- Email: [email protected]
720: Macrosomia - self-fulfilling prophecy
Poster Session IV
ajog.org
delivery). Bivariate tests and multivariate logistic regression identified significant predictors of postpartum ED use. RESULTS: Data for 1,071,232 deliveries were linked; 88,674 women (8.3%) used the ED at least once in the 90 days following delivery discharge. Positive predictors of postpartum ED use in a multivariate regression included (Table 1): Medicaid (OR¼2.16, 95% CI 2.122.20), age <20 years (OR¼1.90, 95% CI 1.84-1.95), SMM at delivery (OR¼1.49, 95% CI 1.43-1.56), antepartum complications (OR¼1.39, 95% CI 1.37-1.41), and cesarean birth (OR¼1.37, 95% CI 1.34-1.39) - p<0.001 for all. Black women, low-income women, and managed care patients were also more likely to visit the ED. Least-square mean probabilities of ED use are reported (Figure 1). A total of 20.3% of ED visits were made >4 days of discharge, and over 50% were within three weeks. The most common ED diagnosis varied by mode of delivery: urinary tract infection for vaginal deliveries, and wound complications for cesareans. CONCLUSION: One in 12 California women had a postpartum ED visit. Results suggest that certain subpopulations could benefit from enhanced outpatient follow up after delivery, and perhaps from scheduled visits earlier than 6 weeks post-discharge.
high utilizers of maternal ED care during the first 90 days after discharge following birth. STUDY DESIGN: This retrospective cross-sectional study analyzed linked inpatient maternal discharge and ED data for all California births from 2009-2011; all women with at least one postpartum ED visit within 90 days of discharge were included. The primary outcome of interest was “high utilization” of maternal postpartum ED care (>3 encounters within the 90 days). Independent variables included demographics (age, race/ethnicity, payer, income) and clinical features (antepartum complications, mode of delivery, severe maternal morbidity - SMM - at delivery). Bivariate tests and multivariate logistic regression described high utilizers. RESULTS: From 2009-2011, 88,674 women used the ED at least once in the 90 days following delivery discharge; 5,171 (5.8%) were designated high utilizers. Positive predictors of high utilization in a multivariate regression model included (Table 1): non-private payer (Medicaid OR¼2.56, 95% CI 2.36-2.78, “self-pay” status OR¼2.95, 95% CI 2.333.74), age <20 years (OR¼1.65, 95% CI 1.45-1.88), low income (<25th percentile OR¼1.30, 95% CI 1.18-1.44), SMM at delivery (OR¼1.37, 95% CI 1.17-1.59), and antepartum complications (OR¼1.42, 95% CI 1.34-1.51). Hispanic and Asian women were significantly less likely to be high ED utilizers than White women. The three most frequent specific diagnoses addressed at the first postpartum ED visits of high utilizers were: obstetrical wound complications (4.7%), cholelithiasis (4.5%), and urinary tract infections (3.6%). CONCLUSION: Subgroups of postpartum women are at increased risk for high ED utilization. Strategies for scheduled outpatient follow up and improved care coordination for complicated deliveries could decrease ED use and health care costs, and improve clinical care and patient satisfaction.
Table 1: Multivariate Logistic Regression - ED Utilization Within 90 Days of Discharge (N=1,071,232) Predictor
Adjusted Odds Ratio (95% CI)
p-value
Age <20 years (reference >35)
1.90 (1.84-1.95)
<0.001
Age 20-34 years (reference >35)
1.36 (1.33-1.39)
<0.001
Black (reference White)
1.30 (1.27-1.33)
<0.001
Hispanic (reference White)
0.90 (0.88-0.92)
<0.001
Asian/Pacific Islander (reference White)
0.56 (0.55-0.58)
<0.001
Adjusted length of stay (one day increase)
1.01 (1.01-1.01)
<0.001
Medicaid (reference private insurance)
2.16 (2.12-2.20)
<0.001
Self-pay (reference private insurance)
1.68 (1.57-1.80)
<0.001
Managed care (reference fee-for-service)
1.16 (1.14-1.18)
<0.001
Cesarean delivery
1.37 (1.34-1.39)
<0.001
Severe maternal morbidity at delivery
1.49 (1.43-1.56)
<0.001
Antepartum complication
1.39 (1.37-1.41)
<0.001
Income <25th percentile (reference >75th)
1.13 (1.11-1.16)
<0.001
720 Macrosomia - self-fulfilling prophecy Lorinne Levitt1, Michal Lipschuetz1, Sara M. Cohen1, Doron Kabiri1, Lior Drukker2, Simcha Yagel1, Hagai Amsalem1 1 Hadassah Hebrew University medical center, Jerusalem, Israel, 2Shaare Zedek Medical Center, Jerusalem, Israel
OBJECTIVE: Fetal macrosomia, birth weight over 4 kg, is a risk factor for
719 California births, 2009-2011: describing high utilizers of postpartum emergency department care 1
2
3
Priya Batra , Moshe Fridman , Mei Leng , Kimberly D. Gregory
4
1
University of California, Riverside, Riverside, CA, 2AMF Consulting, Los Angeles, CA, 3University of California, Los Angeles, Los Angeles, CA, 4 Cedars-Sinai Medical Center, Los Angeles, CA
OBJECTIVE: Childbirth is the most common cause for U.S. hospi-
talizations; patterns of emergency department (ED) use after delivery have not been described previously. This study aimed to describe
adverse obstetrical and fetal outcomes, including urgent caesarean delivery (CD), instrumental delivery, Obstetrical Anal Sphincter Injuries (OASIS) and shoulder dystocia. We investigated whether estimated fetal weight (EFW) rather than actual birth weight (ABW) is more significantly associated with adverse outcomes. STUDY DESIGN: A retrospective chart review was conducted at a tertiary care center. Medical records of all term, singleton, live births (37-42 weeks gestation) from 2004-2014 were included. Small for
S420 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2017
Poster Session IV
ajog.org gestational age (<2500 gr) fetuses and incomplete records were excluded. EFW (clinical/sonographic) obtained at delivery room admission and ABW were collected. We divided the cohort into four groups stratified by EFW and ABW comparing obstetrical outcomes (Table 1). Multinomial logistic regression was used to eliminate confounding factors. RESULTS: Of 112,817 singleton deliveries, 53,953 met the inclusion criteria. EFW above 4 kg significantly increased the risk for an urgent or elective CD (OR 1.8 and 5.4, respectively). There was a trend towards a lower incidence of instrumental delivery when EFW was above 4 kg (OR 0.8, p¼0.053). ABW did not influence mode of delivery. Stratification according to ABW into smaller subgroups, using 250 gram blocks, did not influence results. In deliveries with an ABW above 4 kg, OASIS rate was significantly higher (OR 2.5) when the EFW was below 4 kg. Other obstetrical/neonatal outcomes, including episiotomy, shoulder dystocia, prolonged second stage, 5 minute Apgar, and NICU admission were not significantly different between groups. CONCLUSION: Mode of delivery was strongly influenced by EFW and not by ABW. Antepartum estimation of fetal macrosomia, regardless of ABW, was associated with a significantly higher risk for an urgent or elective CD, a lower maternal risk for OASIS, and a trend towards a lower risk of instrumental delivery.
in patients who did not require intervention was shorter (53.2 minutes) compared to those who did (188 minutes). The estimated blood loss was significantly lower in those who did not require intervention (295.2 mL vs. 464.5 mL, p<0.001). No significant differences were noted in the length of the third stage between ethnicities nor the different primary diagnoses of PPROM, PTL, cervical insufficiency, or IUFD. Using a Kaplan-Meier survival curve, we demonstrated that 90% of the patients who delivered the placenta without intervention did so by 180 minutes and 95% by 240 minutes. CONCLUSION: In midtrimester deliveries, if the placenta has not delivered by 240 minutes, then the provider should consider intervention by either manual extraction or dilation and curettage.
722 Optimal timing of delivery for women with breast cancer according to hormone receptor subtype
721 Management of the third stage of labor in midtrimester deliveries: a 9 year review
Kelly Kuo, Catherine S. John, Aaron B. Caughey
Erica A. Heilman, Melanie Chichester, Matthew K. Hoffman
Oregon Health & Science University, Portland, OR
Christiana Care Hospital, Newark, DE
OBJECTIVE: To compare strategies for the timing of delivery in
OBJECTIVE: To evaluate the length of the third stage of labor in
women with breast cancer and known hormone receptor subtype, and to determine the optimal gestational age for induction in regards to maternal-fetal outcomes. STUDY DESIGN: A decision-analytic model was designed comparing eight different strategies for scheduled delivery at 30, 31, 32, 33, 34, 35, 36, and 37 weeks gestation. Optimal breast cancer treatment was assumed to be delayed until after delivery. Baseline estimates of subtype-specific mortality and the impact of delayed cancer treatment on 5-year survival rates were obtained from the literature. Outcomes factored into the model included the risk of intrauterine fetal demise, spontaneous delivery, respiratory distress syndrome, cerebral palsy, and neonatal demise at each gestational age. Univariate and multivariate sensitivity analyses were performed to test the robustness of our model. RESULTS: For women with estrogen or progesterone receptor-positive, human epidermal receptor-2 negative (HR+/HER2-) breast cancer, scheduled delivery at 36 weeks yielded the highest qualityadjusted life years (QALYs). For women with HER2+ breast cancer, overall QALYs were maximized with scheduled delivery at 36 weeks, although maternal QALYs were maximized with scheduled delivery at 34 weeks. For women with the highest risk subtype of triplenegative (HR-/HER2-) breast cancer, both overall and maternal
midtrimester deliveries in order to determine after what period of time a placenta should be deemed retained and additional intervention pursued. STUDY DESIGN: A retrospective study of midtrimester vaginal deliveries between 14 weeks 0 days to 23 weeks 6 days from January 2005 until December 2013 at a single tertiary care center. Patients who were undergoing induction of labor for fetal anomalies were excluded. Multiple data points were collected on each patient including maternal age, gravidity, parity, gestational age, use of uterotonics, estimated blood loss, length of stay following delivery, method of placental delivery, and postpartum fever. The length of the third stage of labor was calculated and recorded in minutes. Patients were labeled as needing intervention for the third stage if they required manual evacuation or dilation and curettage for removal of the placenta. Patients who required only uterotonics or no uterotonics for delivery of the placenta were labeled as requiring no intervention for the purposes of this study. RESULTS: Of the charts evaluated, 585 patients met inclusion criteria. Women who required intervention for the management of the third stage were at an earlier gestational age (18.4 weeks) than those who did not (19.6 weeks). The mean length of the third stage
Supplement to JANUARY 2017 American Journal of Obstetrics & Gynecology
S421
ajog.org
delivery). Bivariate tests and multivariate logistic regression identified significant predictors of postpartum ED use. RESULTS: Data for 1,071,232 deliveries were linked; 88,674 women (8.3%) used the ED at least once in the 90 days following delivery discharge. Positive predictors of postpartum ED use in a multivariate regression included (Table 1): Medicaid (OR¼2.16, 95% CI 2.122.20), age <20 years (OR¼1.90, 95% CI 1.84-1.95), SMM at delivery (OR¼1.49, 95% CI 1.43-1.56), antepartum complications (OR¼1.39, 95% CI 1.37-1.41), and cesarean birth (OR¼1.37, 95% CI 1.34-1.39) - p<0.001 for all. Black women, low-income women, and managed care patients were also more likely to visit the ED. Least-square mean probabilities of ED use are reported (Figure 1). A total of 20.3% of ED visits were made >4 days of discharge, and over 50% were within three weeks. The most common ED diagnosis varied by mode of delivery: urinary tract infection for vaginal deliveries, and wound complications for cesareans. CONCLUSION: One in 12 California women had a postpartum ED visit. Results suggest that certain subpopulations could benefit from enhanced outpatient follow up after delivery, and perhaps from scheduled visits earlier than 6 weeks post-discharge.
high utilizers of maternal ED care during the first 90 days after discharge following birth. STUDY DESIGN: This retrospective cross-sectional study analyzed linked inpatient maternal discharge and ED data for all California births from 2009-2011; all women with at least one postpartum ED visit within 90 days of discharge were included. The primary outcome of interest was “high utilization” of maternal postpartum ED care (>3 encounters within the 90 days). Independent variables included demographics (age, race/ethnicity, payer, income) and clinical features (antepartum complications, mode of delivery, severe maternal morbidity - SMM - at delivery). Bivariate tests and multivariate logistic regression described high utilizers. RESULTS: From 2009-2011, 88,674 women used the ED at least once in the 90 days following delivery discharge; 5,171 (5.8%) were designated high utilizers. Positive predictors of high utilization in a multivariate regression model included (Table 1): non-private payer (Medicaid OR¼2.56, 95% CI 2.36-2.78, “self-pay” status OR¼2.95, 95% CI 2.333.74), age <20 years (OR¼1.65, 95% CI 1.45-1.88), low income (<25th percentile OR¼1.30, 95% CI 1.18-1.44), SMM at delivery (OR¼1.37, 95% CI 1.17-1.59), and antepartum complications (OR¼1.42, 95% CI 1.34-1.51). Hispanic and Asian women were significantly less likely to be high ED utilizers than White women. The three most frequent specific diagnoses addressed at the first postpartum ED visits of high utilizers were: obstetrical wound complications (4.7%), cholelithiasis (4.5%), and urinary tract infections (3.6%). CONCLUSION: Subgroups of postpartum women are at increased risk for high ED utilization. Strategies for scheduled outpatient follow up and improved care coordination for complicated deliveries could decrease ED use and health care costs, and improve clinical care and patient satisfaction.
Table 1: Multivariate Logistic Regression - ED Utilization Within 90 Days of Discharge (N=1,071,232) Predictor
Adjusted Odds Ratio (95% CI)
p-value
Age <20 years (reference >35)
1.90 (1.84-1.95)
<0.001
Age 20-34 years (reference >35)
1.36 (1.33-1.39)
<0.001
Black (reference White)
1.30 (1.27-1.33)
<0.001
Hispanic (reference White)
0.90 (0.88-0.92)
<0.001
Asian/Pacific Islander (reference White)
0.56 (0.55-0.58)
<0.001
Adjusted length of stay (one day increase)
1.01 (1.01-1.01)
<0.001
Medicaid (reference private insurance)
2.16 (2.12-2.20)
<0.001
Self-pay (reference private insurance)
1.68 (1.57-1.80)
<0.001
Managed care (reference fee-for-service)
1.16 (1.14-1.18)
<0.001
Cesarean delivery
1.37 (1.34-1.39)
<0.001
Severe maternal morbidity at delivery
1.49 (1.43-1.56)
<0.001
Antepartum complication
1.39 (1.37-1.41)
<0.001
Income <25th percentile (reference >75th)
1.13 (1.11-1.16)
<0.001
720 Macrosomia - self-fulfilling prophecy Lorinne Levitt1, Michal Lipschuetz1, Sara M. Cohen1, Doron Kabiri1, Lior Drukker2, Simcha Yagel1, Hagai Amsalem1 1 Hadassah Hebrew University medical center, Jerusalem, Israel, 2Shaare Zedek Medical Center, Jerusalem, Israel
OBJECTIVE: Fetal macrosomia, birth weight over 4 kg, is a risk factor for
719 California births, 2009-2011: describing high utilizers of postpartum emergency department care 1
2
3
Priya Batra , Moshe Fridman , Mei Leng , Kimberly D. Gregory
4
1
University of California, Riverside, Riverside, CA, 2AMF Consulting, Los Angeles, CA, 3University of California, Los Angeles, Los Angeles, CA, 4 Cedars-Sinai Medical Center, Los Angeles, CA
OBJECTIVE: Childbirth is the most common cause for U.S. hospi-
talizations; patterns of emergency department (ED) use after delivery have not been described previously. This study aimed to describe
adverse obstetrical and fetal outcomes, including urgent caesarean delivery (CD), instrumental delivery, Obstetrical Anal Sphincter Injuries (OASIS) and shoulder dystocia. We investigated whether estimated fetal weight (EFW) rather than actual birth weight (ABW) is more significantly associated with adverse outcomes. STUDY DESIGN: A retrospective chart review was conducted at a tertiary care center. Medical records of all term, singleton, live births (37-42 weeks gestation) from 2004-2014 were included. Small for
S420 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2017
Poster Session IV
ajog.org gestational age (<2500 gr) fetuses and incomplete records were excluded. EFW (clinical/sonographic) obtained at delivery room admission and ABW were collected. We divided the cohort into four groups stratified by EFW and ABW comparing obstetrical outcomes (Table 1). Multinomial logistic regression was used to eliminate confounding factors. RESULTS: Of 112,817 singleton deliveries, 53,953 met the inclusion criteria. EFW above 4 kg significantly increased the risk for an urgent or elective CD (OR 1.8 and 5.4, respectively). There was a trend towards a lower incidence of instrumental delivery when EFW was above 4 kg (OR 0.8, p¼0.053). ABW did not influence mode of delivery. Stratification according to ABW into smaller subgroups, using 250 gram blocks, did not influence results. In deliveries with an ABW above 4 kg, OASIS rate was significantly higher (OR 2.5) when the EFW was below 4 kg. Other obstetrical/neonatal outcomes, including episiotomy, shoulder dystocia, prolonged second stage, 5 minute Apgar, and NICU admission were not significantly different between groups. CONCLUSION: Mode of delivery was strongly influenced by EFW and not by ABW. Antepartum estimation of fetal macrosomia, regardless of ABW, was associated with a significantly higher risk for an urgent or elective CD, a lower maternal risk for OASIS, and a trend towards a lower risk of instrumental delivery.
in patients who did not require intervention was shorter (53.2 minutes) compared to those who did (188 minutes). The estimated blood loss was significantly lower in those who did not require intervention (295.2 mL vs. 464.5 mL, p<0.001). No significant differences were noted in the length of the third stage between ethnicities nor the different primary diagnoses of PPROM, PTL, cervical insufficiency, or IUFD. Using a Kaplan-Meier survival curve, we demonstrated that 90% of the patients who delivered the placenta without intervention did so by 180 minutes and 95% by 240 minutes. CONCLUSION: In midtrimester deliveries, if the placenta has not delivered by 240 minutes, then the provider should consider intervention by either manual extraction or dilation and curettage.
722 Optimal timing of delivery for women with breast cancer according to hormone receptor subtype
721 Management of the third stage of labor in midtrimester deliveries: a 9 year review
Kelly Kuo, Catherine S. John, Aaron B. Caughey
Erica A. Heilman, Melanie Chichester, Matthew K. Hoffman
Oregon Health & Science University, Portland, OR
Christiana Care Hospital, Newark, DE
OBJECTIVE: To compare strategies for the timing of delivery in
OBJECTIVE: To evaluate the length of the third stage of labor in
women with breast cancer and known hormone receptor subtype, and to determine the optimal gestational age for induction in regards to maternal-fetal outcomes. STUDY DESIGN: A decision-analytic model was designed comparing eight different strategies for scheduled delivery at 30, 31, 32, 33, 34, 35, 36, and 37 weeks gestation. Optimal breast cancer treatment was assumed to be delayed until after delivery. Baseline estimates of subtype-specific mortality and the impact of delayed cancer treatment on 5-year survival rates were obtained from the literature. Outcomes factored into the model included the risk of intrauterine fetal demise, spontaneous delivery, respiratory distress syndrome, cerebral palsy, and neonatal demise at each gestational age. Univariate and multivariate sensitivity analyses were performed to test the robustness of our model. RESULTS: For women with estrogen or progesterone receptor-positive, human epidermal receptor-2 negative (HR+/HER2-) breast cancer, scheduled delivery at 36 weeks yielded the highest qualityadjusted life years (QALYs). For women with HER2+ breast cancer, overall QALYs were maximized with scheduled delivery at 36 weeks, although maternal QALYs were maximized with scheduled delivery at 34 weeks. For women with the highest risk subtype of triplenegative (HR-/HER2-) breast cancer, both overall and maternal
midtrimester deliveries in order to determine after what period of time a placenta should be deemed retained and additional intervention pursued. STUDY DESIGN: A retrospective study of midtrimester vaginal deliveries between 14 weeks 0 days to 23 weeks 6 days from January 2005 until December 2013 at a single tertiary care center. Patients who were undergoing induction of labor for fetal anomalies were excluded. Multiple data points were collected on each patient including maternal age, gravidity, parity, gestational age, use of uterotonics, estimated blood loss, length of stay following delivery, method of placental delivery, and postpartum fever. The length of the third stage of labor was calculated and recorded in minutes. Patients were labeled as needing intervention for the third stage if they required manual evacuation or dilation and curettage for removal of the placenta. Patients who required only uterotonics or no uterotonics for delivery of the placenta were labeled as requiring no intervention for the purposes of this study. RESULTS: Of the charts evaluated, 585 patients met inclusion criteria. Women who required intervention for the management of the third stage were at an earlier gestational age (18.4 weeks) than those who did not (19.6 weeks). The mean length of the third stage
Supplement to JANUARY 2017 American Journal of Obstetrics & Gynecology
S421