$110

101

SMFM Abstracts

MACROSOMIA: EXPECTANT MANAGEMENT VERSUS LABOR INDUC- TION: A META-ANALYSIS LUIS SANCHEZ-RAMOS 1, SARA BERNSTEIN 1, 1 University of Florida, Obstetrics & Gynecology, Jacksonville, FL

OBJECTIVE: Compared with labor induction, expectant managenlent has been repor ted to reduce cesarean delivmT~ rates and prevent adverse maternal and neonatal outcomes in patients wit1 nmcrosomia. However, the quality of the support ing evidence has not been rigorously evaluated.

STUDY DESIGN: We conducted a meta-analysis of observational studies in which pat ients with macrosomia were m a n a g e d expectantly or underwen t prophylact ic labor induct ion. These studies were analyzed for mode ot' delivery, rates of shoulder dystocia, and abnormal Apgar scores. We calculated an estimate of the odds rat io for b inary outcomes utilizing r a n d o m (Der- Sirmonian and Laird) and fixed-effects (Mantel-Haenszel) models. Homoge- neity was tested across the studies. Whenever statistical analyses revealed significant he terogenei ty [P < .10], random-eftects results were repor ted . Publication bias was assessed by funnel plot analysis (Egger).

RESULTS: We identified 27 observational studies that initially met our inclusion criteria. After the exclusion of 18 studies without relevant outconm data, there were 9 with binary outcomes (involving 3,402 pat ients with a median of 90 patients per study). As compared with labor induct ion , the cesarean delivery rate was significantly decreased with expectant managelnent (8.4% vs 17.3%; M-H pooled OR 0.37, 95%CI 0.28, 0.47). Similarly, expectant nmuagement was associated with a significantly iucreased rate of spontaneous vaginal delivery (82.8% vs 71.6%; OR 2.31, 95%CI 1.51, 3.53). No significant differences were no ted for rates of shoulder dystocia, operative vaginal delivery, or abnormal Apgar scores bem,een the two study groups.

CONCLUSION: Patients with suspected fetal macrosomia should be given the opportuni ty to await the spontaneous onset of labor.

103

December 2001 A m J Obstet Gynecol

ANXIETY TRENDS AND PATTERNS AMONG WOMEN CONSIDERING MFPR DAVID W. BR1TT, PhD 1, SAMANTHA RISINGER, MPH 2, MARY MANS, BA '2, MARK I. EVANS, MD3: IMCP H a h n e m a n n University, Obstetrics & Gynecology, Philadelphia. PA; "-'Wayne State University, Depar tmen t of Sociology, Detroit, M[; 3MCP H a h n e m a n n University, Obstetrics/Gynecology, Philadelphia, PA

OBJECTIVE: We assess the variation over time in sell:reported anxiety in women using fertility therapy and then choosing MFPR as a potential resolu- tion.

STUDY DESIGN: 66 multi-gestation women cons ider ing MFPR were asked to consider how anxious they were on a scale of "0" to "9" when they first started fertility therapy. Using that level of anxiety as a reference point, they then assessed their anxiety levels at di t terent points in their pregnancy. Boxplots were used to describe the variation and the tightness with which cases cluster a round the medians of each situational anxiety sell:report. The shape or course of anxiety across time was tested with the repeated-measures variant of the general linear model.

RESULTS: Boxplots of self-reported anxiety across time displayed considerable variation. On average, there was a considerable drop in anxiety with pregnancy diagnosis. Patients' anxiety shot back up to very high levels with the diagnosis of carrying multiples. Their anxiety then modera ted again on average with consultation, rose up dur ing the course of the procedure , and finally r educed to lower levels on average af ter the p rocedure was over. Repeated measures testing of the shape of this course reveals several statistically significant alterations in shape, with a five-order shape being highly significant

CONCLUSION: We conclude that multi-gestation women exper ience considerable fluctuations in their level of anxiety from the time that they first start fertility therapy until they f ind out that they are carrying umlt iple embryos. Their expectat ions for the future of having a family seem at last fldfilled (getting pregnant ) , become complicated (with nmltiples), appear salvageable (with consultat ion), but with a morally complicated resolution (MFPR), that seems at last to have put the pregnancy hack on a normal track (post-MFPR).

102 EXPECTANT MANAGEMENT OF THE QUADRUPLET PREGNANCY: IN- PATIENT OR OUTPATIENT? J O H N ELLIOTT 1, NIKI ISTWAN 2, DEBBIE JACQUES 2, SUZANNE COLEMAN ~, GARY STANZIANO2; 1Good Samaritan Regional Medical Center, Dept of Maternal /Feta l Medicine, Phoenix, AZ; 2Matria Healthcare, Clinical Research Dept, Marietta, GA

OBJECTIVE: To compare pregnancy outcome and costs of quadruple t gestations (QUADS) managed with inpat ient (IP) versus outpa t ien t (OP) observation.

STUDY DESIGN: A perinatal database was queried to identify' QUADS that enrolled for OP contraction monitor ing (OCM) at <26.0 weeks' gestation. 2 groups were identified: l) women with elective hospitalization (HSP) IP group, and 2) women with OP obsmwation and episodic HSP OP group. A cost model was applied to compare charges incurred fbr antepar tmn (AP) IP and OP care. Analysis was conducted using independent t and Fisher's Exact tests.

RESULTS: 144 women were identified. 25 tIP gronp) had elective HSP for the remainder of pregnancy beginning at a mean of 22.6 _+ 2.2 weeks, while 119 were OP with HSP for complications. Maternal demographics and cerclage usage were similar between the groups. Rates were similar to t preterm labor and delivery (PTLD) (60.0% IP, vs. 64.6% OP), hypertensive (HTN) disorders (8.0% IP, vs. 13.4% OP), and elective delivery (20.0% IP. vs. 12.6% OP). 52.1% of OPs received oral a n d / o r subcutaneous tocolysis. Data presented as mean _+ SD or percentage as indicated in Table. Birth weight (BW) presented fi)r live- born infants only.

CONCLUSION: Elective HSP does not improve outcome in QUADS when compared to OP managenten t with OCM, and is associated with excessive mean cost per patient of $30,270. OP manageumnt is also associated with a statistically significant better chance of delivery at >32 weeks. Table

IP (N = 25) O P (N = 119) P V A L U E

OCM start (wks) 19.8 + 2.3 20.6 -+ 2.2 .085 HSP days 49.1 + 21.6 13.3 _+ 16.7 <.001 Delivery (wks) 30.3 + 2.5 30.9 -+ 2.6 .289 >32 wks 16.0% (4) 42.9% (51) .013 BW (gins) 1316 + 384 1396 +_ 419 .(}85 AP costs ($) 49,920 + 23,431 19,650 _+ 16,503 <.001

104 INTRA-PATIENT CHANGES IN SALIVARY ESTRIOL AS A PREDICTOR OF PRETERM BIRTH JAMES MCGREGOR, MD, CM l, DONALD DYSON, MD2; IUniversity of Colorado Heal th Sciences Center, OB/GYN, Denver, CO: eKaiser Permanente Santa Clara Medical Center, Santa Clara, CA

OBJECTIVE: To assess the ability of salivary estriol (sE3) to predic t spontaneous pre term birth (PTB).

STUDY DESIGN: Results f rom two i n d e p e n d e n t studies to assess the eftectiveness sE3 in predic t ing PTB involved 1,806 patients present ing for prena ta l care. We sought to identit}' if the a m o u n t of sE3 rise between consecutive (1 or 2 weeks apart) n-masuremenLs predicted spontaneous PTB better than sE3 exceeding the s tandard threshold of 2 .1ng/ml.

RESULTS: In a study of 568 low risk women, the accuracy of SALEST in predicting sPTB at <35 weeks gestation was examined. Elnploying a cut-off of 2.1 ng /ml , SALEST had a sensitivity of 50%, specificity of 95%, PPV of 10%, NPV of 99%, RR of 18.6. An intra-patient rise over a 2-week per iod of 0.7 n g / m l had a sensitivity of 83%, specificity of 88%, PPV of 7%, NPV of 99%, RR of 33.4. Although highly significant (P < .001), the number of sPTB at <35 weeks was small (n = 6). In a study of 956 high and low risk women, 23 women delivered prior to 37 weeks gestation. An intra-patient rise over a I-week period of 0.4 n g / m l had a sensitivity of 68%, specificity of 60%, PPV of 6%, NPV of 98%. RR of 3.1, P < .001. Using a cut-off of 2.1 ng /ml , the senitivity was 57%.

CONCLUSION: Analysis of two separate diverse popula t ions were considered. All intra-patient weekly increase of 0.4 n g / m l sE3, or an increase of 0.7 n g / n d over 2-weeks demonstrated improved sensitivity and sensitivity in comparison with exceeding 2.1 ng /ml . Analysis of individual patient increases of sE3 can improve the accuracy of predic t ing spontaneous PTB a m o n g wonmn designated either low or increased risk.