- Email: [email protected]
17: Perinatal outcomes among twin vs singleton pregnancies following previable preterm premature rupture of membranes (PPROM)
IDSOG Abstracts knowledge, use, and negotiation skills. We recruited a convenience sample of women from the Ob/Gyn and Infectious Disease waiting rooms of a large urban medical center in Washington D.C. We used descriptive statistics to describe study subjects’ characteristics. We used T-test and Wilcoxon rank sum test to investigate differences between groups for continuous variables and the Chi-square and Fisher exact tests for categorical variables. Logistic regression analysis was used to examine the relationship between binary outcome variables and the explanatory variables adjusting for potential confounding variables. RESULTS: We collected 438 questionnaires; 114 respondents were HIV positive. Median age was 39.6 and the majority were African American (87.9%). There were no significant differences in age, race, marital status or source of income between HIV positive and negative survey participants. Women living with HIV had lower levels of education and income compared to women without, however, higher number of lifetime sexual partners and pregnancies. HIV positive women were more likely to report condom use (80% vs. 45.4% p¼<0.0001) and to use condoms consistently, 71% reporting “most of the time” or “always” compared to 43.3% (p¼<0.0001). Ninety-two percent of HIV positive women identified sexual intercourse as a mode of HIV transmission compared to 76.2% of HIV negative women (p¼0.0002). Ninety-three percent of HIV positive women identified condoms as a means of preventing HIV compared to 79.3% of HIV negative women (p¼0.0009). Women with HIV were more likely to report using negotiation strategies such as autocracy, bargaining, bullying, disengagement, manipulation, and supplication to request condom use. CONCLUSIONS: Women with HIV reported increased knowledge and use of condoms as a means to prevent transmission of HIV and negotiation skills compared to HIV negative counterparts. Gaps in knowledge, condom use, and negotiation skills highlight need for interventions to further educate and empower both women living with and without HIV to prevent spread of HIV in this high-prevalence, high-risk population.
16 Uropathogens and antibiotic resistance temporal trends among pregnant women: updated assessment and comparison from 2005-2014 S. Suharwardy, K. O’Malley, H. Lee, N. Banaei, N. Aziz Stanford University, Stanford, CA
OBJECTIVES: Urinary tract infection (UTI) is the most common type of bacterial infection among pregnant women. UTI, especially when untreated, is associated with numerous adverse pregnancy outcomes. Given the increased concern for antimicrobial resistance, we sought to describe more recent uropathogen and antibiotic resistance patterns among pregnant women. METHODS: We conducted a retrospective study at a university medical center assessing urine cultures of women collected during pregnancy and postpartum from 2005-2014. All urine cultures with 100,000 cfu/mL, meeting formal criteria for UTI, were included in the analysis. The cultures were evaluated for uropathogen and antibiotic resistance. Uropathogen prevalence and resistance were compared between 2005-2009 and 2010-2014 time periods. RESULTS: Of 1,492 urine cultures performed during the study period, 1,105 met inclusion criteria and were used in final analysis; 594 cultures in 2005-2009 and 511 cultures in 2010-2014. Common uropathogens were not different between the two time periods. Antibiotic resistance profiles between the two cohorts were also similar, with 53.7% (319) vs 55.4% (283) uropathogens pansensitive
834 American Journal of Obstetrics & Gynecology DECEMBER 2016
ajog.org and 46.3% (275) vs 44.6% (228) resistant to 1 antibiotics (p¼0.57). 21.9% (130) vs 20.5% (123) were single-drug resistant and 24.4% (145) vs 24.1% (105) were multidrug resistant (p¼0.14). Considering empiric antibiotic use (and therefore including acquired and intrinsic resistance), resistance to nitrofurantoin was 9.1% (54) vs 9.2% (47) (p¼0.95), while resistance to first-generation cephalosporins was 17.5% (104) vs 16.0% (82) (p¼0.52).
CONCLUSIONS: Common uropathogens in our pregnant patient
cohort have remained similar over a 10-year period. Additionally, uropathogen antibiotic resistance is stable. Despite changes in our medical center antibiogram, sensitivity of uropathogens to common antibiotics used for empiric treatment of UTI in pregnancy is unchanged, and thus our current recommendations for obstetric practice remain appropriate.
17 Perinatal outcomes among twin vs singleton pregnancies following previable preterm premature rupture of membranes (PPROM) S. Dotters-Katz, A. Panzer, M. Smid, K. Boggess, T. Manuck Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
OBJECTIVES: To examine pregnancy outcomes in twin and singleton
pregnancies after previable preterm premature rupture of membranes (PPROM) (<23 wks). METHODS: This study is retrospective cohort from a single institution from 2000-2014 with singleton or twin pregnancies complicated by PPPROM at 14.0-22.9 weeks, without chorioamnionitis at presentation, who elected expectant management and achieved at least 24 hours latency. Pregnancies with fetal anomalies, higher order multiples, PPPROM within 2 weeks of CVS/amniocentesis, or delayed interval twin deliveries were excluded. The primary outcome was any infant in the pregnancy surviving to hospital discharge. Of those pregnancies that delivered 23 weeks, we also examined composite major neonatal morbidity (grade III/IV intraventricular hemorrhage, necrotizing enterocolitis, bronchopulmonary dysplasia, pulmonary hypoplasia, and/or death prior to discharge) and death prior to discharge of any infant in the pregnancy. Twin outcomes were compared to singleton outcomes using chi-square, Fisher’s exact, ttest, and Wilcoxon rank-sum as appropriate. RESULTS: 104 pregnancies (82 singleton, 22 twin) were included. There were no significant differences in maternal age, parity, smoking, race/ethnicity, insurance status, or medical problems (hypertension or diabetes) between singleton and twin pregnancies. When singleton pregnancies were compared to twin pregnancies, PPROM and delivery occurred at similar gestational age, 20.6 wks (IQR 18.7, 22.1) vs. 20.5 wks (IQR 18.7, 21.9) (p¼0.9) and 22.8wks (IQR 20.6, 25) vs 23.1 wks (IQR 20.4, 23.6) (p¼0.8), respectively. There was no difference in chorioamnionitis between singleton and twin pregnancies (37 vs 59%, p¼.06) (Table). In the entire cohort, there was increased survival in at least 1 twin vs. singletons (55% vs 32% p¼0.048. Among only those pregnancies that delivered at or beyond 23 weeks (38 singleton and 12 twin pregnancies), major
IDSOG Abstracts
ajog.org
Table Delivery and survival data for women with preterm premature rupture of membranes with singleton compared to twin pregnancy (2000-2015)
Median GA @ ROM Median Latency (wks) IQR GA @ delivery
Singleton n¼82
Multiple n¼22
20.6 (18.7, 22.1)
20.5 (18.7, 21.9)
0.92
2 (0.6, 4.6)
1.5 (0.6, 4.3)
0.87
23.1 (20.4, 23.6)
0.80
22.8 (20.6, 25)
p-value
Chorioamnionitis as delivery indication
30 (37)
13 (59)
0.06
Delivery before 23 weeks
44 (54)
10 (45)
0.49
Survival*
26 (32)
12 (55)
0.048
*Survival of at least one infant to discharge from NICU/hospital, entire cohort.
neonatal morbidity and/or death (63 vs 50%, p¼0.41). However, survival to hospital discharge of at least one infant (68 vs 100%, p¼0.03) more common in twin gestation. CONCLUSIONS: Initial neonatal outcomes following previable PPROM are poor with high rates of chorioamnionitis. The majority of both twins and singletons delivered prior to viability (23 weeks). For those pregnancies that continue to 23 weeks, neonatal morbidity and mortality was high, though survival of at least one infant may be more likely in twins.
department clinic (18.2% versus 9.0%) and less likely to be diagnosed in a private physician office (0% versus 28.0%) compared with women classified as missed opportunities (p¼0.01). CONCLUSIONS: The majority of CS cases were preventable and resulted from failure of the healthcare system or inability of women to access prenatal care and testing. Differences in place of diagnosis may indicate acute care settings that would benefit from additional training and support in syphilis case reporting, treatment and patient education.
18 Characteristics of and factors contributing to congenital syphilis cases in georgia: 2000-2009
19 Extended spectrum beta-lactamase urinary tract infections during pregnancy
A. Kachikis1, M. A. Schiff1, T. Chapple-McGruder2, J. Arluck3
B. Kelly, M. Beninati, C. Davidson, S. L. Clark, C. S. Eppes
1
Geisinger Medical Center Danville, PA
University of Washington, Seattle, WA, 2Essence of Public Health, Atlanta, GA, 3Emory University, Atlanta, GA
OBJECTIVES: The study’s objectives were to examine characteristics of
congenital syphilis (CS) cases in the state of Georgia from 2000 e 2009 and to compare socio-demographic factors and birth outcomes among women who did and did not utilize the healthcare system during pregnancy. METHODS: This study was a secondary data analysis of CS cases within Georgia from 2000 - 2009 reported on the CDC Congenital Syphilis Case Investigation and Reporting Form. Data included mother’s race and marital status, rural or urban location, number of prenatal visits, place of diagnosis, infant gestational age and weight at birth, whether the child was treated, and the final disease classification for the infant. Women who did access the health care system through prenatal care were classified as missed opportunities for preventing CS during pregnancy. Women who had no prenatal care were classified as those not accessing the healthcare system. Statistical analyses were performed to compare these groups using chi-square tests. RESULTS: From 2000-2009, 101 reported cases of presumptive CS were found. One was classified as a confirmed case, two were syphilitic stillbirths and 98 were presumptive cases. Over 61% were born to Black non-Hispanic women, 14.8% to white non-Hispanic, 22.8% to Hispanic and 1% to Asian/Alaskan native women. Most women were unmarried (82.1%), lived in urban areas (86.1%), and reported receiving prenatal care (77.3%). Infants in 64.4% of these cases were born at term and 66.7% weighed greater than 2500g at birth. Of the 101 cases, 72.3% were defined as missed opportunities within the healthcare system and 21.8% did not utilize the healthcare system. Women not accessing the healthcare system were more likely to be diagnosed in a hospital (81.8% versus 62.7%) or a health
OBJECTIVES: Extended spectrum beta-lactamases (ESBLs) are enzymes produced by gram-negative bacilli that result in resistance against most antibiotics. We sought to evaluate the epidemiology and impact of ESBL urinary tract infections (UTIs) during pregnancy. METHODS: We performed a case control study comparing outcomes in pregnant women with optimally treated ESBL UTIs, sub-optimally treated ESBL UTIs, and non-ESBL UTIs from 2012-2014. Suboptimal treatment was defined as treatment without carbapenems or post-treatment negative urine culture. For those with ESBL UTIs, we identified antecedent infections, prior antibiotic use, and the treatment course. RESULTS: 457 reproductive age female patients with ESBL UTIs were identified, of whom 13% (n¼60) were pregnant. Of these, 45 had pregnancy outcome data. Suboptimal treatment was noted in the majority of cases involving ESBL UTI (89%, n¼40), which was far more likely than what was observed for non-ESBL infections. 12 out of 13 cases of ESBL pyelonephritis arose surrounding suboptimal treatment, as opposed to 1 out of 21 cases of non-ESBL pyelonephritis (p¼0.001). 21 of 287 women with non-ESBL UTI developed pyelonephritis, compared to 13 of 45 women with ESBL UTIs (p¼0.001). One case of pyelonephritis, chorioamnionitis, wound infection, sepsis bacteremia or necrotizing fasciitis was noted in the optimally treated ESBL group, while 14 such outcomes occurred in the group without optimal treatment. CONCLUSIONS: Sub-optimal treatment of ESBL infections in pregnancy is common. Our data support the importance of more aggressive treatment and follow up of pregnant women with ESBL UTIs to prevent secondary clinical pyelonephritis. DECEMBER 2016 American Journal of Obstetrics & Gynecology
835
16 Uropathogens and antibiotic resistance temporal trends among pregnant women: updated assessment and comparison from 2005-2014 S. Suharwardy, K. O’Malley, H. Lee, N. Banaei, N. Aziz Stanford University, Stanford, CA
OBJECTIVES: Urinary tract infection (UTI) is the most common type of bacterial infection among pregnant women. UTI, especially when untreated, is associated with numerous adverse pregnancy outcomes. Given the increased concern for antimicrobial resistance, we sought to describe more recent uropathogen and antibiotic resistance patterns among pregnant women. METHODS: We conducted a retrospective study at a university medical center assessing urine cultures of women collected during pregnancy and postpartum from 2005-2014. All urine cultures with 100,000 cfu/mL, meeting formal criteria for UTI, were included in the analysis. The cultures were evaluated for uropathogen and antibiotic resistance. Uropathogen prevalence and resistance were compared between 2005-2009 and 2010-2014 time periods. RESULTS: Of 1,492 urine cultures performed during the study period, 1,105 met inclusion criteria and were used in final analysis; 594 cultures in 2005-2009 and 511 cultures in 2010-2014. Common uropathogens were not different between the two time periods. Antibiotic resistance profiles between the two cohorts were also similar, with 53.7% (319) vs 55.4% (283) uropathogens pansensitive
834 American Journal of Obstetrics & Gynecology DECEMBER 2016
ajog.org and 46.3% (275) vs 44.6% (228) resistant to 1 antibiotics (p¼0.57). 21.9% (130) vs 20.5% (123) were single-drug resistant and 24.4% (145) vs 24.1% (105) were multidrug resistant (p¼0.14). Considering empiric antibiotic use (and therefore including acquired and intrinsic resistance), resistance to nitrofurantoin was 9.1% (54) vs 9.2% (47) (p¼0.95), while resistance to first-generation cephalosporins was 17.5% (104) vs 16.0% (82) (p¼0.52).
CONCLUSIONS: Common uropathogens in our pregnant patient
cohort have remained similar over a 10-year period. Additionally, uropathogen antibiotic resistance is stable. Despite changes in our medical center antibiogram, sensitivity of uropathogens to common antibiotics used for empiric treatment of UTI in pregnancy is unchanged, and thus our current recommendations for obstetric practice remain appropriate.
17 Perinatal outcomes among twin vs singleton pregnancies following previable preterm premature rupture of membranes (PPROM) S. Dotters-Katz, A. Panzer, M. Smid, K. Boggess, T. Manuck Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC
OBJECTIVES: To examine pregnancy outcomes in twin and singleton
pregnancies after previable preterm premature rupture of membranes (PPROM) (<23 wks). METHODS: This study is retrospective cohort from a single institution from 2000-2014 with singleton or twin pregnancies complicated by PPPROM at 14.0-22.9 weeks, without chorioamnionitis at presentation, who elected expectant management and achieved at least 24 hours latency. Pregnancies with fetal anomalies, higher order multiples, PPPROM within 2 weeks of CVS/amniocentesis, or delayed interval twin deliveries were excluded. The primary outcome was any infant in the pregnancy surviving to hospital discharge. Of those pregnancies that delivered 23 weeks, we also examined composite major neonatal morbidity (grade III/IV intraventricular hemorrhage, necrotizing enterocolitis, bronchopulmonary dysplasia, pulmonary hypoplasia, and/or death prior to discharge) and death prior to discharge of any infant in the pregnancy. Twin outcomes were compared to singleton outcomes using chi-square, Fisher’s exact, ttest, and Wilcoxon rank-sum as appropriate. RESULTS: 104 pregnancies (82 singleton, 22 twin) were included. There were no significant differences in maternal age, parity, smoking, race/ethnicity, insurance status, or medical problems (hypertension or diabetes) between singleton and twin pregnancies. When singleton pregnancies were compared to twin pregnancies, PPROM and delivery occurred at similar gestational age, 20.6 wks (IQR 18.7, 22.1) vs. 20.5 wks (IQR 18.7, 21.9) (p¼0.9) and 22.8wks (IQR 20.6, 25) vs 23.1 wks (IQR 20.4, 23.6) (p¼0.8), respectively. There was no difference in chorioamnionitis between singleton and twin pregnancies (37 vs 59%, p¼.06) (Table). In the entire cohort, there was increased survival in at least 1 twin vs. singletons (55% vs 32% p¼0.048. Among only those pregnancies that delivered at or beyond 23 weeks (38 singleton and 12 twin pregnancies), major
IDSOG Abstracts
ajog.org
Table Delivery and survival data for women with preterm premature rupture of membranes with singleton compared to twin pregnancy (2000-2015)
Median GA @ ROM Median Latency (wks) IQR GA @ delivery
Singleton n¼82
Multiple n¼22
20.6 (18.7, 22.1)
20.5 (18.7, 21.9)
0.92
2 (0.6, 4.6)
1.5 (0.6, 4.3)
0.87
23.1 (20.4, 23.6)
0.80
22.8 (20.6, 25)
p-value
Chorioamnionitis as delivery indication
30 (37)
13 (59)
0.06
Delivery before 23 weeks
44 (54)
10 (45)
0.49
Survival*
26 (32)
12 (55)
0.048
*Survival of at least one infant to discharge from NICU/hospital, entire cohort.
neonatal morbidity and/or death (63 vs 50%, p¼0.41). However, survival to hospital discharge of at least one infant (68 vs 100%, p¼0.03) more common in twin gestation. CONCLUSIONS: Initial neonatal outcomes following previable PPROM are poor with high rates of chorioamnionitis. The majority of both twins and singletons delivered prior to viability (23 weeks). For those pregnancies that continue to 23 weeks, neonatal morbidity and mortality was high, though survival of at least one infant may be more likely in twins.
department clinic (18.2% versus 9.0%) and less likely to be diagnosed in a private physician office (0% versus 28.0%) compared with women classified as missed opportunities (p¼0.01). CONCLUSIONS: The majority of CS cases were preventable and resulted from failure of the healthcare system or inability of women to access prenatal care and testing. Differences in place of diagnosis may indicate acute care settings that would benefit from additional training and support in syphilis case reporting, treatment and patient education.
18 Characteristics of and factors contributing to congenital syphilis cases in georgia: 2000-2009
19 Extended spectrum beta-lactamase urinary tract infections during pregnancy
A. Kachikis1, M. A. Schiff1, T. Chapple-McGruder2, J. Arluck3
B. Kelly, M. Beninati, C. Davidson, S. L. Clark, C. S. Eppes
1
Geisinger Medical Center Danville, PA
University of Washington, Seattle, WA, 2Essence of Public Health, Atlanta, GA, 3Emory University, Atlanta, GA
OBJECTIVES: The study’s objectives were to examine characteristics of
congenital syphilis (CS) cases in the state of Georgia from 2000 e 2009 and to compare socio-demographic factors and birth outcomes among women who did and did not utilize the healthcare system during pregnancy. METHODS: This study was a secondary data analysis of CS cases within Georgia from 2000 - 2009 reported on the CDC Congenital Syphilis Case Investigation and Reporting Form. Data included mother’s race and marital status, rural or urban location, number of prenatal visits, place of diagnosis, infant gestational age and weight at birth, whether the child was treated, and the final disease classification for the infant. Women who did access the health care system through prenatal care were classified as missed opportunities for preventing CS during pregnancy. Women who had no prenatal care were classified as those not accessing the healthcare system. Statistical analyses were performed to compare these groups using chi-square tests. RESULTS: From 2000-2009, 101 reported cases of presumptive CS were found. One was classified as a confirmed case, two were syphilitic stillbirths and 98 were presumptive cases. Over 61% were born to Black non-Hispanic women, 14.8% to white non-Hispanic, 22.8% to Hispanic and 1% to Asian/Alaskan native women. Most women were unmarried (82.1%), lived in urban areas (86.1%), and reported receiving prenatal care (77.3%). Infants in 64.4% of these cases were born at term and 66.7% weighed greater than 2500g at birth. Of the 101 cases, 72.3% were defined as missed opportunities within the healthcare system and 21.8% did not utilize the healthcare system. Women not accessing the healthcare system were more likely to be diagnosed in a hospital (81.8% versus 62.7%) or a health
OBJECTIVES: Extended spectrum beta-lactamases (ESBLs) are enzymes produced by gram-negative bacilli that result in resistance against most antibiotics. We sought to evaluate the epidemiology and impact of ESBL urinary tract infections (UTIs) during pregnancy. METHODS: We performed a case control study comparing outcomes in pregnant women with optimally treated ESBL UTIs, sub-optimally treated ESBL UTIs, and non-ESBL UTIs from 2012-2014. Suboptimal treatment was defined as treatment without carbapenems or post-treatment negative urine culture. For those with ESBL UTIs, we identified antecedent infections, prior antibiotic use, and the treatment course. RESULTS: 457 reproductive age female patients with ESBL UTIs were identified, of whom 13% (n¼60) were pregnant. Of these, 45 had pregnancy outcome data. Suboptimal treatment was noted in the majority of cases involving ESBL UTI (89%, n¼40), which was far more likely than what was observed for non-ESBL infections. 12 out of 13 cases of ESBL pyelonephritis arose surrounding suboptimal treatment, as opposed to 1 out of 21 cases of non-ESBL pyelonephritis (p¼0.001). 21 of 287 women with non-ESBL UTI developed pyelonephritis, compared to 13 of 45 women with ESBL UTIs (p¼0.001). One case of pyelonephritis, chorioamnionitis, wound infection, sepsis bacteremia or necrotizing fasciitis was noted in the optimally treated ESBL group, while 14 such outcomes occurred in the group without optimal treatment. CONCLUSIONS: Sub-optimal treatment of ESBL infections in pregnancy is common. Our data support the importance of more aggressive treatment and follow up of pregnant women with ESBL UTIs to prevent secondary clinical pyelonephritis. DECEMBER 2016 American Journal of Obstetrics & Gynecology
835