Stwalley, Margaret Olsen, Methodius Tuuli, Molly J. Stout Washington University in St. Louis, Saint Louis, MO
OBJECTIVE: To determine whether gestational age of 17-hydroxyprogesterone caproate (17-OHPC) initiation is associated with risk of preterm birth (PTB). STUDY DESIGN: We performed a retrospective cohort study using an administrative commercial health insurance database (MarketScan Commercial Claims and Encounters) from 2006-2014. Women who initiated 17-OHPC between 16-22 weeks were compared to those who initiated 17-OHPC between 22-25 weeks. Inclusion criteria included known gestational age (based on maternal or linked infant data) and initiation of 17-OHPC between 16-25 weeks gestational age. Pregnancies with major fetal anomalies were excluded. The first pregnancy meeting study criteria was included if a woman had multiple pregnancies in the database. The primary outcome was PTB <37 weeks and <32 weeks. Demographic characteristics of the cohort were compared using descriptive statistics. Logistic regression
S96 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2017
Poster Session I
ajog.org was used to assess the relationship between gestational age of initiation and risk for PTB while controlling for compliance. RESULTS: A total of 7610 deliveries met inclusion criteria; 5793 (76.1%) initiated 17-OHPC between 16-22 weeks and 1817 (23.9%) at 22-25 weeks. The rate of recurrent PTB in the entire cohort was 11.2%. Women who initiated 17-OHPC between 16-22 weeks were significantly less likely to have recurrent PTB<37 weeks (10.3% vs. 14.0%; p<0.001) and <32 weeks (2.6% vs. 4.1%; p<0.001) compared to those who started 17-OHPC between 22-25 weeks. In adjusted analysis women starting 17-OHPC after 22 weeks were 30% more likely to have PTB<37 weeks than those initiating it between 16-22 weeks (aOR 1.30; 95% CI 1.10-1.52). CONCLUSION: Women initiating 17-OHPC prior to 22 weeks have significantly reduced rates of PTB and early PTB. Strategies to increase initiation of 17-OHPC prior to 22 weeks will optimize prevention of recurrent PTB.
143 Elective cesarean delivery at term, a significant risk factor for long-term pediatric neurological morbidity of the offspring Yael Baumfeld, Asnat Walfisch, Tamar Wainstock, Idit Segal, Ruslan Sergienko, Daniella Landau, Eyal Sheiner Soroka Medical Center, Beer Sheva, Israel
OBJECTIVE: To determine whether the mode of delivery at term has
an impact on the risk of long-term neurological morbidity of the offspring. STUDY DESIGN: A population-based cohort analysis was performed including all singleton term deliveries occurring between 1991-2013 at a tertiary medical center. A comparison was performed between children delivered via elective cesarean delivery (CD) and those delivered vaginally. Multiple gestations and fetuses with congenital malformations were excluded. All cases of urgent CD due to nonreassuring fetal status, non-progressive labor, prolapse of cord, preeclampsia, placenta previa, placental abruption, gestational diabetes, labor induction and failed induction, fetal growth restriction, as well as instrumental deliveries, were excluded from the analysis. Pediatric hospitalizations of the offspring up to the age of 18 years involving neurological morbidity were evaluated. A Kaplan-Meier survival curve was used to compare cumulative morbidity incidence. A Cox regression model was used to control for confounders. RESULTS: During the study period 132 054 term deliveries met the inclusion criteria; 8.9% were via elective CD (n¼11 746) and 91.1% (n¼120 308) were vaginal deliveries. Hospitalizations up to the age of 18 years involving neurological morbidity were significantly more common in offspring delivered by CD as compared with those delivered vaginally (Table). Specifically, autism and movement disorders were more common in the CD group (p<0.001 in both). The Kaplan-Meier survival curve demonstrated a significantly higher cumulative incidence of neurological morbidity in the CD group (Figure, log rank p<0.001). Using a Cox proportional hazards model while controlling for maternal age, gestational age, and birth weight, elective CD at term exhibited an independent association with longterm neurological morbidity of the offspring (adjusted HR¼1.32, CI 1.18-1.47, p<0.001). CONCLUSION: Elective CD at term is a significant risk factor for longterm pediatric neurological morbidity of the offspring.
144 Intrapartum hyperoxygenation: “First, do no harm” Nandini Raghuraman, Lorene A. Temming, Molly J. Stout, George A. Macones, Alison G. Cahill, Methodius G. Tuuli Washington University in St. Louis, Saint Louis, MO
OBJECTIVE: Oxygen supplementation is commonly used to increase umbilical venous oxygen content during intrauterine resuscitation in labor. While hyperoxygenation during neonatal resuscitation has been shown to be harmful, the effect of intrauterine hyperoxygenation is unknown. We tested the hypothesis that intrauterine hyperoxemia is associated with an increased risk of neonatal morbidity.
Supplement to JANUARY 2017 American Journal of Obstetrics & Gynecology
S97
141 Prediction of shoulder dystocia in a contemporary birth cohort Sean C. Blackwell for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network, Bethesda, MD
OBJECTIVE: Shoulder dystocia has historically been an unpredictable
and unpreventable complication of childbirth. Over the last 20 years patient characteristics, labor progress, and intrapartum management have dramatically changed. The objective of this study was to evaluate the association of traditional risk factors for shoulder dystocia in a contemporary labor cohort. STUDY DESIGN: This is a secondary analysis of a multi-center randomized clinical trial (RCT) of fetal monitoring with adjunctive ST segment analysis performed from 2010 to 2014 across 26 different hospitals in the US. Eligibility criteria were singleton gestation, GA 36 weeks, planned labor attempt, and cervical exam 2-7 cm. The RCT reported no difference in the rates of cesarean delivery (CD) or adverse neonatal outcomes. The clinical characteristics and intrapartum outcomes of women with vaginal deliveries who developed shoulder dystocia were compared to those who did not. Data was collected by trained research nurses and shoulder dystocia was defined as the need to
ajog.org perform additional obstetrical maneuvers to effect vaginal delivery. Logistic regression analyses were performed to evaluate known clinical risk factors. RESULTS: There were 11,108 women in the study; 1,835 underwent cesarean delivery (16.5%) and 3.2% of the remainder developed shoulder dystocia (297/9,273). The table describes the frequency of shoulder dystocia in those with and without the various risk factors, and presents adjusted OR’s when all factors are considered simultaneously. The most parsimonious model included DM, macrosomia, prolonged 2nd stage, and operative vaginal delivery, which had an Area Under the Curve of 0.67, (95% CI 0.64-0.70). Of the cohort 21.5% of women had 1 or more of these risk factors (n¼1,984) but only 50.3% of shoulder dystocia cases occurred in this group (149/296). CONCLUSION: In this contemporary birth cohort, the strongest combination of risk factors for shoulder dystocia has not changed. In addition, predictive models for shoulder dystocia remain limited to adequately guide clinical practice.
142 Does timing of 17-Hydroxyprogesterone caproate initiation influence risk of preterm birth? Ebony B. Carter, George A. Macones, Dustin Stwalley, Margaret Olsen, Methodius Tuuli, Molly J. Stout Washington University in St. Louis, Saint Louis, MO
OBJECTIVE: To determine whether gestational age of 17-hydroxyprogesterone caproate (17-OHPC) initiation is associated with risk of preterm birth (PTB). STUDY DESIGN: We performed a retrospective cohort study using an administrative commercial health insurance database (MarketScan Commercial Claims and Encounters) from 2006-2014. Women who initiated 17-OHPC between 16-22 weeks were compared to those who initiated 17-OHPC between 22-25 weeks. Inclusion criteria included known gestational age (based on maternal or linked infant data) and initiation of 17-OHPC between 16-25 weeks gestational age. Pregnancies with major fetal anomalies were excluded. The first pregnancy meeting study criteria was included if a woman had multiple pregnancies in the database. The primary outcome was PTB <37 weeks and <32 weeks. Demographic characteristics of the cohort were compared using descriptive statistics. Logistic regression
S96 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2017
Poster Session I
ajog.org was used to assess the relationship between gestational age of initiation and risk for PTB while controlling for compliance. RESULTS: A total of 7610 deliveries met inclusion criteria; 5793 (76.1%) initiated 17-OHPC between 16-22 weeks and 1817 (23.9%) at 22-25 weeks. The rate of recurrent PTB in the entire cohort was 11.2%. Women who initiated 17-OHPC between 16-22 weeks were significantly less likely to have recurrent PTB<37 weeks (10.3% vs. 14.0%; p<0.001) and <32 weeks (2.6% vs. 4.1%; p<0.001) compared to those who started 17-OHPC between 22-25 weeks. In adjusted analysis women starting 17-OHPC after 22 weeks were 30% more likely to have PTB<37 weeks than those initiating it between 16-22 weeks (aOR 1.30; 95% CI 1.10-1.52). CONCLUSION: Women initiating 17-OHPC prior to 22 weeks have significantly reduced rates of PTB and early PTB. Strategies to increase initiation of 17-OHPC prior to 22 weeks will optimize prevention of recurrent PTB.
143 Elective cesarean delivery at term, a significant risk factor for long-term pediatric neurological morbidity of the offspring Yael Baumfeld, Asnat Walfisch, Tamar Wainstock, Idit Segal, Ruslan Sergienko, Daniella Landau, Eyal Sheiner Soroka Medical Center, Beer Sheva, Israel
OBJECTIVE: To determine whether the mode of delivery at term has
an impact on the risk of long-term neurological morbidity of the offspring. STUDY DESIGN: A population-based cohort analysis was performed including all singleton term deliveries occurring between 1991-2013 at a tertiary medical center. A comparison was performed between children delivered via elective cesarean delivery (CD) and those delivered vaginally. Multiple gestations and fetuses with congenital malformations were excluded. All cases of urgent CD due to nonreassuring fetal status, non-progressive labor, prolapse of cord, preeclampsia, placenta previa, placental abruption, gestational diabetes, labor induction and failed induction, fetal growth restriction, as well as instrumental deliveries, were excluded from the analysis. Pediatric hospitalizations of the offspring up to the age of 18 years involving neurological morbidity were evaluated. A Kaplan-Meier survival curve was used to compare cumulative morbidity incidence. A Cox regression model was used to control for confounders. RESULTS: During the study period 132 054 term deliveries met the inclusion criteria; 8.9% were via elective CD (n¼11 746) and 91.1% (n¼120 308) were vaginal deliveries. Hospitalizations up to the age of 18 years involving neurological morbidity were significantly more common in offspring delivered by CD as compared with those delivered vaginally (Table). Specifically, autism and movement disorders were more common in the CD group (p<0.001 in both). The Kaplan-Meier survival curve demonstrated a significantly higher cumulative incidence of neurological morbidity in the CD group (Figure, log rank p<0.001). Using a Cox proportional hazards model while controlling for maternal age, gestational age, and birth weight, elective CD at term exhibited an independent association with longterm neurological morbidity of the offspring (adjusted HR¼1.32, CI 1.18-1.47, p<0.001). CONCLUSION: Elective CD at term is a significant risk factor for longterm pediatric neurological morbidity of the offspring.
144 Intrapartum hyperoxygenation: “First, do no harm” Nandini Raghuraman, Lorene A. Temming, Molly J. Stout, George A. Macones, Alison G. Cahill, Methodius G. Tuuli Washington University in St. Louis, Saint Louis, MO
OBJECTIVE: Oxygen supplementation is commonly used to increase umbilical venous oxygen content during intrauterine resuscitation in labor. While hyperoxygenation during neonatal resuscitation has been shown to be harmful, the effect of intrauterine hyperoxygenation is unknown. We tested the hypothesis that intrauterine hyperoxemia is associated with an increased risk of neonatal morbidity.
Supplement to JANUARY 2017 American Journal of Obstetrics & Gynecology
S97