ajog.

org Poster Session I

163 Obstetric management for prenatally

diagnosed fetal congenital heart defects
Breanne E. Bears, Shifa Turan, Chris R. Harman,
Ozhan M. Turan
University of Maryland School of Medicine, Baltimore, MD
OBJECTIVE: Studies of pregnancy complicated by fetal congenital
heart disease (CHD) show higher rates of Cesarean section (CS)
delivery in CHD diagnosed prenatally than in CHD diagnosed after
birth, suggesting provider knowledge of fetal CHD provokes a de-
cision for CS. We hypothesized there is no significant difference in
outcome for CHD babies delivered vaginally compared to those
delivered by CS.
STUDY DESIGN: Retrospective cohort study. Fetuses with CHD
diagnosed antenatally (2007-2016) were identified, excluding
chromosome abnormalities. Obstetric data assessed included:
initiation of labor (spontaneous onset or induction of labor
164 Risk factors for umbilical cord prolapse in
(IOL), route of delivery (vaginal and CS) and CS indication
(elective, CS in labor-maternal reasons, CS in labor-fetal reasons). women who underwent artificial rupture of
Immediate neonatal condition (Continuous variables Apgar score membranes
at 1 and 5min, umbilical artery cord (UA) pH; categorical vari- Tetsuya Kawakita1, Chun-Chih Huang2, Helain Landy3
1
ables Apgar5 <7 and UA pH <7.10) were related to obstetric MedStar Washington Hospital Center, Washington, DC, 2MedStar Health
Research Institute, Hyattsville, MD, 3MedStar Georgetown University
designation. Data were analyzed with Chi square and Mann-
Hospital, Washington, DC
Whitney U.
OBJECTIVE: Artificial rupture of membranes (AROM) is a com-
RESULTS: 266 CHD cases met inclusion criteria: 162 (61%)
mon obstetric intervention to shorten the length of labor. Risk
vaginal (VD) and 104 (39%) CS. CS indications were: elective 36
factors for cord prolapse such as station and cervical dilation at
(34.6%) maternal 22 (21.2%) and fetal 46 (44.2%). Of VD, 112
the time of AROM are not well known. The aim of the study
(69.1%) were IOL and 50 (30.9%) spontaneous. 109 women
was to examine the risk factors for cord prolapse at the time of
(41%) were nulliparous, 30 (11.3%) multiparous with previous
AROM.
CS, and 127 (47.8%) multiparous no previous CS. Primary CS
STUDY DESIGN: We conducted a retrospective cohort study using the
rate was 33%. Distribution of delivery route based on CHD type
data from the Consortium of Safe Labor study between 2002 and
is shown (Figure). CHD babies showed no clinical difference in
2008. We included women with cephalic presentation and singleton
median 1 & 5 minute Apgar scores between VD (8/9) and
pregnancies at 23 weeks gestation or greater who attempted a vaginal
overall CS (8/9) (p>0.05). Median UA pH was slightly lower in
delivery. We excluded women who did not undergo AROM or had
VD (7.26) than total CS group (7.22; p<0.001.). The CS group
an unknown cervical exam at the time of AROM. Bivariable analyses
was not at all homogeneous however. For example, mean UA pH
and multivariable logistic regression were used to identify factors
was 7.27 in elective, 7.21 in maternal, and 7.17 in fetal in-
associated with cord prolapse. Adjusted Odds ratios (aOR) with 95%
dications. Low Apgar5 occurred in 9/162 vaginal births, 3/36
confidence intervals (95%CI) were calculated, controlling for
elective CS, 3/21 maternal-CS and 8/47 fetal-CS in labor
maternal age, race/ethnicity, nulliparity, gestational age, body mass
(p¼0.0725 by Chi square). UA pH was < 7.10 in 3 vaginal
index, and cervical exam.
births and 3 elective CS, 1 maternal-CS but 9 fetal-CS (p
RESULTS: Of 71,646 women who underwent AROM, cord prolapse
<0.0002).
occurred in 146 (0.20%). Lower risks of cord prolapse were seen
CONCLUSION: Vaginal birth is the preferred route of delivery for
with cervical dilation 6 to 9.9 cm compared to <6 cm (aOR 0.56;
infants with CHD. Elective CS does not result in improved
95%CI 0.34-0.92) and with increasing gestational age (aOR 0.91;
neonatal condition. However, the small but significant risk of
95%CI 0.84-0.995). An increased risk of cord prolapse was seen with
neonatal depression after emergent CS for fetal reasons in labor
increasing maternal age (aOR 1.04; 95%CI 1.01-1.07). There was no
needs to be studied further, to optimize patient selection. Simply
statistically significant difference in cord prolapse regarding fetal
planning elective CS for prenatally-diagnosed CHD should be
station at the time of AROM comparing fetal station  0 or -2.5 to
discouraged.
-0.5 with station -3 or higher (aOR 1.08; 95%CI 0.54-2.17 and aOR
1.11; 95%CI 0.66-1.87, respectively).
CONCLUSION: Cord prolapse at the time of AROM was associated
with cervical dilatation <6 cm, increasing maternal age, and lower
gestational age. The risk of cord prolapse was not associated with
the fetal station at the time of AROM. Delaying AROM during
labor induction or augmentation until the cervix is  6 cm
dilated before performing AROM may lower the risk of cord
prolapse.

Supplement to JANUARY 2018 American Journal of Obstetrics & Gynecology S113

Poster Session I ajog.org

to delivery. Normal/overweight (NW, BMI 18.5-29.9), obese

(OB, BMI 30-39.9), morbidly obese (MO, BMI 40-49.9) and
super morbidly obese (SMO, BMI  50) women were
compared. The primary outcome was a composite of severe
maternal morbidity defined as death, ICU admission, ventilator
use, DVT/PE, sepsis, hemorrhage, transfusion, DIC, unplanned
operative procedure, or stroke. Cochran-Armitage test for trend
was used to evaluate the relationship between BMI and maternal
complications. Multivariate logistic regression was used to
determine the association between BMI and the composite
outcome, adjusting for chronic hypertension, preexisting dia-
betes, prior cesarean, parity, maternal age, race, ethnicity,
smoking and insurance
RESULTS: 110,127 women were included. Of these, 45,851 (41.6%)
were OB, 8633 (7.8%) were MO and 1487 (1.4%) were SMO. MO
and SMO were more likely to be multiparous and have diabetes,
hypertension and public insurance compared with NW women,
and were more likely to be smokers and to have had a prior
cesarean. SMO women were also more likely to be African-
Risk factors for cord prolapse. American. The trend of increased rates of induction, AF abnor-
Variables Adjusted OR 95%CI mality, malpresentation, cesarean delivery and pre-eclampsia/
Maternal age 1.04 1.01-1.07 eclampsia across BMI groups was statistically significant (Table 1).
Severe maternal morbidity was more common in OB, MO and
Race: Black (ref: White) 0.91 0.57-1.45
SMO compared with NW women, even after adjusting for
Race: Other/unknown (reference: White) 0.66 0.44-1.00
covariates (Table 2).
BMI > 30 (ref: BMI <25) 1.24 0.73-2.11 CONCLUSION: Obesity, morbid obesity, and super morbid obesity are
BMI 25-20.9(ref: BMI <25) 0.92 0.53-1.60 common in contemporary obstetric populations, and are associated
Nulliparas (ref: multiparas) 1.27 0.90-1.81 with increasing rates of serious maternal morbidity, even after
Gestational age 0.91 0.84-0.995
adjusting for other factors.
Station> 0 (ref: station -3 or higher) 1.08 0.54-2.17
Station-2.5 to -0.5 (ref: Station -3 or higher) 1.11 0.66-1.87
Effacement 80-100% (ref: Effacement 0-39%) 0.47 0.13-1.71
Effacement 60-79% (ref: Effacement 0-39%) 0.57 0.16-2.07
Effacement 40-59% (ref: Effacement 0-39%) 0.78 0.21-2.89
Dilation 10 cm (ref: Dilation 0-5.9 cm) 0.76 0.34-1.68
Dilation 6-9.9 cm (ref: Dilation 0-5.9 cm) 0.56 0.34-0.92

165 Maternal complications increase with

increasing severity of obesity
Mara J. Dinsmoor
for the Eunice Kennedy Shriver National Institute of Child Health and
Human Development, Maternal Fetal Medicine Units Network, Bethesda,
MD
OBJECTIVE: To assess the intrapartum and postpartum risks associ-
ated with increasing maternal obesity.
STUDY DESIGN: Secondary analysis of a cohort of deliveries on
randomly selected days at 25 hospitals from 2008-2011. Data on
comorbid conditions, intrapartum events, and postpartum
course were collected by trained abstractors. This analysis in-
cludes women with singleton deliveries  24 weeks. BMI was
calculated using maternal height and most recent weight prior

S114 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2018