672: General anesthesia at cesarean delivery portends worse maternal and neonatal outcomes
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671 Prevalence of obstructive sleep apnea (OSA) in pregnancy Kathleen Antony 1 , Alpna Agrawal 3 , Melanie Arndt 1 , Adrienne Murphy 1 , Philip Alapat 2 , Kay Guntupalli 2 , Kjersti Aagaard 1 1 Baylor College of Medicine, Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Houston, TX, 2 Baylor College of Medicine, Department of Pulmonary-Critical Care, Houston, TX, 3 University of Texas Health Science Center, Department of Medical Education, Houston, TX OBJECTIVE: While polysomnography (PSG) is the gold standard for di- agnosis of OSA, it is cumbersome and expensive to perform. Several ques- tionnaire-based scales for diagnosis have been developed and validated in non-pregnant subjects, namely the Berlin (BQ) and Epworth sleepiness scale (ESS). We sought to ascertain the validity of these scales in preg- nancy in order to establish the true prevalence of OSA in pregnancy. STUDY DESIGN: Following sample sized estimation based on pilot data, the BQ and ESS were administered to low and high-risk gravidae at initial presentation. Screen positive subjects were referred to a certi- fied sleep lab for PSG, and incentivization reimbursement was pro- vided. All subjects were tracked and, if admitted for antepartum care, underwent a modified sleep study (ResMed ApneaLin (AL) recording continuous pulse oximetry and nasal airflow). RESULTS: 1507 subjects were enrolled (results summarized in Fig.). The prevalence of subjects who screened positive varied by method (15.1% BQ, 19.0% ESS, and 30.1% by either BQ or ESS); screening positive on the BQ was significantly associated with screening positive on the ESS (p0.05). Neither the BQ nor ESS were reliable diagnositic measures for OSA by either AL or PSG (ROC 0.45 for BQ, ROC 0.55 for ESS). Despite incentivization, written and verbal contact, and flex- bile scheduling, 86.8% of subjects did not undergo diagnostic testing. Among 13.2% received PSG or AL, neither the BQ nor ESS were pre- dictive of OSA and a higher than expected AL-negative rate was ob- served (92.6%). Among those screen positive subjects undergoing PSG or AL testing, 14.5% ultimately met OSA diagnostic criteria for an estimated point prevalence of 4.35%. CONCLUSION: In the largest reported prospective trial on OSA to date, we have observed that while screening by either Berlin or Epworth scales may be validated measures in non-pregnant subjects, it is poorly predictive among gravidae. These findings raise concern for studies which report OSA-linked outcomes without corroborating PSG diag- nostic criteria having been met. 672 General anesthesia at cesarean delivery portends worse maternal and neonatal outcomes Kathleen Brookfield 1 , Sarah Osmundson 1 , Mariam Naqvi 1 , Alexander Butwick 2 , Dierdre Lyell 1 1 Stanford University, Obstetrics & Gynecology, Stanford, CA, 2 Stanford University, Anesthesia, Stanford, CA OBJECTIVE: The cesarean delivery rate is more than 34% in the U.S., and is expected to continue to rise. Women undergo cesarean delivery under general anesthesia (GA) for several reasons, some of which may increase maternal and neonatal morbidities. We compared maternal and neonatal outcomes for women undergoing cesarean delivery un- der GA vs. other types of anesthesia (spinal, epidural, narcotics, and local) to assess the effect of anesthetic on outcome. STUDY DESIGN: A subset of women who underwent primary or repeat cesarean delivery were identified from the NICHHD MFMU Network registry, which collected data on pregnancy outcomes from patients at 19 centers from 1999-2002. We compared outcomes including time to delivery, birthweight, Apgars, need for prolonged ventilation, and maternal/neonatal death among patients receiving GA vs. other anes- thesia. RESULTS: 54,632 patients underwent cesarean, of whom 4,172 under- went GA and 50,460 underwent another type of anesthesia. Women who received GA were more likely to have an abruption, chorioam- nionitis, pulmonary edema, emergency cesarean, abnormal placenta- tion, maternal ICU admission and death, stillbirth, neonatal hypoten- sion, prolonged hypotonicity, and respiratory morbidity (p0.01). Although mean incision to delivery time was faster for women under- going GA (6.2 mins vs. 10.7 mins; p0.001), mean neonatal umbilical cord pH was lower (7.21 vs. 7.24; p0.001). When emergent cesare- ans were excluded (n365), a multilogistic regression model demon- strated that exposure to GA vs. other types of anesthesia was an inde- pendent predictor of 5 minute Apgar score 5 (p0.01), as was delivery at 32 weeks. In a second model including only women who received GA for non-emergent cesarean deliveries, prolonged inci- sion-to-delivery time ( 18 mins) was an independent predictor of 5 minute Apgar scores of 5 (p0.037). CONCLUSION: Multiple maternal and neonatal effects exist from the use of general anesthesia. Shortening the incision to delivery time may improve neonatal outcomes. 673 Postpartum depression signals ongoing health risks Loraine Endres 1 , Heather Straub 1 , Beth Plunkett 1 , Elizabeth Clark-Kauffman 2 , Kim Wagenaar 3 , Ying Zhou 2 , Sharon Ramey 4 , Madeleine Shalowitz for the Community Child Health Network 2 1 Northshore University HealthSystem, Obstetrics and Gynecology, Evanston, IL, 2 Northshore University HealthSystem, Research Institute, Evanston, IL, 3 Lake County Health Department, Primary Care Services, Waukegan, IL, 4 Virginia Tech Carilion School of Medicine, Research Institute, Roanoke, VA OBJECTIVE: Postpartum depression (PPD) is common and screening recommended as part of obstetric care. This abstract identifies other health risks from PPD in addition to concern for the new mother’s mental health. STUDY DESIGN: The sample of 822 women with depression screening at 1 yr postpartum (PP) by the Edinburgh Postnatal Depression Scale (EPDS) was drawn from 2510 participants in the NIH Community Child Health Network (CCHN), a national five-site, mixed urban, suburban and rural study of women 18-40 years of diverse backgrounds. CCHN was con- ducted according to principles of community-based participatory re- search to better understand multi-level sources of parental stress and resiliency on pregnancy outcomes. Participants were enrolled primar- ily in-hospital immediately following delivery. They were interviewed at 1, 6, and 12 mo PP. Medical records provided preconception and delivery information. A score 13 on the EPDS was considered high risk for PPD. RESULTS: The average EPDS score was 5 at each interview in the first year PP. 4.6% of women scored 13 at 1 mo, 5.2% at 6 mo, and 6.4% at 1 yr PP. Of women high risk on the EPDS at 1 mo, 20.5% remained 1507 subjects were eligible for inclusion Among the 454 women who screened positive on either the Berlin question- naire or the Epworth sleepiness scale, 60 had polysomnography or ApneaLink studies performed. Among the 54 subjects undergoing ApneaLink testing, 7.4% (n4) were diagnosed as OSA positive. Among the 8 subjects undergo- ing polysomnography testing, 62.5% were diagnosed as OSA positive. www.AJOG.org Academic Issues, Antepartum Fetal, Clinical Ob, Fetus, Genetics, Hypertension, Med-Surg-Diseases, Operative Ob, U/S Poster Session IV Supplement to JANUARY 2013 American Journal of Obstetrics & Gynecology S283
Transcript of 672: General anesthesia at cesarean delivery portends worse maternal and neonatal outcomes
671 Prevalence of obstructive sleep apnea(OSA) in pregnancyKathleen Antony1, Alpna Agrawal3, Melanie Arndt1, AdrienneMurphy1, Philip Alapat2, Kay Guntupalli2, Kjersti Aagaard1
1Baylor College of Medicine, Obstetrics and Gynecology, Division ofMaternal-Fetal Medicine, Houston, TX, 2Baylor College of Medicine,Department of Pulmonary-Critical Care, Houston, TX, 3University of TexasHealth Science Center, Department of Medical Education, Houston, TXOBJECTIVE: While polysomnography (PSG) is the gold standard for di-agnosisofOSA, it is cumbersomeandexpensive toperform.Severalques-tionnaire-based scales for diagnosis have been developed and validated innon-pregnant subjects, namely the Berlin (BQ) and Epworth sleepinessscale (ESS). We sought to ascertain the validity of these scales in preg-nancy in order to establish the true prevalence of OSA in pregnancy.STUDY DESIGN: Following sample sized estimation based on pilot data,the BQ and ESS were administered to low and high-risk gravidae atinitial presentation. Screen positive subjects were referred to a certi-fied sleep lab for PSG, and incentivization reimbursement was pro-vided. All subjects were tracked and, if admitted for antepartum care,underwent a modified sleep study (ResMed ApneaLin (AL) recordingcontinuous pulse oximetry and nasal airflow).RESULTS: 1507 subjects were enrolled (results summarized in Fig.).The prevalence of subjects who screened positive varied by method(15.1% BQ, 19.0% ESS, and 30.1% by either BQ or ESS); screeningpositive on the BQ was significantly associated with screening positiveon the ESS (p�0.05). Neither the BQ nor ESS were reliable diagnositicmeasures for OSA by either AL or PSG (ROC 0.45 for BQ, ROC 0.55for ESS). Despite incentivization, written and verbal contact, and flex-bile scheduling, 86.8% of subjects did not undergo diagnostic testing.Among 13.2% received PSG or AL, neither the BQ nor ESS were pre-dictive of OSA and a higher than expected AL-negative rate was ob-served (92.6%). Among those screen positive subjects undergoingPSG or AL testing, 14.5% ultimately met OSA diagnostic criteria foran estimated point prevalence of 4.35%.CONCLUSION: In the largest reported prospective trial on OSA to date,we have observed that while screening by either Berlin or Epworthscales may be validated measures in non-pregnant subjects, it is poorlypredictive among gravidae. These findings raise concern for studieswhich report OSA-linked outcomes without corroborating PSG diag-nostic criteria having been met.
672 General anesthesia at cesarean delivery portendsworse maternal and neonatal outcomesKathleen Brookfield1, Sarah Osmundson1, Mariam Naqvi1,Alexander Butwick2, Dierdre Lyell11Stanford University, Obstetrics & Gynecology, Stanford, CA, 2StanfordUniversity, Anesthesia, Stanford, CAOBJECTIVE: The cesarean delivery rate is more than 34% in the U.S.,and is expected to continue to rise. Women undergo cesarean deliveryunder general anesthesia (GA) for several reasons, some of which mayincrease maternal and neonatal morbidities. We compared maternaland neonatal outcomes for women undergoing cesarean delivery un-der GA vs. other types of anesthesia (spinal, epidural, narcotics, andlocal) to assess the effect of anesthetic on outcome.STUDY DESIGN: A subset of women who underwent primary or repeatcesarean delivery were identified from the NICHHD MFMU Networkregistry, which collected data on pregnancy outcomes from patients at19 centers from 1999-2002. We compared outcomes including time todelivery, birthweight, Apgars, need for prolonged ventilation, andmaternal/neonatal death among patients receiving GA vs. other anes-thesia.RESULTS: 54,632 patients underwent cesarean, of whom 4,172 under-went GA and 50,460 underwent another type of anesthesia. Womenwho received GA were more likely to have an abruption, chorioam-nionitis, pulmonary edema, emergency cesarean, abnormal placenta-tion, maternal ICU admission and death, stillbirth, neonatal hypoten-sion, prolonged hypotonicity, and respiratory morbidity (p�0.01).Although mean incision to delivery time was faster for women under-going GA (6.2 mins vs. 10.7 mins; p�0.001), mean neonatal umbilicalcord pH was lower (7.21 vs. 7.24; p�0.001). When emergent cesare-ans were excluded (n�365), a multilogistic regression model demon-strated that exposure to GA vs. other types of anesthesia was an inde-pendent predictor of 5 minute Apgar score �5 (p�0.01), as wasdelivery at �32 weeks. In a second model including only women whoreceived GA for non-emergent cesarean deliveries, prolonged inci-sion-to-delivery time (� 18 mins) was an independent predictor of 5minute Apgar scores of � 5 (p�0.037).CONCLUSION: Multiple maternal and neonatal effects exist from theuse of general anesthesia. Shortening the incision to delivery time mayimprove neonatal outcomes.
673 Postpartum depression signals ongoing health risksLoraine Endres1, Heather Straub1, Beth Plunkett1, ElizabethClark-Kauffman2, Kim Wagenaar3, Ying Zhou2, Sharon Ramey4,Madeleine Shalowitz for the Community Child Health Network2
1Northshore University HealthSystem, Obstetrics and Gynecology, Evanston,IL, 2Northshore University HealthSystem, Research Institute, Evanston, IL,3Lake County Health Department, Primary Care Services, Waukegan, IL,4Virginia Tech Carilion School of Medicine, Research Institute, Roanoke, VAOBJECTIVE: Postpartum depression (PPD) is common and screeningrecommended as part of obstetric care. This abstract identifies otherhealth risks from PPD in addition to concern for the new mother’smental health.STUDY DESIGN: The sample of 822 women with depression screening at 1yr postpartum (PP) by the Edinburgh Postnatal Depression Scale (EPDS)was drawn from 2510 participants in the NIH Community Child HealthNetwork (CCHN), a national five-site, mixed urban, suburban and ruralstudy of women 18-40 years of diverse backgrounds. CCHN was con-ducted according to principles of community-based participatory re-search to better understand multi-level sources of parental stress andresiliency on pregnancy outcomes. Participants were enrolled primar-ily in-hospital immediately following delivery. They were interviewedat 1, 6, and 12 mo PP. Medical records provided preconception anddelivery information. A score �13 on the EPDS was considered highrisk for PPD.RESULTS: The average EPDS score was 5 at each interview in the firstyear PP. 4.6% of women scored �13 at 1 mo, 5.2% at 6 mo, and 6.4%at 1 yr PP. Of women high risk on the EPDS at 1 mo, 20.5% remained
1507 subjects were eligible for inclusion
Among the 454 women who screened positive on either the Berlin question-naire or the Epworth sleepiness scale, 60 had polysomnography or ApneaLinkstudies performed. Among the 54 subjects undergoing ApneaLink testing,7.4% (n�4) were diagnosed as OSA positive. Among the 8 subjects undergo-ing polysomnography testing, 62.5% were diagnosed as OSA positive.
www.AJOG.org Academic Issues, Antepartum Fetal, Clinical Ob, Fetus, Genetics, Hypertension, Med-Surg-Diseases, Operative Ob, U/S Poster Session IV
Supplement to JANUARY 2013 American Journal of Obstetrics & Gynecology S283
