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The effect of VBAC's and “fetal distress” on cesarean section rates
S120 SMFM Abstracts compared with group 1 (GA singletons 36.9 vs 38.4 weeks, p = 0.005; GA multiples 35.1 vs 36.4 weeks, p = 0.01; BW singletons 2693.5 vs 3027.3 gr, p = 0.019; BW multiples 1976.4 vs 2310.3 gr, p = 0.038 respectively). Additionally, women aged R50 gave birth to significantly more low birth weight babies (!2500 gr) (32.2% in Group 1 vs. 60.6% in Group 2, p=0.002). CONCLUSION: With pregnancy in the 6th and 7th decades now feasible, prepregnancy counseling for elderly women should include the increased risks of prematurity and low birth weight, in addition to known risk factors such as diabetes, hypertension and c-section.
403 PREDICTING FAILURE OF A VAGINAL BIRTH ATTEMPT AFTER CESAREAN DELIVERY SINDHU K. SRINIVAS (F)1, DAVID STAMILIO2, ERIKA J. STEVENS3, JEFFREY PEIPERT4, ANTHONY O. ODIBO1, GEORGE A. MACONES1, 1University of Pennsylvania, Obstetrics and Gynecology, Philadelphia, Pennsylvania, 2University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, 3University of Pennsylvania, Philadelphia, Pennsylvania, 4Brown University, Obstetrics & Gynecology, Providence, Rhode Island OBJECTIVE: Thus far, methods to predict vaginal birth after cesarean (VBAC) delivery outcome have not been successful. If it were possible to predict VBAC candidates destined to fail an attempt at vaginal delivery, physicians could avert a significant amount of morbidity by advising high-risk patients against VBAC. Our aim was to identify a group of clinical factors that could be used to accurately predict failure in women attempting VBAC. STUDY DESIGN: We conducted a planned secondary analysis of a retrospective cohort study of women who were offered VBAC from 1996-2000 in 17 community and university hospitals. We collected information about maternal history and outcomes of the index pregnancy. We used bivariate and multivariable statistical methods to develop a multivariable prediction model for the outcome of VBAC failure. RESULTS: 13,706 (54.8%) patients attempted VBAC with a failure rate of 24.5%. Nine variables were significantly associated with VBAC failure in our final logistic regression model: maternal race, advanced maternal age, gestational diabetes, chronic hypertension, gestational age at delivery, spontaneous (vs. induced) labor, history of prior vaginal delivery, macrosomia, and prior cesarean indication. The area under the receiver-operator characteristic (ROC) curve is 0.73. To achieve a sensitivity of approximately 75%, a false positive rate of 38% would result (figure 1). Because the ROC curve revealed the model to be poorly predictive, we did not develop a simplified clinical prediction rule for VBAC failure. CONCLUSION: This is the largest multi-center study used to attempt to develop a prediction model for VBAC failure. Our results indicate that VBAC failure cannot be predicted efficiently using a combination of the strongest clinical risk factors.
RESULTS: Response rates were: dentists 66%, obstetricians 50%, and patients 46%. Ninety-seven percent of dentists, but only 64% of obstetricians, listed oral health screens as necessary in prenatal care. During pregnancy, 84% of patients reported dental visits as safe; 54% listed screening as necessary; 40% were advised by their provider to have an assessment; and 32% received care. The most common reason cited by patients for not seeing a dentist was insufficient funds. Providers agreed (O90%) that pregnant patients could safely undergo dental cleanings, caries treatments and abscess drainage. Differences (dentists versus obstetricians) were found regarding the safety of x-rays (69% vs. 92%), periodontal surgery (29% vs. 71%), and narcotic usage (15% vs. 95%). Most providers agreed that poor dental hygiene was related to some adverse pregnancy outcomes, with low birth weight the most frequently cited and pre-eclampsia the least. CONCLUSION: The majority of respondents agreed that dental care is safe and important for pregnant women. Significant differences were found between providers about the safety of specific procedures. Professional guidelines about oral health in pregnancy, its effect on pregnancy outcome, and the safety of dental procedures would benefit our patients and colleagues.
405 THE EFFECT OF VBAC’S AND ‘‘FETAL DISTRESS’’ ON CESAREAN SECTION RATES JAMES GREENBERG (F)1, ALISON STUEBE2, LOUISE WILKINS-HAUG2, 1Brigham and Women’s Hospital, Boston, Massachusetts, 2Brigham and Women’s Hospital, Obstetrics and Gynecology, Boston, Massachusetts OBJECTIVE: To determine what factors influence rising cesarean section rates. STUDY DESION: ICD-9 and CPT code data were reviewed for all births at Brigham & Women’s Hospital from 1997-2003. C-section and VBAC rates were calculated and the indications for c-sections were recorded. The five most frequent indications for c-section were 1) Elective repeat 2) Failure to progress 3) Non-reassuring fetal testing 4) Multiples 5) Breech. The rates of the c-sections, VBAC’s and indications were compared over the study period. The Mantel-Haenszel test was used to assess trends. RESULTS: There were 75,863 births (range: 8567-10,042 per year) with an average c-section rate of 26.6% (range: 22.4%-31.4%) and an average VBAC rate of 25.4% (range: 13.5%-34.4%). Statistically significant findings included rising c-section rates, with an increasing proportion for fetal distress, and declining VBAC rates. See Table I. CONCLUSION: Our data suggest a rise in c-section rates is associated with a fall in VBAC rates and an increase in the use of non-reassuring fetal testing as an indication for c-section. We hypothesize that in a more cautious medical environment, obstetrical providers are less willing to tolerate uncertainties and have a lower threshold to recommend abdominal delivery. C-section, VBAC and indications rates (%) (*p ! 0.01) Yr
’97
’98
’99
’00
’01
’02
’03
’04
Brth 8831 9395 9787 10042 9980 9859 9402 8567 C/S* 22.8 22.4 25 25.1 26.8 27.8 31.2 31.4 VBAC* 31.2 34.4 28.5 30.4 22.9 23.0 19.5 13.5 Elec* 30.9 29.9 29.2 29.3 30.7 31.8 30.6 33.6 FTP 33.2 30.8 32.9 30.4 29 30.7 31.2 30.7 Distress* 14.3 14.2 17.4 20.6 20.8 22.6 22.7 24.2 Multiple 8.0 8.6 8.2 7.5 7.7 7.9 8.0 9.2 Breech* 8.1 10.6 9.7 9.7 8.4 7.2 5.8 6.0
404 PROVIDER AND PATIENT PERCEPTIONS ABOUT DENTAL CARE DURING PREGNANCY CYNTHIA SHELLHAAS1, KATHERINE STRAFFORD1, 1Ohio State University, Obstetrics and Gynecology, Columbus, Ohio OBJECTIVE: This survey compares the opinions of dentists, obstetricians and patients on dental care in pregnancy: its necessity, accessibility and safety. Perceptions about the relationship between periodontal disease and adverse perinatal outcomes were explored. STUDY DESION: Four hundred patient surveys were distributed at prenatal visits at offices associated with our institution. Provider surveys were mailed to 500 obstetricians and 500 dentists throughout Ohio. Data was collected from October 2004 through July 2005. Univariate analysis of the data was performed using chi squared and Fisher´ s exact tests.
406 OBSTETRICAL OUTCOMES IN OVERWEIGHT ADOLESCENTS SARA SUKALICH1, MATTHEW MINGIONE1, CHRISTOPHER GLANTZ1, 1University of Rochester, Department of Obstetrics and Gynecology, Rochester, New York OBJECTIVE: In the United States, the rate of overweight exceeds 15% in girls 12-19. Obese adult gravidas have increased rates of maternal and neonatal complications. Our objective was to examine obstetrical complications in overweight adolescents using a large regional database. STUDY DESION: This is a retrospective case control study of 5,851 women age 18 or younger that were entered into a birth certificate registry from 1998 to 2003. Seventy-four percent (4,353) were of appropriate weight prior to pregnancy while 26% (1,498) were considered overweight (body mass index [BMI] O25). The odds ratios (OR) for adverse maternal or neonatal events were computed using chi-square tests (univariate) or logistic regression (multivariate) as appropriate. P-values !0.05 were considered significant. RESULTS: Primary cesarean section (OR 1.6), failure to progress/cephalopelvic disproportion (OR 1.6), labor induction (OR 1.5), pregnancy induced hypertension (OR 1.7), preeclampsia (OR 1.7) and gestational diabetes (OR 2.7) were significantly more common in overweight adolescents than in those of appropriate weight. Overweight gravidas were more likely to have a macrosomic baby (OR 1.6) independent of gestational diabetes and less likely to have a low birth weight (OR 0.6) or small for gestational age infant (OR 0.8) independent of hypertension or preterm delivery. CONCLUSION: Overweight adolescent women are at increased risk for adverse neonatal and perinatal outcomes. With rates of overweight increasing at all ages, overweight in the gravid adolescent is a pressing perinatal and public health concern.
403 PREDICTING FAILURE OF A VAGINAL BIRTH ATTEMPT AFTER CESAREAN DELIVERY SINDHU K. SRINIVAS (F)1, DAVID STAMILIO2, ERIKA J. STEVENS3, JEFFREY PEIPERT4, ANTHONY O. ODIBO1, GEORGE A. MACONES1, 1University of Pennsylvania, Obstetrics and Gynecology, Philadelphia, Pennsylvania, 2University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, 3University of Pennsylvania, Philadelphia, Pennsylvania, 4Brown University, Obstetrics & Gynecology, Providence, Rhode Island OBJECTIVE: Thus far, methods to predict vaginal birth after cesarean (VBAC) delivery outcome have not been successful. If it were possible to predict VBAC candidates destined to fail an attempt at vaginal delivery, physicians could avert a significant amount of morbidity by advising high-risk patients against VBAC. Our aim was to identify a group of clinical factors that could be used to accurately predict failure in women attempting VBAC. STUDY DESIGN: We conducted a planned secondary analysis of a retrospective cohort study of women who were offered VBAC from 1996-2000 in 17 community and university hospitals. We collected information about maternal history and outcomes of the index pregnancy. We used bivariate and multivariable statistical methods to develop a multivariable prediction model for the outcome of VBAC failure. RESULTS: 13,706 (54.8%) patients attempted VBAC with a failure rate of 24.5%. Nine variables were significantly associated with VBAC failure in our final logistic regression model: maternal race, advanced maternal age, gestational diabetes, chronic hypertension, gestational age at delivery, spontaneous (vs. induced) labor, history of prior vaginal delivery, macrosomia, and prior cesarean indication. The area under the receiver-operator characteristic (ROC) curve is 0.73. To achieve a sensitivity of approximately 75%, a false positive rate of 38% would result (figure 1). Because the ROC curve revealed the model to be poorly predictive, we did not develop a simplified clinical prediction rule for VBAC failure. CONCLUSION: This is the largest multi-center study used to attempt to develop a prediction model for VBAC failure. Our results indicate that VBAC failure cannot be predicted efficiently using a combination of the strongest clinical risk factors.
RESULTS: Response rates were: dentists 66%, obstetricians 50%, and patients 46%. Ninety-seven percent of dentists, but only 64% of obstetricians, listed oral health screens as necessary in prenatal care. During pregnancy, 84% of patients reported dental visits as safe; 54% listed screening as necessary; 40% were advised by their provider to have an assessment; and 32% received care. The most common reason cited by patients for not seeing a dentist was insufficient funds. Providers agreed (O90%) that pregnant patients could safely undergo dental cleanings, caries treatments and abscess drainage. Differences (dentists versus obstetricians) were found regarding the safety of x-rays (69% vs. 92%), periodontal surgery (29% vs. 71%), and narcotic usage (15% vs. 95%). Most providers agreed that poor dental hygiene was related to some adverse pregnancy outcomes, with low birth weight the most frequently cited and pre-eclampsia the least. CONCLUSION: The majority of respondents agreed that dental care is safe and important for pregnant women. Significant differences were found between providers about the safety of specific procedures. Professional guidelines about oral health in pregnancy, its effect on pregnancy outcome, and the safety of dental procedures would benefit our patients and colleagues.
405 THE EFFECT OF VBAC’S AND ‘‘FETAL DISTRESS’’ ON CESAREAN SECTION RATES JAMES GREENBERG (F)1, ALISON STUEBE2, LOUISE WILKINS-HAUG2, 1Brigham and Women’s Hospital, Boston, Massachusetts, 2Brigham and Women’s Hospital, Obstetrics and Gynecology, Boston, Massachusetts OBJECTIVE: To determine what factors influence rising cesarean section rates. STUDY DESION: ICD-9 and CPT code data were reviewed for all births at Brigham & Women’s Hospital from 1997-2003. C-section and VBAC rates were calculated and the indications for c-sections were recorded. The five most frequent indications for c-section were 1) Elective repeat 2) Failure to progress 3) Non-reassuring fetal testing 4) Multiples 5) Breech. The rates of the c-sections, VBAC’s and indications were compared over the study period. The Mantel-Haenszel test was used to assess trends. RESULTS: There were 75,863 births (range: 8567-10,042 per year) with an average c-section rate of 26.6% (range: 22.4%-31.4%) and an average VBAC rate of 25.4% (range: 13.5%-34.4%). Statistically significant findings included rising c-section rates, with an increasing proportion for fetal distress, and declining VBAC rates. See Table I. CONCLUSION: Our data suggest a rise in c-section rates is associated with a fall in VBAC rates and an increase in the use of non-reassuring fetal testing as an indication for c-section. We hypothesize that in a more cautious medical environment, obstetrical providers are less willing to tolerate uncertainties and have a lower threshold to recommend abdominal delivery. C-section, VBAC and indications rates (%) (*p ! 0.01) Yr
’97
’98
’99
’00
’01
’02
’03
’04
Brth 8831 9395 9787 10042 9980 9859 9402 8567 C/S* 22.8 22.4 25 25.1 26.8 27.8 31.2 31.4 VBAC* 31.2 34.4 28.5 30.4 22.9 23.0 19.5 13.5 Elec* 30.9 29.9 29.2 29.3 30.7 31.8 30.6 33.6 FTP 33.2 30.8 32.9 30.4 29 30.7 31.2 30.7 Distress* 14.3 14.2 17.4 20.6 20.8 22.6 22.7 24.2 Multiple 8.0 8.6 8.2 7.5 7.7 7.9 8.0 9.2 Breech* 8.1 10.6 9.7 9.7 8.4 7.2 5.8 6.0
404 PROVIDER AND PATIENT PERCEPTIONS ABOUT DENTAL CARE DURING PREGNANCY CYNTHIA SHELLHAAS1, KATHERINE STRAFFORD1, 1Ohio State University, Obstetrics and Gynecology, Columbus, Ohio OBJECTIVE: This survey compares the opinions of dentists, obstetricians and patients on dental care in pregnancy: its necessity, accessibility and safety. Perceptions about the relationship between periodontal disease and adverse perinatal outcomes were explored. STUDY DESION: Four hundred patient surveys were distributed at prenatal visits at offices associated with our institution. Provider surveys were mailed to 500 obstetricians and 500 dentists throughout Ohio. Data was collected from October 2004 through July 2005. Univariate analysis of the data was performed using chi squared and Fisher´ s exact tests.
406 OBSTETRICAL OUTCOMES IN OVERWEIGHT ADOLESCENTS SARA SUKALICH1, MATTHEW MINGIONE1, CHRISTOPHER GLANTZ1, 1University of Rochester, Department of Obstetrics and Gynecology, Rochester, New York OBJECTIVE: In the United States, the rate of overweight exceeds 15% in girls 12-19. Obese adult gravidas have increased rates of maternal and neonatal complications. Our objective was to examine obstetrical complications in overweight adolescents using a large regional database. STUDY DESION: This is a retrospective case control study of 5,851 women age 18 or younger that were entered into a birth certificate registry from 1998 to 2003. Seventy-four percent (4,353) were of appropriate weight prior to pregnancy while 26% (1,498) were considered overweight (body mass index [BMI] O25). The odds ratios (OR) for adverse maternal or neonatal events were computed using chi-square tests (univariate) or logistic regression (multivariate) as appropriate. P-values !0.05 were considered significant. RESULTS: Primary cesarean section (OR 1.6), failure to progress/cephalopelvic disproportion (OR 1.6), labor induction (OR 1.5), pregnancy induced hypertension (OR 1.7), preeclampsia (OR 1.7) and gestational diabetes (OR 2.7) were significantly more common in overweight adolescents than in those of appropriate weight. Overweight gravidas were more likely to have a macrosomic baby (OR 1.6) independent of gestational diabetes and less likely to have a low birth weight (OR 0.6) or small for gestational age infant (OR 0.8) independent of hypertension or preterm delivery. CONCLUSION: Overweight adolescent women are at increased risk for adverse neonatal and perinatal outcomes. With rates of overweight increasing at all ages, overweight in the gravid adolescent is a pressing perinatal and public health concern.