96: The effect of CenteringPregnancy Group prenatal care on enrollment in the post-partum family planning Medicaid waiver program

Abstract

twins when one twin has a major cardiac anomaly? Amy Doss, Keenan Yanit, Allison Allen, Brian Shaffer, Yvonne Cheng, Aaron Caughey Oregon Health & Science University, Obstetrics & Gynecology, Portland, OR, University of California San Francisco, Obstetrics, Gynecology, & Reproductive Sciences, San Francisco, CA OBJECTIVE: Optimal timing of twin delivery involves balancing the risk of IUFD against the potential morbidity of late preterm/early term birth, which becomes more challenging if one twin has a major cardiac anomaly, as this increases the IUFD risk and neonatal morbidity/mortality. We used decision analysis to estimate the optimal GA for delivery of dichorionic diamniotic (DCDA) twins when one has a cardiac anomaly. STUDY DESIGN: A decision-analytic model was created using TreeAge to compare the outcomes of delivery at 34 through 38 weeks in a theoretical cohort of DCDA twin pregnancies when one twin has a major cardiac anomaly. Our baseline assumption was that a twin with a cardiac anomaly was at 10-fold increased risk of IUFD. Strategies involving expectant management (EM) until a later GA accounted for the probabilities of spontaneous delivery, indicated delivery, and IUFD during each successive week. GA associated risks of neonatal complications including major neurodevelopmental disability, perinatal and neonatal mortality. Baseline assumptions were derived from the literature. Total quality-adjusted life years (QALYs) were calculated, accounting for both neonatal and maternal utilities. Sensitivity analyses were conducted. RESULTS: Our model showed that earlier GAs were associated with increased neonatal morbidity, but lower overall IUFD rates (Table). Balancing these outcomes, the optimal delivery strategy was EM until 38 weeks, which maximized the total QALYs. Sensitivity analysis showed that optimal GA at delivery was sensitive to the increased risk of IUFD associated with major cardiac anomalies. EM until 38 weeks was the optimal strategy until the increased risk of IUFD in an cardiac anomaly twin increased beyond a relative risk of 21.6, when delivery strategies at earlier GAs became preferred. CONCLUSION: Weighing the risks of IUFD against the outcomes of iatrogenic prematurity, the ideal GA to deliver DCDA twins in one with a major cardiac anomaly is 38 weeks.