Maternal and neonatal outcomes by attempted mode of operative ...

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1Mount Sinai Hospital, Obstetrics and Gynaecology, Toronto, ON, Canada. OBJECTIVE: Compared with first twins, second twins born at term or late preterm are ...
Poster Session IV

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722 Maternal and neonatal outcomes by attempted mode of operative delivery during the second stage of labor in term singleton gestations

Torre Halscott1, Uma Reddy2, Helain Landy4, Patrick Ramsey1, Sara Iqbal1, Jim Huang3, Katherine Laughon Grantz2

1 MedStar Washington Hospital Center; MedStar Georgetown University Hospital, Obstetrics and Gynecology, Washington, DC, 2Eunice Kennedy Shriver National Institute for Child Health and Human Development, NIH, Bethesda, MD, 3MedStar Health Research Institute, Biostatistics and Epidemiology, Hyattsville, MD, 4MedStar Georgetown University Hospital, Obstetrics and Gynecology, Washington, DC

721 Neonatal mortality and morbidity in early premature second twin

Elad Mei-Dan1, Jyotsna Shah1, Anne Synnes1, Sandesh Shivananda1, Greg Ryan1, Prakeshkumar Shah1, Kellie Murphy1 1

Mount Sinai Hospital, Obstetrics and Gynaecology, Toronto, ON, Canada

OBJECTIVE: Compared with first twins, second twins born at term or

late preterm are known to be at increased risk of adverse neonatal outcomes. The aim of this study was to determine the effect of birth order on neonatal morbidity and mortality in a population of very preterm twin pregnancies. STUDY DESIGN: A retrospective cohort study using data from the Canadian Neonatal Network, between 2005 and 2012. Risk of mortality and adverse outcomes of second twins relative to first-born co-twins were examined by matched-pair analysis. Main outcomes measures included: a composite outcome of neonatal death or one of the following severe injuries, intraventricular haemorrhage, periventricular leukomalacia, bronchopulmonary dysplasia, retinopathy of prematurity (ROP), Necrotizing enterocolitis. Furthermore a multivariable analysis was performed to control for the, following covariates: gestational age, small for gestational age (SGA), gender and SNAPII score>20. RESULTS: In total 6636 twin pregnancies, born between 24-32 weeks of gestation, were included in this analysis. There was no difference in the composite outcome between the second and the first-born twin (Odd ratio [OR] 1.07, 95% confidence interval [CI] 0.95, 1.20). Furthermore, the mortality rate was higher for the first twins compared to the second twins (5.3% vs. 4.3%, p¼0.02). The rate of SGA was higher in the second twins compared to the first twins (6.0 vs. 10.3, p¼0.01). In a multivariable analysis, being the first born twin was found to be an independent predictor for neonatal death (OR 0.75; 95% CI 0.59, 0.95), whereas being the second born twin was associated with ROP and respiratory distress syndrome (OR 1.46; 95% CI 1.07, 2.01 and OR 1.40, 95% CI 1.29, 1.52, respectively). There was no association between birth order and other adverse outcomes. CONCLUSION: In very preterm twins, the second twin is not at greater risk of neonatal death or severe neurologic injury as compared to the first. This is in contrast to the supported literature for the outcomes of term and late preterm second twins.

OBJECTIVE: To evaluate attempted mode of operative delivery in the second stage of labor and adverse outcomes. Investigating attempted as opposed to actual route of delivery better approximates prospective clinical decision making in such patients. STUDY DESIGN: In the Consortium on Safe Labor we included 2729 singleton, vertex deliveries  37 weeks with attempted operative vaginal or cesarean delivery who reached low station ( +2/3 or +3/ 5). Rates and adjusted odds ratios (aOR) with 95% confidence intervals (CI) of morbidities associated with attempted forceps (FD) or vacuum assisted vaginal (VAVD) compared to cesarean delivery (CD, referent) were calculated controlling for maternal race, insurance status, and site. RESULTS: In nulliparas, attempted FD was associated with decreased postpartum hemorrhage; attempted VAVD with decreased endometritis; and both attempted FD and attempted VAVD with lower risk of wound complications (Table 1). In multiparas, both attempted FD and VAVD were associated with decreased blood transfusion as well as occurrence of the overall composite outcome (Table 1). For neonatal outcomes, both attempted FD and attempted VAVD were associated with decreased neonatal ICU admission, and attempted FD with lower rates of sepsis, respiratory morbidity, and overall composite (Table 2). In multiparas, attempted FD was associated with decreased birth trauma. CONCLUSION: Attempted FD and VAVD as compared to CD in the second stage were associated with decreased maternal and neonatal risks, particularly blood loss related and short term infectious morbidities. The major strength of our study was the ability to compare attempted, rather than actual, mode of delivery at a low station, which has been a significant limitation of studies that included all second stage cesarean deliveries as a referent group. A trial of operative vaginal delivery as an alternative to CD from a low station demonstrated improved maternal and neonatal outcomes in this diverse cohort.

Supplement to JANUARY 2015 American Journal of Obstetrics & Gynecology

S351

Poster Session IV

ajog.org 723 Outcomes of late preterm pregnancies complicated by gestational diabetes mellitus and polyhydramnios

Vanessa Lee1, Richard Burwick1, Rachel Pilliod2, Brian Shaffer1, Yvonne Cheng3, Aaron Caughey1

1 Oregon Health & Science University, Obstetrics and Gynecology, Portland, OR, 2Brigham and Women’s Hospital, Obstetrics and Gynecology, Boston, MA, 3University of California, Davis, Obstetrics and Gynecology, Sacramento, CA

OBJECTIVE: Polyhydramnios is seen more commonly in pregnancies

with gestational diabetes and thought to be associated with worse glycemic control. This study investigates the association between polyhydramnios and perinatal outcomes in women with gestational diabetes (GDM). STUDY DESIGN: This is a retrospective cohort study of linked vital statistics and hospital discharge data among births in California between 2005 and 2008. Singleton, nonanomalous, late preterm pregnancies (34-37 weeks’ gestation) complicated by GDM were eligible for this analysis. The exposure of interest was polyhydramnios. Outcomes included birthweight, respiratory distress syndrome, neonatal jaundice, hypoglycemia, stillbirth, and infant mortality. To compare outcomes, we used bivariate statistics (chisquare) and multivariate logistic regression, controlling for age, parity, gestational age, ethnicity, socioeconomic status, and substance abuse. RESULTS: 11,853 women were included in our sample. There were no significant differences in the proportions of stillbirths between groups. Women with polyhydramnios had higher odds of large for gestational age (odds ratio [OR] 4.1, 95% confidence interval [CI] 2.87-5.85), macrosomia (OR 4.94, 95% CI 3.54-6.90), jaundice (OR 1.39, 95% CI 1.03-1.87), hypoglycemia (OR 2.44, 95% CI 1.06-5.68), and infant death (OR 8.19, 95% CI 2.3828.16). GDM pregnancies complicated by polyhydramnios also had higher proportions of respiratory distress syndrome, although this did not remain statistically significant after controlling for key confounders. CONCLUSION: In late preterm pregnancies with GDM, polyhydramnios is associated with greater odds of neonatal morbidities and infant mortality. These associations should be considered in managing GDM pregnancies, and further investigations into polyhydramnios as a marker for poor glycemic control are warranted.

724 Third-trimester growth ultrasound vs fundal height screening for small for gestational age: a decision analysis Vanessa Lee1, Sarah Little2, Teresa Sparks3, Aaron Caughey1 1

Oregon Health & Science University, Obstetrics and Gynecology, Portland, OR, 2Brigham & Women’s Hospital, Obstetrics and Gynecology, Boston, MA, 3 University of California, San Francisco, Obstetrics and Gynecology, San Francisco, CA

OBJECTIVE: The purpose of this study was to determine whether third-trimester growth ultrasound (US) or fundal height

S352 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2015