586 Severe maternal morbidity and management of major obstetric haemorrhage in Ireland Edel Manning 1 , Richard Greene 1 , Jennifer Lutomski 1 , Leanne O’Connor 1 , Paul Corcoran 1 1 University College, National Perinatal Epidemiology Centre, Department of Obstetrics & Gynaecology, Cork, Ireland OBJECTIVE: Severe maternal morbidity is an indicator of quality of care in the maternity services. For this reason, the National Perinatal Epidemiology Centre established the first national clinical audit of severe maternal morbidity in Ireland. STUDY DESIGN: Cases that occurred in 2011 in 19 of the country’ s 20 maternity units were reported. Fifteen categories of maternal morbidity were used in the case-definition criteria. Major obstetric haemorrhage (MOH) events and their management was also assessed (MOH was defined as blood loss>2,500ml, transfusion 5 units of blood or documented treatment for coagulopathy). RESULTS: Overall, 260 women experienced severe maternal morbidity, a national rate of 3.8 cases per 1,000 maternities. MOH was the most frequent type of morbidity (61.2% of cases) followed by ICU admission (42.7%). Previous Caesarean section, placenta praevia and/or morbidly adherent placenta were associated with MOH. The onset of haemorrhage usually occurred postpartum (63.9%), uterine atony was the commonest identified cause (42.8%) and Caesarean section was the mode of delivery in 67.1% of cases. The maternity units deemed the care they provided to be appro- priate for the vast majority of cases (85.8%). Nearly all units (94.7%) had a protocol for the management of MOH and management was in accordance with the local protocol in 94.8% of cases. CONCLUSION: The incidence of severe maternal morbidity in Ireland is similar or lower than comparable internationally figures. The good practice and learning points identified in the assessment of MOH cases may be useful on a national level to improve clinical care. 587 The effect of oocyte donation on pregnancy outcomes in IVF twin gestations Lucky Sekhon 1 , Rachel Gerber 2 , Andrei Rebarber 3 , Daniel Saltzman 3 , Chad Klauser 3 , Simi Gupta 3 , Nathan Fox 3 1 Icahn School of Medicine at Mount Sinai, Obstetrics, Gynecology, and Reproductive Science, New York, NY, 2 Weill Cornell Medical College, Obstetrics and Gynecology, New York, NY, 3 Maternal Fetal Medicine Associates, PLLC, New York, NY OBJECTIVE: To estimate the effect of oocyte donation on pregnancy outcomes in patients with twin pregnancies conceived via IVF. STUDY DESIGN: Cohort study of patients with IVF twin pregnancies delivered by one maternal-fetal medicine practice from 2005-2013. We compared outcomes between patients who had oocyte donation to age-matched controls using autologous oocytes. We excluded women over 50 years old as there were no age-matched controls over 50 using autologous oocytes. RESULTS: 112 patients were included, 56 with oocyte donors and 56 with autologous oocytes. The baseline characteristics were similar between the groups, including maternal age, race, parity, chorio- nicity, and comorbidities. The mean age was 43.0 +/- 6.0 vs. 41.9 +/- 1.7 years (p¼0.181). Pregnancy outcomes are shown in Table 1. There were no differences in outcomes between the groups in regards to preterm birth, birthweight or gestational diabetes. There was a greater incidence of gestational hypertension (32.1% vs. 13.0%, P¼0.018) and preeclampsia (28.3% vs. 13.0%, P¼0.05) in the group that underwent IVF with donor oocytes. CONCLUSION: In patients who conceive twin pregnancies using IVF, oocyte donation increases the risk of gestational hypertension and preeclampsia. However, this did not translate into increased rates of preterm birth or low birth weight. Patients who require oocyte donation should be carefully counseled regarding the increased risk for preeclampsia and gestational hypertension, but should be reas- sured that oocyte donation does not appear to lead to other adverse outcomes. Pregnancy outcomes in patients with IVF twin pregnancies, patients with donated oocytes vs. age-matched controls 588 Gestational weight gain targets are safely modified in obese women Rachael Overcash 1 , Andrew Hull 1 , Thomas Moore 1 , Yvette LaCoursiere 1 1 University of California San Diego, Reproductive Medicine, San Diego, CA OBJECTIVE: During pregnancy, obese women are advised to gain between 11-20 pounds, regardless of degree of obesity. We assessed gestational weight gain (GWG) in women with BMI 35 to deter- mine an inflection point that identifies women at risk of excess GWG. STUDY DESIGN: A prospective cohort study was performed on preg- nancies managed through the UC San Diego Maternal Weight and Wellness Program from 2011-2013. The independent variable was GWG category: inadequate (<11 lbs), adequate (11-20 lbs), and excessive (>20 lbs) weight gain based on IOM recommendations. Anthropometric, maternal, and neonatal factors were analyzed by ANOVA. RESULTS: 71 patients were included with a mean pre-pregnancy BMI of 41.9 8.9, and total GWG of 21.9 19 lbs. GWG in the first trimester was -0.1 6.4 lbs (0 lbs/wk), second trimester was 11.1 11.6 lbs (0.74 lbs/wk), and third trimester was 12.2 7.9 lbs (1.1 lbs/wk). The primary cesarean delivery rate was 27.8%. Regarding GWG, 29.6% had inadequate, 19.7% had adequate, and 50.7% had excessive weight gains. www.AJOG.org Operative Obstetrics, Clinical Obstetrics, Intrapartum, Medical-Surgical Poster Session IV Supplement to JANUARY 2014 American Journal of Obstetrics & Gynecology S289
Transcript
www.AJOG.org Operative Obstetrics, Clinical Obstetrics, Intrapartum, Medical-Surgical Poster Session IV
586 Severe maternal morbidity and management of major
obstetric haemorrhage in IrelandEdel Manning1, Richard Greene1, Jennifer Lutomski1,Leanne O’Connor1, Paul Corcoran11University College, National Perinatal Epidemiology Centre, Department ofObstetrics & Gynaecology, Cork, Ireland
OBJECTIVE: Severe maternal morbidity is an indicator of quality ofcare in the maternity services. For this reason, the National PerinatalEpidemiology Centre established the first national clinical audit ofsevere maternal morbidity in Ireland.STUDY DESIGN: Cases that occurred in 2011 in 19 of the country’s 20maternity units were reported. Fifteen categories of maternalmorbidity were used in the case-definition criteria. Major obstetrichaemorrhage (MOH) events and their management was alsoassessed (MOH was defined as blood loss>2,500ml, transfusion �5units of blood or documented treatment for coagulopathy).RESULTS: Overall, 260 women experienced severe maternalmorbidity, a national rate of 3.8 cases per 1,000 maternities. MOHwas the most frequent type of morbidity (61.2% of cases) followedby ICU admission (42.7%). Previous Caesarean section, placentapraevia and/or morbidly adherent placenta were associated withMOH. The onset of haemorrhage usually occurred postpartum(63.9%), uterine atony was the commonest identified cause (42.8%)and Caesarean section was the mode of delivery in 67.1% of cases.The maternity units deemed the care they provided to be appro-priate for the vast majority of cases (85.8%). Nearly all units (94.7%)had a protocol for the management of MOH and management wasin accordance with the local protocol in 94.8% of cases.CONCLUSION: The incidence of severe maternal morbidity in Irelandis similar or lower than comparable internationally figures. The goodpractice and learning points identified in the assessment of MOHcases may be useful on a national level to improve clinical care.
587
The effect of oocyte donation on pregnancy outcomes inIVF twin gestationsLucky Sekhon1, Rachel Gerber2, Andrei Rebarber3,Daniel Saltzman3, Chad Klauser3, Simi Gupta3, Nathan Fox31Icahn School of Medicine at Mount Sinai, Obstetrics, Gynecology, andReproductive Science, New York, NY, 2Weill Cornell Medical College,Obstetrics and Gynecology, New York, NY, 3Maternal Fetal MedicineAssociates, PLLC, New York, NY
OBJECTIVE: To estimate the effect of oocyte donation on pregnancyoutcomes in patients with twin pregnancies conceived via IVF.STUDY DESIGN: Cohort study of patients with IVF twin pregnanciesdelivered by one maternal-fetal medicine practice from 2005-2013.We compared outcomes between patients who had oocyte donationto age-matched controls using autologous oocytes. We excludedwomen over 50 years old as there were no age-matched controls over50 using autologous oocytes.
Supplem
RESULTS: 112 patients were included, 56 with oocyte donors and 56with autologous oocytes. The baseline characteristics were similarbetween the groups, including maternal age, race, parity, chorio-nicity, and comorbidities. The mean age was 43.0 +/- 6.0 vs. 41.9 +/-1.7 years (p¼0.181). Pregnancy outcomes are shown in Table 1.There were no differences in outcomes between the groups inregards to preterm birth, birthweight or gestational diabetes. Therewas a greater incidence of gestational hypertension (32.1% vs.13.0%, P¼0.018) and preeclampsia (28.3% vs. 13.0%, P¼0.05) inthe group that underwent IVF with donor oocytes.CONCLUSION: In patients who conceive twin pregnancies using IVF,oocyte donation increases the risk of gestational hypertension andpreeclampsia. However, this did not translate into increased rates ofpreterm birth or low birth weight. Patients who require oocytedonation should be carefully counseled regarding the increased riskfor preeclampsia and gestational hypertension, but should be reas-sured that oocyte donation does not appear to lead to other adverseoutcomes.
Pregnancy outcomes in patients with IVF twinpregnancies, patients with donated oocytesvs. age-matched controls
588 Gestational weight gain targets are safely modified in
obese womenRachael Overcash1, Andrew Hull1, Thomas Moore1,Yvette LaCoursiere11University of California San Diego, Reproductive Medicine, San Diego, CA
OBJECTIVE: During pregnancy, obese women are advised to gainbetween 11-20 pounds, regardless of degree of obesity. We assessedgestational weight gain (GWG) in women with BMI �35 to deter-mine an inflection point that identifies women at risk of excessGWG.STUDY DESIGN: A prospective cohort study was performed on preg-nancies managed through the UC San Diego Maternal Weight andWellness Program from 2011-2013. The independent variable wasGWG category: inadequate (<11 lbs), adequate (11-20 lbs), andexcessive (>20 lbs) weight gain based on IOM recommendations.Anthropometric, maternal, and neonatal factors were analyzed byANOVA.RESULTS: 71 patients were included with a mean pre-pregnancy BMI of41.9 �8.9, and total GWG of 21.9 �19 lbs. GWG in the first trimesterwas -0.1 �6.4 lbs (0 lbs/wk), second trimester was 11.1 �11.6 lbs(0.74 lbs/wk), and third trimester was 12.2 �7.9 lbs (1.1 lbs/wk). Theprimary cesarean delivery rate was 27.8%. Regarding GWG, 29.6% hadinadequate, 19.7% had adequate, and 50.7%had excessive weight gains.
ent to JANUARY 2014 American Journal of Obstetrics & Gynecology S289
Poster Session IV Operative Obstetrics, Clinical Obstetrics, Intrapartum, Medical-Surgical www.AJOG.org
There was a significant difference between the rates of GWG pertrimester between groups (Table 1). By 12-14 weeks women whosubsequently exceeded end-pregnancy GWG had the greatest gain inthe second trimester. Hypertension, diabetes, mode of delivery, birthweight, and neonatal length of stay were not different between groups.At six weeks post-partum, those with inadequate GWG had a meanweight loss of 14�7.4 lbs from their pre-pregnancy weight, those withadequate GWG return returned to their pre-pregnancy weight (0.75�8.8 lbs) and those with excessive GWG were 13.8 �14.6 lbs abovepre-pregnancy weight (p<0.001).CONCLUSION: Obese women at risk for excessive GWG may beidentified as early as 12-14 weeks and are at most risk of GWGduring the second trimester. Excessive GWG is associated with sig-nificant post-partum weight retention. In closely supervised womenwith BMI �35, GWG <11 lbs is not associated with adversematernal or neonatal outcomes, and in fact results in increased post-partum weight loss.
589 Using pattern-recognition software to evaluate
OBJECTIVE: Visual interpretation of FHR is vulnerable to humanerror. Our purpose was to evaluate the association between neonataloutcome and intrapartum FHR characteristics using computerizedpattern-recognition.STUDY DESIGN: Secondary analysis of data from a multi-center trial ofintrapartum fetal monitoring in nulliparous women with singleton�36 weeks. The final 60 mins of stored digital FHR (scalp electrode)were analyzed by PeriCALM Patterns. Files missing >30 mins beforedelivery were excluded. The outcome was a composite of either 5-min Apgar <4, umbilical artery pH <7.0, seizure, intubation atdelivery, stillbirth, neonatal death, or NICU >48 hrs. Prediction ofoutcome was evaluated using ROC curves with incremental additionof FHR characteristics. Classification and regression tree (CART)analysis was used to segment the population into meaningful sub-groups. Adjustment for the presence of preeclampsia was included assurrogate for magnesium use.RESULTS: 4,208 patients were included. Several characteristics wereassociated with the outcome (Table). While very few had variability<5 bpm, average variability was lower in cases vs. controls. Accel-erations were associated with better outcomes, while prolongeddecelerations were associated with worse outcomes. Late and variabledecelerations were common and not associated with the outcome.Prediction was significantly improved after addition of prolongeddeceleration (p¼0.0007), followed by %time in acceleration(p¼0.006), and variability in the last 15 mins (p¼0.02; Figure).CART analysis revealed that only prolonged deceleration providedsignificant differentiation.CONCLUSION: FHR pattern-recognition software discriminates be-tween fetuses with vs. without adverse outcome. Criteria used forvisual interpretation of FHR, such as minimal variability, may not beapplicable when using computerized assessment. Decelerations are
S290 American Journal of Obstetrics & Gynecology Supplement to JANUARY
common and not discriminatory, unless prolonged. Accelerationsand variability are other useful features.
590
Very advanced maternal age (45+ years) and associatedobstetrical morbiditiesAlex Fong1, Allison Serra1, Deyu Pan2, Dotun Ogunyemi3,David Lagrew4
1University of California, Irvine, Obstetrics and Gynecology, Orange, CA,2Charles Drew University of Medicine and Science, Center for Health ServicesResearch, Los Angeles, CA, 3David Geffen School of Medicine, Los Angeles,CA, 4Saddleback Memorial Medical Center, Laguna Hills, CA, Obstetrics andGynecology, Los Angeles, CA
OBJECTIVE: To describe trends over time and identify antepartum anddelivery-related morbidities of very advanced maternal age (VAMA)pregnancies.STUDY DESIGN: This is a retrospective cohort study using all Cali-fornia deliveries from 2001-2009. We defined the VAMA cohort asthose deliveries to a subject aged >¼45 years. Comparisons weremade against subjects aged <45 years. We used a logistic regressionmodel to control for confounders.RESULTS: Of 4.4 million deliveries during the study period, 8,680were to VAMA subjects, giving a prevalence of 1 in 510 cases. Theincidence of VAMA deliveries increased over time, from 1.7 per1,000 deliveries in 2001 to 2.3 per 1,000 in 2009. VAMA subjects hadhigher rates of pre-existing diabetes, cardiac disease, asthma, obesity,thyroid disease, and chronic hypertension.
VAMA subjects had more than a 7-fold higher rate of multiplegestations (15.1%) compared to their younger counterparts (1.9%).They also had significantly higher rates of placenta previa (OR 3.57,95% CI 3.15-4.04), gestational diabetes (OR 2.75, 95% CI 2.60-2.92), severe preeclampsia (OR 2.49, 95% CI 2.19-2.82), stillbirth(OR 2.00, 95% CI 1.65-2.41), abruption (OR 1.80, 95% CI 1.54-2.09), fetal growth restriction (OR 1.33, 95% CI 1.16-1.52), andpreterm delivery (OR 1.22, 95% CI 1.14-1.31). Cesarean deliverieswere performed in more than half of VAMA subjects (52.1%) versus28.9% of non-VAMA subjects. There were higher risks of failedinduction (OR 1.70, 95% CI 1.49-1.95), failed operative vaginaldelivery (OR 2.27, 95% CI 1.86-2.76), and postpartum hemorrhage(OR 1.43, 95% CI 1.28-1.59). There was an 8-fold higher risk ofhysterectomy (OR 7.92, 95% CI 5.67-11.05) as well as higher odds ofmaternal death (OR 2.76, 95% CI 1.01-7.56).CONCLUSION: VAMA subjects have worse pre-pregnancy health andtheir pregnancies are complicated by increased obstetrical morbidityacross the board. These findings should be an integral part of dis-cussion with a VAMA subject during pre-conception or prenatalcounseling.
