obstetric outcomes during time of conflict

441 INTRAPARTUM COMPLICATIONS IN THE YOUNG GRAND MULTIPARA SARAELLIS SIMONSEN1, JOSEPH LYON1, STEPHEN ALDER1, MICHAEL VARNER2,1University of Utah, Family and Preventive Medicine, Salt Lake City, Utah,2University of Utah, Maternal-Fetal Medicine, Salt Lake City, Utah

OBJECTIVE: Grand multiparity (para R5) is viewed as a risk factor forobstetric complications. Most studies of grand multiparity have not consideredthe confounding effect of maternal age, and few have stratified risk by age. Theobjective of this study is to examine the intrapartum complications that occur inyoung grand multiparas (parity 5-9) compared with young women of lowerparity (1-4).

STUDY DESIGN: This population-based cross sectional study analyzed sevenyears of Utah birth certificate data to determine the risk of intrapartumcomplications in young women, age 18-29, with singleton pregnancies(n = 216094 pregnancies). The impact of parity on select intrapartum compli-cations was analyzed using logistic regression, controlling for a number ofdemographic and lifestyle factors.

RESULTS: Young grand multiparas were more likely to be unmarried, lackinga high school diploma, non-white, to initiate prenatal care after the firsttrimester, and to report having used alcohol or tobacco during pregnancy.

Compared with young women of lower parity, young grand multiparas hada statistically significant increased risk for premature rupture of membranes (OR1.56) and precipitous labor (OR 1.48). Parity had a protective effect on forceps/vacuum assisted delivery (OR 0.34), febrile morbidity (OR 0.57), labor induction(OR 0.64), and Cesarean section (OR 0.64). There was no increased risk formeconium stained amniotic fluid, prolonged labor, dysfunctional labor, fetalmalpresentation, fetal distress, or labor augmentation associated with increasingparity.

CONCLUSION: Overall, young grandmultiparas are not at increased risk forintrapartum complications. Information about the areas of increased anddecreased risk in this population can be used to assist health care providers inproviding adequate care while avoiding unnecessary medical procedures andcosts.

442 DOES LITHIUM EXPOSURE WARRANT REFERRAL FOR FETAL ECHOCARDIOGRAM?RICHARD BENOIT1, 1Women & Infants’ Hospital, Obstetrics & Gynecology,Providence, Rhode Island

OBJECTIVE: Describe the significance of lithium exposure as a risk factor forcongenital cardiac anomaly, particularly Ebstein’s anomaly.

STUDY DESIGN: A restropective cohort of 3259 fetuses referred for fetalechocardiogram at a prenatal diagnosis center affiliated with an academichospital over an eight year period (1996-2004) for all indications was included.All exams with reported findings of a structural cardiac defect were identified.All exams with the indication of maternal lithium exposure and all cases ofEbstein’s anomaly described on ultrasound findings were also identifed. Aretrospective case-control to determine the association of lithium exposure to thefinding of Ebstein’s anomaly in this population of pregnancies screened by fetalechocaradiogram for diverse reasons was then assessed.

RESULTS: The retrospective cohort of 3259 fetuses included a total of 56 withreported exposure to lithium. Overall, 87 congenital cardiac anomalies wereidentified- for a rate of 2.6%, which is consistent with this being a high-riskreferral group. Among exams with maternal exposure to lithium as the soleindication, 1/56 or 1.7% were noted to have a cardiac anomaly. Among all 7cases of Ebstein’s anomaly described antenatally, only 1 had reported exposureto lithium during pregnancy. However, the odds ratio for Ebstein’s anomalyoccurring among those reported as exposed to lithium was 10.0 in this cohort.

CONCLUSION: Some controversy has been reported in the literature withrespect to the significance of lithium exposure as a risk factor for congenitalcardiac anomaly, particularly Ebstein’s anomaly. In this retrospective cohortreview, those referred for fetal echocardiogram because of maternal lithiumexposure had abnormal cardiac findings at a rate similar to the overall rate ofabnormal exams in the cohort of referred high-risk patients. However, Esbtein’sanomaly was more likely to be identified among those exposed to lithium than inthe general referral group. Referral for detailed fetal cardiac evaluation appearswarranted with maternal lithium exposure.

443 DOES CAPACITY PLANNING UTILIZING STATISTICAL MODELING OFFER HOSPITALSA TOOL TO HELP PREVENT OVER-CROWDED SPECIAL CARE CENTERS FOR AT-RISKNEWBORNS AND PREGNANT WOMEN? RICHARD BENOIT1, 1Women & Infants’Hospital, Obstetrics & Gynecology, Providence, Rhode Island

OBJECTIVE: Describe the use of statistical modeling to analyze hospitalcapacity problems in the areas of newborn special care and maternity care.

STUDY DESIGN: Data from two separate large academic tertiary hospitalsundergoing planning efforts was assessed. Queuing theory was utilized todescribe and optimize capacity planning with respect to the number of hospitalbeds present in several key units, including newborn intensive care, labor anddelivery, antepartum care, and postpartum care units. Inputs for the queuemodel included the average arrival rate (admissions) and the average service rate(length of stay) for each type of unit. These were calculated from existing data ondischarges and length of stay, though adjustments were made to account forshort-term stays. The Erlang Loss model was utilized to calculate the estimatednumber of potential patients who would be turned away at different capacitylevels.

RESULTS: Analysis of data from two large academic hospitals providingtertiary level care revealed that a coordinated discussion among hospitaladministration and providers is a key element in the development of capacityplanning efforts. Utilizing queue theory and the Erlang loss model, capacity maybe projected to future demands and adjusted to determine acceptable probabilityof refusals of between 1-5% (% of time patients must be turned away fromadmission to a unit due to over-capacity). Case mix, length of stay averages, andreimbursement levels can be targeted to national averages and adjusted by DRGdiagnoses in order to optimize planning.

CONCLUSION: Hospital capacity can limit regional availability of special careservices for high-risk newborns and pregnant women. Thus, coordinatedmultidisciplinary capacity planning efforts must be undertaken to prevent lackof access to needed services. Operations modeling utilizing queuing theory andthe Erlang loss model may assist in the understanding of this process, andprovide for a rationalization of bed planning efforts in order to optimize capacityand access to health care.

SMFM Abstracts S127

444 OBSTETRIC OUTCOMES DURING TIME OF CONFLICT MARIA SMALL1, EDWARD MAGEE2,EVECARM COLIMON3, CHRISTIAN BLANC4, LISSA MAGLOIRE5, TRACE KERSHAW2, 1YaleUniversity, OB/GYN, New Haven, Connecticut, 2Yale University, School ofPublic Health, New Haven, Connecticut, 3Hopital Albert Schweitzer, Obstetricsand Gynecology, Port au Prince, Port au Prince, Haiti, 4Hospital AlbertSchweitzer, Surgery, port au prince, port au prince haiti, Haiti, 5YaleUniversity, Obstetrics & Gynecology, new haven, Connecticut

OBJECTIVE: To determine the impact of violence on maternal health in ruralHaiti.

STUDY DESIGN: In February 2004, armed conflict between rebels and Haitiangovernment forces resulted in widespread violence. The onset and termination ofthe most intense period of armed conflict occurred during a single month,February, 2004. The Hospital Albert Schweitzer, a private, nongovernmentalhospital in rural Haiti remained open and functional throughout this time. Weused the perinatal database to compare rates of obstetric outcomes for themonth of armed conflict with baseline rates from the preceding year, 2003. Chi-square or Fishers exact test were used for analysis.

RESULTS: Rates of preeclampsia were not significantly different between thebaseline and the conflict, 13% and 12%, respectively (c2 .11, P = .75).Surrounding hospital closures caused in an increase in patients from outsidethe hospital catchement area, however, this number was not significant. The fetalmortality rate for the time of conflict, 9.7%, was not significantly different frombaseline, 14.7% (c2 1.89, P= .17).

In 2003, the baseline eclampsia rate was 4.3% and 8.7% during the conflict(c2 with Fisher’s exact test 1.36, P ! .001) Maternal deaths occurred in 1.2% ofwomen at baseline, and 5.2% during the conflict (c2 and Fisher’s exact test10.36, P ! .001).

CONCLUSION: In areas of poverty, access to care is one of the most importantdeterminants of health. Maternal mortality and eclampsia reflect issues of access;in one month of instability these indices peaked. This analysis provides a directcorrelation between national events and individual adverse outcomes.