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98: Escitalopram use in pregnancy: an observational cohort study
Poster Session I
Clinical Obstetrics, Medical-Surgical-Disease, Neonatology, Physiology-Endocrinology
96 Barriers to desired postpartum sterilization in a diverse population Bonnie Patel1, Stacey Amsden1, Krystal White1, Amy Picklesimer1 1 Greenville Hospital System University Medical Center, Obstetrics and Gynecology, Greenville, SC
OBJECTIVE: Many women who plan post-partum tubal ligation (PPTL) do not receive this procedure after delivery. We sought reasons why women were not receiving desired sterilization procedures, in order to identify potentially modifiable barriers. STUDY DESIGN: A retrospective cohort study was performed including all consecutive patients from a single practice admitted for delivery between August 2009 and July 2010. Women indicating desire for PPTL by signing Medicaid consent documents during prenatal care were included for analysis. Data were abstracted from the medical record. Comparisons were made using -Square and Students T-test. Stepwise logistic regression was then performed. RESULTS: During the study period, 2475 patients delivered, 521 (21%) of whom desired PPTL. Only 354 (14.3%) underwent planned PPTL. Most failures were due to patient choice (n⫽83, 49.7%), the remainder were due to potentially avoidable systems failures (n⫽45, 27.2%) and physician choice (n⫽39, 23.6%). Of women who did not receive PPTL, 92% requested alternate contraception at discharge but only 8.2% desired interval sterilization. Factors associated with receiving intended PPTL on logistic regression modeling included cesarean section (OR 5.3, 95% CI 3.29-8.62), Hispanic race (OR 1.74, 95% CI 1.09-2.77), and increasing maternal age (OR 1.06, 95% CI 1.02 - 1.10 per year increase in age). Unmarried status (OR 0.60, 95% CI 0.410.88), preterm delivery (OR 0.26, 95% CI 0.13-0.54) and NICU admission (OR 0.43, 95% CI 0.23-0.77) were negatively associated with PPTL. CONCLUSION: Although we identified barriers arising from physician decisions and system structures, patient choice was the most important cause of procedure cancellation. Eliminating modifiable systems related failures and minimizing variations in physician practices will protect womens access to desired PPTL, but there is need to improve prenatal counseling regarding alternatives to permanent contraception. Nearly 30% of women indicating a desire for PPTL will choose an alternate method after delivery, and it is important that they understand all available options.
97 Obstetrical decision-making for management of periviable deliveries Brownsyne Tucker Edmonds1, Sarah Krasny2, Sindhu Srinivas3, Judy Shea4 1 Indiana University School of Medicine, Department of Obstetrics and Gynecology, Indianapolis, IN, 2University of Pennsylvania, Department of Family Medicine and Community Health, Philadilphia, PA, 3University of Pennsylvania Perelman School of Medicine, Maternal and Child Research Program; Department of OBGYN, Philadelphia, PA, 4University of Pennsylvania Perelman School of Medicine, Department of Medicine, Philadelphia, PA
OBJECTIVE: To examine patient, physician, and institution-level factors that influence obstetrical decision-making and counseling for periviable deliveries. STUDY DESIGN: We conducted 21 semi-structured interviews with general obstetrician-gynecologists and maternal fetal medicine physicians recruited from 5 academic medical centers in Philadelphia. Interviews were transcribed verbatim. Two trained reviewers independently coded transcripts following a grounded theory methodology. NVivo 9 facilitated qualitative analysis. RESULTS: Obstetricians described significant institutional variation in periviable care even among institutions with comparable neonatal intensive care capacity. Likewise, thresholds for intervention varied substantially from “attending to attending”. Though circumscribed by institutional norms, neonatalogy practices, and clinical acuity, obstetrical decision-making was primarily influenced by the perception that patients prefer to “do everything.” Perspectives on patient auton-
S58
www.AJOG.org
omy guided approaches to counseling. Liability concerns were minimal but made some obstetricians less likely to communicate hope and more likely to perform cesarean section for fetal distress. Most obstetricians felt that patient sociodemographic factors did not influence their clinical decision-making, but did influence their style of counseling. However, in vitro fertilization pregnancies were discussed as “precious pregnancies” and admittedly managed more aggressively by almost all. This difference was attributed to obstetrical history, age, and level of education/understanding. CONCLUSION: Though often overlooked in the literature, obstetricians are actively involved in counseling parents about periviable delivery management and resuscitation decisions. The impact of institutional variation on periviable care warrants greater attention. The influence of sociodemographic factors on patient preferences and physician counseling also deserves further investigation. Differential treatment for infertility patients may lead to unintended disparities in periviable care.
98 Escitalopram use in pregnancy: an observational cohort study Chagit Klieger Grossmann1, Brenda Weitzner2, Alessandra Pistelli3, Ariel Many4, Joseph Lessing4, Gideon Koren5 1
Lis Maternity Hospital, OB GYN, Tel Aviv, Israel, 2University of Toronto, Clinical Pharmacology, Toronto, ON, Canada, 3TIS, TIS, Florence, Italy, 4Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, OB GYN, Tel Aviv, Israel, 5Division of Clinical Pharmacology & Toxicology, BeMORE collaboration (Ben-Gurion Motherisk Obstetric Registry of Exposure collaboration), Clinical Pharmacology, Toronto, Canada
OBJECTIVE: Escitalopram is a 5-HT re-uptake inhibitor prescribed for depression and anxiety. To date, a single published study has described fetal outcome following gestational exposure to escitalopram. We sought to determine whether escitalopram is associated with an increased risk for adverse pregnancy outcomes. STUDY DESIGN: We analysed pregnancy outcomes of women who contacted the Motherisk Program and other Teratogen Information Services regarding the safety of escitalopram during pregnancy. Data were collected using a standardized questionnaire. Two comparison groups of pregnant women exposed to other antidepressants (N⫽212) and non-teratogenic exposures (N⫽212) were matched for maternal age (⫹/⫺2 years) alcohol and tobacco use and gestational age at time of initial call (⫹/⫺2 years). Statistical analysis was performed using Chi Squared. RESULTS: Among 213 escitalopram exposures were 172 (80.8%) live births, 32 (15.0%) spontaneous abortions, 3 (1.4%) stillbirth, 6 (2.8%) artificial abortions, 19 (8.9%) premature births and 4 (1.9%) major malformations. Mean birth weight of exposed infants was 3198 (plus/minus) 594 gram and mean gestational age at delivery was 38.6 (plus/minus) 2.2 weeks. Rates of spontaneous abortions were significantly higher in both antidepressant groups [17.3% escitalopram, 16.0% other antidepressants] in comparison to the non teratogen group (8.5%). The rate of low birth weight (⬍2500 grams) was higher in the escitalopram group (9.9%) compared to the other antidepressants (3.6%, P⫽0.038) and non-teratogens (2.1%, P⫽0.003). There were no differences in the rates of major malformations, premature births, stillbirths or NICU admissions. CONCLUSION: escitalopram exposure during pregnancy does not appear to increase the rate of major malformations above baseline (13%). However, the higher number of spontaneous abortions in both antidepressant groups confirms previous findings. The high rate of low birth weight requires further investigation.
American Journal of Obstetrics & Gynecology Supplement to JANUARY 2012
Clinical Obstetrics, Medical-Surgical-Disease, Neonatology, Physiology-Endocrinology
96 Barriers to desired postpartum sterilization in a diverse population Bonnie Patel1, Stacey Amsden1, Krystal White1, Amy Picklesimer1 1 Greenville Hospital System University Medical Center, Obstetrics and Gynecology, Greenville, SC
OBJECTIVE: Many women who plan post-partum tubal ligation (PPTL) do not receive this procedure after delivery. We sought reasons why women were not receiving desired sterilization procedures, in order to identify potentially modifiable barriers. STUDY DESIGN: A retrospective cohort study was performed including all consecutive patients from a single practice admitted for delivery between August 2009 and July 2010. Women indicating desire for PPTL by signing Medicaid consent documents during prenatal care were included for analysis. Data were abstracted from the medical record. Comparisons were made using -Square and Students T-test. Stepwise logistic regression was then performed. RESULTS: During the study period, 2475 patients delivered, 521 (21%) of whom desired PPTL. Only 354 (14.3%) underwent planned PPTL. Most failures were due to patient choice (n⫽83, 49.7%), the remainder were due to potentially avoidable systems failures (n⫽45, 27.2%) and physician choice (n⫽39, 23.6%). Of women who did not receive PPTL, 92% requested alternate contraception at discharge but only 8.2% desired interval sterilization. Factors associated with receiving intended PPTL on logistic regression modeling included cesarean section (OR 5.3, 95% CI 3.29-8.62), Hispanic race (OR 1.74, 95% CI 1.09-2.77), and increasing maternal age (OR 1.06, 95% CI 1.02 - 1.10 per year increase in age). Unmarried status (OR 0.60, 95% CI 0.410.88), preterm delivery (OR 0.26, 95% CI 0.13-0.54) and NICU admission (OR 0.43, 95% CI 0.23-0.77) were negatively associated with PPTL. CONCLUSION: Although we identified barriers arising from physician decisions and system structures, patient choice was the most important cause of procedure cancellation. Eliminating modifiable systems related failures and minimizing variations in physician practices will protect womens access to desired PPTL, but there is need to improve prenatal counseling regarding alternatives to permanent contraception. Nearly 30% of women indicating a desire for PPTL will choose an alternate method after delivery, and it is important that they understand all available options.
97 Obstetrical decision-making for management of periviable deliveries Brownsyne Tucker Edmonds1, Sarah Krasny2, Sindhu Srinivas3, Judy Shea4 1 Indiana University School of Medicine, Department of Obstetrics and Gynecology, Indianapolis, IN, 2University of Pennsylvania, Department of Family Medicine and Community Health, Philadilphia, PA, 3University of Pennsylvania Perelman School of Medicine, Maternal and Child Research Program; Department of OBGYN, Philadelphia, PA, 4University of Pennsylvania Perelman School of Medicine, Department of Medicine, Philadelphia, PA
OBJECTIVE: To examine patient, physician, and institution-level factors that influence obstetrical decision-making and counseling for periviable deliveries. STUDY DESIGN: We conducted 21 semi-structured interviews with general obstetrician-gynecologists and maternal fetal medicine physicians recruited from 5 academic medical centers in Philadelphia. Interviews were transcribed verbatim. Two trained reviewers independently coded transcripts following a grounded theory methodology. NVivo 9 facilitated qualitative analysis. RESULTS: Obstetricians described significant institutional variation in periviable care even among institutions with comparable neonatal intensive care capacity. Likewise, thresholds for intervention varied substantially from “attending to attending”. Though circumscribed by institutional norms, neonatalogy practices, and clinical acuity, obstetrical decision-making was primarily influenced by the perception that patients prefer to “do everything.” Perspectives on patient auton-
S58
www.AJOG.org
omy guided approaches to counseling. Liability concerns were minimal but made some obstetricians less likely to communicate hope and more likely to perform cesarean section for fetal distress. Most obstetricians felt that patient sociodemographic factors did not influence their clinical decision-making, but did influence their style of counseling. However, in vitro fertilization pregnancies were discussed as “precious pregnancies” and admittedly managed more aggressively by almost all. This difference was attributed to obstetrical history, age, and level of education/understanding. CONCLUSION: Though often overlooked in the literature, obstetricians are actively involved in counseling parents about periviable delivery management and resuscitation decisions. The impact of institutional variation on periviable care warrants greater attention. The influence of sociodemographic factors on patient preferences and physician counseling also deserves further investigation. Differential treatment for infertility patients may lead to unintended disparities in periviable care.
98 Escitalopram use in pregnancy: an observational cohort study Chagit Klieger Grossmann1, Brenda Weitzner2, Alessandra Pistelli3, Ariel Many4, Joseph Lessing4, Gideon Koren5 1
Lis Maternity Hospital, OB GYN, Tel Aviv, Israel, 2University of Toronto, Clinical Pharmacology, Toronto, ON, Canada, 3TIS, TIS, Florence, Italy, 4Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, OB GYN, Tel Aviv, Israel, 5Division of Clinical Pharmacology & Toxicology, BeMORE collaboration (Ben-Gurion Motherisk Obstetric Registry of Exposure collaboration), Clinical Pharmacology, Toronto, Canada
OBJECTIVE: Escitalopram is a 5-HT re-uptake inhibitor prescribed for depression and anxiety. To date, a single published study has described fetal outcome following gestational exposure to escitalopram. We sought to determine whether escitalopram is associated with an increased risk for adverse pregnancy outcomes. STUDY DESIGN: We analysed pregnancy outcomes of women who contacted the Motherisk Program and other Teratogen Information Services regarding the safety of escitalopram during pregnancy. Data were collected using a standardized questionnaire. Two comparison groups of pregnant women exposed to other antidepressants (N⫽212) and non-teratogenic exposures (N⫽212) were matched for maternal age (⫹/⫺2 years) alcohol and tobacco use and gestational age at time of initial call (⫹/⫺2 years). Statistical analysis was performed using Chi Squared. RESULTS: Among 213 escitalopram exposures were 172 (80.8%) live births, 32 (15.0%) spontaneous abortions, 3 (1.4%) stillbirth, 6 (2.8%) artificial abortions, 19 (8.9%) premature births and 4 (1.9%) major malformations. Mean birth weight of exposed infants was 3198 (plus/minus) 594 gram and mean gestational age at delivery was 38.6 (plus/minus) 2.2 weeks. Rates of spontaneous abortions were significantly higher in both antidepressant groups [17.3% escitalopram, 16.0% other antidepressants] in comparison to the non teratogen group (8.5%). The rate of low birth weight (⬍2500 grams) was higher in the escitalopram group (9.9%) compared to the other antidepressants (3.6%, P⫽0.038) and non-teratogens (2.1%, P⫽0.003). There were no differences in the rates of major malformations, premature births, stillbirths or NICU admissions. CONCLUSION: escitalopram exposure during pregnancy does not appear to increase the rate of major malformations above baseline (13%). However, the higher number of spontaneous abortions in both antidepressant groups confirms previous findings. The high rate of low birth weight requires further investigation.
American Journal of Obstetrics & Gynecology Supplement to JANUARY 2012