- Email: [email protected]
439: 2013 SMFM quality management survey
Poster Session III
Epidemiology, Ob Quality, Operative Obstetrics, Public Health, Infectious Disease, Academic Issues
TLR based therapies to reduce both short and long term adverse neonatal outcomes from exposure to prenatal inflammation.
www.AJOG.org
smaller reduction in IP fever and elucidate the relationship of 2% CHG wipe use with neonatal sepsis. This study does confirm that 2% CHG wipes are a well tolerated method of MEPC.
Anti-TLR-4 therapy reduces inflammationenhanced IL-6 levels in the amniotic fluid
Independent predictors of intrapartum fever
439 2013 SMFM quality management survey Robert Stiller1, Erol Amon2, Arnold Cohen3, A. George Bronsky4, Alan Bombard13, Gary Eglinton5, Washington Hill6, David McLean7, A. George Neubert8, J. Parer9, Jeffrey Phelan10, Howard Strassner11, Jerome Yankowitz12 1
438 Effect of maternal external chlorhexidine (CHG) perineal cleansing on intrapartum (IP) fever Cynthia Anderson1, Karin Blakemore1 1
Johns Hopkins University School of Medicine, Baltimore, MD
OBJECTIVE: To examine if the incidence of IP fever is reduced with
use of a 2% CHG wipe for maternal external perineal cleansing (MEPC) prior to every digital examination (SVE) during labor. STUDY DESIGN: Patients admitted to L&D for anticipated vaginal birth were allotted into 3 non-equivalent study groups post-test only design by intervention of MEPC: 1) use of a plain bath wipe prior to SVE in presence of visible contamination only (prn), 2) 2% CHG wipe prior to SVE prn, and 3) 2% CHG wipe prior to every SVE. Data abstracted included patient demographics, primary outcome IP fever, and secondary outcomes postpartum fever, chorioamnionitis, endomyometritis, wound infection, neonatal sepsis workup and confirmed neonatal sepsis. Data were analyzed using chi square, one way ANOVA, Kruskal-Wallis, and logistic regression. A sample size of 170 patients/group was required to detect a 67% reduction in our hospital’s baseline IP fever rate of 10%. RESULTS: IP fever was not reduced by MEPC with 2% CHG wipes prior to every SVE (group 1: 14/226 (6%) vs group 2: 19/191 (10%) vs group 3: 19/205 (9%), p¼0.328). The incidence of confirmed cases of neonatal sepsis was statistically significant (1: 1/226 (0.5%) vs 2: 6/191 (3%) vs 3: 8/205 (4%), p¼0.048). Multivariable logistic regression demonstrated lengths of the 1st stage (OR 1.06 (1.021.09), p<0.001) and the 2nd stage (OR 1.59 (1.21-2.08), p<0.001) of labor were independent predictors of IP fever, irrespective of intervention group. For every hour increase in the 1st stage of labor, risk of IP fever increased by 5.7%; in the 2nd stage by 58.7%. No allergy/ adverse reaction was reported to the 2% CHG wipe. CONCLUSION: MEPC with a 2% CHG wipe prior to every SVE during labor did not reduce the incidence of IP fever compared to MEPC prn. A larger RCT would be an appropriate next step to detect a
Bridgeport Hospital-Yale New Haven Health Sytem, Obstetrics and Gynecology, Bridgeport, CT, 2St. Louis University, Obstetrics and Gynecology, St. Louis, MO, 3Albert Einstein Medical Center, Obstetrics and Gynecology, Philadelphia, PA, 4Inova Fairfax Hospital, Obstetrics and Gynecology, Fairfax, VA, 5New York Hospital Medical Center of Queens, Obstetrics and Gynecology, Flushing, NY, 6Duke University School of Medicine, Obstetrics and Gynecology, Durham, NC, 7Lehigh Valley Health, Obstetrics and Gynecology, Allentown, PA, 8Geisinger Health System, Obstetrics and Gynecology, Danville, PA, 9UC- San Francisco, Obstetrics and Gynecology, San Francisco, CA, 10San Antonio Community Hospital, Obstetrics and Gynecology, Upland, CA, 11Presence St. Joseph Hospital, Obstetrics and Gynecology, Chicago, IL, 12Univ of South Florida, Obstetrics and Gynecology, Tampa, FL, 13UC-SD, Obstetrics and Gynecology, San Diego, CA
OBJECTIVE: Quality management and patient safety initiatives have increased in the field of Obstetrics. Little data is available concerning the current role the MFM specialist plays in these areas. The Risk Management Committee of the Society for Maternal-Fetal medicine sent an electronic survey to its members in 2013 questioning MFMs about their activities in this area. STUDY DESIGN: An e-mail survey was sent to the SMFM membership in 2013. Questions were designed to determine active involvement (defined as within the past 3 years) in different aspects of patient safety and quality management activities. RESULTS: 710/1971 (36%) members responded to the survey answering some or all of the questions. All ACOG districts were represented. The median age of respondents was 48 yrs. The highest involvement of respondents was in the area of drafting policies and protocols (74.7%) followed by involvement in quality management committees (59.3%). 46.4% of the respondents participated in simulation training. 27.4% are involved in giving expert witness testimony, with the majority of work being done for defendants, Few respondents note activity outside their institution in quality management activities ( state, professional, or insurance agencies). CONCLUSION: MFM specialists are actively involved in all areas of quality management and patient safety, with the highest level of involvement in drafting obstetrical protocols, followed by participation on quality management committees. Simulation training involvement is also high, although only 27% actually serve as patient safety/team training trainers. MFM fellowship programs should include quality management/patient safety topics in their curriculums to help prepare candidates for these important roles, along with the SMFM supporting continuing medical education in this area for physicians already in practice.
S222 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2014
www.AJOG.org
Epidemiology, Ob Quality, Operative Obstetrics, Public Health, Infectious Disease, Academic Issues
Poster Session III
441 Bacterial colonization of cervical cerclage is an independent risk factor for preterm PROM Ruth Beer Wiesel1, Offer Erez1, Renana Vilkof2, Batel Hamou1, Vered Klaitman-Mayer1, Tal Rafaeli1, Moshe Mazor1 1 Soroak University Medical Center, School of Medicine, Faculty of Health scienes Benn Gurion University of the Negev, Obstetrics and Gynecology, Beer Sheva, Israel, 2Soroka University Medical Center, School of Medicine, Faculty of Health scienes Benn Gurion University of the Negev, School of Medicine, Beer Sheva, Israel
440 Material and psychosocial determinants of preterm birth: assessing the effects of social inequality using birth cohort data from the U.K. John Snelgrove1, Kellie Murphy2 1 Faculty of Medicine, University of Toronto, Department of Obstetrics & Gynaecology, Toronto, ON, Canada, 2Mt. Sinai Hospital, Faculty of Medicine, University of Toronto, Division of Maternal-Fetal Medicine, Toronto, ON, Canada
OBJECTIVE: Preterm birth is a worldwide health problem. Risk of this perinatal complication follows a social gradient. The aim of this study was to examine the association between social inequalities and preterm birth using both psychosocial and material determinants. STUDY DESIGN: This study was a retrospective analysis of survey and linked hospital data from 16,886 women giving birth to singletons in the U.K. who were included in wave 1 (2000-2002) of the Millennium Cohort Study. Preterm birth was the main outcome and defined as delivery between 24 weeks and 36 weeks, 6 days gestation. Social inequalities were measured with material (household income, housing tenure, perceived neighbourhood deprivation) and psychosocial (education, occupational class, employment, social support) indicators. Analysis used nested multivariate logistic regression to assess odds of preterm birth, adjusting for demographics, baseline health and health-related behaviours, pregnancy and delivery conditions, and pregnancy complications. RESULTS: Employment (OR¼0.70, 95%CI: 0.50-0.90, p¼0.039) and one indicator of social support (OR¼0.84, 95%CI: 0.72-0.97, p¼0.021) were protective against the risk of preterm birth and persisted following full adjustment. Effects of household income, housing tenure, perceived neighbourhood deprivation, and education were largely attenuated with adjustment for other social determinants. CONCLUSION: In this study, employment and one indicator of social support were associated with decreased odds of preterm birth, supporting the hypothesis that poor psychosocial and material circumstances place women at higher risk of preterm birth. Further research is needed to examine the causal pathways through which social inequalities affect this adverse health outcome.
OBJECTIVE: Cerclage is emerging as one of the emerging treatment for the prevention of recurrent preterm birth. The aim of this study was to determine the association between bacterial colonization of cerclage and pregnancy outcome. STUDY DESIGN: This retrospective cohort study included pregnancies of women who had a cervical cerclage that was sent to microbacterial culture following its removal prior to delivery (n¼101). RESULTS: The rate of a positive culture of cervical cerclage was 51% (52/101). E. coli was the most prevalent microorganism isolated from the cerclage and placental cultures. Women with a positive cerclage culture had a higher mean maternal age (p¼0.02), and a median parity (p¼0.01), than those who had a negative culture. The rate of premature contractions (p¼0.001), preterm PROM (p¼0.01) were increased in women with a positive cerclage culture. These women also had a higher proportion of betamethasone treatment [positive culture 36.7% (18/49) vs. negative culture 17.3% (9/52), p¼0.03] that was administrated at earlier mean gestational age than those with a negative cerclage culture (27.5+2.6 vs. 30.7+2.4, p¼0.007, respectively). Among the indications for early removal of cerclage, women with a positive culture had a higher rate of preterm PROM than those who had a negative culture (p¼0.005). After adjustment for confounding factors, the gestational age in which the cerclage was placed (HR 1.8, 95% CI 1.3-2.6) and a positive culture (HR 15.4, 95% CI 1.02-232.3) were independent risk factors for preterm PROM. CONCLUSION: 1) Colonization of a cervical cerclage is associated with adverse pregnancy outcome, and it is an independent risk factor for preterm PROM. 2) Performing a cerclage at advanced gestational age may increase the risk for preterm PROM.
442 Severe maternal infectious morbidity during the second half of pregnancy is an independent risk factor for an SGA neonate Tal Kedar2, Offer Erez1, Moshe Mazor1, Yael Perl2, Lena Novack3, Ruth Beer Wiesel1, Limor Besser1, Salvatore Mastrolia4, Batel Hamou1 1
Soroka University Medical Center, School of Medicine, Faculty of Health scienes Benn Gurion University of the Negev, Obstetrics and Gynecology, Beer Sheva, Israel, 2School of Medicine, Faculty of Health scienes Benn Gurion University of the Negev, Epidemiology, Beer Sheva, Israel, 3Faculty of Health scienes Benn Gurion University of the Negev, School of Medicine, Beer Sheva, Israel, 4University of Bari, Obstetrics and Gynecology, Bari, Italy
OBJECTIVE: The effect of severe maternal infectious morbidity on fetal growth is under debate. Preliminary evidence suggests that such association may be plausible. The objectives of this study were to determine: 1) the association between severe maternal infectious morbidity (SMI) and adverse pregnancy outcome; and 2) The effect of SMI during pregnancy on fetal growth. STUDY DESIGN: This retrospective cohort study included 4771 women who gave birth at our medical center during the study period. The women were allocated into two groups: 1) patients with SMI during
Supplement to JANUARY 2014 American Journal of Obstetrics & Gynecology
S223
Epidemiology, Ob Quality, Operative Obstetrics, Public Health, Infectious Disease, Academic Issues
TLR based therapies to reduce both short and long term adverse neonatal outcomes from exposure to prenatal inflammation.
www.AJOG.org
smaller reduction in IP fever and elucidate the relationship of 2% CHG wipe use with neonatal sepsis. This study does confirm that 2% CHG wipes are a well tolerated method of MEPC.
Anti-TLR-4 therapy reduces inflammationenhanced IL-6 levels in the amniotic fluid
Independent predictors of intrapartum fever
439 2013 SMFM quality management survey Robert Stiller1, Erol Amon2, Arnold Cohen3, A. George Bronsky4, Alan Bombard13, Gary Eglinton5, Washington Hill6, David McLean7, A. George Neubert8, J. Parer9, Jeffrey Phelan10, Howard Strassner11, Jerome Yankowitz12 1
438 Effect of maternal external chlorhexidine (CHG) perineal cleansing on intrapartum (IP) fever Cynthia Anderson1, Karin Blakemore1 1
Johns Hopkins University School of Medicine, Baltimore, MD
OBJECTIVE: To examine if the incidence of IP fever is reduced with
use of a 2% CHG wipe for maternal external perineal cleansing (MEPC) prior to every digital examination (SVE) during labor. STUDY DESIGN: Patients admitted to L&D for anticipated vaginal birth were allotted into 3 non-equivalent study groups post-test only design by intervention of MEPC: 1) use of a plain bath wipe prior to SVE in presence of visible contamination only (prn), 2) 2% CHG wipe prior to SVE prn, and 3) 2% CHG wipe prior to every SVE. Data abstracted included patient demographics, primary outcome IP fever, and secondary outcomes postpartum fever, chorioamnionitis, endomyometritis, wound infection, neonatal sepsis workup and confirmed neonatal sepsis. Data were analyzed using chi square, one way ANOVA, Kruskal-Wallis, and logistic regression. A sample size of 170 patients/group was required to detect a 67% reduction in our hospital’s baseline IP fever rate of 10%. RESULTS: IP fever was not reduced by MEPC with 2% CHG wipes prior to every SVE (group 1: 14/226 (6%) vs group 2: 19/191 (10%) vs group 3: 19/205 (9%), p¼0.328). The incidence of confirmed cases of neonatal sepsis was statistically significant (1: 1/226 (0.5%) vs 2: 6/191 (3%) vs 3: 8/205 (4%), p¼0.048). Multivariable logistic regression demonstrated lengths of the 1st stage (OR 1.06 (1.021.09), p<0.001) and the 2nd stage (OR 1.59 (1.21-2.08), p<0.001) of labor were independent predictors of IP fever, irrespective of intervention group. For every hour increase in the 1st stage of labor, risk of IP fever increased by 5.7%; in the 2nd stage by 58.7%. No allergy/ adverse reaction was reported to the 2% CHG wipe. CONCLUSION: MEPC with a 2% CHG wipe prior to every SVE during labor did not reduce the incidence of IP fever compared to MEPC prn. A larger RCT would be an appropriate next step to detect a
Bridgeport Hospital-Yale New Haven Health Sytem, Obstetrics and Gynecology, Bridgeport, CT, 2St. Louis University, Obstetrics and Gynecology, St. Louis, MO, 3Albert Einstein Medical Center, Obstetrics and Gynecology, Philadelphia, PA, 4Inova Fairfax Hospital, Obstetrics and Gynecology, Fairfax, VA, 5New York Hospital Medical Center of Queens, Obstetrics and Gynecology, Flushing, NY, 6Duke University School of Medicine, Obstetrics and Gynecology, Durham, NC, 7Lehigh Valley Health, Obstetrics and Gynecology, Allentown, PA, 8Geisinger Health System, Obstetrics and Gynecology, Danville, PA, 9UC- San Francisco, Obstetrics and Gynecology, San Francisco, CA, 10San Antonio Community Hospital, Obstetrics and Gynecology, Upland, CA, 11Presence St. Joseph Hospital, Obstetrics and Gynecology, Chicago, IL, 12Univ of South Florida, Obstetrics and Gynecology, Tampa, FL, 13UC-SD, Obstetrics and Gynecology, San Diego, CA
OBJECTIVE: Quality management and patient safety initiatives have increased in the field of Obstetrics. Little data is available concerning the current role the MFM specialist plays in these areas. The Risk Management Committee of the Society for Maternal-Fetal medicine sent an electronic survey to its members in 2013 questioning MFMs about their activities in this area. STUDY DESIGN: An e-mail survey was sent to the SMFM membership in 2013. Questions were designed to determine active involvement (defined as within the past 3 years) in different aspects of patient safety and quality management activities. RESULTS: 710/1971 (36%) members responded to the survey answering some or all of the questions. All ACOG districts were represented. The median age of respondents was 48 yrs. The highest involvement of respondents was in the area of drafting policies and protocols (74.7%) followed by involvement in quality management committees (59.3%). 46.4% of the respondents participated in simulation training. 27.4% are involved in giving expert witness testimony, with the majority of work being done for defendants, Few respondents note activity outside their institution in quality management activities ( state, professional, or insurance agencies). CONCLUSION: MFM specialists are actively involved in all areas of quality management and patient safety, with the highest level of involvement in drafting obstetrical protocols, followed by participation on quality management committees. Simulation training involvement is also high, although only 27% actually serve as patient safety/team training trainers. MFM fellowship programs should include quality management/patient safety topics in their curriculums to help prepare candidates for these important roles, along with the SMFM supporting continuing medical education in this area for physicians already in practice.
S222 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2014
www.AJOG.org
Epidemiology, Ob Quality, Operative Obstetrics, Public Health, Infectious Disease, Academic Issues
Poster Session III
441 Bacterial colonization of cervical cerclage is an independent risk factor for preterm PROM Ruth Beer Wiesel1, Offer Erez1, Renana Vilkof2, Batel Hamou1, Vered Klaitman-Mayer1, Tal Rafaeli1, Moshe Mazor1 1 Soroak University Medical Center, School of Medicine, Faculty of Health scienes Benn Gurion University of the Negev, Obstetrics and Gynecology, Beer Sheva, Israel, 2Soroka University Medical Center, School of Medicine, Faculty of Health scienes Benn Gurion University of the Negev, School of Medicine, Beer Sheva, Israel
440 Material and psychosocial determinants of preterm birth: assessing the effects of social inequality using birth cohort data from the U.K. John Snelgrove1, Kellie Murphy2 1 Faculty of Medicine, University of Toronto, Department of Obstetrics & Gynaecology, Toronto, ON, Canada, 2Mt. Sinai Hospital, Faculty of Medicine, University of Toronto, Division of Maternal-Fetal Medicine, Toronto, ON, Canada
OBJECTIVE: Preterm birth is a worldwide health problem. Risk of this perinatal complication follows a social gradient. The aim of this study was to examine the association between social inequalities and preterm birth using both psychosocial and material determinants. STUDY DESIGN: This study was a retrospective analysis of survey and linked hospital data from 16,886 women giving birth to singletons in the U.K. who were included in wave 1 (2000-2002) of the Millennium Cohort Study. Preterm birth was the main outcome and defined as delivery between 24 weeks and 36 weeks, 6 days gestation. Social inequalities were measured with material (household income, housing tenure, perceived neighbourhood deprivation) and psychosocial (education, occupational class, employment, social support) indicators. Analysis used nested multivariate logistic regression to assess odds of preterm birth, adjusting for demographics, baseline health and health-related behaviours, pregnancy and delivery conditions, and pregnancy complications. RESULTS: Employment (OR¼0.70, 95%CI: 0.50-0.90, p¼0.039) and one indicator of social support (OR¼0.84, 95%CI: 0.72-0.97, p¼0.021) were protective against the risk of preterm birth and persisted following full adjustment. Effects of household income, housing tenure, perceived neighbourhood deprivation, and education were largely attenuated with adjustment for other social determinants. CONCLUSION: In this study, employment and one indicator of social support were associated with decreased odds of preterm birth, supporting the hypothesis that poor psychosocial and material circumstances place women at higher risk of preterm birth. Further research is needed to examine the causal pathways through which social inequalities affect this adverse health outcome.
OBJECTIVE: Cerclage is emerging as one of the emerging treatment for the prevention of recurrent preterm birth. The aim of this study was to determine the association between bacterial colonization of cerclage and pregnancy outcome. STUDY DESIGN: This retrospective cohort study included pregnancies of women who had a cervical cerclage that was sent to microbacterial culture following its removal prior to delivery (n¼101). RESULTS: The rate of a positive culture of cervical cerclage was 51% (52/101). E. coli was the most prevalent microorganism isolated from the cerclage and placental cultures. Women with a positive cerclage culture had a higher mean maternal age (p¼0.02), and a median parity (p¼0.01), than those who had a negative culture. The rate of premature contractions (p¼0.001), preterm PROM (p¼0.01) were increased in women with a positive cerclage culture. These women also had a higher proportion of betamethasone treatment [positive culture 36.7% (18/49) vs. negative culture 17.3% (9/52), p¼0.03] that was administrated at earlier mean gestational age than those with a negative cerclage culture (27.5+2.6 vs. 30.7+2.4, p¼0.007, respectively). Among the indications for early removal of cerclage, women with a positive culture had a higher rate of preterm PROM than those who had a negative culture (p¼0.005). After adjustment for confounding factors, the gestational age in which the cerclage was placed (HR 1.8, 95% CI 1.3-2.6) and a positive culture (HR 15.4, 95% CI 1.02-232.3) were independent risk factors for preterm PROM. CONCLUSION: 1) Colonization of a cervical cerclage is associated with adverse pregnancy outcome, and it is an independent risk factor for preterm PROM. 2) Performing a cerclage at advanced gestational age may increase the risk for preterm PROM.
442 Severe maternal infectious morbidity during the second half of pregnancy is an independent risk factor for an SGA neonate Tal Kedar2, Offer Erez1, Moshe Mazor1, Yael Perl2, Lena Novack3, Ruth Beer Wiesel1, Limor Besser1, Salvatore Mastrolia4, Batel Hamou1 1
Soroka University Medical Center, School of Medicine, Faculty of Health scienes Benn Gurion University of the Negev, Obstetrics and Gynecology, Beer Sheva, Israel, 2School of Medicine, Faculty of Health scienes Benn Gurion University of the Negev, Epidemiology, Beer Sheva, Israel, 3Faculty of Health scienes Benn Gurion University of the Negev, School of Medicine, Beer Sheva, Israel, 4University of Bari, Obstetrics and Gynecology, Bari, Italy
OBJECTIVE: The effect of severe maternal infectious morbidity on fetal growth is under debate. Preliminary evidence suggests that such association may be plausible. The objectives of this study were to determine: 1) the association between severe maternal infectious morbidity (SMI) and adverse pregnancy outcome; and 2) The effect of SMI during pregnancy on fetal growth. STUDY DESIGN: This retrospective cohort study included 4771 women who gave birth at our medical center during the study period. The women were allocated into two groups: 1) patients with SMI during
Supplement to JANUARY 2014 American Journal of Obstetrics & Gynecology
S223