442 the Fiscal impact of the Medicaid Abofmon Funding Ban in Michigan
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Volume 166 Number I, Part 2 440 ACTIVE MANAGEMENT OF LATENT LABOR WITH UNKNOWN UTERINE SCAR INCREASES RISK OF UTERINE RUPTURE, D.K. Grubb,x S.L. Kjos, R.H. Paul. University of Southern California, Los Angeles, CA 441 Trial of labor is now frequently undertaken after prior cesarean birth. The term patient with an unknown uterine scar and persistent uterine contractions presents an unknown risk of uterine rupture. A prospective, randomized study was undertaken to determine if prolonged labor and operative delivery could be minimized by outpatient observation until labor was confirmed. Uncomplicated, term patients with one or two prior cesarean births were randomly assigned to active inpatient management, with oxytocin augmentation for persistent contractions, or to outpatient evaluation and observation until labor was ruled in. Of 197 patients enrolled, 8 failed to return for delivery, and were excluded from analysis. Four initially requesting trial of labor elected repeat cesarean section after enrolling. Expectant (94) Active (95) p 2 prior cesarean births 20 (21%) 16 (17%) NS Prior vaginal birth 31 (33%) 31 (33%) NS Cesarean delivery 17 (18%) 15 (16%) NS Oxytocin used 49 (52%) 76 (80%) 0.0001 Hours active labor (median) 4.25 4 NS Uterine scar disruption 0 (0%) 5 (5%) 0.03 Four cases of asymptomatic low transverse uterine scar dehiscence and one case of vertical uterine scar rupture requiring hysterectomy occurred. All five were in the inpatient active management group, and all had received oxytocin augmentation. We conclude that, in term gravidas with unknown uterine scars exhibiting persistent uterine contractions, expectant management did not reduce the rate of cesarean delivery or prolonged labor. Second, expectant management was associated with a decreased usage of oxytocin. Finally, the risk of uterine scar dehiscence or rupture was increased significantly by active inpatient management compared to expectant outpatient management. CLINICAL CHARACTERISTICS AND NEONATAL ruTCIJIE IN PATIENTS IIITH PRETERM PREMATURE RUPTURED MEMBRANES IlItO DELIVER IIITHIN 72 HWRS, S,J,Carlan,J,V,Parker',U of S FL,Ta"l"",FL,ORMC,Orlando,FL Over a two-year period 386 patients with preterm premature ruptured membranes (rupture of merrbranes prior to labor < 37 weeks gestation) deL ivered at GeneraL HospitaL. Of these, 19 terminated electively and 14 resealed. Of the remaining 335, 205 (61X) del ivered within 72 hours, No patient was tocolyzed, The group that del ivered within n hours was simi lar in GTPAL, racial makeup, incidence of smoking, and positive cervical cul- tures for Gc and GBBHS to the group that del i vered after 72 hours. The incidence of rn.Jltiple gestations, breech presenta- tions, abruptios and fetal distress in labor was also not sign- i fi cant L y di fferent between the groups. NeonataL outcomes were similar in incidence of NEe, IVH, and positive blood cultures. CLINICAL CHARACTERISTICS AND ruTCIJIE PARAMETERS (MEAN .150) DeL ivery DeL ivery E <72 hrs >72 hrs N=205 N=130 Age (yrs) 24:1±6,6 23,5±5,5 EGA at rupture (wks) 32,5 ± 3,5 30,9 ± 3,7 Cx Clamydia + (X) 5,3 13,8 Initial US deepest 2,6 ± 1.6 3,1 ± 1.6 pocket (em) (N=156) (N=126) NS <,05 <,05 <,05 Armio + gr stain;#(%) 11/36 (30) 6/59 (10) <,05 Cl inical chorio (X) 14 18 NS Pit induction (%) 8,2 12,3 NS C-Section (%) 19,5 25 NS Newborn wt. (grs) 1999 ± 661 1879 ± 714 NS ROM to delivery (d) 1.07 ± OJ 11,9 ± 14,1 <,05 Cord pH 7,29 ± 0,08 7,31 ± 0,09 NS Newborn Respirator (d) 1.9 ± 6,3 3,9 ± 12_3 ,05 NICU (d) 10,7 ± 19,3 17,4 ± 28.1 <,05 We conclude that women with earl ier gestationaL ages, deeper ami otic fluid pockets, and a lower incidence of positive arrniotic fluid bacterial studies are likely to delay del ivery > 72 hrs, Inspite of a mean latent period of almost 12 days and simi lar gestationaL ages at del ivery, the neonates in the delayed del ivery group had more venti lator and NICU days, SPO Abstracts 397 442 lHE RSCALIMPACT OF lHE MEDICAID ABORTION FUNDING BAN IN MlOiIGAN, MI Evans, E Gleicher, MP Johnson, RJ Sokol, Dept ObiGyn, Wayne State University/Hutzel Hospital, Detroit, MI 443 Attacks upon the availability of abortion have occurred in many states. In Michigan after several attempts, a '00 Medicaid funding of abortion law went into effect in December, 1988, prior to which the number of abortions per year in Michigan and the number of abortions per 1000 re 'd . d I . I d Sl ents remal ne re at,ve,v s1eMV, # Abortions # Abortions! Year Reoorted 1000 Livebirths Deliveries 1987 49098 340.4 140466 1988 46747 331.2 139635 1989 36557 248.4 148164 1990 36183 236.0 153304 FollOWing the change In the law the number of abortions decreased by about 10,000 which was closely reflected in increased births. Such an increase was not seen in surrounding states. At Hutzel Hospital, the largest delivery service in Michigan, deliveries rose 10% in 1989 and 7% in 1990. However, while the overall percentage of Medicaid patients remained steady at approximately 50% in our hospital (an increase of 600 Medicaid deliveries), the percentage of NICU Medicaid volume rose from 64 to 68%. These findings are consistent with the supposition that unwanted pregnancies result in neglected prenatal care. Poor care gives rise to prenatal complications and NICU admissions which may have been avoided had freedom of access to abortion services been an option for these women, It is unknown just how many of these pregnancies would have continued, but using the cohort of an additional 13,669 Michigan babies born in 1990 over 1988 numbers at an average medical cost of $3708 (Medicaid estimate) for the first year, the overall cost will be $54,748,620. There have been no increased appropriations by the Michigan legislature to care for these babies, EARLY REPAIR OF EPISIOTC»IY DEHISCENCE ASSOCIATED IIITH INFECTlON_ R. Ramus X , S. Ramin, B. Little X , L. Gilstrap, Dept. Ob/Gyn, Univ. Texas Southwestern Med. Ctr., Dallas, TX The traditional approach to episiotomy dehiscence has been delayed repair, Recently, early repair of episiotomy dehiscence has been examined in a mt l itary population. The purpose of the present study was to examine early repair in a hospitaL setting serving predominantly an indigent population. The incidence of episiotomy breakdown at our institution was 0.5%. Our policy, since September 1, 1989, has been to proceed with early repair in the inmediate postpartLITI period. Medical records were reviewed on 34 of TI patients who have undergone earLy repair, Of these, 21 (62%) had midline and 13 (38%) had mediolateral episiotomies. Twenty of the former and 8 of the latter group had a third-degree or fourth-degree extension. Dehiscence was associated with episiotomy infection in 27 (79%) of the 34 patients -- 18 (86%) in the midl ine and 9 (69%) in the mediolateral group. All patients received antibiotic therapy and wound care prior to repair. In addition, those with fourth-degree episiotomy breakdowns received a gO-'!'ytely bowel prep, Repair was accomplished from 3 to 13 days (x=6,4) following dehiscence, Successful repairs were accomplished in 32 of 34 (94%) patients, Two patients (6%), with an initial third-degree episiotomy, had a subsequent breakdown of their repair and were allowed to heal by secondary intention. In conclusion, most dehiscences in our popuLation are associated with infection. Unl ike previous reports, infection was as coomon in midl ine as in mediolateral episiotomy dehiscences. Early repair of episiotomy dehiscence in this population is associated with a satisfactory outcome in the vast majority of patients.
Transcript of 442 the Fiscal impact of the Medicaid Abofmon Funding Ban in Michigan
Volume 166 Number I, Part 2
440 ACTIVE MANAGEMENT OF LATENT LABOR WITH UNKNOWN UTERINE SCAR INCREASES RISK OF UTERINE RUPTURE, D.K. Grubb,x S.L. Kjos, R.H. Paul. University of Southern California, Los Angeles, CA
441
Trial of labor is now frequently undertaken after prior cesarean birth. The term patient with an unknown uterine scar and persistent uterine contractions presents an unknown risk of uterine rupture. A prospective, randomized study was undertaken to determine if prolonged labor and operative delivery could be minimized by outpatient observation until labor was confirmed. Uncomplicated, term patients with one or two prior cesarean births were randomly assigned to active inpatient management, with oxytocin augmentation for persistent contractions, or to outpatient evaluation and observation until labor was ruled in. Of 197 patients enrolled, 8 failed to return for delivery, and were excluded from analysis. Four initially requesting trial of labor elected repeat cesarean section after enrolling.
Expectant (94) Active (95) p 2 prior cesarean births 20 (21%) 16 (17%) NS Prior vaginal birth 31 (33%) 31 (33%) NS Cesarean delivery 17 (18%) 15 (16%) NS Oxytocin used 49 (52%) 76 (80%) 0.0001 Hours active labor (median) 4.25 4 NS Uterine scar disruption 0 (0%) 5 (5%) 0.03 Four cases of asymptomatic low transverse uterine scar dehiscence and one case of vertical uterine scar rupture requiring hysterectomy occurred. All five were in the inpatient active management group, and all had received oxytocin augmentation. We conclude that, in term gravidas with unknown uterine scars exhibiting persistent uterine contractions, expectant management did not reduce the rate of cesarean delivery or prolonged labor. Second, expectant management was associated with a decreased usage of oxytocin. Finally, the risk of uterine scar dehiscence or rupture was increased significantly by active inpatient management compared to expectant outpatient management.
CLINICAL CHARACTERISTICS AND NEONATAL ruTCIJIE IN PATIENTS IIITH PRETERM PREMATURE RUPTURED MEMBRANES IlItO DELIVER IIITHIN 72 HWRS, S,J,Carlan,J,V,Parker',U of S FL,Ta"l"",FL,ORMC,Orlando,FL
Over a two-year period 386 patients with preterm premature ruptured membranes (rupture of merrbranes prior to labor < 37 weeks gestation) deL ivered at Ta~a GeneraL HospitaL. Of these, 19 terminated electively and 14 resealed. Of the remaining 335, 205 (61X) del ivered within 72 hours, No patient was tocolyzed, The group that del ivered within n hours was simi lar in GTPAL, racial makeup, incidence of smoking, and positive cervical cultures for Gc and GBBHS to the group that del i vered after 72 hours. The incidence of rn.Jltiple gestations, breech presentations, abruptios and fetal distress in labor was also not signi fi cant L y di fferent between the groups. NeonataL outcomes were similar in incidence of NEe, IVH, and positive blood cultures. CLINICAL CHARACTERISTICS AND ruTCIJIE PARAMETERS (MEAN .150)
DeL ivery DeL ivery E <72 hrs >72 hrs N=205 N=130
Age (yrs) 24:1±6,6 23,5±5,5 EGA at rupture (wks) 32,5 ± 3,5 30,9 ± 3,7 Cx Clamydia + (X) 5,3 13,8 Initial US deepest 2,6 ± 1.6 3,1 ± 1.6
pocket (em) (N=156) (N=126)
NS <,05 <,05 <,05
Armio + gr stain;#(%) 11/36 (30) 6/59 (10) <,05 Cl inical chorio (X) 14 18 NS Pit induction (%) 8,2 12,3 NS C-Section (%) 19,5 25 NS Newborn wt. (grs) 1999 ± 661 1879 ± 714 NS ROM to delivery (d) 1.07 ± OJ 11,9 ± 14,1 <,05 Cord pH 7,29 ± 0,08 7,31 ± 0,09 NS Newborn Respirator (d) 1.9 ± 6,3 3,9 ± 12_3 ,05 NICU (d) 10,7 ± 19,3 17,4 ± 28.1 <,05 We conclude that women with earl ier gestationaL ages, deeper ami otic fluid pockets, and a lower incidence of positive arrniotic fluid bacterial studies are likely to delay del ivery > 72 hrs, Inspite of a mean latent period of almost 12 days and simi lar gestationaL ages at del ivery, the neonates in the delayed del ivery group had more venti lator and NICU days,
SPO Abstracts 397
442 lHE RSCALIMPACT OF lHE MEDICAID ABORTION FUNDING BAN IN MlOiIGAN, MI Evans, E Gleicher, MP Johnson, RJ Sokol, Dept
ObiGyn, Wayne State University/Hutzel Hospital, Detroit, MI
443
Attacks upon the availability of abortion have occurred in many states. In Michigan after several attempts, a '00 Medicaid funding of abortion law went into effect in December, 1988, prior to which the number of abortions per year in Michigan and the number of abortions per 1000 re 'd . d I . I d Sl ents remal ne re at,ve,v s1eMV,
# Abortions # Abortions! Year Reoorted 1000 Livebirths Deliveries
1987 49098 340.4 140466
1988 46747 331.2 139635
1989 36557 248.4 148164
1990 36183 236.0 153304
FollOWing the change In the law the number of abortions decreased by about 10,000 which was closely reflected in increased births. Such an increase was not seen in surrounding states. At Hutzel Hospital, the largest delivery service in Michigan, deliveries rose 10% in 1989 and 7% in 1990. However, while the overall percentage of Medicaid patients remained steady at approximately 50% in our hospital (an increase of 600 Medicaid deliveries), the percentage of NICU Medicaid volume rose from 64 to 68%. These findings are consistent with the supposition that unwanted pregnancies result in neglected prenatal care. Poor care gives rise to prenatal complications and NICU admissions which may have been avoided had freedom of access to abortion services been an option for these women, It is unknown just how many of these pregnancies would have continued, but using the cohort of an additional 13,669 Michigan babies born in 1990 over 1988 numbers at an average medical cost of $3708 (Medicaid estimate) for the first year, the overall cost will be $54,748,620. There have been no increased appropriations by the Michigan legislature to care for these babies,
EARLY REPAIR OF EPISIOTC»IY DEHISCENCE ASSOCIATED IIITH INFECTlON_ R. RamusX
, S. Ramin, B. LittleX, L. Gilstrap, Dept. Ob/Gyn, Univ.
Texas Southwestern Med. Ctr., Dallas, TX The traditional approach to episiotomy dehiscence has been
delayed repair, Recently, early repair of episiotomy dehiscence has been examined in a mt l itary population. The purpose of the present study was to examine early repair in a city~county hospitaL setting serving predominantly an indigent population. The incidence of episiotomy breakdown at our institution was 0.5%. Our policy, since September 1, 1989, has been to proceed with early repair in the inmediate postpartLITI period. Medical records were reviewed on 34 of TI patients who have undergone earLy repair, Of these, 21 (62%) had midline and 13 (38%) had mediolateral episiotomies. Twenty of the former and 8 of the latter group had a third-degree or fourth-degree extension. Dehiscence was associated with episiotomy infection in 27 (79%) of the 34 patients -- 18 (86%) in the midl ine and 9 (69%) in the mediolateral group. All patients received antibiotic therapy and wound care prior to repair. In addition, those with fourth-degree episiotomy breakdowns received a gO-'!'ytely bowel prep, Repair was accomplished from 3 to 13 days (x=6,4) following dehiscence, Successful repairs were accomplished in 32 of 34 (94%) patients, Two patients (6%), with an initial third-degree episiotomy, had a subsequent breakdown of their repair and were allowed to heal by secondary intention. In conclusion, most dehiscences in our popuLation are associated with infection. Unl ike previous reports, infection was as coomon in midl ine as in mediolateral episiotomy dehiscences. Early repair of episiotomy dehiscence in this population is associated with a satisfactory outcome in the vast majority of patients.
