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362 SPO Abstracts
308 lftPROVING LONG TER!! IlENTAL AIID IlEUROLOGIC ooTeOIES IN INFAHTS~ < 1~ G OVER PAST 5 YEARS. W. J. lorales, D. Hurford, S. Schorr, Orlando Regional ledical Center, Orlando, FL
Over 10 year period, 1981-1991, 1,605 infants < 1500 g were ad.i tted to NIeU and of these 8119 were born in the second half of the decade. lental and neurologic exuinations were perfoned on 60J infants at corrected one year of life, 300 born fro. 1986-19911. The .an birth weight was 796 g. for the first 5 years as cOlpared to 8119. While no significant ilprove.nt was achieved in the last 5 years in neonatal survivor (88 vs 851), ROS (59 vs 591), ROP (27 vs 221) and NEC (2 vs 21), there has been a significant decrease in the incidence of BPD (23 vs l&U, IVH - total (43 vs 301), IVY - grade 3, 4 (21 vs 121) and lore ilportantly, in the proportion considered to have MORIAL develop.nt - (IDI and PDI>8II, no blindness or chronic lung disease or cerebral palsy) - &&X vs 791. These encouraging findings relain valid .hen groups were cOlpared at different birth weight groups < 750 g, 750-999 g, 10011-1249 g, 1250-1500 g. hproved long ten neonatal outcOIeII were related to antenatal cOlbined with neonatal pharlacology therapy in the fOri of cOlbined steroids and TRH along with artificial surfactant in addition to advances in perinatal and neonatal outco ••
309 CLINICAL DECISION ANALYSIS IN PRETERM PREMATIJRE RUPTIJRE OF TIlE MEMBRANES. Bebbington. Michael W x Grace Hospital. Vancouver B.C. Canada.
Preterm premature rupture of the membranes (PPROM) is responsible for a significant amount of perinatal morbidity and mortality. 'There are no consistent guidelines that help to answer the question; At what gestational age should delivery take place when presented with PPROM? A nonrecursive decision analysis model was developed to answer this question. Analysis was carried out for three separate gestational ages; 26. 30 and 34 weeks. Utility values were determined for each of the outcomes using a standard gamble technique. Probability values for each branch of the model were determined using values from data at our institution. As expected. at 26 weeks the model preferred the conservative therapy option. while at 34 weeks. the immediate delivery option was preferred. At 30 weeks. the preferred treatment option varied with how the patient ranked the outcomes of pregnancy prolongation and intact survival of the newborn. If preference was given to prolonging the pregnancy the model preferred conservative therapy whereas if intact survival was given priority then the immediate delivery option was preferred. This study shows the value of clinical decision analysis in perinatal medicine and the importance of patient input into management decisions.
January 1992 Am J Obstet Gynecol
310 THE EffECT OF SUBCUTANEOUS TERBUTALINE INfUSION ON UTERINE
ACTIVITY IN PATIENTS AT RISK fOR PRETERH DELIVERY. P.J. ~einbaum
AND H. Olsonx, Dept. OB/GYN, Albany Medical College, Albany. N.Y.
AND Healthdyne, Inc., Marietta, GA.
Continuous subcutaneous infusion of Terbutal ine via pump
(T-pump) has recently been uti l ized as tocolytic therapy for ambulatory management of preterm labor. The concomitant use of home uterine activity monitoring allowed us to examine the effect of T-pump therapy on the pattern of uterine activity. A group of 202 patients at risk for preterm delivery were monitored for a minimun of 10 days prior to the onset of preterm labor and tocolytic therapy. The mean gestational age (GA) at the
initiation of monitoring was 28.5 wks. and 30.1 wks. at start of T-pllnp. Mean frequency of uterine contractions over that 10 day period was 3.3/hr., with an increase to 6.6/hr., over the final 72 hrs. This increase in uterine activity was associated with an increase in subjective symptoms and/or cervical change in the majority of patients. T-pump was initiated and over the first 24 hrs. mean uterine activity was significantly decreased to 3.3/hr. With appropriate alterations in either bolus or basal infusion dosage, contractions were maintained at a mean of 3.9/hr. over the duration of T-pump therapy lasting an average of 4.9 wks. Repeat hospital ization for excessive uterine activity unresponsive to home manipUlation of T-pump occurred in only
9.6%. Hean GA at del ivery was 36.2 wks. and 70% of patients
completed 35 wks. This study confirms the observation of a significant increase in monitored uterine activity shortly before the onset of preterm labor. It also suggests that T-pump rapidly and effectively decreases mean uterine activity and sustains this effect deLaying delivery for a clinically significant period.
311 EXPANDED PIlBlI C FI NAMC I NG OF PRENATAL CARE: I MPACT ON BRONX
PRETERM BIRTHS 1985- 1989. JE Deaver, Albert Einstein
College of Medicine (AECOM), Dept Ob/Gyn, Bronx, New York.
There have been few rigorous birth outcomes evaluations of policies designed to reduce financial barriers to util ization of prenatal care. The New York State Prenatal Care Assistance Program (PCAP). from 1985-1989. provided
prenatal care to women lacking heal th insurance with incomes between 100% (the Medicaid limit) and 185% of the poverty
level. The present study hypothesizes that PCAP-el igible
patients who were not enrolLed in the program (i.e. selfpay) had increased rates of preterm bi rth c""""red to PCAP
enrollees. Prenatal, birth outcome, and PCAP enroLlment data in the POPRAS database of the AECOM were l inked using Oracle
and Structured Query language (SQl) to produce 11,013
c~lete records. Logistic regression analysis with SPSS determined that seLf-pay status was a significant predictor of preterm birth (p=0.0354, odds 1.38) along with previous
preterm birth (p=O.00005, odds 1.95) and delivery in the
i"""verished South Bronx (p=0.00005, odds 2.14) whi le age,
race, ethnicity, gestational age at onset of care, location
of prenatal care, and program year were not predictive.
Selection bias is an i"""rtant consideration with respect to
i nterpretat i on of these data since the ass i grvnent to PCAP
versus self-pay was not random. However, it appears that
el igible patients who did not participate in a publ ic
prenatal care financing program experienc'ed increased rates of preterm birth c~red to participants even white all other factors were controlled.