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Time of delivery and neonatal morbidity and mortality
SMFM Abstracts S177 622 THE RELATIONSHIP BETWEEN SELF-REPORTED AND BIOLOGIC MEASURES OF STRESS IN LOW-INCOME, REPRODUCTIVE AGE WOMEN ANN BRYANT (F)1, WILLIAM GROBMAN1, LAURA AMSDEN2, JANE HOLL3, 1Northwestern University, Obstetrics and Gynecology, Institute for Healthcare Studies, Chicago, Illinois, 2 Northwestern University, Institute for Healthcare Studies, Chicago, Illinois, 3 Northwestern University, Pediatrics, Institute for Healthcare Studies, Chicago, Illinois OBJECTIVE: To determine if there is an association between self-reported and biologic measures of stress in low-income, reproductive age women. STUDY DESIGN: Between 1999 and 2005, randomly selected women from the 1998 welfare rolls in 9 Illinois counties were interviewed yearly to assess their psychosocial, socioeconomic, and health characteristics. Self-reported psychosocial stress was assessed with several indices, including: (1) external stressors index (e.g. life events, economic hardship, food security, hardship obtaining medical care, child with chronic illness, number of children in the home); (2) enhancers of stress index (e.g. depression, mental health, drug or alcohol use), (3) buffers against stress index (e.g. social support, community group involvement, church attendance, measure of hope, goals and coping); and (4) perceived stress index (e.g. perceived economic hardship, self-rated health, perceived neighborhood safety and perceived discrimination). In the final year, a dried blood spot sample was obtained from a subset of the women. The blood spots were analyzed for two stress biomarkers: Epstein-Barr virus antibody (EBV) and C-reactive protein (CRP) levels. RESULTS: 196 women provided a blood sample for analysis. There was no difference in mean EBV or CRP levels based on age, race, parity, employment, marital status or education. However, women who had the greatest degree of perceived discrimination had significantly elevated levels of EBV, (mean 175.6 C 71.5 vs. mean 132.5 C 71.7 ELISA units, p = .038). In addition, higher levels of CRP were seen in women with the fewest buffers against stress (mean 6.7 C 7.2 vs. mean 3.7 C 5.1 mg/L, p = .037). EBV and CRP levels were found to be highly correlated (p!.001). CONCLUSION: Some measures of self-reported psychosocial stress are associated with elevated levels of stress biomarkers in a low-income population of reproductive age women.
624 TIME OF DELIVERY AND NEONATAL MORBIDITY AND MORTALITY AARON B. CAUGHEY1, ADAM C. URATO2, MARI-PAULE THIET1, KATHRYN A. LEE3, A. EUGENE WASHINGTON1, RUSSELL K. LAROS JR1, 1University of California, San Francisco, Obstetrics, Gynecology, and Reproductive Sciences, San Francisco, California, 2Tufts University, Maternal-Fetal Medicine, Boston, Massachusetts, 3University of California, San Francisco, Family Health Care Nursing, San Francisco, California OBJECTIVE: To examine the association between time of delivery and neonatal outcomes. STUDY DESIGN: We conducted a retrospective cohort study of all term pregnancies delivered at our institution from 1976 to 2001. Time of delivery was categorized as day (7AM to 6PM) evening (6PM to 12MN) and late night (12MN to 7AM). Outcomes examined included 5 minute Apgar !7, umbilical artery pH!7.0, base excess ! ÿ12, admission to the ICN, and neonatal death (NND). We excluded patients delivered via cesarean delivery not in labor. Bivariate and multiple regression analyses were utilized for statistical analysis. We had greater than 80% power to detect a 25% difference in Apgar score, base excess and admission to the ICN and 80% power to detect a 50% difference in low pH. RESULTS: Among the 34,424 deliveries who met study inclusion criteria, 15,664 were during the day, 8,495 during the evening, and 10,265 were late night. When we controlled for obstetric history, demographics, mode of delivery, medical history, and labor characteristics, we found no differences in the rates of either neonatal morbidity or mortality (Table). CONCLUSION: At our institution, we could not demonstrate any statistically significant differences in neonatal morbidity or mortality by time of day among neonates delivered at term. These data can be used to counsel patients concerned about differences in time of delivery.
623 STATEWIDE IMPLEMENTATION OF PERINATAL RAPID HIV TESTING IN ILLINOIS ANN BRYANT (F)1, REBECCA EARY2, YOLANDA OLSZEWSKI3, ANNE STATTON4, MARDGE COHEN5, PATRICIA GARCIA1, 1Northwestern University, Obstetrics and Gynecology, Chicago, Illinois, 2University of Illinois at Chicago School of Public Health, Chicago, Illinois, 3Hektoen Institute, Chicago, Illinois, 4Chicago Pediatric AIDS Prevention Initiative, Chicago, Illinois, 5CORE Center, Cook County Bureau of Health Services, Medicine, Chicago, Illinois OBJECTIVE: In August 2003, Illinois passed the HIV Perinatal HIV Prevention Act mandating rapid HIV test counseling for all HIV-undocumented women in labor. The Perinatal Rapid Testing Initiative in Illinois (PRTII) was organized to implement this law in Illinois birthing hospitals. The objective was to determine how implementation strategies and hospital characteristics affected time to implementation of rapid HIV testing (RHT). STUDY DESIGN: Beginning July 2004, PRTII developed a hospital-specific implementation plan: conducting key players meetings, staff trainings, providing technical support and an implementation tool kit in each hospital. Pilot hospitals were selected to test if a less resource-intense implementation strategy affected time to RHT. Implementation tracking with monthly data collection was initiated in all hospitals. GIS mapping was used to track statewide progress. Time to implementation was linked to hospital demographics and compared across hospitals. RESULTS: All 133 birthing hospitals received rapid testing tool kits and key player meetings. Over 200 staff trainings were held, training over 5000 nurses in 127 hospitals. To date, RHT has started in 132/133 (99%) of hospitals. The 6 pilot hospitals provided full PRTII resources averaged 49 days to implementation; 4 hospitals with fewer PRTII resources averaged 189 days. For all hospitals, shorter mean time to RHT implementation was associated with: rural location (97 vs. 131 days, p = .005), greater percentage white patients (95 vs. 131 days, p = .004), lowest quartile births (92 vs. 132 days, p = .001) and Perinatal Level I status (82 vs. 129 days, p = .003). CONCLUSION: Statewide implementation of RHT in a timely manner is feasible using a hospital specific, resource-intense strategy. Within one year, 99% of Illinois birthing hospitals had implemented testing. While RHT was more readily implemented in small hospitals, those in rural locations and those with predominantly white populations; universal implementation is the key to eliminating missed opportunities to prevent perinatal transmission of HIV.
625 ETHNICITY AND SMALL FOR GESTATIONAL AGE: DOES THE PERINATAL MORBIDITY VARY? YVONNE W. CHENG (F)1, ALLISON S. BRYANT1, JUDITH H. CHUNG2, NAOMI E. STOTLAND1, LINDA M. HOPKINS1, AARON B. CAUGHEY1, 1University of California, San Francisco, Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California, 2University of California, Irvine, Obstetrics & Gynecology, Orange, California OBJECTIVE: Currently, most birthweight centiles are based on universal standardized thresholds regardless of patient race/ethnicity. We sought to determine whether perinatal morbidity varies by ethnicity for small for gestational age (SGA) infants. STUDY DESIGN: This is a retrospective cohort study of all SGA, term, singleton, deliveries at a single institution. Primary predictor was race/ethnicity and the outcomes examined included cesarean for fetal intolerance of labor (FIOL), umbilical artery pH !7.10 and base excess !ÿ10, and 5 minute Apgar score !7. RESULTS: Of the 27,240 women, 6.0% of Caucasians, 12.9% of AfricanAmericans, 6.1% of Latinas, and 8.5% of Asians had and SGA fetus (p!0.001). However, among the SGA neonates, there were differences in outcomes (Table). CONCLUSION: Depending on the outcome examined, Asians and AfricanAmerican SGA neonates were at lower risk than those of Caucasians and Latinas. Utilizing the same weight threshold to determine SGA for different racial/ethnic groups may not identify fetuses at similar risk for perinatal morbidity. Ethnicity specific thresholds should be devised and utilized by obstetricians.
Time of delivery and neonatal outcomes in term deliveries
5Min Apgar!7 UA pH !7.0 UA BE !ÿ12 ICN admit NND
Day (%)
Eve AOR, 95% CI
Late Night AOR, 95% CI
2.3% 0.8% 2.0% 3.7% 0.3%
0.8, 0.9, 1.2, 0.9, 0.8,
1.0, 0.9, 1.2, 0.9, 0.8,
0.7-1.1 0.6-1.3 0.9-1.6 0.8-1.1 0.4-1.5
0.8-1.2 0.6-1.3 0.9-1.5 0.8-1.1 0.5-1.4
Neonatal morbidity by ethnicity
CS for FIOL 5 min Apgar!7 UApH !7.1 UABE !ÿ10
Cauc
Afr Am
Latina
Asian
p-value
3.9% 5.3% 7.1% 9.3%
3.3% 5.3% 4.8% 5.2%
5.4% 5.0% 8.3% 8.6%
1.4% 2.6% 4.2% 4.8%
0.013 0.045 0.137 0.036
624 TIME OF DELIVERY AND NEONATAL MORBIDITY AND MORTALITY AARON B. CAUGHEY1, ADAM C. URATO2, MARI-PAULE THIET1, KATHRYN A. LEE3, A. EUGENE WASHINGTON1, RUSSELL K. LAROS JR1, 1University of California, San Francisco, Obstetrics, Gynecology, and Reproductive Sciences, San Francisco, California, 2Tufts University, Maternal-Fetal Medicine, Boston, Massachusetts, 3University of California, San Francisco, Family Health Care Nursing, San Francisco, California OBJECTIVE: To examine the association between time of delivery and neonatal outcomes. STUDY DESIGN: We conducted a retrospective cohort study of all term pregnancies delivered at our institution from 1976 to 2001. Time of delivery was categorized as day (7AM to 6PM) evening (6PM to 12MN) and late night (12MN to 7AM). Outcomes examined included 5 minute Apgar !7, umbilical artery pH!7.0, base excess ! ÿ12, admission to the ICN, and neonatal death (NND). We excluded patients delivered via cesarean delivery not in labor. Bivariate and multiple regression analyses were utilized for statistical analysis. We had greater than 80% power to detect a 25% difference in Apgar score, base excess and admission to the ICN and 80% power to detect a 50% difference in low pH. RESULTS: Among the 34,424 deliveries who met study inclusion criteria, 15,664 were during the day, 8,495 during the evening, and 10,265 were late night. When we controlled for obstetric history, demographics, mode of delivery, medical history, and labor characteristics, we found no differences in the rates of either neonatal morbidity or mortality (Table). CONCLUSION: At our institution, we could not demonstrate any statistically significant differences in neonatal morbidity or mortality by time of day among neonates delivered at term. These data can be used to counsel patients concerned about differences in time of delivery.
623 STATEWIDE IMPLEMENTATION OF PERINATAL RAPID HIV TESTING IN ILLINOIS ANN BRYANT (F)1, REBECCA EARY2, YOLANDA OLSZEWSKI3, ANNE STATTON4, MARDGE COHEN5, PATRICIA GARCIA1, 1Northwestern University, Obstetrics and Gynecology, Chicago, Illinois, 2University of Illinois at Chicago School of Public Health, Chicago, Illinois, 3Hektoen Institute, Chicago, Illinois, 4Chicago Pediatric AIDS Prevention Initiative, Chicago, Illinois, 5CORE Center, Cook County Bureau of Health Services, Medicine, Chicago, Illinois OBJECTIVE: In August 2003, Illinois passed the HIV Perinatal HIV Prevention Act mandating rapid HIV test counseling for all HIV-undocumented women in labor. The Perinatal Rapid Testing Initiative in Illinois (PRTII) was organized to implement this law in Illinois birthing hospitals. The objective was to determine how implementation strategies and hospital characteristics affected time to implementation of rapid HIV testing (RHT). STUDY DESIGN: Beginning July 2004, PRTII developed a hospital-specific implementation plan: conducting key players meetings, staff trainings, providing technical support and an implementation tool kit in each hospital. Pilot hospitals were selected to test if a less resource-intense implementation strategy affected time to RHT. Implementation tracking with monthly data collection was initiated in all hospitals. GIS mapping was used to track statewide progress. Time to implementation was linked to hospital demographics and compared across hospitals. RESULTS: All 133 birthing hospitals received rapid testing tool kits and key player meetings. Over 200 staff trainings were held, training over 5000 nurses in 127 hospitals. To date, RHT has started in 132/133 (99%) of hospitals. The 6 pilot hospitals provided full PRTII resources averaged 49 days to implementation; 4 hospitals with fewer PRTII resources averaged 189 days. For all hospitals, shorter mean time to RHT implementation was associated with: rural location (97 vs. 131 days, p = .005), greater percentage white patients (95 vs. 131 days, p = .004), lowest quartile births (92 vs. 132 days, p = .001) and Perinatal Level I status (82 vs. 129 days, p = .003). CONCLUSION: Statewide implementation of RHT in a timely manner is feasible using a hospital specific, resource-intense strategy. Within one year, 99% of Illinois birthing hospitals had implemented testing. While RHT was more readily implemented in small hospitals, those in rural locations and those with predominantly white populations; universal implementation is the key to eliminating missed opportunities to prevent perinatal transmission of HIV.
625 ETHNICITY AND SMALL FOR GESTATIONAL AGE: DOES THE PERINATAL MORBIDITY VARY? YVONNE W. CHENG (F)1, ALLISON S. BRYANT1, JUDITH H. CHUNG2, NAOMI E. STOTLAND1, LINDA M. HOPKINS1, AARON B. CAUGHEY1, 1University of California, San Francisco, Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California, 2University of California, Irvine, Obstetrics & Gynecology, Orange, California OBJECTIVE: Currently, most birthweight centiles are based on universal standardized thresholds regardless of patient race/ethnicity. We sought to determine whether perinatal morbidity varies by ethnicity for small for gestational age (SGA) infants. STUDY DESIGN: This is a retrospective cohort study of all SGA, term, singleton, deliveries at a single institution. Primary predictor was race/ethnicity and the outcomes examined included cesarean for fetal intolerance of labor (FIOL), umbilical artery pH !7.10 and base excess !ÿ10, and 5 minute Apgar score !7. RESULTS: Of the 27,240 women, 6.0% of Caucasians, 12.9% of AfricanAmericans, 6.1% of Latinas, and 8.5% of Asians had and SGA fetus (p!0.001). However, among the SGA neonates, there were differences in outcomes (Table). CONCLUSION: Depending on the outcome examined, Asians and AfricanAmerican SGA neonates were at lower risk than those of Caucasians and Latinas. Utilizing the same weight threshold to determine SGA for different racial/ethnic groups may not identify fetuses at similar risk for perinatal morbidity. Ethnicity specific thresholds should be devised and utilized by obstetricians.
Time of delivery and neonatal outcomes in term deliveries
5Min Apgar!7 UA pH !7.0 UA BE !ÿ12 ICN admit NND
Day (%)
Eve AOR, 95% CI
Late Night AOR, 95% CI
2.3% 0.8% 2.0% 3.7% 0.3%
0.8, 0.9, 1.2, 0.9, 0.8,
1.0, 0.9, 1.2, 0.9, 0.8,
0.7-1.1 0.6-1.3 0.9-1.6 0.8-1.1 0.4-1.5
0.8-1.2 0.6-1.3 0.9-1.5 0.8-1.1 0.5-1.4
Neonatal morbidity by ethnicity
CS for FIOL 5 min Apgar!7 UApH !7.1 UABE !ÿ10
Cauc
Afr Am
Latina
Asian
p-value
3.9% 5.3% 7.1% 9.3%
3.3% 5.3% 4.8% 5.2%
5.4% 5.0% 8.3% 8.6%
1.4% 2.6% 4.2% 4.8%
0.013 0.045 0.137 0.036