- Email: [email protected]
485: SMFM liability survey
Poster Session III
Epidemiology, Ob Quality, Operative Obstetrics, Public Health, Infectious Disease, Academic Issues
www.AJOG.org
significant weight differences are necessary to achieve clinically meaningful risk reduction.
Adjusted probability of adverse maternal and perinatal outcomes according to maternal pre-pregnancy weight (n¼243,464)
484 Informing preconception weight loss counseling for women above their ideal body weight Laura Schummers1, Jennifer Hutcheon2, Lisa Bodnar3, Katherine Himes4 1 Harvard School of Public Health, Epidemiology, Boston, MA, 2University of British Columbia, Obstetrics & Gyaecology, Vancouver, BC, Canada, 3 University of Pittsburgh, Epidemiology, Pittsburgh, PA, 4University of Pittsburgh, Obstetrics, Gyecology, & Reproductive Sciences; Division of Maternal-Fetal Medicine, Pittsburgh, PA
OBJECTIVE: It is well-established that women who are overweight or obese before pregnancy are at increased risk of adverse pregnancy outcomes compared with normal-weight women. However, little is known regarding whether smaller, more achievable weight losses among heavy women result in meaningful reductions in risk. This study estimates the probability of adverse maternal and perinatal outcomes based on incremental (10 lb.) differences in prepregnancy weight to assist clinicians in preconception weight loss counseling. STUDY DESIGN: The study population for this population-based cohort study (n¼243,464) was drawn from singleton births in British Columbia over 10 years. The relationships between prepregnancy weight and pre-eclampsia, gestational diabetes, cesarean section, spontaneous preterm labour <32 weeks, postpartum hemorrhage requiring intervention, macrosomia, and neonatal intensive care unit (NICU) admission 48 hours were examined using logistic regression. Analyses were adjusted for maternal age, height, parity, pre-existing hypertension, pre-existing diabetes, smoking, and calendar year. We report adjusted probabilities of each outcome associated with prepregnancy weight in 10 lb. increments. RESULTS: Table 1 quantifies the probability of adverse pregnancy outcomes according to prepregnancy weight. For example, for a woman of average height weighing 200 lbs. (BMI¼33.6), a 10 lb. decrease in weight was associated with a reduction in risk of gestational diabetes (11.29% to 10.21%) and cesarean section (42.54% to 40.78). Larger weight decreases (20-50 lbs.) were necessary to reduce the risk of macrosomia, pre-eclampsia, and NICU admission. Differences in weight were not associated with a reduced risk of spontaneous preterm delivery <32 weeks or postpartum hemorrhage requiring intervention. CONCLUSION: While modest prepregnancy weight differences result in statistically significant reductions in some adverse outcomes, more
Models were adjusted for: height squared, maternal age at delivery, parity, pre-existing hypertension, pre-existing diabetes, and maternal smoking in pregnancy. Probabilities are reported at the average population age (30.4) and height (5’5”, or 1.64 meters), among nulliparous non-smokers without pre-existing diabetes or hypertension. Gestational diabetes analyses were restricted to those without pre-existing diabetes; cesarean section analyses were restricted to nulliparous women. *Severe postpartum hemorrhage is defined as postpartum hemorrhage requiring blood transfusion or hysterectomy.
485 SMFM liability survey Erol Amon1, Alan Bombard1, George Bronsky1, Arnold Cohen1, Gary Eglinton1, Washington Hill1, David Mclean1, A. George Neubert1, J. Parer1, Jeffrey Phelan1, Robert Stiller1, Howard Strassner1, Jerome Yankowitz1 1
SMFM Risk Management Committee, Washington, DC
OBJECTIVE: The purpose was to describe our experience with pro-
fessional liability insurance (PLI) & claims. STUDY DESIGN: An e-mail survey of SMFM members was conducted in 2013. RESULTS: The overall response rate was 393/1971 (20%). All ACOG districts were represented. 79.3% of respondents were Regular members, 11.2% were Associate Fellow members, & 9.5% were others. 84% are salaried employees. 75% perform full MFM / obstetric responsibilities. The median age of respondents was 50y, range is 28-78 & IQR is 40-58. 98% are covered by PLI & 84% had PLI polices paid by an institution. 33% did not know their type of policy (occurrence, claims made). 27% did not know their policy limits per claim and 1/ 3 did not know their aggregate limits. 64% did not know their individual premium / allocation under a group. 67% had experienced a liability claim. At first claim, median age was 35y, range of 25-59 and IQR of 30-40. 29% had 5 claims, 54% had 3 and 71% had 2 claims; 29% had experienced only 1 claim. Most closed claims were dropped without payment (567/858; 66%); 24% settled with payment. 9.7% went to trial with 78% as defense verdicts. As a result of liability claims, 21% made significant changes to their practice patterns (e.g. stopping or decreased deliveries, stopped offering VBAC, moved away, became an employee). Moreover, 45% of respondents made significant defensive medicine changes in their practice (e.g. increased c/sections, fetal testing and ultrasounds, while decreasing or stopping TOLAC, & increased documentation, lab testing, and referrals).
S242 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2014
www.AJOG.org
Epidemiology, Ob Quality, Operative Obstetrics, Public Health, Infectious Disease, Academic Issues
CONCLUSION: 1. 84% of respondents are salaried employees and have their PLI paid for by an institution. 2. Significant percentages are unsure or have no knowledge of their type of PLI policy or policy limits. 3. Two thirds experienced at least one liability claim. 4. Two thirds of claims were dropped without payment, about 1/4 were settled with payment and < 10% went to trial with majority of Defense verdicts. 5. Experience with liability claims prompted significant changes in practice patterns and the practice of defensive medicine.
486 Comparison of the QuantiFERON-TB Gold assay and tuberculin skin test in prenatal screening for tuberculosis in pregnant women, with prior BCG vaccination Kara Rood1, Laifer Steven1 1
Bridgeport Hospital Yale New Haven Health, Maternal Fetal Medicine, Bridgeport, CT
OBJECTIVE: The traditional screening technique for tuberculosis is
the tuberculin skin test (TST), but this test has several limitations, such as false positives in BCG vaccinated individuals. In 2001, Interferon-gamma release assays (IGRAs), a new test became available to aid in the diagnosis of tuberculosis. Our objective was to compare QuantiFERON-TB Gold assay (QTF-G) an InterferonGamma Release Assays (IGRA), with tuberculin skin test (TST) for the detection of tuberculosis infection in pregnant women with history of prior Bacillus Calmette-Guérin (BCG) vaccination. STUDY DESIGN: This was a prospective study of pregnant women receiving prenatal care at Bridgeport Hospital Outpatient Clinics in Bridgeport CT. Fifty five patients with history of BCG vaccination were identified through completion of a survey and asked to participate in the study. IGRA (QTF-G), followed by a TST were performed at their first prenatal appointment. QTF-G results were recorded as positive, negative or indeterminate. A positive TST was defined as & 10mm. Chest radiograph (CXR) was performed on all TST and/or QTF-G positive participants. RESULTS: Fifty five patients reported history of BCG vaccination, 13 out of 53 (24.5%) BCG vaccinated patients had positive TST. Two out of 53 (4%) patients had a positive QTF-G test and also had positive TSTs. Two patients had an indeterminate QTF-G result and positive TSTs. These results were excluded for purpose of this study. CXR’s on the two positive QTF-G and TST participants had abnormal findings suggested evidence prior tuberculosis infection. CONCLUSION: In screening high risk pregnancies for tuberculosis, the QTF-G assay appears to be a more accurate test for the detection of tuberculosis in prior BCG vaccinated patients. Decreasing the number of false positives would help eliminate the amount of prenatal radiation exposure, by a CXR and unnecessary medical treatment.
487 Prenatal screening for aneuploidy: do women know what’s been done? Damien Croft1, Allison Bryant1, Sanae Nakagawa2, Mary Norton2, Miriam Kuppermann2 1
Massachusetts General Hospital, Division of Maternal Fetal Medicine, Vincent Obstetrics and Gynecology, Boston, MA, 2University of California, San Francisco, Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, San Francisco, CA
OBJECTIVE: Aneuploidy screening guidelines emphasize the impor-
tance of informed patient decision making. One very basic measure of informed decision making regarding prenatal testing is awareness of having undergone screening. We sought to assess the extent to which women understand whether or not they have had screening,
Poster Session III
and to identify characteristics of women who lack this understanding. STUDY DESIGN: This was a secondary analysis of data from the control population of an RCT of a computerized prenatal testing decision support guide for women of varying literacy levels. Our primary outcome was “screening discordance”, defined as a woman’s selfreport at 24-30 weeks gestation of first trimester screening that was inconsistent with medical chart documentation. We assessed maternal demographics, literacy (measured using the STOFHLA score) and insurance status as risk factors for discordance using multivariable logistic regression. RESULTS: Of 366 women, 81 (22%) were “screen discordant” (either incorrect or unsure of whether they had had first trimester screening). Having public insurance increased this risk (AOR 4.5 [95% CI 2.22- 9.22]). For every 5-point increase in STOFHLA literacy score the risk of discordance decreased (AOR 0.74 [95% CI 0.56- 0.96]). Spanish-speaking Latinas were more likely than white women to deny having had first trimester screening despite having screening documented (AOR 4.6 [95% CI 1.34- 16.36]). Higher STOFHLA scores also were protective against discordance in the opposite direction, i.e., reporting first trimester testing when none occurred (AOR 0.69 [95% CI 0.51- 0.95]). CONCLUSION: A large percentage of publicly insured women are less likely to have an adequate understanding of whether or not they have had first trimester screening for aneuploidy. This may be related to communication barriers such as inadequate time for thorough counseling. Better health literacy is protective against such misunderstandings. Certain ethnic minorities may be at increased risk: providers may need to account for this when counseling.
**Final model adjusted for insurance status and literacy score.
488 Trends in termination of pregnancy in women with positive CMV IgM in the 1st trimester Ron Beloosesky1, Jenny Kertes1, Alon Shrim2, Rachel Bachar1, Jacob Segal1, Ilana Feldblum1, Yuval Yefet1 1 Maccabi HMO, Medical services, Ob/Gyn, Tel Aviv, Israel, 2Hillel Yaffe Medical Center, Ob/Gyn, Hadera, Israel
OBJECTIVE: To evaluate trends in termination of pregnancies in pa-
tient with suspected CMV exposure during the 1st trimester. STUDY DESIGN: Retrospective computerized cohort study. All blood
tests for CMV IgM done between January 2008 and December 2009 on pregnant women in Israel second biggest HMO were retrieved. For all women with IgM positive result, IgG Avidity was measured and women were classified according to the risk of acquiring CMV during pregnancy; High risk (avidity 0-35), moderate risk (Avidity 36-44) and low risk (Avidity 45). Results of Amniocentesis (if done) were mined and documented. Termination of pregnancy was determined by a report on termination of pregnancy and/or by the absence of Glucose Challenge Test (GCT) or OGTT in the relevant pregnancy. RESULTS: During the study period 109,439 women were pregnant, of which 76,712 (70.1%) were tested for CMV IgM. Positive IgM results were documented in 792 women (1.03% of women who were tested - table 1). Among women with Positive IgM, only 206 (26%) underwent amniocentesis. The rate of Termination of Pregnancy was doubled in women with positive CMV IgM (28.3%) Vs. women with negative CMV IgM (14.3%) p<0.05. It was mostly elevated in
Supplement to JANUARY 2014 American Journal of Obstetrics & Gynecology
S243
Epidemiology, Ob Quality, Operative Obstetrics, Public Health, Infectious Disease, Academic Issues
www.AJOG.org
significant weight differences are necessary to achieve clinically meaningful risk reduction.
Adjusted probability of adverse maternal and perinatal outcomes according to maternal pre-pregnancy weight (n¼243,464)
484 Informing preconception weight loss counseling for women above their ideal body weight Laura Schummers1, Jennifer Hutcheon2, Lisa Bodnar3, Katherine Himes4 1 Harvard School of Public Health, Epidemiology, Boston, MA, 2University of British Columbia, Obstetrics & Gyaecology, Vancouver, BC, Canada, 3 University of Pittsburgh, Epidemiology, Pittsburgh, PA, 4University of Pittsburgh, Obstetrics, Gyecology, & Reproductive Sciences; Division of Maternal-Fetal Medicine, Pittsburgh, PA
OBJECTIVE: It is well-established that women who are overweight or obese before pregnancy are at increased risk of adverse pregnancy outcomes compared with normal-weight women. However, little is known regarding whether smaller, more achievable weight losses among heavy women result in meaningful reductions in risk. This study estimates the probability of adverse maternal and perinatal outcomes based on incremental (10 lb.) differences in prepregnancy weight to assist clinicians in preconception weight loss counseling. STUDY DESIGN: The study population for this population-based cohort study (n¼243,464) was drawn from singleton births in British Columbia over 10 years. The relationships between prepregnancy weight and pre-eclampsia, gestational diabetes, cesarean section, spontaneous preterm labour <32 weeks, postpartum hemorrhage requiring intervention, macrosomia, and neonatal intensive care unit (NICU) admission 48 hours were examined using logistic regression. Analyses were adjusted for maternal age, height, parity, pre-existing hypertension, pre-existing diabetes, smoking, and calendar year. We report adjusted probabilities of each outcome associated with prepregnancy weight in 10 lb. increments. RESULTS: Table 1 quantifies the probability of adverse pregnancy outcomes according to prepregnancy weight. For example, for a woman of average height weighing 200 lbs. (BMI¼33.6), a 10 lb. decrease in weight was associated with a reduction in risk of gestational diabetes (11.29% to 10.21%) and cesarean section (42.54% to 40.78). Larger weight decreases (20-50 lbs.) were necessary to reduce the risk of macrosomia, pre-eclampsia, and NICU admission. Differences in weight were not associated with a reduced risk of spontaneous preterm delivery <32 weeks or postpartum hemorrhage requiring intervention. CONCLUSION: While modest prepregnancy weight differences result in statistically significant reductions in some adverse outcomes, more
Models were adjusted for: height squared, maternal age at delivery, parity, pre-existing hypertension, pre-existing diabetes, and maternal smoking in pregnancy. Probabilities are reported at the average population age (30.4) and height (5’5”, or 1.64 meters), among nulliparous non-smokers without pre-existing diabetes or hypertension. Gestational diabetes analyses were restricted to those without pre-existing diabetes; cesarean section analyses were restricted to nulliparous women. *Severe postpartum hemorrhage is defined as postpartum hemorrhage requiring blood transfusion or hysterectomy.
485 SMFM liability survey Erol Amon1, Alan Bombard1, George Bronsky1, Arnold Cohen1, Gary Eglinton1, Washington Hill1, David Mclean1, A. George Neubert1, J. Parer1, Jeffrey Phelan1, Robert Stiller1, Howard Strassner1, Jerome Yankowitz1 1
SMFM Risk Management Committee, Washington, DC
OBJECTIVE: The purpose was to describe our experience with pro-
fessional liability insurance (PLI) & claims. STUDY DESIGN: An e-mail survey of SMFM members was conducted in 2013. RESULTS: The overall response rate was 393/1971 (20%). All ACOG districts were represented. 79.3% of respondents were Regular members, 11.2% were Associate Fellow members, & 9.5% were others. 84% are salaried employees. 75% perform full MFM / obstetric responsibilities. The median age of respondents was 50y, range is 28-78 & IQR is 40-58. 98% are covered by PLI & 84% had PLI polices paid by an institution. 33% did not know their type of policy (occurrence, claims made). 27% did not know their policy limits per claim and 1/ 3 did not know their aggregate limits. 64% did not know their individual premium / allocation under a group. 67% had experienced a liability claim. At first claim, median age was 35y, range of 25-59 and IQR of 30-40. 29% had 5 claims, 54% had 3 and 71% had 2 claims; 29% had experienced only 1 claim. Most closed claims were dropped without payment (567/858; 66%); 24% settled with payment. 9.7% went to trial with 78% as defense verdicts. As a result of liability claims, 21% made significant changes to their practice patterns (e.g. stopping or decreased deliveries, stopped offering VBAC, moved away, became an employee). Moreover, 45% of respondents made significant defensive medicine changes in their practice (e.g. increased c/sections, fetal testing and ultrasounds, while decreasing or stopping TOLAC, & increased documentation, lab testing, and referrals).
S242 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2014
www.AJOG.org
Epidemiology, Ob Quality, Operative Obstetrics, Public Health, Infectious Disease, Academic Issues
CONCLUSION: 1. 84% of respondents are salaried employees and have their PLI paid for by an institution. 2. Significant percentages are unsure or have no knowledge of their type of PLI policy or policy limits. 3. Two thirds experienced at least one liability claim. 4. Two thirds of claims were dropped without payment, about 1/4 were settled with payment and < 10% went to trial with majority of Defense verdicts. 5. Experience with liability claims prompted significant changes in practice patterns and the practice of defensive medicine.
486 Comparison of the QuantiFERON-TB Gold assay and tuberculin skin test in prenatal screening for tuberculosis in pregnant women, with prior BCG vaccination Kara Rood1, Laifer Steven1 1
Bridgeport Hospital Yale New Haven Health, Maternal Fetal Medicine, Bridgeport, CT
OBJECTIVE: The traditional screening technique for tuberculosis is
the tuberculin skin test (TST), but this test has several limitations, such as false positives in BCG vaccinated individuals. In 2001, Interferon-gamma release assays (IGRAs), a new test became available to aid in the diagnosis of tuberculosis. Our objective was to compare QuantiFERON-TB Gold assay (QTF-G) an InterferonGamma Release Assays (IGRA), with tuberculin skin test (TST) for the detection of tuberculosis infection in pregnant women with history of prior Bacillus Calmette-Guérin (BCG) vaccination. STUDY DESIGN: This was a prospective study of pregnant women receiving prenatal care at Bridgeport Hospital Outpatient Clinics in Bridgeport CT. Fifty five patients with history of BCG vaccination were identified through completion of a survey and asked to participate in the study. IGRA (QTF-G), followed by a TST were performed at their first prenatal appointment. QTF-G results were recorded as positive, negative or indeterminate. A positive TST was defined as & 10mm. Chest radiograph (CXR) was performed on all TST and/or QTF-G positive participants. RESULTS: Fifty five patients reported history of BCG vaccination, 13 out of 53 (24.5%) BCG vaccinated patients had positive TST. Two out of 53 (4%) patients had a positive QTF-G test and also had positive TSTs. Two patients had an indeterminate QTF-G result and positive TSTs. These results were excluded for purpose of this study. CXR’s on the two positive QTF-G and TST participants had abnormal findings suggested evidence prior tuberculosis infection. CONCLUSION: In screening high risk pregnancies for tuberculosis, the QTF-G assay appears to be a more accurate test for the detection of tuberculosis in prior BCG vaccinated patients. Decreasing the number of false positives would help eliminate the amount of prenatal radiation exposure, by a CXR and unnecessary medical treatment.
487 Prenatal screening for aneuploidy: do women know what’s been done? Damien Croft1, Allison Bryant1, Sanae Nakagawa2, Mary Norton2, Miriam Kuppermann2 1
Massachusetts General Hospital, Division of Maternal Fetal Medicine, Vincent Obstetrics and Gynecology, Boston, MA, 2University of California, San Francisco, Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, San Francisco, CA
OBJECTIVE: Aneuploidy screening guidelines emphasize the impor-
tance of informed patient decision making. One very basic measure of informed decision making regarding prenatal testing is awareness of having undergone screening. We sought to assess the extent to which women understand whether or not they have had screening,
Poster Session III
and to identify characteristics of women who lack this understanding. STUDY DESIGN: This was a secondary analysis of data from the control population of an RCT of a computerized prenatal testing decision support guide for women of varying literacy levels. Our primary outcome was “screening discordance”, defined as a woman’s selfreport at 24-30 weeks gestation of first trimester screening that was inconsistent with medical chart documentation. We assessed maternal demographics, literacy (measured using the STOFHLA score) and insurance status as risk factors for discordance using multivariable logistic regression. RESULTS: Of 366 women, 81 (22%) were “screen discordant” (either incorrect or unsure of whether they had had first trimester screening). Having public insurance increased this risk (AOR 4.5 [95% CI 2.22- 9.22]). For every 5-point increase in STOFHLA literacy score the risk of discordance decreased (AOR 0.74 [95% CI 0.56- 0.96]). Spanish-speaking Latinas were more likely than white women to deny having had first trimester screening despite having screening documented (AOR 4.6 [95% CI 1.34- 16.36]). Higher STOFHLA scores also were protective against discordance in the opposite direction, i.e., reporting first trimester testing when none occurred (AOR 0.69 [95% CI 0.51- 0.95]). CONCLUSION: A large percentage of publicly insured women are less likely to have an adequate understanding of whether or not they have had first trimester screening for aneuploidy. This may be related to communication barriers such as inadequate time for thorough counseling. Better health literacy is protective against such misunderstandings. Certain ethnic minorities may be at increased risk: providers may need to account for this when counseling.
**Final model adjusted for insurance status and literacy score.
488 Trends in termination of pregnancy in women with positive CMV IgM in the 1st trimester Ron Beloosesky1, Jenny Kertes1, Alon Shrim2, Rachel Bachar1, Jacob Segal1, Ilana Feldblum1, Yuval Yefet1 1 Maccabi HMO, Medical services, Ob/Gyn, Tel Aviv, Israel, 2Hillel Yaffe Medical Center, Ob/Gyn, Hadera, Israel
OBJECTIVE: To evaluate trends in termination of pregnancies in pa-
tient with suspected CMV exposure during the 1st trimester. STUDY DESIGN: Retrospective computerized cohort study. All blood
tests for CMV IgM done between January 2008 and December 2009 on pregnant women in Israel second biggest HMO were retrieved. For all women with IgM positive result, IgG Avidity was measured and women were classified according to the risk of acquiring CMV during pregnancy; High risk (avidity 0-35), moderate risk (Avidity 36-44) and low risk (Avidity 45). Results of Amniocentesis (if done) were mined and documented. Termination of pregnancy was determined by a report on termination of pregnancy and/or by the absence of Glucose Challenge Test (GCT) or OGTT in the relevant pregnancy. RESULTS: During the study period 109,439 women were pregnant, of which 76,712 (70.1%) were tested for CMV IgM. Positive IgM results were documented in 792 women (1.03% of women who were tested - table 1). Among women with Positive IgM, only 206 (26%) underwent amniocentesis. The rate of Termination of Pregnancy was doubled in women with positive CMV IgM (28.3%) Vs. women with negative CMV IgM (14.3%) p<0.05. It was mostly elevated in
Supplement to JANUARY 2014 American Journal of Obstetrics & Gynecology
S243