Poster Session I ajog.org

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Third and fourth degree perineal lacerations: are they agood care quality marker?Alexander Friedman1, Cande Ananth1, Eri Prendergast1,Mary D’Alton1, Jason Wright11ColumbiaUniversityMedical Center, Obstetrics andGynecology, NewYork,NYOBJECTIVE: 3rd and 4th degree vaginal lacerations have been proposedas a marker of inpatient obstetric care quality. We examined thepatterns and predictors of 3rd and 4th degree laceration in womenundergoing vaginal delivery.STUDY DESIGN: We identified a population-based cohort of women intheUSwhounderwent a vaginal delivery between 1998 and 2010 usingthe Nationwide Inpatient Sample. Multivariable log-linear regressionmodels were developed to account for patient, obstetric, and hospitalfactors related to lacerations. Between-hospital variability of lacerationrates was calculated using generalized log-linear mixed-models.RESULTS: Among 7,096,056 women who underwent vaginal delivery,3.3% of women (n¼232,762) had a 3rd degree laceration and 1.1%(n¼76,347) had a 4th degree laceration. In an adjusted model for 3rd

degree lacerations, important risk factors included nulliparity (riskratio [RR] 2.2, 95% confidence interval [CI] 1.6, 2.9), shoulderdystocia (RR 2.7, 95% CI 2.6, 2.8), forceps with and withoutepisiotomy (RR 10.6, 95% CI 10.3, 10.8 and RR 8.8, 95% CI 8.5, 9.1respectively), and vacuum delivery with and without episiotomy (RR7.4, 95% CI 7.3, 7.6 and RR 3.3, 95% CI 3.2, 3.4 respectively). Otherdemographic, obstetric, medical, and hospital variables were notmajor determinants of lacerations. Risk factors in a multivariablemodel for 4th degree lacerations were similar to those in the 3rd

degree model. Regression analysis of hospital rates (n¼3,070) oflacerations demonstrated limited variation. Between-hospital varia-tion in 3rd degree lacerations is displayed graphically in the Figure.CONCLUSION: Risk of 3rd and 4th degree laceration was most stronglyrelated to operative delivery, shoulder dystocia, and nulliparity. Hos-pital variation was limited. Given these findings and that the mostmodifiable practice related to lacerations would be reduction inoperative deliveries (and a possible increase in cesarean delivery) 3rd

and 4th degree laceration rates may be a quality metric of limited utility.

121 Clinical chorioamnionitis and uterine contractility

Alyssa Zackler1, Rori Dajao1, Pamela Flood2, Laura Goetzl11Temple University School of Medicine, Obstetrics & Gynecology,Philadelphia, PA, 2Stanford University, Anesthesiology, Perioperative and PainMedicine, Palo Alto, CAOBJECTIVE: Clinical chorioamnionitis (CHORIO) is associated withan increased risk of cesarean delivery (CD). We hypothesized thatthe development of hyperthermia and inflammation are followed bydecreased uterine contractility and cesarean delivery for labordysfunction.STUDY DESIGN: Retrospective data were abstracted by chart reviewfrom term subjects with CHORIO (T>100.4�F) concurrent with an

S78 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2

IUPC (Years 2009-12). Montevideo units (MVUs), oxytocin dose(OXY) and other clinical information were abstracted hourly at Time0 (first T>100.4�F) and in the 5 hour time blocks preceding andfollowing. Uterine contractility with respect to time before fever, andtime after fever were analyzed with linear regression independently.The results were adjusted for oxytocin dose and parity with a mixedeffects model using the R programing language.RESULTS: 100 subjects were enrolled. Mean gestational age was 39.9� 1.2 weeks, median BMI was 31.5 (20-61), 86% were nulliparous,17% were GBS+, and 99% received epidural analgesia. The final CDrate was 69%; 68% of CD was for dysfunctional labor. Funisitis wasdetected in 35.9% of samples sent (23/64). Uterine contractilitysignificantly and steadily declined starting on average two hoursfollowing CHORIO Dx (p¼0.03, Figure 1). The mean adjusteddecrease was 6.9 � 3.2 MVU/hr. Waning contractility was not due tofalling OXY dosing, which remained flat. Oxytocin increasedcontractility 0.6 � 0.1 MVU/unit before the diagnosis of CHORIOand 0.4 � 0.1 MVU/unit after diagnosis (p<0.001).CONCLUSION: CHORIO is associated with a subsequent degradationin uterine contractility and a substantial rate of CD for labordysfunction. Oxytocin is significantly less effective at stimulatinguterine contractility following CHORIO. These data provideimportant guidance for intrapartum management; close attentionshould be given to assiduously maintaining adequate uterine con-tractions following a diagnosis of CHORIO. The likelihood of suc-cessful vaginal delivery appears to decrease over time.

Figure 1. Uterine contractility and oxytocin dose relative to hoursfrom diagnosis of intrapartum fever

122

The microbiome of the placenta is altered amongsubjects with severe chorioamnionitis & spontaneous pretermbirthAmanda Prince1, Jun Ma1, Paranthaman Kannan2,Manuel Alvarez2, Tate Gisslen2, Kathleen Antony1,Christine Knox3, Alan Jobe2, Claire Chougnet2, Suhas Kallapur2,Kjersti Aagaard11Baylor College of Medicine, Houston, TX, 2Cincinnati Children’s HospitalMedical Center, Cincinnati, OH, 3Queensland University of Technology,Brisbane, QLD, AustraliaOBJECTIVE: Chorioamnionitis (IAI) is frequently associated withpreterm birth, and has long been associated with the presence ofbacteria in the placenta. We have recently demonstrated that theplacenta harbors a unique microbiome, which can be robustlycharacterized employing metagenomics. Here, we aimed to examinethe differences in the placental microbiome in association withpreterm birth and IAI.STUDY DESIGN: This was a cross-sectional analysis with six nestedspontaneous birth cohorts (n¼9-15 subjects/cohort, Table 1 & Fig.

015

ajog.org Poster Session I

1A): Term spontaneous birth without IAI (Cohort 1), term with IAI(Cohort 2), preterm without IAI (Cohort 3), preterm with mild IAI(Cohort 4), preterm with severe IAI (Cohort 5), and pretermspontaneous birth with IAI and funisitis (Cohort 6). Clean sampleswere obtained with sterile placental swabs immediately at delivery,and DNAwas extracted (MoBio) and whole genome shotgun (WGS)metagenomic sequencing was performed on the Illumina HiSeqplatform. Filtered microbial DNA sequences were annotated andanalyzed using MG-RAST and R.RESULTS: The mean GA for spontaneous preterm infants was 35.1,while term was 39.6 weeks (p<0.05). We observed distinct clusteringof placental microbial communities among preterm subjects withand without severe IAI (Fig. 1B, p¼0.07) and associated bacterialmetabolic pathways were significantly altered between pretermsubjects with and without severe IAI (Kendall’s rank correlation, Fig.1C). Surprisingly, these alterations in metabolism were not associ-ated with detectable Ureaplasma parvum and Mycoplasma hominis(bacterial species previously reported as associated with pretermbirth).CONCLUSION: Consistent with ours and others prior findings, womenwho experience spontaneous preterm labor harbor placentalmicrobiota which differed by virtue of severity of IAI. Integrativemetagenomic analysis revealed significant variation in distinct bac-terial metabolic pathways, which we speculate may contribute to riskof preterm birth with severe IAI.

Table 1. Cross-sectional cohorts.

Figure 1. Subjects with chorioamnionitis have a distinct placentalmicrobiome. (A) Histology (H&E) of placental sections from the sixcohorts described in Table 1. (B) Principle coordinates analysis(PCoA) of preterm subjects without no (blue), mild (yellow), orsevere (red) chorioamnionitis. (C) Inferred metabolic pathwayanalysis of preterm subjects with and without chorioamnionitis.Increase in metabolic functions is indicated by red while a decrease isindicated by blue. Red boxes indicate a significant difference (p <0.05) in the metabolic pathways associated with the bacterial taxa onthe left.

Supplem

123

Preexisting maternal depression confers increased riskof neonatal morbidityAmanda Yeaton-Massey1, Teresa Sparks2, Aaron Caughey31Stanford University School of Medicine, Department of Obstetrics &Gynecology, Stanford, CA, 2University of California, San Francisco, Divisionof Maternal-Fetal Medicine, Obstetrics & Gynecology, Pediatrics-Genetics,San Francisco, CA, 3Oregon Health & Science University, Obstetrics &Gynecology, Portland, OROBJECTIVE: To determine the relationship between maternaldepression and adverse neonatal outcomes.STUDY DESIGN: This is a retrospective cohort study of all womendelivering singleton non-anomalous gestations (N¼2,039,870) in thestate of California between 2005 and 2008. Rates of intrauterine fetaldemise (IUFD), preterm delivery (PTD), small for gestational age(SGA), large for gestational age (LGA), fetal anomaly, shoulderdystocia, asphyxia, respiratory distress syndrome (RDS), jaundice,grade 3-4 intraventricular hemorrhage (IVH), necrotizing entero-colitis (NEC), neonatal death (NND), and infant death wereexamined for women with and without depression. Univariate an-alyses were performed with the chi-squared test. Multivariable lo-gistic regression was used to control for potential confounding.RESULTS: Rates of IUFD, PTD, LGA, fetal anomaly, shoulderdystocia, asphyxia RDS, IVH, NEC, and NND were higher forwomen with a history of depression compared to those withoutdepression (table). On multivariable analyses, maternal depressionconferred higher odds of IUFD (1.5 [1.14-2.08]), fetal anomaly (1.4[95% CI 1.35-1.50]), PTD < 37 weeks (1.2 [1.17-1.30]), PTD <34weeks (1.3 [1.13-1.39]), PTD < 32 weeks (1.2 [1.06-1.41]), asphyxia(1.7 [1.19-2.49]), and RDS (1.4 (1.25-1.68]), after adjusting forgestational age, maternal age, education, parity, comorbidities suchas chronic hypertension and diabetes, ethnicity, prenatal care, in-surance status, and drug use.CONCLUSION: Maternal depression is an important predictor of riskfor a number of adverse neonatal outcomes, including IUFD, fetalanomaly, preterm delivery, asphyxia, and respiratory distress.

Maternal depression and risk of adverse neonataloutcome

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Is depression a predictor of cesarean delivery?Amanda Yeaton-Massey1, Teresa Sparks2, Aaron Caughey31Stanford University School of Medicine, Department Obstetrics &Gynecology, Stanford, CA, 2University of California, San Francisco, Divisionof Maternal-Fetal Medicine, Obstetrics & Gynecology, Pediatrics-Genetics,San Francisco, CA, 3Oregon Health & Science University, Obstetrics &Gynecology, Portland, OROBJECTIVE: To determine the relationship between depression andmode of delivery.STUDY DESIGN: This is a retrospective cohort study of all womendelivering singleton non-anomalous gestations (N¼2,039,870) in thestate of California between 2005 and 2008. Rates of primary cesarean(CS) were examined for women with and without depression andwere stratified by parity and gestational age. Univariate analyses wereperformed with the chi-squared test. Multivariable logistic regressionwas used to control for confounding.

ent to JANUARY 2015 American Journal of Obstetrics & Gynecology S79

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