- Email: [email protected]
157: Rates of preterm delivery in women receiving nurse administered 17P in a home vs office setting
Poster Session I
Clinical Obstetrics, Medical-Surgical-Disease, Neonatology, Physiology-Endocrinology
www.AJOG.org
gestational age at which to deliver monochorionic diamniotic twins is 36 weeks.
156 Antenatal vaginal bleeding and perinatal outcomes among women with suspected placenta accreta Marilee Simons1, Tracy Manuck1, Alexandra Eller1, Bob Silver1 1 University of Utah Health Sciences Center and Intermountain Healthcare, Obstetrics and Gynecology, Salt Lake City, UT
OBJECTIVE: Placenta accreta (PA) is associated with high rates of major maternal and neonatal morbidity and mortality. Delivery timing among women with suspected PA attempts to balance the risks of prematurity and maternal morbidity. We hypothesized that among pregnancies with suspected PA, those with antenatal vaginal bleeding (VB) would have increased morbidity. STUDY DESIGN: Retrospective cohort of women with a clinically suspected PA who delivered 1/2000-4/2011 in our tertiary hospital system. Women were identified by ICD-9 codes and delivery logs. Women with ⱖ1 episode of VB were compared to those without VB. Major maternal morbidity was defined as at least one of the following: coagulopathy, transfusion of ⱖ4 units pRBCs, reoperation, thromboembolism, ureter or bowel injury, ICU stay ⬎24 hrs, or maternal death. Major neonatal morbidity was defined as at least one of the following: NEC, RDS, IVH, or neonatal death. Data were analyzed by Chi-square, Fishers exact, students t-test, and Kaplan-Meier. A pvalue ⬍0.05 was considered significant. RESULTS: 60 women were included; all had ⱖ1 prior cesarean delivery. 38 (63%) had antenatal VB. Women with VB had a median of 2 VB episodes; 14 (23%) had more than 3 episodes of VB. Demographic characteristics and hospital courses were similar among women with and without VB, although those with VB were more likely to be transported, admitted antenatally, and receive betamethasone (Table). All women had a clinically confirmed PA at delivery and were delivered by cesarean hysterectomy. 40 (67%) had a pathologically confirmed PA. Women with VB were delivered earlier compared to those without VB (Figure). VB was highly correlated with delivery gestational age (r ⫽ -0.31, p⫽0.012). CONCLUSION: Women with suspected PA who experience antenatal VB are more likely to be admitted to the hospital, receive betamethasone, and require blood transfusion at the time of delivery compared to women who do not experience VB. Despite delivering ⬃2 weeks earlier than women without antenatal VB, initial maternal and neonatal outcomes are similar.
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157 Rates of preterm delivery in women receiving nurse administered 17P in a home vs office setting Victor Hugo Gonzalez-Quintero1, Felipe Jose Tudela2, Yvette Cordova2, Letty Romary2, Debbie Rhea3, Cheryl Desch3, Niki Istwan3 1 Associates in Advanced Maternal Fetal Medicine, Maternal Fetal Medicine, Miami, FL, 2University of Miami School of Medicine, Obstetrics and Gynecology, Miami, FL, 3Alere Health, Department of Clinical Research, Atlanta, GA
OBJECTIVE: To compare clinical characteristics and rates of preterm delivery (PTD) in women receiving 17P via a weekly home nurse visit vs. through their physician’s office. STUDY DESIGN: Study sample identified from a database of clinical information received from pregnant women enrolled for risk assessment-case management or outpatient perinatal nursing services. Included were records with a documented delivery date from women with singleton gestations prescribed 17P by their physician. PTD history and rates of recurrent spontaneous PTD (SPTD) were compared between those women enrolled in the 17P home administration program which included a weekly home nurse visit with compounded17P injection and maternal assessment vs. women receiving 17P injections through their physician’s office. A logistic regression model was used to assess the effect of significant univariate differences between the groups onto dependent outcome of SPTD. RESULTS: Of the 16,225 records identified, 15,533 (95.7%) were enrolled in the 17P home administration program and 692 (4.3%) received 17P at their physician’s office. Women enrolled for home administration services were more likely to have a history of PTD (90.0% vs. 62.0%, p⬍0.001), received a greater number of 17P injections (14.9 ⫹/⫺ 4.8 vs. 12.6 ⫹/⫺ 5.5, p⬍0.001), and had lower rates of SPTD (28.0% vs. 39.0%, p⬍0.001) than those women receiving 17P through their physician’s office. In only women with PTD history,
American Journal of Obstetrics & Gynecology Supplement to JANUARY 2012
www.AJOG.org
Clinical Obstetrics, Medical-Surgical-Disease, Neonatology, Physiology-Endocrinology
rates of recurrent SPTD were significantly lower (p⬍0.001) in the home administration group vs. physician’s office group for both those with 1 PTD (25.6% vs. 39.4%) and with 2 or more PTD (34.7% vs. 50.7%). Logistic regression model results are presented in Table. CONCLUSION: Women enrolled in a 17P home administration program received a greater number of 17P injections and had lower rates of SPTD than those women that received 17P in an office setting. After controlling for significant clinical differences between the groups those having 17P home administration had a 43% lower risk for SPTD compared to women receiving 17P injections at their physician’s office.
158 Prenatal diagnosis, antenatal surveillance, and timing of delivery for vasa previa: a national survey Vivian Romero1, Dipa Joshi2, Cosmas Van de Ven1, Ellen Mozurkewich1, Clark Nugent1, Uma Perni1, Mark Chames1, Marjorie Treadwell1 1 University of Michigan Medical Center, Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Ann Arbor, MI, 2University of Michigan Medical School, Obstetrics and Gynecology, Ann Arbor, MI
OBJECTIVE: To assess the current patterns of clinical practice on prenatal screening and antenatal management of vasa previa among maternal-fetal medicine specialists in the United States. STUDY DESIGN: We conducted a national postal survey of screening, surveillance, and delivery practices for pregnancies complicated by vasa previa. We mailed 1943 questionnaires to the members of the Society for Maternal-Fetal Medicine in October 2010. RESULTS: 556 surveys were returned, a response rate of 30%. 50% of respondents were in university-based practice. 79.5% of respondents had at least one case of vasa previa in their careers. 43% of respondents reported following a protocol to routinely screen for vasa previa in their ultrasound unit; 33% had a protocol for antenatal management. 38% of respondents would routinely offer serial measurements of cervical length to patients with prenatal diagnosis of vasa previa, of these 55% monitor cervical length at a frequency of every 2 weeks. 63% of respondents reserve use of preterm prediction tests for symptomatic patients. Most respondents (36%) would offer elective delivery at 36 weeks gestation whereas 18% would deliver at 37 weeks, 20% at 34 weeks and 9% at 35 weeks gestation. 6% would offer amniocentesis to document fetal lung maturity prior to delivery. Only 29% would give steroids before delivery between 34-37 weeks gestation, whereas 5% would administer steroids at 37-39 weeks. CONCLUSION: Despite evidence that perinatal outcomes can be improved with antenatal diagnosis and elective cesarean delivery, only 43% of maternal-fetal specialists have a protocol for screening and 33% follow a protocol for antenatal management. Although most respondents would recommend elective delivery at 36 weeks, there is no consensus regarding the optimal antepartum management and timing of delivery. Our findings suggest the need for research to establish evidence-based guidelines for screening, antenatal management and timing of delivery of vasa previa.
Poster Session I
159 Obstetric outcomes in women with intrauterine fetal demise and prior cesarean delivery Vivian Romero1, Kataneh Salari1, Stacey Ehrenberg-Buchner1, Marjorie Treadwell1, Ellen Mozurkewich1, Katherine Gold2 1 University of Michigan Medical Center, Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Ann Arbor, MI, 2University of Michigan Medical Center, Family Medicine, Ann Arbor, MI
OBJECTIVE: To determine the obstetric outcomes of women with prior cesarean delivery (CD) presenting with an intrauterine fetal demise (IUFD). STUDY DESIGN: This was a retrospective chart review of pregnancies complicated by an IUFD diagnosed greater than 20 weeks gestation from 1996 to 2006 at three large academic hospitals. Data on maternal characteristics, prior medical and obstetrical histories and obstetrical outcomes were collected. Data were analyzed with Stata SE 10.1 (College Station, TX). RESULTS: Among 548 women with a pregnancy complicated by IUFD, 116 (21.2%) had a history of prior cesarean delivery. Mean gestational age of delivery was 28.9 weeks, SD 6.4 weeks. Infant mean birthweight was 1376.20 g, SD 1288.80 g. Nineteen percent (22/116) underwent a repeat cesarean delivery. The majority of women 56.9% (66/116) required induction of labor with most (93.9%) having a successful vaginal birth after cesarean delivery (VBAC). Of 28 women who presented in spontaneous labor, 26 (92.9%) achieved a successful VBAC. Only 4 women of the induction group and 2 women of the spontaneous labor group failed a trial of labor and underwent repeat CD. Among the methods of induction used were prostaglandins in 42.2%, laminaria in 10.3%, and Foley catheter in 17.2%. Oxytocin was used for induction or augmentation of labor in 43.1%. No differences in the rate of complications were seen in the group that delivered vaginally versus CD. Uterine rupture occurred in 2 patients (1.7%), both delivered by CD, with 1 in the failed VBAC group. Other complications observed were DIC (0.9%), blood transfusion (1.7%), maternal shock (0.9%), respiratory failure requiring intubation (0.9%), cesarean hysterectomy (1.7%) and maternal death (0.9%). CONCLUSION: Induction of labor is a common evidence-based practice for women diagnosed with an IUFD and a prior CD. A high success rate of VBAC was reported in this group of patients, with a high proportion of women receiving prostaglandins as the method for induction. Low rates of maternal complications were seen.
160 Mode of delivery and risk of adverse perinatal outcome in twins with the first twin in vertex position Stephanie de Haseth1, Sophie Liem2, Enrico Lopriore3, Eline van den Akker4, Dick Oepkes5 1 Leiden University Medical Center, Department of Obstetrics and Gynecology, Den Haag, Netherlands, 2Academic Medical Center, Department of Obstetrics and Gynaecology, Amsterdam, Netherlands, 3 Leiden University Medical Center, Department of Pediatrics, Leiden, Netherlands, 4OLVG, Obstetrics and Gynecology, Amsterdam, Netherlands, 5 Leiden University Medical Center, Obstetrics, Leiden, Netherlands
OBJECTIVE: Mode of delivery in twin pregnancies is an ongoing subject of discussion, with conflicting conclusions from previous studies. We aimed to evaluate the outcome of twin births ⱖ32 weeks gestation with vertex position of the first twin in relation to the mode of delivery. STUDY DESIGN: Retrospective multicenter cohort-study of consecutive twin births ⱖ 32 weeks gestation with the first twin in cephalic position. We excluded twins with congenital anomalies and fetal death before the onset of labor. Primary outcome was perinatal mortality and severe neonatal morbidity, defined as one or more of the following: 5-minute Apgar score ⬍4, cord blood pH ⬍7.06, birth trauma, admission to the NICU. Differences were analyzed using Chi-square or Fishers Exact test as appropriate, two-tailed with a p-value of 0.05 considered to be statistically significant. RESULTS: During the study period (2002 2009), 1352 twins were born in the two participating institutions, of which 658 twins fulfilled the
Supplement to JANUARY 2012 American Journal of Obstetrics & Gynecology
S83
Clinical Obstetrics, Medical-Surgical-Disease, Neonatology, Physiology-Endocrinology
www.AJOG.org
gestational age at which to deliver monochorionic diamniotic twins is 36 weeks.
156 Antenatal vaginal bleeding and perinatal outcomes among women with suspected placenta accreta Marilee Simons1, Tracy Manuck1, Alexandra Eller1, Bob Silver1 1 University of Utah Health Sciences Center and Intermountain Healthcare, Obstetrics and Gynecology, Salt Lake City, UT
OBJECTIVE: Placenta accreta (PA) is associated with high rates of major maternal and neonatal morbidity and mortality. Delivery timing among women with suspected PA attempts to balance the risks of prematurity and maternal morbidity. We hypothesized that among pregnancies with suspected PA, those with antenatal vaginal bleeding (VB) would have increased morbidity. STUDY DESIGN: Retrospective cohort of women with a clinically suspected PA who delivered 1/2000-4/2011 in our tertiary hospital system. Women were identified by ICD-9 codes and delivery logs. Women with ⱖ1 episode of VB were compared to those without VB. Major maternal morbidity was defined as at least one of the following: coagulopathy, transfusion of ⱖ4 units pRBCs, reoperation, thromboembolism, ureter or bowel injury, ICU stay ⬎24 hrs, or maternal death. Major neonatal morbidity was defined as at least one of the following: NEC, RDS, IVH, or neonatal death. Data were analyzed by Chi-square, Fishers exact, students t-test, and Kaplan-Meier. A pvalue ⬍0.05 was considered significant. RESULTS: 60 women were included; all had ⱖ1 prior cesarean delivery. 38 (63%) had antenatal VB. Women with VB had a median of 2 VB episodes; 14 (23%) had more than 3 episodes of VB. Demographic characteristics and hospital courses were similar among women with and without VB, although those with VB were more likely to be transported, admitted antenatally, and receive betamethasone (Table). All women had a clinically confirmed PA at delivery and were delivered by cesarean hysterectomy. 40 (67%) had a pathologically confirmed PA. Women with VB were delivered earlier compared to those without VB (Figure). VB was highly correlated with delivery gestational age (r ⫽ -0.31, p⫽0.012). CONCLUSION: Women with suspected PA who experience antenatal VB are more likely to be admitted to the hospital, receive betamethasone, and require blood transfusion at the time of delivery compared to women who do not experience VB. Despite delivering ⬃2 weeks earlier than women without antenatal VB, initial maternal and neonatal outcomes are similar.
S82
157 Rates of preterm delivery in women receiving nurse administered 17P in a home vs office setting Victor Hugo Gonzalez-Quintero1, Felipe Jose Tudela2, Yvette Cordova2, Letty Romary2, Debbie Rhea3, Cheryl Desch3, Niki Istwan3 1 Associates in Advanced Maternal Fetal Medicine, Maternal Fetal Medicine, Miami, FL, 2University of Miami School of Medicine, Obstetrics and Gynecology, Miami, FL, 3Alere Health, Department of Clinical Research, Atlanta, GA
OBJECTIVE: To compare clinical characteristics and rates of preterm delivery (PTD) in women receiving 17P via a weekly home nurse visit vs. through their physician’s office. STUDY DESIGN: Study sample identified from a database of clinical information received from pregnant women enrolled for risk assessment-case management or outpatient perinatal nursing services. Included were records with a documented delivery date from women with singleton gestations prescribed 17P by their physician. PTD history and rates of recurrent spontaneous PTD (SPTD) were compared between those women enrolled in the 17P home administration program which included a weekly home nurse visit with compounded17P injection and maternal assessment vs. women receiving 17P injections through their physician’s office. A logistic regression model was used to assess the effect of significant univariate differences between the groups onto dependent outcome of SPTD. RESULTS: Of the 16,225 records identified, 15,533 (95.7%) were enrolled in the 17P home administration program and 692 (4.3%) received 17P at their physician’s office. Women enrolled for home administration services were more likely to have a history of PTD (90.0% vs. 62.0%, p⬍0.001), received a greater number of 17P injections (14.9 ⫹/⫺ 4.8 vs. 12.6 ⫹/⫺ 5.5, p⬍0.001), and had lower rates of SPTD (28.0% vs. 39.0%, p⬍0.001) than those women receiving 17P through their physician’s office. In only women with PTD history,
American Journal of Obstetrics & Gynecology Supplement to JANUARY 2012
www.AJOG.org
Clinical Obstetrics, Medical-Surgical-Disease, Neonatology, Physiology-Endocrinology
rates of recurrent SPTD were significantly lower (p⬍0.001) in the home administration group vs. physician’s office group for both those with 1 PTD (25.6% vs. 39.4%) and with 2 or more PTD (34.7% vs. 50.7%). Logistic regression model results are presented in Table. CONCLUSION: Women enrolled in a 17P home administration program received a greater number of 17P injections and had lower rates of SPTD than those women that received 17P in an office setting. After controlling for significant clinical differences between the groups those having 17P home administration had a 43% lower risk for SPTD compared to women receiving 17P injections at their physician’s office.
158 Prenatal diagnosis, antenatal surveillance, and timing of delivery for vasa previa: a national survey Vivian Romero1, Dipa Joshi2, Cosmas Van de Ven1, Ellen Mozurkewich1, Clark Nugent1, Uma Perni1, Mark Chames1, Marjorie Treadwell1 1 University of Michigan Medical Center, Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Ann Arbor, MI, 2University of Michigan Medical School, Obstetrics and Gynecology, Ann Arbor, MI
OBJECTIVE: To assess the current patterns of clinical practice on prenatal screening and antenatal management of vasa previa among maternal-fetal medicine specialists in the United States. STUDY DESIGN: We conducted a national postal survey of screening, surveillance, and delivery practices for pregnancies complicated by vasa previa. We mailed 1943 questionnaires to the members of the Society for Maternal-Fetal Medicine in October 2010. RESULTS: 556 surveys were returned, a response rate of 30%. 50% of respondents were in university-based practice. 79.5% of respondents had at least one case of vasa previa in their careers. 43% of respondents reported following a protocol to routinely screen for vasa previa in their ultrasound unit; 33% had a protocol for antenatal management. 38% of respondents would routinely offer serial measurements of cervical length to patients with prenatal diagnosis of vasa previa, of these 55% monitor cervical length at a frequency of every 2 weeks. 63% of respondents reserve use of preterm prediction tests for symptomatic patients. Most respondents (36%) would offer elective delivery at 36 weeks gestation whereas 18% would deliver at 37 weeks, 20% at 34 weeks and 9% at 35 weeks gestation. 6% would offer amniocentesis to document fetal lung maturity prior to delivery. Only 29% would give steroids before delivery between 34-37 weeks gestation, whereas 5% would administer steroids at 37-39 weeks. CONCLUSION: Despite evidence that perinatal outcomes can be improved with antenatal diagnosis and elective cesarean delivery, only 43% of maternal-fetal specialists have a protocol for screening and 33% follow a protocol for antenatal management. Although most respondents would recommend elective delivery at 36 weeks, there is no consensus regarding the optimal antepartum management and timing of delivery. Our findings suggest the need for research to establish evidence-based guidelines for screening, antenatal management and timing of delivery of vasa previa.
Poster Session I
159 Obstetric outcomes in women with intrauterine fetal demise and prior cesarean delivery Vivian Romero1, Kataneh Salari1, Stacey Ehrenberg-Buchner1, Marjorie Treadwell1, Ellen Mozurkewich1, Katherine Gold2 1 University of Michigan Medical Center, Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Ann Arbor, MI, 2University of Michigan Medical Center, Family Medicine, Ann Arbor, MI
OBJECTIVE: To determine the obstetric outcomes of women with prior cesarean delivery (CD) presenting with an intrauterine fetal demise (IUFD). STUDY DESIGN: This was a retrospective chart review of pregnancies complicated by an IUFD diagnosed greater than 20 weeks gestation from 1996 to 2006 at three large academic hospitals. Data on maternal characteristics, prior medical and obstetrical histories and obstetrical outcomes were collected. Data were analyzed with Stata SE 10.1 (College Station, TX). RESULTS: Among 548 women with a pregnancy complicated by IUFD, 116 (21.2%) had a history of prior cesarean delivery. Mean gestational age of delivery was 28.9 weeks, SD 6.4 weeks. Infant mean birthweight was 1376.20 g, SD 1288.80 g. Nineteen percent (22/116) underwent a repeat cesarean delivery. The majority of women 56.9% (66/116) required induction of labor with most (93.9%) having a successful vaginal birth after cesarean delivery (VBAC). Of 28 women who presented in spontaneous labor, 26 (92.9%) achieved a successful VBAC. Only 4 women of the induction group and 2 women of the spontaneous labor group failed a trial of labor and underwent repeat CD. Among the methods of induction used were prostaglandins in 42.2%, laminaria in 10.3%, and Foley catheter in 17.2%. Oxytocin was used for induction or augmentation of labor in 43.1%. No differences in the rate of complications were seen in the group that delivered vaginally versus CD. Uterine rupture occurred in 2 patients (1.7%), both delivered by CD, with 1 in the failed VBAC group. Other complications observed were DIC (0.9%), blood transfusion (1.7%), maternal shock (0.9%), respiratory failure requiring intubation (0.9%), cesarean hysterectomy (1.7%) and maternal death (0.9%). CONCLUSION: Induction of labor is a common evidence-based practice for women diagnosed with an IUFD and a prior CD. A high success rate of VBAC was reported in this group of patients, with a high proportion of women receiving prostaglandins as the method for induction. Low rates of maternal complications were seen.
160 Mode of delivery and risk of adverse perinatal outcome in twins with the first twin in vertex position Stephanie de Haseth1, Sophie Liem2, Enrico Lopriore3, Eline van den Akker4, Dick Oepkes5 1 Leiden University Medical Center, Department of Obstetrics and Gynecology, Den Haag, Netherlands, 2Academic Medical Center, Department of Obstetrics and Gynaecology, Amsterdam, Netherlands, 3 Leiden University Medical Center, Department of Pediatrics, Leiden, Netherlands, 4OLVG, Obstetrics and Gynecology, Amsterdam, Netherlands, 5 Leiden University Medical Center, Obstetrics, Leiden, Netherlands
OBJECTIVE: Mode of delivery in twin pregnancies is an ongoing subject of discussion, with conflicting conclusions from previous studies. We aimed to evaluate the outcome of twin births ⱖ32 weeks gestation with vertex position of the first twin in relation to the mode of delivery. STUDY DESIGN: Retrospective multicenter cohort-study of consecutive twin births ⱖ 32 weeks gestation with the first twin in cephalic position. We excluded twins with congenital anomalies and fetal death before the onset of labor. Primary outcome was perinatal mortality and severe neonatal morbidity, defined as one or more of the following: 5-minute Apgar score ⬍4, cord blood pH ⬍7.06, birth trauma, admission to the NICU. Differences were analyzed using Chi-square or Fishers Exact test as appropriate, two-tailed with a p-value of 0.05 considered to be statistically significant. RESULTS: During the study period (2002 2009), 1352 twins were born in the two participating institutions, of which 658 twins fulfilled the
Supplement to JANUARY 2012 American Journal of Obstetrics & Gynecology
S83