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Willingness or unwillingness to perform cesarean section for impending preterm delivery at 24 weeks gestation: A cost effectiveness analysis
SMFM Abstracts S109 369
PEROXISOME PROLIFERATOR-ACTIVATED RECEPTOR-GAMMA AND CYCLOOXYGENASE-2 EXPRESSION IN HUMAN PRETERM PARTURITION SAJU JOY1, WILLIAM ACKERMAN IV1, JAY IAMS1, DOUGLAS KNISS1, 1Ohio State University, Obstetrics and Gynecology, Columbus, Ohio OBJECTIVE: Peroxisome proliferator-activated receptor-g (PPAR-g) is a nuclear receptor shown to exert negative control over cyclooxygenase-2 (COX-2) gene expression in many cell types. A previous report from our group has shown that PPAR-g was reduced in fetal membranes following term labor. In this study, we evaluated the expression of PPAR-g in relation to COX-2 within intrauterine tissues in the setting of preterm human parturition. STUDY DESIGN: Fifty consecutive preterm deliveries at the Ohio State University Medical Center were enrolled from August to November 2003. Placental specimens were collected from women with preterm singleton pregnancies prior to labor (delivering via cesarean) or following labor (delivering either vaginally or by cesarean). Tissue specimens (amnion, choriodecidua, and villous trophoblast) were collected, prepared for immunoblotting and probed for PPAR-g and COX-2. RESULTS: Complete data are available for 36 participants with gestational ages ranging from 20 2/7 weeks to 36 5/7 weeks: 8 patients (22%) - no labor with cesarean delivery, 21 (58%) - labor with vaginal delivery and 7 (20%) - labor with cesarean delivery. Patient demographics include race and average maternal age: 24 Caucasians (27.9 years), 9 African-Americans (29.3 years), and 3 Hispanics (21.3 years). In a representative sample of 18 participants, COX-2 expression was elevated in trophoblast and choriodecidual specimens following preterm labor. Although present in amnion, COX-2 was not elevated compared to the non-laboring group. Variable expression of PPAR-g was observed in all tissues. Within participants who underwent labor, neither PPAR-g nor COX-2 expression was affected by route of delivery. CONCLUSION: These findings suggest that increased COX-2 expression in preterm deliveries is tissue-specific. Variability in PPAR-g expression may reflect heterogeneity among mechanisms for preterm birth. The route of delivery does not appear to affect PPAR-g or COX-2 expression in laboring patients.
371
WILLINGNESS OR UNWILLINGNESS TO PERFORM CESAREAN SECTION FOR IMPENDING PRETERM DELIVERY AT 24 WEEKS GESTATION: A COST EFFECTIVENESS ANALYSIS GIANINA CAZAN-LONDON1, ELLEN MOZURKEWICH2, XIAO XU2, SCOTT RANSOM2, 1University of Michigan, Obstetrics & Gynecology, Ann Arbor, Michigan, 2University of Michigan, Obstetrics and Gynecology, Ann Arbor, Michigan OBJECTIVE: To calculate the total and incremental cost effectiveness ratios for two management options when encountering a 24 weeks gestation in labor. STUDY DESIGN: A decision model using Precisiontree was constructed encompassing a decision branch for willingness and unwillingness to perform cesarean for fetal indications when confronted with a possibly viable 24 week pregnancy in labor. Four fetal outcomes were diagrammed: stillbirth, NICU death, survival with major deficits, and intact survival. Costs and outcome probabilities were determined from existing relevant peer reviewed publications. All costs were adjusted to 2004 dollars and included: neonatal hospitalization, burial for death, normal child rearing to age six, and lifetime interventions/ special education for infants with major disabilities. Cost effectiveness ratios and sensitivity analyses were performed to determine the optimal intervention to minimize the cost per intact and live (intact plus handicapped) infants. RESULTS: The costs per intact and live infant were minimized by unwillingness to perform cesarean section: $1,348,526 and $539,410 respectively. With willingness to perform a cesarean, costs were: $1,955,957 and $586,787 respectively. Incremental cost-effectiveness ratios were: $6,450,947 per intact and $679,047 per live infant. The analysis presented a 17.0% (1.1%-35.4%) versus 14.8% (0.5%-26.7%) probability of an intact survivor with willingness and unwillingness to perform cesarean section, respectively. CONCLUSION: Very preterm deliveries have exceptionally high risk of neonatal death or major handicaps among survivors. While the probability of producing an intact survivor is slightly improved with willingness to perform cesarean section, the most cost effective management option is unwillingness to perform cesarean section in the setting of a 24 weeks gestation in labor. This conclusion is strongly related to the increased probability of survival with major and costly morbidity when physicians are willing versus unwilling to perform cesarean section for impending delivery (39% versus 22%).
370
INFLAMMATORY MARKERS AND CERCLAGE OUTCOME ERIC KNUDTSON1, JENNIFER WRENN2, JAY IAMS3, LYNN SHAFFER2, GREG RICE4, 1University of Oklahoma, Obstetrics & Gynecology, Oklahoma City, Oklahoma, 2Riverside Methodist Hospital, Obstetrics and Gynecology, Columbus, Ohio, 3Ohio State University, Obstetrics and Gynecology, Columbus, Ohio, 4The Royal Women’s Hospital, Gynaecological Cancer Research Centre, Carlton, Victoria, Australia OBJECTIVE: We tested the hypothesis that cerclage outcomes will correlate with pre-surgical fibronectin (fFN) and systemic inflammatory markers. STUDY DESIGN: An observational study from 10/01 to 3/03. Blood and cervical fFN were obtained from singleton pregnancies at 11-24 weeks before non-emergent cerclage. Age, race, obstetrical history, pre and post cerclage cervical length, technique and pregnancy outcome were recorded. Women with indicated preterm birth (PTB) were excluded. fFN samples were stored & measured quantitatively in one lab. IL-2,4,6,8,10, GM-CSF, IFNg and TNFa serum concentrations were quantified by muliplex immunoassay (BioPlexÔ, BioRad Laboratories). Data were blinded to clinicians & evaluated with logistic regressions to identify factors associated with PTB ! 32 & 35 wks. RESULTS: 97 patients met criteria. A + fFn was related to PTB !32 and 35 wks (see table) & a shorter mean (SD) interval to delivery f14.9 (8.9) vs 18.8 (5.1) weeks (P = .079)g. Increased fFN values were significantly associated with PTB !32 (P = .024) and !35 weeks (P = .006) by c2 test for trend. The final regression model shows associations between + fFN, R2 abortions, black race, age !18 or R35 years and PTB !32 and !35 weeks. Cytokine levels were not related to preterm birth in any analyses. CONCLUSION: A positive fFN before cerclage is strongly associated with likelihood of early delivery.
372
OBSTETRIC OUTCOMES FOLLOWING SURGICAL ABORTION AT 20 WEEKS’ GESTATION STEPHEN CHASEN1, ROBIN B. KALISH1, MERUKA GUPTA1, FRANK A. CHERVENAK1, 1 Weill Medical College of Cornell University, Obstetrics and Gynecology, New York, New York OBJECTIVE: Our objective was to describe obstetric outcomes following Dilation and Evacuation (D&E) late in the second trimester, and to identify risk factors for subsequent spontaneous preterm birth (SPTB). STUDY DESIGN: Patients who had D&E at our hospital at R 20 weeks’ gestation from 1996-2003 and received subsequent prenatal care here were identified. Data obtained included indication for D&E, operative technique (disarticulation with forceps vs. intact D&E), and subsequent pregnancy outcomes. Relative risk (RR) of SPTB with 95% Confidence Intervals (CI) were calculated for various clinical factors. Logistic regression identified independent risk factors for SPTB. RESULTS: 118 pregnancies in 87 women were identified. 13 (11.0%) ended with early SAB, and 5 were electively terminated. There were no midtrimester losses. Of the remaining 100 pregnancies, 9 delivered prior to term, 2 for maternal indications in a women with SLE. The remaining 7 preterm births were due to SPTB. Those who underwent D&E due to midtrimester cervical dilation or PPROM were more likely to have subsequent SPTB (27.3 vs. 4.5%; RR = 6.1; 95% CI = 1.6-21.3). Those with a multifetal pregnancy in the subsequent pregnancy were also more likely to have SPTB (75% vs. 4.2%; RR = 18; 95% CI = 5.5-28.7). Those who underwent intact D&E had a 9.7% rate of SPTB, compared to a 5.8% rate for those those who underwent D&E using forceps (RR = 1.7; 95% CI = 0.43-6.4). In patients who underwent D&E for reasons other than midtrimester cervical dilation or PPROM, rates of SPTB were identical between those who had intact D&E and D&E using forceps (4.3% vs. 4.5%; RR = 0.96; 95% CI = 0.14-6.4). Logistic regression identified only D&E due to midtrimester cervical dilation or PPROM and subsequent multifetal pregnancy as independent risk factors for SPTB. CONCLUSION: In those who have undergone D&E at R 20 weeks, only a history of midtrimester cervical dilation or PPROM or a current multifetal pregnancy, all known risk factors, were associated with SPTB. A history of D&E late in the second trimester should not be considered a risk factor for SPTB.
Risk of delivering at !32 and !35 weeks Odds ratio !32 wk + fFN Hx R2 abortions Age !18 or R35 y Black race !35 wk + fFN Hx R2 abortions Age !18 or R35 y Black race
95% CI
9.33 4.73 5.77 3.16
2.35-37.06 1.31-17.09 1.04-32.17 0.82-12.20
13.05 3.43 2.67 3.65
3.51-48.56 1.13-10.46 0.52-13.80 1.10-12.10
P value .001 .017 .045 .094 ! .0001 .029 .242 .034
PEROXISOME PROLIFERATOR-ACTIVATED RECEPTOR-GAMMA AND CYCLOOXYGENASE-2 EXPRESSION IN HUMAN PRETERM PARTURITION SAJU JOY1, WILLIAM ACKERMAN IV1, JAY IAMS1, DOUGLAS KNISS1, 1Ohio State University, Obstetrics and Gynecology, Columbus, Ohio OBJECTIVE: Peroxisome proliferator-activated receptor-g (PPAR-g) is a nuclear receptor shown to exert negative control over cyclooxygenase-2 (COX-2) gene expression in many cell types. A previous report from our group has shown that PPAR-g was reduced in fetal membranes following term labor. In this study, we evaluated the expression of PPAR-g in relation to COX-2 within intrauterine tissues in the setting of preterm human parturition. STUDY DESIGN: Fifty consecutive preterm deliveries at the Ohio State University Medical Center were enrolled from August to November 2003. Placental specimens were collected from women with preterm singleton pregnancies prior to labor (delivering via cesarean) or following labor (delivering either vaginally or by cesarean). Tissue specimens (amnion, choriodecidua, and villous trophoblast) were collected, prepared for immunoblotting and probed for PPAR-g and COX-2. RESULTS: Complete data are available for 36 participants with gestational ages ranging from 20 2/7 weeks to 36 5/7 weeks: 8 patients (22%) - no labor with cesarean delivery, 21 (58%) - labor with vaginal delivery and 7 (20%) - labor with cesarean delivery. Patient demographics include race and average maternal age: 24 Caucasians (27.9 years), 9 African-Americans (29.3 years), and 3 Hispanics (21.3 years). In a representative sample of 18 participants, COX-2 expression was elevated in trophoblast and choriodecidual specimens following preterm labor. Although present in amnion, COX-2 was not elevated compared to the non-laboring group. Variable expression of PPAR-g was observed in all tissues. Within participants who underwent labor, neither PPAR-g nor COX-2 expression was affected by route of delivery. CONCLUSION: These findings suggest that increased COX-2 expression in preterm deliveries is tissue-specific. Variability in PPAR-g expression may reflect heterogeneity among mechanisms for preterm birth. The route of delivery does not appear to affect PPAR-g or COX-2 expression in laboring patients.
371
WILLINGNESS OR UNWILLINGNESS TO PERFORM CESAREAN SECTION FOR IMPENDING PRETERM DELIVERY AT 24 WEEKS GESTATION: A COST EFFECTIVENESS ANALYSIS GIANINA CAZAN-LONDON1, ELLEN MOZURKEWICH2, XIAO XU2, SCOTT RANSOM2, 1University of Michigan, Obstetrics & Gynecology, Ann Arbor, Michigan, 2University of Michigan, Obstetrics and Gynecology, Ann Arbor, Michigan OBJECTIVE: To calculate the total and incremental cost effectiveness ratios for two management options when encountering a 24 weeks gestation in labor. STUDY DESIGN: A decision model using Precisiontree was constructed encompassing a decision branch for willingness and unwillingness to perform cesarean for fetal indications when confronted with a possibly viable 24 week pregnancy in labor. Four fetal outcomes were diagrammed: stillbirth, NICU death, survival with major deficits, and intact survival. Costs and outcome probabilities were determined from existing relevant peer reviewed publications. All costs were adjusted to 2004 dollars and included: neonatal hospitalization, burial for death, normal child rearing to age six, and lifetime interventions/ special education for infants with major disabilities. Cost effectiveness ratios and sensitivity analyses were performed to determine the optimal intervention to minimize the cost per intact and live (intact plus handicapped) infants. RESULTS: The costs per intact and live infant were minimized by unwillingness to perform cesarean section: $1,348,526 and $539,410 respectively. With willingness to perform a cesarean, costs were: $1,955,957 and $586,787 respectively. Incremental cost-effectiveness ratios were: $6,450,947 per intact and $679,047 per live infant. The analysis presented a 17.0% (1.1%-35.4%) versus 14.8% (0.5%-26.7%) probability of an intact survivor with willingness and unwillingness to perform cesarean section, respectively. CONCLUSION: Very preterm deliveries have exceptionally high risk of neonatal death or major handicaps among survivors. While the probability of producing an intact survivor is slightly improved with willingness to perform cesarean section, the most cost effective management option is unwillingness to perform cesarean section in the setting of a 24 weeks gestation in labor. This conclusion is strongly related to the increased probability of survival with major and costly morbidity when physicians are willing versus unwilling to perform cesarean section for impending delivery (39% versus 22%).
370
INFLAMMATORY MARKERS AND CERCLAGE OUTCOME ERIC KNUDTSON1, JENNIFER WRENN2, JAY IAMS3, LYNN SHAFFER2, GREG RICE4, 1University of Oklahoma, Obstetrics & Gynecology, Oklahoma City, Oklahoma, 2Riverside Methodist Hospital, Obstetrics and Gynecology, Columbus, Ohio, 3Ohio State University, Obstetrics and Gynecology, Columbus, Ohio, 4The Royal Women’s Hospital, Gynaecological Cancer Research Centre, Carlton, Victoria, Australia OBJECTIVE: We tested the hypothesis that cerclage outcomes will correlate with pre-surgical fibronectin (fFN) and systemic inflammatory markers. STUDY DESIGN: An observational study from 10/01 to 3/03. Blood and cervical fFN were obtained from singleton pregnancies at 11-24 weeks before non-emergent cerclage. Age, race, obstetrical history, pre and post cerclage cervical length, technique and pregnancy outcome were recorded. Women with indicated preterm birth (PTB) were excluded. fFN samples were stored & measured quantitatively in one lab. IL-2,4,6,8,10, GM-CSF, IFNg and TNFa serum concentrations were quantified by muliplex immunoassay (BioPlexÔ, BioRad Laboratories). Data were blinded to clinicians & evaluated with logistic regressions to identify factors associated with PTB ! 32 & 35 wks. RESULTS: 97 patients met criteria. A + fFn was related to PTB !32 and 35 wks (see table) & a shorter mean (SD) interval to delivery f14.9 (8.9) vs 18.8 (5.1) weeks (P = .079)g. Increased fFN values were significantly associated with PTB !32 (P = .024) and !35 weeks (P = .006) by c2 test for trend. The final regression model shows associations between + fFN, R2 abortions, black race, age !18 or R35 years and PTB !32 and !35 weeks. Cytokine levels were not related to preterm birth in any analyses. CONCLUSION: A positive fFN before cerclage is strongly associated with likelihood of early delivery.
372
OBSTETRIC OUTCOMES FOLLOWING SURGICAL ABORTION AT 20 WEEKS’ GESTATION STEPHEN CHASEN1, ROBIN B. KALISH1, MERUKA GUPTA1, FRANK A. CHERVENAK1, 1 Weill Medical College of Cornell University, Obstetrics and Gynecology, New York, New York OBJECTIVE: Our objective was to describe obstetric outcomes following Dilation and Evacuation (D&E) late in the second trimester, and to identify risk factors for subsequent spontaneous preterm birth (SPTB). STUDY DESIGN: Patients who had D&E at our hospital at R 20 weeks’ gestation from 1996-2003 and received subsequent prenatal care here were identified. Data obtained included indication for D&E, operative technique (disarticulation with forceps vs. intact D&E), and subsequent pregnancy outcomes. Relative risk (RR) of SPTB with 95% Confidence Intervals (CI) were calculated for various clinical factors. Logistic regression identified independent risk factors for SPTB. RESULTS: 118 pregnancies in 87 women were identified. 13 (11.0%) ended with early SAB, and 5 were electively terminated. There were no midtrimester losses. Of the remaining 100 pregnancies, 9 delivered prior to term, 2 for maternal indications in a women with SLE. The remaining 7 preterm births were due to SPTB. Those who underwent D&E due to midtrimester cervical dilation or PPROM were more likely to have subsequent SPTB (27.3 vs. 4.5%; RR = 6.1; 95% CI = 1.6-21.3). Those with a multifetal pregnancy in the subsequent pregnancy were also more likely to have SPTB (75% vs. 4.2%; RR = 18; 95% CI = 5.5-28.7). Those who underwent intact D&E had a 9.7% rate of SPTB, compared to a 5.8% rate for those those who underwent D&E using forceps (RR = 1.7; 95% CI = 0.43-6.4). In patients who underwent D&E for reasons other than midtrimester cervical dilation or PPROM, rates of SPTB were identical between those who had intact D&E and D&E using forceps (4.3% vs. 4.5%; RR = 0.96; 95% CI = 0.14-6.4). Logistic regression identified only D&E due to midtrimester cervical dilation or PPROM and subsequent multifetal pregnancy as independent risk factors for SPTB. CONCLUSION: In those who have undergone D&E at R 20 weeks, only a history of midtrimester cervical dilation or PPROM or a current multifetal pregnancy, all known risk factors, were associated with SPTB. A history of D&E late in the second trimester should not be considered a risk factor for SPTB.
Risk of delivering at !32 and !35 weeks Odds ratio !32 wk + fFN Hx R2 abortions Age !18 or R35 y Black race !35 wk + fFN Hx R2 abortions Age !18 or R35 y Black race
95% CI
9.33 4.73 5.77 3.16
2.35-37.06 1.31-17.09 1.04-32.17 0.82-12.20
13.05 3.43 2.67 3.65
3.51-48.56 1.13-10.46 0.52-13.80 1.10-12.10
P value .001 .017 .045 .094 ! .0001 .029 .242 .034