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Grandmultiparae in modern obstetrics
S84 SMFM Abstracts 275
FIRST STAGE OF LABOR IN MULTIPAROUS WOMEN WITH SHOULDER DYSTOCIA SHOBHA MEHTA1, EMILY HAMILTON2, EMMANUEL BUJOLD1, SEAN BLACKWELL1, Wayne State University, Obstetrics/Gynecology, Detroit, Michigan, 2McGill University, Montreal, Quebec, Canada OBJECTIVE: The purpose of this study was to evaluate the progression of the first stage of labor in multiparous women complicated by shoulder dystocia (SD). STUDY DESIGN: Deliveries diagnosed with shoulder dystocia from 1/1996-1/ 2001 at a single institution were identified from ICD-9 codes and confirmed by chart review. Each pregnancy was matched 1:1 to a control patient that had vaginal delivery based on four factors: maternal parity, neonatal birth weight within 200 g, labor induction and maternal race. Labor progress was quantified using a mathematical model that compared dilations in the study groups to a reference population adjusting at each exam for parity and changing conditions such as contraction frequency, epidural use and the state of the cervix at the previous examination. Statistical methods included paired t test, Wilcoxon rank sum and c2. RESULTS: Of 16,084 multiparous patients meeting inclusion criteria, 141 patients (0.9%) had SD. Neurological injury occurred in 14.2%. There were no differences between SD cases and controls for admission mean dilation (4.1 vs. 4.3 cm, P = .50), effacement (70 vs. 71%, P = .85), station (ÿ2.3 vs.ÿ2.4, P = .25) or the length of the first stage (8.3 vs. 7.1 hrs, P = .15). The average percentile of all exams, however, was lower (31.5 vs. 25.2 %, P = .003). There were more examinations that ranked below the 5th percentile (31.0 vs. 23.5%, P = .012) and below the 3rd percentile (24.6 vs.15.8%, P = .001). CONCLUSION: Despite beginning labor in a similar state these multiparous women with SD had slower labors compared to their matched controls. This was more evident using a measure that adjusts for contraction frequency than a simple duration of first stage.
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INTERVAL BETWEEN PREGNANCIES AND MATERNAL AGE: THEIR IMPACT: ON PREGNANCY OUTCOME THOMAS MYLES1, HEATHER VOLK2, LINDA MUNDY3, TERRY LEET4, 1Saint Louis University, Obstetrics and Gynecology, St. Louis, Missouri, 2Saint Louis University, School of Public Health, St. Louis, Missouri, 3 Washington University in St. Louis, St. Louis, Missouri, 4Saint Louis University, Community Health, St. Louis, Missouri OBJECTIVE: Advanced maternal age (AMA) and short/long interpregnancy intervals (IPI) have been shown to be independently associated with increased risk for adverse perinatal outcomes. The interaction effect of age and IPI as risks for adverse perinatal outcomes has not been characterized. STUDY DESIGN: This population-based cohort study examines the relationship between AMA (age R35), IPI, and the interaction between these 2 factors on pregnancy, fetal, and neonatal outcomes in the 2nd pregnancy. The study population included women enrolled in the Missouri maternally-linked cohort between 1/89-12/97. Of the 313,784 patients with R2 deliveries, 75,527 met final inclusion criteria. Only subjects >20 years of age at first birth and with singleton or twin births were eligible. Adjusted odds ratios (OR) and 95%confidence intervals (CI) were calculated using logistic regression, with adjustments for nonindependent events. RESULTS: AMA (n = 2105) at first pregnancy increased risk for gestational diabetes (GDM) (OR 1.7, CI 1.3-2.2), placenta previa (2.0, 1.3-2.3), very low birth weight (VLBW) (1.7, 1.2-2.6), macrosomia (M) (1.2, 1.02-1.3), and preterm delivery (PTD) (1.4, 1.2-1.6). IPI !6 months significantly increased risk for PTD.(2.0, 1.01-4.0); IPI of 6-18 months decreased risk for GDM (OR 0.7 [0.60.9]) and M (0.8, 0.8-0.9) and increased risk for fetal death (1.7, 1.3-2.3), VLBW (1.9, 1.8-2.3), and PTD (1.7, 1.2-2.3); IPI of 24-48 months increased risk for small for gestational age infants (1.2, 1.1-1.3) and M (1.1, 1.05-1.14). For IPI >48 months there was increased risk for GDM (1.4, 1.2-1.6), and VLBW (1.4, 1.1-1.8). After adjusting for demographic factors and IPI, the risks for AMA patients were increased for PTD (1.2, 1.01-1.5) and M (1.2, 1.1-1.4). No interaction between AMA and IPI was found for the other variables studied. CONCLUSION: AMA and IPI were independently associated with risk for adverse perinatal outcomes. Strategically spacing childbirth around life events for the older woman will not bring any additional risk or benefit.
SOFT TISSUE MASS IN SHOULDER DYSTOCIA NEONATES SHOBHA MEHTA1, SEAN BLACKWELL1, EMMANUEL BUJOLD1, POOJA MITTAL1, TODD KRAEMER1, ROBERT SOKOL1, 1Wayne State University, Obstetrics/Gynecology, Detroit, Michigan OBJECTIVE: Bone growth is a reflection of lean body mass, while soft tissue growth a measure of fat mass. Our objective was to determine, using neonatal radiological studies, whether soft tissue parameters in shoulder dystocia (SD) neonates were increased relative to bone length when compared to controls. STUDY DESIGN: SD cases from 1/1996-1/2001 at a single institution were identified from ICD-9 codes and confirmed by chart review. Cases in which the newborn underwent chest radiography (CXR) within 1 week of delivery were matched to a similar control group without SD by birth weight within 250 g. CXRs were reviewed in a blinded fashion for the following: outer bisacromial diameter (BAD), biclavicular diameter (BCD), and the soft tissue diameter (STD). The STD was defined as the length from lateral arm skin edge to lateral arm skin edge at the level of the humeral head (shoulder-to-shoulder diameter). The ratio of BAD/STD and the BCD/STD were compared between groups. RESULTS: During this 5-year period, there were 24,094 deliveries and 206 (0.8%) confirmed cases of SD. 30 (14.6%) had CXR performed and 24 cases were of sufficient quality to be used for analysis. There was no difference in the BAD/STD ratio between SD and controls (1.60 [1.45-1.89] vs. 1.63 [1.50-1.77] P = .12). There was also no difference in the BCD/STD ratio (1.84 [1.58-2.13] vs. 1.84 [1.66-2.07]; P = .918). Of 9 brachial plexus injuries, there was no difference in the ratio of BAD/STD compared to the SD group without injury (1.58 [1.45-1.72] vs. 1.61 [1.48-1.89]; P = .64), or in the BCD/STD ratio (1.84 [1.68-2.04] vs. 1.84 [1.58-2.13], P = .9). CONCLUSION: Although fetal truncal obesity is considered a risk factor for shoulder dystocia, this study did not find a difference in neonatal shoulder soft tissue mass as compared to controls.
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GRANDMULTIPARAE IN MODERN OBSTETRICS ANWAR NASSAR1, RANIA FAYYUMY1, WAEL SAAB1, GHASSAN MEHIO1, IHAB USTA1, 1American University of Beirut, Obstetrics and Gynecology, New York, New York, Lebanon OBJECTIVE: To compare the incidence of antenatal and intrapartum complications among women who had previously delivered five or more times (grandmultiparas) with that of age-matched control women who had previously delivered one to three times (multiparas). STUDY DESIGN: One hundred nineteen grand multiparous women (cases) who delivered at AUBMC, a tertiary care teaching hospital between 1998 and 2003 were retrospectively compared with 119 age-matched multiparas (controls). Characteristics and complications occurring in the two groups were compared. Chi square, two-tailed Fisher exact test or Student t test were used where appropriate. A P ! .05 was considered significant. RESULTS: Grand multiparity was associated with a low socioeconomic status (73.1% vs 47.9%; P ! .001) and higher incidence of smoking (31.1% vs 7.6%; P ! .001). Grand multiparas had a higher body mass index (31.5 G 5.5 vs 29.8 G 6.4 kg/m2; P = .035) but a similar incidence of gestational diabetes and hypertensive disorders of pregnancy. The rate of preterm delivery (!37 weeks) was higher in cases but this did not reach statistical significance (12.1% vs 7.6%; P = .380). No significant differences were found between the 2 groups for antepartum hemorrhage, antenatal anemia, post-term births, polyhydramnios, placenta previa or abruptio placentae. Both groups had similar intrapartum complications (induction of labor, non-reassuring fetal heart, arrest of cervical dilatation, operative vaginal delivery, primary cesarean delivery and intrapartum fever). Birth weight was significantly larger in grand multiparas compared to controls (3409 G 555 vs 3234 G 548 grams; P = .016). However, there were no significant differences between the 2 groups regarding macrosomia, intrauterine growth restriction (!10th percentile), Apgar scores !4 at 1 minute and !7 at 5 minutes or perinatal death. CONCLUSION: Grandmultiparity does not appear to be an independent risk factor for adverse obsterical outcome in the setting of good prenatal care.
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FIRST STAGE OF LABOR IN MULTIPAROUS WOMEN WITH SHOULDER DYSTOCIA SHOBHA MEHTA1, EMILY HAMILTON2, EMMANUEL BUJOLD1, SEAN BLACKWELL1, Wayne State University, Obstetrics/Gynecology, Detroit, Michigan, 2McGill University, Montreal, Quebec, Canada OBJECTIVE: The purpose of this study was to evaluate the progression of the first stage of labor in multiparous women complicated by shoulder dystocia (SD). STUDY DESIGN: Deliveries diagnosed with shoulder dystocia from 1/1996-1/ 2001 at a single institution were identified from ICD-9 codes and confirmed by chart review. Each pregnancy was matched 1:1 to a control patient that had vaginal delivery based on four factors: maternal parity, neonatal birth weight within 200 g, labor induction and maternal race. Labor progress was quantified using a mathematical model that compared dilations in the study groups to a reference population adjusting at each exam for parity and changing conditions such as contraction frequency, epidural use and the state of the cervix at the previous examination. Statistical methods included paired t test, Wilcoxon rank sum and c2. RESULTS: Of 16,084 multiparous patients meeting inclusion criteria, 141 patients (0.9%) had SD. Neurological injury occurred in 14.2%. There were no differences between SD cases and controls for admission mean dilation (4.1 vs. 4.3 cm, P = .50), effacement (70 vs. 71%, P = .85), station (ÿ2.3 vs.ÿ2.4, P = .25) or the length of the first stage (8.3 vs. 7.1 hrs, P = .15). The average percentile of all exams, however, was lower (31.5 vs. 25.2 %, P = .003). There were more examinations that ranked below the 5th percentile (31.0 vs. 23.5%, P = .012) and below the 3rd percentile (24.6 vs.15.8%, P = .001). CONCLUSION: Despite beginning labor in a similar state these multiparous women with SD had slower labors compared to their matched controls. This was more evident using a measure that adjusts for contraction frequency than a simple duration of first stage.
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INTERVAL BETWEEN PREGNANCIES AND MATERNAL AGE: THEIR IMPACT: ON PREGNANCY OUTCOME THOMAS MYLES1, HEATHER VOLK2, LINDA MUNDY3, TERRY LEET4, 1Saint Louis University, Obstetrics and Gynecology, St. Louis, Missouri, 2Saint Louis University, School of Public Health, St. Louis, Missouri, 3 Washington University in St. Louis, St. Louis, Missouri, 4Saint Louis University, Community Health, St. Louis, Missouri OBJECTIVE: Advanced maternal age (AMA) and short/long interpregnancy intervals (IPI) have been shown to be independently associated with increased risk for adverse perinatal outcomes. The interaction effect of age and IPI as risks for adverse perinatal outcomes has not been characterized. STUDY DESIGN: This population-based cohort study examines the relationship between AMA (age R35), IPI, and the interaction between these 2 factors on pregnancy, fetal, and neonatal outcomes in the 2nd pregnancy. The study population included women enrolled in the Missouri maternally-linked cohort between 1/89-12/97. Of the 313,784 patients with R2 deliveries, 75,527 met final inclusion criteria. Only subjects >20 years of age at first birth and with singleton or twin births were eligible. Adjusted odds ratios (OR) and 95%confidence intervals (CI) were calculated using logistic regression, with adjustments for nonindependent events. RESULTS: AMA (n = 2105) at first pregnancy increased risk for gestational diabetes (GDM) (OR 1.7, CI 1.3-2.2), placenta previa (2.0, 1.3-2.3), very low birth weight (VLBW) (1.7, 1.2-2.6), macrosomia (M) (1.2, 1.02-1.3), and preterm delivery (PTD) (1.4, 1.2-1.6). IPI !6 months significantly increased risk for PTD.(2.0, 1.01-4.0); IPI of 6-18 months decreased risk for GDM (OR 0.7 [0.60.9]) and M (0.8, 0.8-0.9) and increased risk for fetal death (1.7, 1.3-2.3), VLBW (1.9, 1.8-2.3), and PTD (1.7, 1.2-2.3); IPI of 24-48 months increased risk for small for gestational age infants (1.2, 1.1-1.3) and M (1.1, 1.05-1.14). For IPI >48 months there was increased risk for GDM (1.4, 1.2-1.6), and VLBW (1.4, 1.1-1.8). After adjusting for demographic factors and IPI, the risks for AMA patients were increased for PTD (1.2, 1.01-1.5) and M (1.2, 1.1-1.4). No interaction between AMA and IPI was found for the other variables studied. CONCLUSION: AMA and IPI were independently associated with risk for adverse perinatal outcomes. Strategically spacing childbirth around life events for the older woman will not bring any additional risk or benefit.
SOFT TISSUE MASS IN SHOULDER DYSTOCIA NEONATES SHOBHA MEHTA1, SEAN BLACKWELL1, EMMANUEL BUJOLD1, POOJA MITTAL1, TODD KRAEMER1, ROBERT SOKOL1, 1Wayne State University, Obstetrics/Gynecology, Detroit, Michigan OBJECTIVE: Bone growth is a reflection of lean body mass, while soft tissue growth a measure of fat mass. Our objective was to determine, using neonatal radiological studies, whether soft tissue parameters in shoulder dystocia (SD) neonates were increased relative to bone length when compared to controls. STUDY DESIGN: SD cases from 1/1996-1/2001 at a single institution were identified from ICD-9 codes and confirmed by chart review. Cases in which the newborn underwent chest radiography (CXR) within 1 week of delivery were matched to a similar control group without SD by birth weight within 250 g. CXRs were reviewed in a blinded fashion for the following: outer bisacromial diameter (BAD), biclavicular diameter (BCD), and the soft tissue diameter (STD). The STD was defined as the length from lateral arm skin edge to lateral arm skin edge at the level of the humeral head (shoulder-to-shoulder diameter). The ratio of BAD/STD and the BCD/STD were compared between groups. RESULTS: During this 5-year period, there were 24,094 deliveries and 206 (0.8%) confirmed cases of SD. 30 (14.6%) had CXR performed and 24 cases were of sufficient quality to be used for analysis. There was no difference in the BAD/STD ratio between SD and controls (1.60 [1.45-1.89] vs. 1.63 [1.50-1.77] P = .12). There was also no difference in the BCD/STD ratio (1.84 [1.58-2.13] vs. 1.84 [1.66-2.07]; P = .918). Of 9 brachial plexus injuries, there was no difference in the ratio of BAD/STD compared to the SD group without injury (1.58 [1.45-1.72] vs. 1.61 [1.48-1.89]; P = .64), or in the BCD/STD ratio (1.84 [1.68-2.04] vs. 1.84 [1.58-2.13], P = .9). CONCLUSION: Although fetal truncal obesity is considered a risk factor for shoulder dystocia, this study did not find a difference in neonatal shoulder soft tissue mass as compared to controls.
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GRANDMULTIPARAE IN MODERN OBSTETRICS ANWAR NASSAR1, RANIA FAYYUMY1, WAEL SAAB1, GHASSAN MEHIO1, IHAB USTA1, 1American University of Beirut, Obstetrics and Gynecology, New York, New York, Lebanon OBJECTIVE: To compare the incidence of antenatal and intrapartum complications among women who had previously delivered five or more times (grandmultiparas) with that of age-matched control women who had previously delivered one to three times (multiparas). STUDY DESIGN: One hundred nineteen grand multiparous women (cases) who delivered at AUBMC, a tertiary care teaching hospital between 1998 and 2003 were retrospectively compared with 119 age-matched multiparas (controls). Characteristics and complications occurring in the two groups were compared. Chi square, two-tailed Fisher exact test or Student t test were used where appropriate. A P ! .05 was considered significant. RESULTS: Grand multiparity was associated with a low socioeconomic status (73.1% vs 47.9%; P ! .001) and higher incidence of smoking (31.1% vs 7.6%; P ! .001). Grand multiparas had a higher body mass index (31.5 G 5.5 vs 29.8 G 6.4 kg/m2; P = .035) but a similar incidence of gestational diabetes and hypertensive disorders of pregnancy. The rate of preterm delivery (!37 weeks) was higher in cases but this did not reach statistical significance (12.1% vs 7.6%; P = .380). No significant differences were found between the 2 groups for antepartum hemorrhage, antenatal anemia, post-term births, polyhydramnios, placenta previa or abruptio placentae. Both groups had similar intrapartum complications (induction of labor, non-reassuring fetal heart, arrest of cervical dilatation, operative vaginal delivery, primary cesarean delivery and intrapartum fever). Birth weight was significantly larger in grand multiparas compared to controls (3409 G 555 vs 3234 G 548 grams; P = .016). However, there were no significant differences between the 2 groups regarding macrosomia, intrauterine growth restriction (!10th percentile), Apgar scores !4 at 1 minute and !7 at 5 minutes or perinatal death. CONCLUSION: Grandmultiparity does not appear to be an independent risk factor for adverse obsterical outcome in the setting of good prenatal care.
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