- Email: [email protected]
175: Rates of recurrent preterm delivery in women receiving 17 alpha-hydroxyprogesterone caproate by gestational age and reason for prior preterm birth
Poster Session I
% of Cesarean Sections
Clinical Obstetrics, Neonatology, Physiology-Endocrinology www.AJOG.org
Induction of labor (nⴝ148)
Spontaneous onset of labor (nⴝ483)
P
54.1%
11.4%
0.001
..........................................................................................................................................................................................
% of patients with 3.5% 2.4% 0.1 Apgar ⱕ 7 at 1 minute .......................................................................................................................................................................................... % of pateints with 0% 0.6% 0.5 Apgar ⱕ 7 at 5 minute .......................................................................................................................................................................................... Avarage # of neonatal 3.8⫾2.5 3⫾1.4 0.001 admission days ..........................................................................................................................................................................................
173 Maternal body mass index: effect on pregnancy outcomes over a 10 year period Tamula M. Patterson1, Alan T. Tita1, Suzanne P. Cliver1, Cherry L. Neely1, Joseph Biggio1 1
University of Alabama at Birmingham, Birmingham, AL
OBJECTIVE: Quantify the relationship of maternal body mass index
(BMI) and maternal and neonatal outcomes over a recent 10 year period. STUDY DESIGN: Retrospective cohort study of women delivering singletons ⬎20 weeks gestational age (GA) with recorded height and weight between 2000-2009 was conducted. Women were stratified by maternal BMI: underweight (⬍18.5), normal (18.5-24.9), overweight (25-29.9), obese (30-39.9) and morbidly obese (ⱖ40). Selected maternal and neonatal morbidities were analyzed and compared using Mantel Haenszel test for trend. Logistic regression was used to adjust for confounders when comparing underweight, overweight, obese and morbidly obese BMI categories to normal weight women. RESULTS: Of the 18,057 eligible women, 3% were underweight, 34% normal, 26% overweight, 27% obese and 9% morbidly obese. With increasing BMI, spontaneous preterm birth (PTB) and delivery of a SGA infant decreased significantly (trend p⬍ 0.0001 for both), while other pregnancy outcomes including gestational diabetes, hypertensive disorders, gestational hypertension, preeclampsia, chorioamnionitis, cesarean delivery, indicated PTB, birthweight ⬎4000 grams, and LGA significantly increased (all trend p⬍0.0001 except chorioamnionitis p⫽0.04). Adjusted risk ratios for selected outcomes according to maternal BMI when compared to normal BMI are presented (Table). CONCLUSIONS: Our data from the past 10 years quantify the dose response of maternal BMI on specific pregnancy outcomes. Underweight women are at increased risk for spontaneous preterm birth, while women with BMI ⱖ25 are at increased risk for gestational diabetes, hypertensive disorders, cesarean delivery and LGA infants. Thus, interventions are warranted to promote a normal BMI to decrease adverse consequences for pregnant women and their infants. Table. Pregnancy Outcomes by BMI categories compared to normal BMI women (Nⴝ6160).* Underweight (Nⴝ592)
Overweight (Nⴝ4685)
Obese (Nⴝ4917)
Morbidly Obese (Nⴝ1703)
Spontaneous PTB 1.39 [1.06-1.82] 0.88 [0.76-1.01] 0.65 [0.56-0.75] 0.45 [0.35-0.58]
..........................................................................................................................................................................................
Indicated PTB
0.80 [0.51-1.26] 1.13 [0.94-1.36] 1.44 [1.21-1.72] 1.76 [1.41-2.20]
C-Section
0.86 [0.67-1.12] 1.37 [1.23-1.52] 1.86 [1.68-2.05] 2.84 [2.49-3.24]
Gestational DM
1.20 [0.55-2.64] 1.97 [1.47-2.65] 3.95 [3.02-5.17] 5.30 [3.88-7.24]
Chorioamnionitis
0.63 [0.39-1.01] 1.34 [1.12-1.59] 1.58 [1.33-1.88] 1.60 [1.24-2.06]
.......................................................................................................................................................................................... .......................................................................................................................................................................................... .......................................................................................................................................................................................... ..........................................................................................................................................................................................
Hypertensive d/o
0.89 [0.64-1.23] 1.45 [1.27-1.67] 2.06 [1.81-2.35] 3.35 [2.85-3.93]
Gestational HTN
0.84 [0.50-1.41] 1.65 [1.34-2.03] 2.44 [2.02-2.97] 3.54 [2.80-4.46]
.......................................................................................................................................................................................... ..........................................................................................................................................................................................
Preeclampsia
0.92 [0.60-1.41] 1.29 [1.08-1.55] 1.73 [1.46-2.06] 2.76 [2.24-3.41]
BWT ⬎ 4000 g
0.50 [0.25-1.03] 1.83 [1.50-2.22] 2.37 [1.96-2.87] 3.33 [2.63-4.22]
LGA – Brenner
0.49 [0.30-0.79] 1.74 [1.52-2.00] 2.22 [1.94-2.53] 3.07 [2.59-3.64]
SGA – Brenner
1.59 [1.21-2.09] 0.83 [0.71-0.97] 0.69 [0.59-0.82] 0.61 [0.48-0.79]
.......................................................................................................................................................................................... .......................................................................................................................................................................................... .......................................................................................................................................................................................... ..........................................................................................................................................................................................
*Adjusted for race, parity, payer status, education, smoking, alcohol use and maternal age. PTB ⫽ preterm birth, DM ⫽ diabetes mellitus, HTN ⫽ hypertension, BWT ⫽ birthweight, LGA ⫽ large for gestational age, SGA ⫽ small for gestational age
S80
174 25 (OH) vitamin D levels do not change between the first and third trimesters with the standard prenatal vitamin dose of 400 IU of vitamin D Tiffany Blake-Lamb1, Chloe Zera1, Jennifer Stuart1, Scott Weiss1, Janet Rich-Edwards1, Louise Wilkins-Haug1, Thomas McElrath1 1
Brigham & Women’s Hospital, Boston, MA
OBJECTIVE: We tested the hypothesis that the standard 400 IU dose of
vitamin D found in prenatal vitamins (PNV) will prevent or correct first trimester 25-hydroxy-vitamin D (25-OH-D) deficiency. STUDY DESIGN: We conducted a nested case-control study of 426 women with singleton pregnancies followed prospectively from the initiation of prenatal care through delivery. We measured plasma 25OH-D concentrations in the first trimester (T1, mean 10.1 weeks) and third trimester (T3, mean 26.1 weeks). Maternal race and T1 PNV use were assessed by questionnaire. Regression was used to examine change in 25-OH-D concentration from T1 to T3 in women taking a PNV at T1, controlling for age, race, and season of conception. We had 80% power to detect a 30% change in mean 25-OH-D, assuming an alpha of 0.05. RESULTS: Among 306 women taking a T1 PNV, the mean (⫾SD) T1 25-OH-D level was 24.4 ⫾ 8.2 ng/mL compared to 18.7 ⫾ 8.6 ng/mL in 120 women not taking a T1 PNV (p⬍0.0001). Mean T3 25-OH-D levels (25.9 ⫾ 9.2 ng/mL) increased only slightly among women taking a PNV at T1 (p⫽0.03, adjusted for age, race, and season of conception). Of the women taking a T1 PNV, 29% were vitamin D deficient (⬍20 ng/ml) at T1 and 30% at T3. Fifty-eight (64%) of the 90 women taking a T1 PNV who were vitamin D deficient at baseline remained deficient in the third trimester. CONCLUSIONS: Although women taking a PNV at initial prenatal care have higher baseline 25-OH-D levels than women who are not taking a PNV, the continued use of a PNV from 1st to 3rd trimester is associated with only minimal increase in 25-OH-D level. The majority of vitamin D deficient women who took a PNV remained deficient in the third trimester. The standard dose of vitamin D in PNV’s is insufficient to protect women against vitamin D deficiency in pregnancy.
175 Rates of recurrent preterm delivery in women receiving 17 alpha-hydroxyprogesterone caproate by gestational age and reason for prior preterm birth Victor Hugo Gonzalez-Quintero1, Yvette C. Cordova1, Niki Istwan2, Felipe Tudela1, Debbie Rhea2, Adrian Marimon1, Cheryl Desch2, Leticia Maria Romary1, Gary Stanziano2 1
University of Miami, Miami, FL, 2Alere Health, Atlanta, GA
OBJECTIVE: Administration of 17P has been widely adopted in clinical
practice as a prophylactic treatment for prevention of recurrent preterm delivery. We sought to evaluate if rates of recurrent spontaneous preterm birth (SPTB) are different in women whose prior SPTB was due to preterm labor (PTL) or due to preterm premature rupture of membranes (PPROM). STUDY DESIGN: Identified from a database of women enrolled for outpatient 17P administration services were women with current singleton gestation having 1 prior SPTB resulting from PTL or PPROM. Included were those initiating 17P at 16-24.9 weeks’ gestation. Rates of recurrent SPTB (RSPTB) were compared between those with prior SPTB due to PTL or due to PPROM overall and within each gestational age (GA) at prior SPTB group (20-27.9 weeks, 28-33.9 weeks and 34-36.9 weeks) using Pearson’s chi-square (2-sided p-values ⬍0.05 considered statistically significant). RESULTS: Records from 2123 women were analyzed; 1639 (77.2%) with a prior SPTB due to PTL and 484 (22.8%) due to PPROM. In the overall population the rate of RSPTB ⬍37 weeks was 28.1%. The prior PTL group vs. the prior PPROM group experienced higher rates of recurrent SPTB at ⬍37 weeks of 29.7% vs. 22.9% (p⫽0.004), ⬍35 weeks of 14.0% vs. 9.1% (p⫽0.004), and ⬍32 weeks of 5.9% vs. 3.3% (p⫽0.024) respectively. Rates of RSPTB by GA at prior SPTB are presented in Table.
American Journal of Obstetrics & Gynecology Supplement to JANUARY 2011
www.AJOG.org Clinical Obstetrics, Neonatology, Physiology-Endocrinology CONCLUSIONS: Overall while receiving 17P, women with one prior SPTB due to PPROM were less likely to experience RSPTB than patients with a prior SPTB due to PTL with intact membranes. No differences in rates of RSPTB were observed between those with prior PTL or PPROM if the GA of the first SPTB occurred between 28-33.9 weeks’ gestation. 17P prophylaxis should be offered to all women with history of SPTB. Prior GA SPTB
20-27.9w
28-33.9w
34-36.9w
RSPTB ⬍37w
.................................................................................................................................................................................
PTL group 30.8% 29.7% 29.0% ................................................................................................................................................................................. PPROM group 15.4%* 30.3% 17.6%* ..........................................................................................................................................................................................
Poster Session I
SPTB <37w 17P start 16-20.9w (n⫽5058)
26.3%
SPTB <35w 10.8%
SPTB <32w 4.5%
..........................................................................................................................................................................................
17P start 21-24.9w (n⫽1488) 27.0% 11.9% 4.8% .......................................................................................................................................................................................... p-value 0.600 0.252 0.547 .......................................................................................................................................................................................... Interval ⱕ10d (n⫽6449) 26.3% 10.9% 4.4% .......................................................................................................................................................................................... Interval ⬎10d (n⫽60) 33.3% 20.0% 6.7% .......................................................................................................................................................................................... p-value 0.222 0.025 0.341 .......................................................................................................................................................................................... No Early DC (n⫽ 5561) 24.9% 10.2% 4.1% .......................................................................................................................................................................................... Early DC ⬍34w (n⫽985) 35.2% 16.1% 7.2% .......................................................................................................................................................................................... p-value ⬍0.001 ⬍0.001 ⬍0.001 ..........................................................................................................................................................................................
RSPTB ⬍35w ................................................................................................................................................................................. PTL group 21.4% 14.4% 9.9% ................................................................................................................................................................................. PPROM group
10.3%*
12.8%
4.3%*
..........................................................................................................................................................................................
RPTB................................................................................................................................................................................. ⬍32w
177 Amniotic fluid sludge in the presence of cervical cerclage is associated with poor obstetric outcomes
PTL group 13.1% 5.8% 2.3% .................................................................................................................................................................................
Vikas Sachar1, M Ismail2, L DiGiovanni2, O Rust3, Julie Moldenhauer4
PPROM group
1
6.4%
4.6%
0.5%
..........................................................................................................................................................................................
* ⫽p⬍0.05 vs. PTL group
176 Conformity with treatment standards and pregnancy outcomes in patients receiving 17 alpha-hydroxyprogesterone caproate (17p) for preterm birth prophylaxis Victor Hugo Gonzalez-Quintero1, Niki Istwan2, Felipe Jose Tudela1, Debbie Rhea2, Leticia Maria Romary1, Yvette C. Cordova1, Fabienne Achille1, Cheryl Desch2, Gary Stanziano2 1
University of Miami , Miami, FL, 2Alere Health, Atlanta, GA
OBJECTIVE: 17P is recommended for women with a history of spontaneous preterm birth (SPTB) to reduce the risk for SPTB recurrence, though patient compliance with timely initiation of treatment, injection interval and completion of therapy are clinical challenges. We sought to examine rates of compliance and recurrent SPTB in women enrolled for outpatient 17P administration services. STUDY DESIGN: Identified from a database were women enrolled in an outpatient 17P administration program of education and weekly home visits with nurse administered 17P injections. Included were women with prior SPTB, current singleton pregnancy, and no cerclage, enrolled at ⬍25 weeks’ gestation (N⫽6546). We examined rates of recurrent SPTB at ⬍37, ⬍35 and ⬍32 weeks by timing of 17P initiation (16-20.9 weeks vs. 21-24.9 weeks), mean injection interval for those having ⬎1 injection (within 10 days vs. ⬎10 day interval), and timing of 17P discontinuation (DC) (elective DC prior to 34 weeks vs. DC due to preterm birth or after 34 completed weeks). RESULTS: Overall, within the outpatient program of weekly nurse visits 77.3% of women initiated 17P at 16-20.9 weeks and 98.5% had a mean injection interval within 10 days. Only 0.5% of patients electively discontinued 17P after 1 injection. Early DC at ⬍34 weeks which was elective and not due to preterm birth occurred in 15.0% of patients. SPTB outcomes presented in table. CONCLUSIONS: High rates of compliance with timing of 17P prophylaxis initiation and recommended injection interval are observed for women enrolled in an outpatient 17P administration program of patient education and weekly home nursing visits. Elective early DC of 17P at ⬍34 weeks’ gestation is associated with increased rates of recurrent SPTB.
St. Francis Medical Center, Beverly Hills, CA, 2University of Chicago, Chicago, IL, 3Grand View Hospital, Sellersville, PA, 4The Children’s Hospital of Philadelphia, Philadelphia, PA
OBJECTIVE: To determine if the prenatal ultrasound finding of amniotic fluid sludge in patients with cervical cerclage is associated with adverse pregnancy outcome. STUDY DESIGN: Retrospective review of patients receiving cervical cerclage and subsequent delivery at one institution over a five year period. Maternal demographics, operative cerclage details, obstetric and neonatal outcome data were collected through chart review. Ultrasound images were retrospectively reviewed for the presence or absence of amniotic fluid sludge and cervical sonographic characteristics. Primary outcomes measured were preterm delivery ⬍ 32 weeks and composite neonatal morbidity, including grade III-IV intraventricular hemorrhage, bronchopulmonary dysplasia, respiratory distress syndrome, necrotizing enterocolitis, culture proven sepsis and death, in the presence of amniotic fluid sludge. RESULTS: A total of 105 patients were included in the study. Of those, 66 had sonographic evidence of sludge and 39 did not. Delivery at ⬍32 weeks (34.8% vs 5.1%, p⬍0.0001) and ⬍28 weeks (29% vs 5.1%, p⫽0.005) was significantly increased in the sludge present group vs the sludge absent group. There was no difference in composite neonatal morbidity between the two groups (p⫽0.056). The interval from cerclage to delivery was significantly less in the group with sludge present (114.6 ⫹/- 56.1 days) compared to the group with no sludge (148.4 ⫹/- 32 days, p⫽0.0008). Gestational age at delivery was significantly less in the sludge present group compared to the sludge absent group (33.3 ⫹/- 6.7 weeks vs. 36.9⫹/-3.3 weeks; p⫽0.0025). CONCLUSIONS: In women undergoing cerclage placement, the presence of amniotic fluid sludge increases the risk for delivery at less than 32 weeks. The interval from cerclage placement to delivery is also shortened in women with amniotic fluid sludge.
Supplement to JANUARY 2011 American Journal of Obstetrics & Gynecology
S81
% of Cesarean Sections
Clinical Obstetrics, Neonatology, Physiology-Endocrinology www.AJOG.org
Induction of labor (nⴝ148)
Spontaneous onset of labor (nⴝ483)
P
54.1%
11.4%
0.001
..........................................................................................................................................................................................
% of patients with 3.5% 2.4% 0.1 Apgar ⱕ 7 at 1 minute .......................................................................................................................................................................................... % of pateints with 0% 0.6% 0.5 Apgar ⱕ 7 at 5 minute .......................................................................................................................................................................................... Avarage # of neonatal 3.8⫾2.5 3⫾1.4 0.001 admission days ..........................................................................................................................................................................................
173 Maternal body mass index: effect on pregnancy outcomes over a 10 year period Tamula M. Patterson1, Alan T. Tita1, Suzanne P. Cliver1, Cherry L. Neely1, Joseph Biggio1 1
University of Alabama at Birmingham, Birmingham, AL
OBJECTIVE: Quantify the relationship of maternal body mass index
(BMI) and maternal and neonatal outcomes over a recent 10 year period. STUDY DESIGN: Retrospective cohort study of women delivering singletons ⬎20 weeks gestational age (GA) with recorded height and weight between 2000-2009 was conducted. Women were stratified by maternal BMI: underweight (⬍18.5), normal (18.5-24.9), overweight (25-29.9), obese (30-39.9) and morbidly obese (ⱖ40). Selected maternal and neonatal morbidities were analyzed and compared using Mantel Haenszel test for trend. Logistic regression was used to adjust for confounders when comparing underweight, overweight, obese and morbidly obese BMI categories to normal weight women. RESULTS: Of the 18,057 eligible women, 3% were underweight, 34% normal, 26% overweight, 27% obese and 9% morbidly obese. With increasing BMI, spontaneous preterm birth (PTB) and delivery of a SGA infant decreased significantly (trend p⬍ 0.0001 for both), while other pregnancy outcomes including gestational diabetes, hypertensive disorders, gestational hypertension, preeclampsia, chorioamnionitis, cesarean delivery, indicated PTB, birthweight ⬎4000 grams, and LGA significantly increased (all trend p⬍0.0001 except chorioamnionitis p⫽0.04). Adjusted risk ratios for selected outcomes according to maternal BMI when compared to normal BMI are presented (Table). CONCLUSIONS: Our data from the past 10 years quantify the dose response of maternal BMI on specific pregnancy outcomes. Underweight women are at increased risk for spontaneous preterm birth, while women with BMI ⱖ25 are at increased risk for gestational diabetes, hypertensive disorders, cesarean delivery and LGA infants. Thus, interventions are warranted to promote a normal BMI to decrease adverse consequences for pregnant women and their infants. Table. Pregnancy Outcomes by BMI categories compared to normal BMI women (Nⴝ6160).* Underweight (Nⴝ592)
Overweight (Nⴝ4685)
Obese (Nⴝ4917)
Morbidly Obese (Nⴝ1703)
Spontaneous PTB 1.39 [1.06-1.82] 0.88 [0.76-1.01] 0.65 [0.56-0.75] 0.45 [0.35-0.58]
..........................................................................................................................................................................................
Indicated PTB
0.80 [0.51-1.26] 1.13 [0.94-1.36] 1.44 [1.21-1.72] 1.76 [1.41-2.20]
C-Section
0.86 [0.67-1.12] 1.37 [1.23-1.52] 1.86 [1.68-2.05] 2.84 [2.49-3.24]
Gestational DM
1.20 [0.55-2.64] 1.97 [1.47-2.65] 3.95 [3.02-5.17] 5.30 [3.88-7.24]
Chorioamnionitis
0.63 [0.39-1.01] 1.34 [1.12-1.59] 1.58 [1.33-1.88] 1.60 [1.24-2.06]
.......................................................................................................................................................................................... .......................................................................................................................................................................................... .......................................................................................................................................................................................... ..........................................................................................................................................................................................
Hypertensive d/o
0.89 [0.64-1.23] 1.45 [1.27-1.67] 2.06 [1.81-2.35] 3.35 [2.85-3.93]
Gestational HTN
0.84 [0.50-1.41] 1.65 [1.34-2.03] 2.44 [2.02-2.97] 3.54 [2.80-4.46]
.......................................................................................................................................................................................... ..........................................................................................................................................................................................
Preeclampsia
0.92 [0.60-1.41] 1.29 [1.08-1.55] 1.73 [1.46-2.06] 2.76 [2.24-3.41]
BWT ⬎ 4000 g
0.50 [0.25-1.03] 1.83 [1.50-2.22] 2.37 [1.96-2.87] 3.33 [2.63-4.22]
LGA – Brenner
0.49 [0.30-0.79] 1.74 [1.52-2.00] 2.22 [1.94-2.53] 3.07 [2.59-3.64]
SGA – Brenner
1.59 [1.21-2.09] 0.83 [0.71-0.97] 0.69 [0.59-0.82] 0.61 [0.48-0.79]
.......................................................................................................................................................................................... .......................................................................................................................................................................................... .......................................................................................................................................................................................... ..........................................................................................................................................................................................
*Adjusted for race, parity, payer status, education, smoking, alcohol use and maternal age. PTB ⫽ preterm birth, DM ⫽ diabetes mellitus, HTN ⫽ hypertension, BWT ⫽ birthweight, LGA ⫽ large for gestational age, SGA ⫽ small for gestational age
S80
174 25 (OH) vitamin D levels do not change between the first and third trimesters with the standard prenatal vitamin dose of 400 IU of vitamin D Tiffany Blake-Lamb1, Chloe Zera1, Jennifer Stuart1, Scott Weiss1, Janet Rich-Edwards1, Louise Wilkins-Haug1, Thomas McElrath1 1
Brigham & Women’s Hospital, Boston, MA
OBJECTIVE: We tested the hypothesis that the standard 400 IU dose of
vitamin D found in prenatal vitamins (PNV) will prevent or correct first trimester 25-hydroxy-vitamin D (25-OH-D) deficiency. STUDY DESIGN: We conducted a nested case-control study of 426 women with singleton pregnancies followed prospectively from the initiation of prenatal care through delivery. We measured plasma 25OH-D concentrations in the first trimester (T1, mean 10.1 weeks) and third trimester (T3, mean 26.1 weeks). Maternal race and T1 PNV use were assessed by questionnaire. Regression was used to examine change in 25-OH-D concentration from T1 to T3 in women taking a PNV at T1, controlling for age, race, and season of conception. We had 80% power to detect a 30% change in mean 25-OH-D, assuming an alpha of 0.05. RESULTS: Among 306 women taking a T1 PNV, the mean (⫾SD) T1 25-OH-D level was 24.4 ⫾ 8.2 ng/mL compared to 18.7 ⫾ 8.6 ng/mL in 120 women not taking a T1 PNV (p⬍0.0001). Mean T3 25-OH-D levels (25.9 ⫾ 9.2 ng/mL) increased only slightly among women taking a PNV at T1 (p⫽0.03, adjusted for age, race, and season of conception). Of the women taking a T1 PNV, 29% were vitamin D deficient (⬍20 ng/ml) at T1 and 30% at T3. Fifty-eight (64%) of the 90 women taking a T1 PNV who were vitamin D deficient at baseline remained deficient in the third trimester. CONCLUSIONS: Although women taking a PNV at initial prenatal care have higher baseline 25-OH-D levels than women who are not taking a PNV, the continued use of a PNV from 1st to 3rd trimester is associated with only minimal increase in 25-OH-D level. The majority of vitamin D deficient women who took a PNV remained deficient in the third trimester. The standard dose of vitamin D in PNV’s is insufficient to protect women against vitamin D deficiency in pregnancy.
175 Rates of recurrent preterm delivery in women receiving 17 alpha-hydroxyprogesterone caproate by gestational age and reason for prior preterm birth Victor Hugo Gonzalez-Quintero1, Yvette C. Cordova1, Niki Istwan2, Felipe Tudela1, Debbie Rhea2, Adrian Marimon1, Cheryl Desch2, Leticia Maria Romary1, Gary Stanziano2 1
University of Miami, Miami, FL, 2Alere Health, Atlanta, GA
OBJECTIVE: Administration of 17P has been widely adopted in clinical
practice as a prophylactic treatment for prevention of recurrent preterm delivery. We sought to evaluate if rates of recurrent spontaneous preterm birth (SPTB) are different in women whose prior SPTB was due to preterm labor (PTL) or due to preterm premature rupture of membranes (PPROM). STUDY DESIGN: Identified from a database of women enrolled for outpatient 17P administration services were women with current singleton gestation having 1 prior SPTB resulting from PTL or PPROM. Included were those initiating 17P at 16-24.9 weeks’ gestation. Rates of recurrent SPTB (RSPTB) were compared between those with prior SPTB due to PTL or due to PPROM overall and within each gestational age (GA) at prior SPTB group (20-27.9 weeks, 28-33.9 weeks and 34-36.9 weeks) using Pearson’s chi-square (2-sided p-values ⬍0.05 considered statistically significant). RESULTS: Records from 2123 women were analyzed; 1639 (77.2%) with a prior SPTB due to PTL and 484 (22.8%) due to PPROM. In the overall population the rate of RSPTB ⬍37 weeks was 28.1%. The prior PTL group vs. the prior PPROM group experienced higher rates of recurrent SPTB at ⬍37 weeks of 29.7% vs. 22.9% (p⫽0.004), ⬍35 weeks of 14.0% vs. 9.1% (p⫽0.004), and ⬍32 weeks of 5.9% vs. 3.3% (p⫽0.024) respectively. Rates of RSPTB by GA at prior SPTB are presented in Table.
American Journal of Obstetrics & Gynecology Supplement to JANUARY 2011
www.AJOG.org Clinical Obstetrics, Neonatology, Physiology-Endocrinology CONCLUSIONS: Overall while receiving 17P, women with one prior SPTB due to PPROM were less likely to experience RSPTB than patients with a prior SPTB due to PTL with intact membranes. No differences in rates of RSPTB were observed between those with prior PTL or PPROM if the GA of the first SPTB occurred between 28-33.9 weeks’ gestation. 17P prophylaxis should be offered to all women with history of SPTB. Prior GA SPTB
20-27.9w
28-33.9w
34-36.9w
RSPTB ⬍37w
.................................................................................................................................................................................
PTL group 30.8% 29.7% 29.0% ................................................................................................................................................................................. PPROM group 15.4%* 30.3% 17.6%* ..........................................................................................................................................................................................
Poster Session I
SPTB <37w 17P start 16-20.9w (n⫽5058)
26.3%
SPTB <35w 10.8%
SPTB <32w 4.5%
..........................................................................................................................................................................................
17P start 21-24.9w (n⫽1488) 27.0% 11.9% 4.8% .......................................................................................................................................................................................... p-value 0.600 0.252 0.547 .......................................................................................................................................................................................... Interval ⱕ10d (n⫽6449) 26.3% 10.9% 4.4% .......................................................................................................................................................................................... Interval ⬎10d (n⫽60) 33.3% 20.0% 6.7% .......................................................................................................................................................................................... p-value 0.222 0.025 0.341 .......................................................................................................................................................................................... No Early DC (n⫽ 5561) 24.9% 10.2% 4.1% .......................................................................................................................................................................................... Early DC ⬍34w (n⫽985) 35.2% 16.1% 7.2% .......................................................................................................................................................................................... p-value ⬍0.001 ⬍0.001 ⬍0.001 ..........................................................................................................................................................................................
RSPTB ⬍35w ................................................................................................................................................................................. PTL group 21.4% 14.4% 9.9% ................................................................................................................................................................................. PPROM group
10.3%*
12.8%
4.3%*
..........................................................................................................................................................................................
RPTB................................................................................................................................................................................. ⬍32w
177 Amniotic fluid sludge in the presence of cervical cerclage is associated with poor obstetric outcomes
PTL group 13.1% 5.8% 2.3% .................................................................................................................................................................................
Vikas Sachar1, M Ismail2, L DiGiovanni2, O Rust3, Julie Moldenhauer4
PPROM group
1
6.4%
4.6%
0.5%
..........................................................................................................................................................................................
* ⫽p⬍0.05 vs. PTL group
176 Conformity with treatment standards and pregnancy outcomes in patients receiving 17 alpha-hydroxyprogesterone caproate (17p) for preterm birth prophylaxis Victor Hugo Gonzalez-Quintero1, Niki Istwan2, Felipe Jose Tudela1, Debbie Rhea2, Leticia Maria Romary1, Yvette C. Cordova1, Fabienne Achille1, Cheryl Desch2, Gary Stanziano2 1
University of Miami , Miami, FL, 2Alere Health, Atlanta, GA
OBJECTIVE: 17P is recommended for women with a history of spontaneous preterm birth (SPTB) to reduce the risk for SPTB recurrence, though patient compliance with timely initiation of treatment, injection interval and completion of therapy are clinical challenges. We sought to examine rates of compliance and recurrent SPTB in women enrolled for outpatient 17P administration services. STUDY DESIGN: Identified from a database were women enrolled in an outpatient 17P administration program of education and weekly home visits with nurse administered 17P injections. Included were women with prior SPTB, current singleton pregnancy, and no cerclage, enrolled at ⬍25 weeks’ gestation (N⫽6546). We examined rates of recurrent SPTB at ⬍37, ⬍35 and ⬍32 weeks by timing of 17P initiation (16-20.9 weeks vs. 21-24.9 weeks), mean injection interval for those having ⬎1 injection (within 10 days vs. ⬎10 day interval), and timing of 17P discontinuation (DC) (elective DC prior to 34 weeks vs. DC due to preterm birth or after 34 completed weeks). RESULTS: Overall, within the outpatient program of weekly nurse visits 77.3% of women initiated 17P at 16-20.9 weeks and 98.5% had a mean injection interval within 10 days. Only 0.5% of patients electively discontinued 17P after 1 injection. Early DC at ⬍34 weeks which was elective and not due to preterm birth occurred in 15.0% of patients. SPTB outcomes presented in table. CONCLUSIONS: High rates of compliance with timing of 17P prophylaxis initiation and recommended injection interval are observed for women enrolled in an outpatient 17P administration program of patient education and weekly home nursing visits. Elective early DC of 17P at ⬍34 weeks’ gestation is associated with increased rates of recurrent SPTB.
St. Francis Medical Center, Beverly Hills, CA, 2University of Chicago, Chicago, IL, 3Grand View Hospital, Sellersville, PA, 4The Children’s Hospital of Philadelphia, Philadelphia, PA
OBJECTIVE: To determine if the prenatal ultrasound finding of amniotic fluid sludge in patients with cervical cerclage is associated with adverse pregnancy outcome. STUDY DESIGN: Retrospective review of patients receiving cervical cerclage and subsequent delivery at one institution over a five year period. Maternal demographics, operative cerclage details, obstetric and neonatal outcome data were collected through chart review. Ultrasound images were retrospectively reviewed for the presence or absence of amniotic fluid sludge and cervical sonographic characteristics. Primary outcomes measured were preterm delivery ⬍ 32 weeks and composite neonatal morbidity, including grade III-IV intraventricular hemorrhage, bronchopulmonary dysplasia, respiratory distress syndrome, necrotizing enterocolitis, culture proven sepsis and death, in the presence of amniotic fluid sludge. RESULTS: A total of 105 patients were included in the study. Of those, 66 had sonographic evidence of sludge and 39 did not. Delivery at ⬍32 weeks (34.8% vs 5.1%, p⬍0.0001) and ⬍28 weeks (29% vs 5.1%, p⫽0.005) was significantly increased in the sludge present group vs the sludge absent group. There was no difference in composite neonatal morbidity between the two groups (p⫽0.056). The interval from cerclage to delivery was significantly less in the group with sludge present (114.6 ⫹/- 56.1 days) compared to the group with no sludge (148.4 ⫹/- 32 days, p⫽0.0008). Gestational age at delivery was significantly less in the sludge present group compared to the sludge absent group (33.3 ⫹/- 6.7 weeks vs. 36.9⫹/-3.3 weeks; p⫽0.0025). CONCLUSIONS: In women undergoing cerclage placement, the presence of amniotic fluid sludge increases the risk for delivery at less than 32 weeks. The interval from cerclage placement to delivery is also shortened in women with amniotic fluid sludge.
Supplement to JANUARY 2011 American Journal of Obstetrics & Gynecology
S81