Poster Session IV ajog.

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spontaneous PTB. Our primary exposure was self-reported sh 669 Hypertensive disorders of pregnancy -
intake (servings/week) at time of enrollment (16-22.9 weeks gesta- unrecognized risk factors for post-cesarean wound
tion; before randomization). Maternal pre-pregnancy BMI was complications
categorized as lean (BMI < 25 kg/m2) overweight (25-29.9 kg/m2) Marcela Carolina Smid, Jessica McPherson, Sarah K. Dotters-Katz,
and obese (
30 kg/m2). The primary outcome was PTB (<37, <35 Matthew Grace, Tracy A. Manuck, David M. Stamilio,
or <32 weeks). Maternal demographics and clinical characteristics Kim A. Boggess
were compared by BMI category in bivariate analysis. An interaction University of North Carolina - Chapel Hill, Chapel Hill, NC
term to assess the effect modication of associations between sh OBJECTIVE: Women who develop hypertensive disorders of
intake and PTD by BMI category (Breslow Day test). Logistic pregnancy (HDP) (gestational hypertension (GHTN), preeclampsia
regression was used to estimate the odds of PTD by sh intake (pre-e), eclampsia, HELLP) have reduced colloid oncotic pressure
within each BMI group, after adjustment for potential confounders: and capillary leakage with uid shifts from intravascular to inter-
number of prior PTB, maternal age, and race/ethnicity. stitial spaces, including subcutaneous tissue. Our objective was to
RESULTS: 852 women met inclusion criteria. 47% of women were measure the association between hypertensive disorders of preg-
lean, 25% overweight and 28% obese. Median sh intake for obese nancy (HDP) and post-cesarean wound complications.
women was 1 serving/wk (interquartile range (IQR) 1, 1.5); over- STUDY DESIGN: This is a secondary retrospective cohort analysis of
weight and lean women consumed 0.5 serving/wk (IQR 0, 1.5) the MFMU Cesarean Registry of women undergoing cesarean de-
(p0.03). Maternal BMI was a signicant effect modier of livery (CD). The exposure was dened as HDP, and included GHTN,
the association between sh intake and recurrent PTB (p0.04) pre-e, HELLP or eclampsia. The primary outcome was wound
(Figure 1). Among lean women, greater sh intake was associated complication, dened as having at least one of the following: wound
with decreased risk of recurrent PTB<37, <35 and < 32 weeks infection, seroma, hematoma, dehiscence with or without eviscera-
(Table 1). However among obese women, greater sh intake was tion, necrotizing fasciitis, sepsis, wound debridement, or wound-
associated with higher odds of PTB. related hospital readmission. Outcomes among women with HDP
CONCLUSION: Among women with
1 prior spontaneous PTB, were compared using non-parametric test for trend across ordered
maternal BMI modies the association between sh intake and PTB groups. Logistic regression was performed to estimate the adjusted
risk. Although obese women consumed more sh, higher intake was odds ratio (AOR) for wound complication. We included in the
associated with a higher risk of PTB. model a priori maternal obesity (BMI
30 kg/m2), pre-gestational
Odds Ratio (OR) estimate of recurrent PTB for a one serving increase in fish per week by maternal ob or GDM, and presence of labor as confounders and included other
Fish intake serving/week (continuous) P value (1) confounders based on change-in-estimate of > 10% on AOR.
Lean Overweight Obese
RESULTS: Of the 47,184 women in the cohort, 6488 (14%) had HDP:
PTD <37 wks 0.89 (0.76 - 1.05) 0.94 (0.71-1.24) 1.34 (1.02-1.78) 0.04
PTD <35 wks 0.92 (0.76 - 1.11) 1.05 (0.83-1.32) 1.45 (1.06-1.71) 0.05
1628 GHTN, 4405 pre-e; and 455 HELLP/eclampsia. Compared with
PTD <32 wks 0.87 (0.68-1.12) 1.03 (0.77-1.38) 1.47 (1.12-1.93) 0.02 women without HDP, wound complication was more frequent
Models adjusted for number of prior PTB, maternal age, and race/ethnicity among women with HDP (1.8 vs. 3.4%, p<0.001, AOR 1.49, 95%
(1) Test of OR homogeneity by maternalBMI category
CI 1.26-1.77). When stratied by HDP-disease type, wound
complication was most frequent among women with HELLP/
eclampsia (Table 1). Compared to women without HDP, after
adjusting for a priori risk factors and also preterm delivery, blood
transfusion, and chorioamnionitis, women with pre-e or HELLP/E
but not GHTN had higher odds of wound complication (Figure 1).
CONCLUSION: Compared to women without HDP, women with pre-
eclampsia or HELLP/eclampsia are at increased risk of post-cesarean
wound complication. This data may help inform preventive inter-
ventional studies aimed at reducing wound complication risk in this
high-risk group.
Post-cesarean wound complications in women with hypertensive disorders of pregnancy (HDP) n = 47,184
No HDP Gestational HTN Pre-eclampsia HELLP/eclampsia p value
n = 39,965 n=1628 n=4405 n=455
n(%) n(%) n(%) n(%)
Any wound complication 721 (1.8) 44 (2.7) 148 (3.3) 27 (5.9) <0.001
Infection 250 (0.6) 15 (0.9) 40 (0.9) 6 (1.7) 0.002
Seroma 152 (0.4) 10 0.6) 28 (0.6) 6 (1.7) <0.001
Hematoma 107 (0.3) 11 (0.7) 32 (0.7) 15 (3.9) <0.001
Dehiscence or eviseration 69 (0.2) 4 (0.3) 19 (0.4) 5 (1.4) <0.001
Necrotizing fascisitis 5 (0.01) 1 (0.1) 1 (0.02) 0 0.47
Sepsis 58 (0.2) 4 (0.3) 17 (0.4)4 (0.9) 4 (0.9) <0.001
Wound readmission 211 (0.5) 9 (0.6) 39 (0.9) 2 (0.4) 0.01

S392 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2017

ajog.org
670 Is there an association between attempted
external cephalic version and neonatal morbidity?
Moeun Son, Archana Roy, William A. Grobman, Emily S. Miller
Northwestern University, Feinberg School of Medicine, Chicago, IL
OBJECTIVE: External cephalic version (ECV) can be complicated by
fetal bradycardia, abruption, or cord prolapse leading to adverse
neonatal outcomes. However the alternative to ECV, expectant
management, also carries risks associated with an unscheduled
presentation in labor with a non-cephalic fetus. We sought to
examine whether, in the setting of non-cephalic presentation,
women who undergo an ECV attempt have greater neonatal
morbidity than those who do not and are expectantly managed.
STUDY DESIGN: A retrospective cohort study of women with non-
anomalous singleton gestations in non-cephalic presentation deliv-
ering at a tertiary care institution from 2006-2016. Women
attempting ECV at
37 weeks were compared to those who did not
undergo an ECV attempt with a noncephalic neonate and delivered
at
37 weeks. The primary outcome was a composite neonatal
morbidity including stillbirth, neonatal death within 72 hours, Apgar
score <5 at 5 minutes, cord artery pH <7.0 or base decit
12
mmol/L, or neonatal brain cooling. Secondary outcomes were
neonatal intensive care unit (NICU) admission and neonatal anemia
(Hgb <13.5 g/dL). Bivariable analyses and multivariable logistic
regression were performed.
RESULTS: Of a total of 4117 women, 1262 (30.7%) attempted ECV;
508 (40.3%) of these attempts successfully converted the fetus to
cephalic presentation. In bivariable analyses, women who attemp-
ted ECV were more likely to be non-Hispanic white and multip-
arous, and had a lower mean body mass index at delivery. The
composite neonatal morbidity outcome did not differ signicantly
between the groups. The frequencies of NICU admission and
neonatal anemia were also similar (Table). After adjusting for
potential confounders, ECV attempt was still not signicantly
associated with composite neonatal morbidity (aOR 1.02, 95% CI
0.66-1.35). Using an alpha of 0.05, we had 80% power to detect a
minimum relative risk of 1.7 for composite neonatal morbidity
associated with ECV attempt.
CONCLUSION: Compared to expectant management, an ECV attempt
at
37 weeks is not associated with increased neonatal morbidity.
Supplement to JANUARY 2017 American Journal of Obstetrics & Gynecology
Poster Session IV
671 A randomized controlled trial comparing two
post cesarean analgesia protocols: long acting
spinal morphine versus fixed time interval oral
analgesia
Enav Yefet1, Salih Nassar1, Yulia Carmeli2, Manal Massalha1,
Michael Rudin3, Jamal Hasanein4, Noah Zafran1,5,
Zohar Nachum1,5
1
Obstetrics and Gynecology, Emek Medical Center, Afula, Israel, 2Obstetrical
Anesthesiology Unit, Department of Anesthesiology, Emek Medical Center,
Afula, Israel, 3Department of Anesthesiology, Emek Medical Center, Afula,
Israel, 4Neonatology Department, Emek Medical Center, Afula, Israel,
5
Rappaport Faculty of Medicine, Technion, Haifa, Israel
OBJECTIVE: To compare the efcacy of two methods of analgesia for
post cesarean pain: long acting spinal morphine Vs xed time in-
terval oral analgesia.
STUDY DESIGN: Women who underwent cesarean section with
bupivacaine (10 mg) spinal anesthesia were randomly assigned to
receive in addition, either 25 mcg fentanyl (short acting analgesia) or
150 mcg morphine (long acting analgesia). In the maternity
department women who received fentanyl were treated with oral
doses of tramadol, paracetamol and diclofenac at predetermined
regular intervals of 6 hours for the rst 48 hours (oral analgesia
group). If the patient requested additional analgesia, percocet
(oxycodone and paracetamol) was given. Women who received
spinal morphine did not routinely receive oral analgesia unless
requested, using the same medications (except for percocet) and
order (spinal morphine group). The primary outcome was the
number of breakthrough events of moderate to severe pain (dened
as a score
4 in a 0 to 10 visual analog scale (VAS)). Additional
outcomes were satisfaction scores, the quality of breastfeeding, and
maternal and neonatal adverse effects. A sample size of 85+15%
drop out for each group was calculated assuming a 25% reduction in
the average number of breakthrough pain events from 41 to 31
in the oral analgesia group vs the spinal morphine group (5% 2-
sided alpha, 90% power).
RESULTS: Baseline characteristics of the oral analgesia group
(N98) and the spinal morphine group (N95) were similar.
Compared with the oral analgesia group, patients in the spinal
morphine group had fewer breakthrough events of moderate to
severe pain (table), particularly between 6-18 hours after the
womans arrival to the maternity department (gure). The time until
the rst event was longer as well (gure). However, the spinal
morphine group had more adverse events of pruritus, nausea and
vomiting. Satisfaction scores were high and comparable between the
groups. No adverse events were reported for the neonates.
CONCLUSION: Spinal morphine was associated with fewer events of
pain breakthrough but higher rates of adverse events compared with
xed time interval oral analgesia. Since both protocols received high
S393