N Spillane

Day Care Compared With Inpatient Management of Nausea and Vomiting of Pregnancy: A Randomized Controlled Trial

OBJECTIVE: To examine day care treatment of nausea and vomiting of pregnancy compared with the traditional inpatient management of this condition. METHODS: We conducted an open-label, single-center, randomized controlled trial to examine the differences between day care and inpatient management of pregnant women with nausea and vomiting of pregnancy. Primary outcome was total number of inpatient nights related to nausea and vomiting of pregnancy. RESULTS: Ninety-eight women were randomized to initial day care management (n=42) or inpatient management (n=56). Results are calculated from the time of randomization until resolution of nausea and vomiting of pregnancy. Women randomized to inpatient care experienced a median (interquartile range) of 2 (1–4) inpatient days compared with 0 (0–2) inpatient days for women randomized to day care (P<.001). Women randomized to initial treatment as an inpatient had significantly more median total number of inpatient admissions (one [1–2] compared with zero [0–1] admissions; P<.001) compared with women randomized to day care. No significant differences were observed in day care visits (median [interquartile range] one [1–4] compared with two [1–4]; P=.30). Women randomized to inpatient care were as satisfied with their care as those randomized to day care (median [interquartile range]: 67 [57–69] compared with 63 [58–71] Client Satisfaction Questionnaire score; P=.7). CONCLUSION: Day care treatment of nausea and vomiting of pregnancy reduced hospital inpatient stay and was acceptable to patients. CLINICAL TRIAL REGISTRATION: ISRCTN Register, http://www.isrctn.org, ISRCTN05023126. LEVEL OF EVIDENCE: I

Experience of miscarriage: an interpretative phenomenological analysis

Objective The objective of the study was to explore the experiences of those who have experienced miscarriage, focusing on mens and womens accounts of miscarriage. Design This was a qualitative study using a phenomenological framework. Following in-depth semistructured interviews, analysis was undertaken in order to identify superordinate themes relating to their experience of miscarriage. Setting A large tertiary-level maternity hospital in Ireland. Participants A purposive sample of 16 participants, comprising 10 women and 6 men, was recruited. Results 6 superordinate themes in relation to the participants experience of miscarriage were identified: (1) acknowledgement of miscarriage as a valid loss; (2) misperceptions of miscarriage; (3) the hospital environment, management of miscarriage; (4) support and coping; (5) reproductive history; and (6) implications for future pregnancies. Conclusions One of the key findings illustrates a need for increased awareness in relation to miscarriage. The study also indicates that the experience of miscarriage has a considerable impact on men and women. This study highlights that a thorough investigation of the underlying causes of miscarriage and continuity of care in subsequent pregnancies are priorities for those who experience miscarriage. Consideration should be given to the manner in which women who have not experienced recurrent miscarriage but have other potential risk factors for miscarriage could be followed up in clinical practice.

Day care versus inpatient management of nausea and vomiting of pregnancy: cost utility analysis of a randomised controlled trial ☆

OBJECTIVE To assess the comparative cost effectiveness of day care over inpatient management of nausea and vomiting of pregnancy (NVP). STUDY DESIGN A cost utility analysis was performed using a decision analytical model in which a Markov model was constructed. The Markov model was primarily populated with data from a recently published randomised controlled trial. Which included pregnant women presenting to Cork University Maternity Hospital, a tertiary referral maternity hospital, seeking treatment for NVP. Costs and outcomes were estimated from the perspective of the Irish health service (HSE) and patients. A probabilistic sensitivity analysis, using a Monte Carlo simulation, was also performed. A Bayesian Value of Information analysis was used to estimate the value of collecting additional information. RESULTS When both the healthcare provider and patients perspective was considered, day care management of NVP remained less costly (mean €985; 95% C.I. 705-1456 vs. €3837 (2124-8466)) and more effective (9.42; 4.19-12.25 vs. 9.49; 4.32-12.39 quality adjusted life years) compared with inpatient management. The Cost Effectiveness Acceptability Curve indicates the probability that day care management is 70% more cost effective compared to inpatient management at a ceiling ratio of €45,000 per QALY, indicating little decision uncertainty. The Bayesian Value of Information analysis indicates there is value in collecting further information; the Expected Value of Perfect Information (EVPI) is estimated to be €5.4 million. CONCLUSION Day care management of NVP is cost effective compared to inpatient management.

PPO.50 Evaluation of non-response in the Women’s Health Cohort Study

Objective The Women’s Health Study was designed to examine associations between maternal and paternal reproductive histories, behavioural and lifestyle risk factors and miscarriage. The objective of this study was to examine underlying differences in characteristics and pregnancy outcome between responders and non-responders. Methods A cohort study was conducted in a large, tertiary hospital (8,500 deliveries per annum) in the Republic of Ireland in 2012. Women were randomly selected at their first booking visit (10–14wks) and were asked to complete a detailed lifestyle postal questionnaire containing common risk factors for miscarriage. Basic demographic data and pregnancy status at 20 weeks gestation were collected for all recruited women. Chi-square tests were performed to assess differences in characteristics and pregnancy status. Results 715 women agreed to participate in the study of which 61.3% (n = 431) completed the detailed questionnaire. Responders and non-responders were similar in terms of the proportions who were primiparous (39.1% vs. 38.5%) and multiparous (25.0% vs. 21.1%). Average age was the same (32.8 (5.6) versus 32.1 (5.3) years; p = 0.441). Non-responders were slightly more likely to be nulliparous (40.5% vs. 35.9%; P = 0.256) and married (65.4% vs. 62.6%). In terms of the outcome, non-responders had a higher rate of miscarriage (40.4% vs. 32.1%; p = 0.025). Conclusions While basic demographics were broadly similar between responders and non-responders, the discrepancy between miscarriage rates may be a result of unobserved factors. Participation bias towards healthier individuals is frequent in clinical and public health studies, and thus subsequent results should be interpreted with caution.

PPO.56 A retrospective observational study of second-trimester miscarriage

In the UK and Ireland, second-trimester miscarriage is defined as pregnancy loss after the 14th and before the 24th week of gestation.1 Those who suffer a second-trimester loss represent a small cohort but experience significant morbidity associated with both their index loss and subsequent pregnancies.1 The literature on this topic, however, is limited. This study aimed to assess maternal characteristics of second-trimester loss. A retrospective observational study of women who experienced a second-trimester miscarriage was undertaken in a large, tertiary hospital (8,500 deliveries per annum) in the Republic of Ireland. All cases between July 2009 and June 2013 were identified. Charts were reviewed; examining maternal demographics, mechanism of pregnancy loss and inpatient course. During this 4 year period, 173 women experienced a second-trimester miscarriage; with a mean age of 33.59 years (SD:5.46)and mean BMI of 27.09 (SD:6.58). 30.6% were primiparous. 11.4% had previously experienced a second-trimester loss. The average gestation of loss was 17+5 weeks (SD:30 days). 66.3% of losses were intra-uterine deaths with 17.4% following pre-term premature rupture of membranes and 16.3% following preterm labour. 32.4% delivered spontaneously, however 59.5% required medical induction of labour. All patients required inpatient admission with a mean stay of 2.67 days (SD:2.98). 16.9% required oral antibiotic therapy, 8.1% required intravenous therapy and 12.8% requiring both. 26% required manual removal of placenta. Identification of maternal and pregnancy characteristics of second-trimester loss may aid optimisation of risk-stratification and surveillance in future populations, reducing morbidity. Our understanding would benefit from more populous prospective case-control studies. Reference Edlow AG, Srinivas SK, Elovitz MA. Second-trimester loss and subsequent pregnancy outcomes: What is the real risk? Am J Obstet Gynecol. 2007 Dec; 197(6):581.e1–6

OP64 Women’s experiences of ectopic pregnancy: a qualitative study

Background Ectopic pregnancy is a potentially life threating condition. Due to the specific nature of Ectopic pregnancy the grief experienced may well be overlooked compared to other pregnancy losses. Fertility concerns for the future and recovery from surgical or medical treatment may instead become the focus of care. The aim of this study was to gain insight into women’s experience of Ectopic pregnancy, focusing on the area of emotional recovery. Methods Seven women who had experienced an Ectopic pregnancy in a large tertiary-level Irish maternity hospital partook in in-depth qualitative interviews. This sample was recruited purposively ensuring Ectopic pregnancies which were managed expectantly, medically and surgically were included. In this study an interpretative phenomenological analysis was utilised as it has an ideographic approach which allows us to gain insight into the women’s experiences of Ectopic pregnancy. Results In this sample the hope and expectations of a healthy pregnancy were wiped out on the diagnosis of Ectopic pregnancy. Women expressed feelings of shock, disbelief and confusion as they tried to come to terms with this diagnosis. Management of Ectopic pregnancy includes scans and blood tests to confirm the location of the pregnancy. These women highlighted the importance of scans to reassure themselves that the pregnancy was not viable. This coping mechanism was adopted by all women in order to protect themselves emotionally. A key theme indicated by these women was the importance of clear and detailed information in relation to the management of their pregnancy and what to expect in relation to the treatment necessary. At interview women expressed dissatisfaction with how the end of their outpatient care was communicated via phone call. This was further compounded by the fact that no women were offered any form of bereavement counselling. As no forum was made available to discuss future pregnancies, apprehension about their fertility escalated and women were reluctant to conceive again. Conclusion The findings of this study show that women had difficulty coming to terms with their diagnosis and its implication for treatment. This study found that the lack of follow up had a negative impact on their ability to recover from the Ectopic pregnancy and illustrated women’s reservations to embark on future pregnancies. The results of this study have implications for the care of women who experience Ectopic pregnancy particularly in relation to how they are managed from diagnosis to completion of treatment.

OP61 Perceived maternal stress and emotional wellbeing as risk factors for miscarriage

Background Miscarriage is the most common adverse outcome in pregnancy. Investigations suggest numerous risk factors however the cause remains poorly understood. The study aimed to examine the contribution of an array of psychological factors to risk of miscarriage. Methods A cohort study was conducted in a large, tertiary hospital (8500 deliveries per annum) in the Republic of Ireland in 2012. Women randomly selected at their first booking visit (10–14 weeks) were asked to complete a detailed lifestyle questionnaire, which included common risk factors for miscarriage. Emotional wellbeing, social support, life orientation and perceived stress were assessed using the following validated psychometric tests; the RAND 36-Item Health Survey, the Maternity Social Support Scale, the Revised Life Orientation Test and the Perceived Stress Scale. All participants were followed up at 20 weeks gestation to determine pregnancy outcome. Logistic regression was conducted to assess associations with risk of miscarriage. Results Of the 417 participants, 32.1% (n = 134) had a confirmed miscarriage at follow-up. After adjustment, women with high levels of perceived stress had increased odds of miscarriage (OR 1.97, 95% CI 1.14–3.44) relative to women with low perceived stress (44.1% vs. 26.0%). While high emotional wellbeing was somewhat protective (OR 0.68, 95% CI 0.38–1.11) relative to women with low emotional wellbeing (26.8% vs. 35.9%). Maternal social support and life orientation were not associated with miscarriage. Conclusion Perceived stress and low emotional wellbeing may increase risk of miscarriage. Early assessment and greater support to vulnerable women may be important and warrants further investigation.

PPO.33 Perceived maternal stress and emotional wellbeing as risk factors for miscarriage

Objective Miscarriage is the most common adverse outcome in pregnancy. Investigations suggest numerous risk factors however the cause remains poorly understood. The study aimed to examine the contribution of an array of psychological factors to risk of miscarriage. Study design A cohort study was conducted in a large, tertiary hospital (8,500 deliveries per annum) in the Republic of Ireland in 2012. Women randomly selected at their first booking visit (10–14wks) were asked to complete a detailed lifestyle questionnaire, which included common risk factors for miscarriage. Emotional wellbeing, social support, life orientation and perceived stress were assessed using the following validated psychometric tests; the RAND 36-Item Health Survey, the Maternity Social Support Scale, the Revised Life Orientation Test and the Perceived Stress Scale. All participants were followed up at 20 weeks gestation to determine pregnancy outcome. Logistic regression was conducted to assess associations with risk of miscarriage. Results Of the 417 participants, 32.1% (n = 134) had a confirmed miscarriage at follow-up. After adjustment, women with high levels of perceived stress had an increased odds of miscarriage (OR: 1.97; 95% CI: 1.14–3.44) relative to women with low perceived stress (44.1% vs. 26.0%). While high emotional wellbeing was somewhat protective (OR: 0.68; 95% CI: 0.38–1.11) relative to women with low emotional wellbeing (26.8% vs. 35.9%). Maternal social support and life orientation were not associated with miscarriage. Conclusion Perceived stress and low emotional wellbeing may increase risk of miscarriage. Early assessment and greater support to vulnerable women may be important and warrants further investigation.

PPO.46 Risk of Miscarriage associated with Maternal and Paternal Smoking

Objective Maternal smoking has been associated with increased risk of miscarriage. However little is known about the influence of paternal smoking. The study aimed to examine maternal and paternal smoking as risk factors for miscarriage. Study Design A cohort study was conducted in a large, tertiary hospital (8,500 deliveries per annum) in the Republic of Ireland in 2012. Women randomly selected at their first booking visit (10–14 wks) were asked to complete a detailed lifestyle questionnaire including maternal and paternal smoking and the mother’s exposure to partner’s smoke. All participants were followed up at 20 weeks gestation to determine pregnancy outcome. Results Of the 417 participants, the prevalence of maternal and paternal smoking was 26.3% and 30.7%, respectively, and 13.4% of mothers were exposed to their partner’s smoke. One in three (n = 134, 32.1%) had a confirmed miscarriage at follow-up. Miscarriage was not associated with maternal smoking (30.6% for non-smokers versus 32.4% for smokers; P = 0.737) or paternal smoking (31.2% for non-smokers versus 32.8% for smokers; P = 0.763). A higher proportion of women exposed to their partner’s smoke experienced miscarriage (44.2% vs. 29.9%; Odds ratio = 1.86, 95% CI = 1.03–3.38; P = 0.038). The association remained even after adjustment for the mother’s own smoking (Adjusted odds ratio = 2.22, 95% CI = 1.12–4.40; P = 0.022). Conclusion Our findings suggest an association between mother’s exposure to partner’s smoke and miscarriage. That risk of miscarriage could be influenced by passive smoking but not active smoking is biologically implausible. However, a mother’s exposure to her partner’s smoke may be a proxy for other risk factors that warrant further investigation.