- Email: [email protected]
293: Outcomes after trauma in pregnancy
SMFM Abstracts 292
www.AJOG.org
ALPHA HEMOGLOBIN STABILIZING PROTEIN (AHSP) IN RECURRENT MISCARRIAGE MONICA EMANUELLI1, PIERGIORGIO STORTONI2, DAVIDE SARTINI1, MONIA CECATI2, ALESSANDRA CORRADETTI2, STEFANO RAFFAELE GIANNUBILO2, ANDREA TRANQUILLI2, 1 Marche Polytechnic University, Biochemical biotechnologies, Ancona, Italy, 2 Marche Polytechnic University, Maternal and Child Sciences, Ancona, Italy OBJECTIVE: Alpha hemoglobin-stabilizing protein (AHSP) inhibits the production of reactive oxygen species in various cells, including erythrocytes. Reduced AHSP indicates reduced protection from oxidative stressors. Our objective was to investigate if and how AHSP varies in recurrent miscarriage. STUDY DESIGN: Forty specimens of trophoblast were collected from women at 10 weeks= gestation. Five were having recurrent miscarriage. Twenty women were experiencing a first spontaneous miscarriage. Those were followed up to their next pregnancy. Five of them experienced a repeated miscarriage. Ten women who had decided for voluntary abortion served as controls. At the end of the collection we had four groups: VA (Voluntary abortion-Controls; n⫽10); SA (Spontaneous first miscarriage with subsequent normal pregnancy, n⫽15); SASA (Spontaneous first miscarriage subsequent miscarriage; n⫽5); RSA (Recurrent miscarriage; not previously investigated n⫽5); RSAPS (Recurrent miscarriage previously studied, n⫽5). AHSP mRNA was determined using real time quantitative PCR. All statistical analyses were performed by using the GraphPad Prism Software. Differences were considered significant at p ⬍ 0.05. RESULTS: All patients had AHSP mRNA levels significantly lower than controls. AHSP mRNA levels were maximally reduced in RSA and RSAPS (8.0E10-6 ⫾ 1.3 and 8.1E10-6 ⫾ 0.7, respectively) when compared to first miscarriage and controls. (16.1E10-6 ⫾ 2.37 and 26.1E10-6 ⫾ 2.7, respectively). Women experiencing first spontaneous miscarriage followed by subsequent repeated miscarriage showed levels significantly reduced, as well (9.0.0E10-6 ⫾ 2.3). CONCLUSION: Recurrent miscarriage is charachterized by a status of reduced defense from oxifdative cell stressors. Such status may be evidenced already at a first miscarriage, thus identifying women who are at high risk for subsequent eventful pregnancy.
294
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.307
293
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.309
OUTCOMES AFTER TRAUMA IN PREGNANCY JOSIAH HAWKINS1, BRIAN CASEY1, JOSEPH MINEI2, DONALD MCINTIRE1, KENNETH LEVENO1, 1University of Texas Southwestern Medical Center, Department of Obstetrics and Gynecology, Dallas, Texas, 2 University of Texas Southwestern Medical Center, Trauma Surgery, Dallas, Texas OBJECTIVE: To describe outcomes in pregnant women evaluated in a large, urban Level I trauma center. STUDY DESIGN: This is an observational study completed after electronically linking databases for the obstetric service and the trauma unit at Parkland Hospital in Dallas. All pregnant women evaluated in the trauma unit between October 1995 and March 2004 were eligible for inclusion. Pregnancy outcomes for those women subsequently delivered at our hospital were evaluated, along with Abreviated Injury Severity scores for the abdomen (aAIS), which were assigned by trauma physicians in the Emergency Department and based on a scale of 1 to 5, with higher numbers indicating more severe injuries. RESULTS: A total of 1,328 pregnant women were evaluated during the study period, and 710 (53%) were Hispanic, 428 (32%) were black, 148 (11%) were white, and 42 (4%) were Asian or other ethnicity. Of these, 901 women (68%) delivered at our hospital. Of all women who delivered within 24 hours of injury, 64% labored spontaneously.
Mechanism of Injury n (%) Fail 407 (45) MVC 358 (40) Assault 92 (10) Other 44 (5) Total 901 (100) aAIS mean (range) 1
P-value 2 P-value 3 P-value 4 P-value
(compared (compared (compared (compared
to to to to
women women women women
SENSITIVITY OF TWO HOUR VERSUS FOUR HOUR MONITORING IN OBSTETRICAL PATIENTS FOLLOWING TRAUMA KELLY FOGLEMAN, MICHAEL PAGLIA, Brown University / Women & Infants’ Hospital of Rhode Island, Obstetrics and Gynecology, Providence, Rhode Island OBJECTIVE: To determine whether two hours of fetal monitoring after maternal trauma accurately predicts the need for admission when compared to four hours of monitoring. STUDY DESIGN: A retrospective chart analysis at a single, large academic institution was performed. Women with a singleton pregnancy greater than 24 weeks gestation presenting to an obstetric triage unit after experiencing trauma were included. The primary outcome was the ultimate disposition from triage. An investigator who was blinded to the ultimate disposition reviewed the first two hours of cardiotocographic monitoring and made a determination whether the patient should be admitted for further monitoring. The disposition decision made by the reviewer was compared with the actual disposition decision made after four hours of monitoring. The sample size was calculated to test the hypothesis that the sensitivity of the 2 hour test would be at least 92%. RESULTS: Between September 2004 through June 2006, 478 patients that met criteria were seen in the triage unit. 115 patients were admitted for further observation after four hours of monitoring. Based on the blinded reviewer=s decision, 63 of the admitted patients (54.8%) would have been discharged if the decision was based on only two hours of monitoring. Two hours of monitoring would have led to admission for 24 patients who were actually discharged from the triage unit. The sensitivity of two hours of monitoring was 45% (95% CI, 36-55%), significantly less than expected. The specificity, positive and negative predictive values of two versus four hours of monitoring is 93% (95% CI, 89-95%), 68% (95% CI, 57-79%), and 83% (95% CI, 78-86%) respectively. CONCLUSION: Two hours of fetal monitoring after maternal trauma does not accurately predict which patients will eventually be admitted for further observation after four hours of monitoring.
Delivery ⬍ 500 g
Preterm Delivery (⬍ 24 hrs of injury)
Abruption
Perinatal Death (⬍ 1 wk of injury
n (%)
n (%)
n (%)
n (%)
2 (0.2) 6 (0.7) 0 0 8 (0.9) 3 1.63 (0–5)
0 7 (0.8) 0 0 7 (0.8) 4 0.75 (0–4)
0 6 (0.7) 3 (0.3) 10 (1.1) 3 (0.3) 0 0 1 (0.1) 6 (0.7) 17 (1.9) 1 2 0.83 (0–5) 0.23 (0–2)
without delivery ⬍ 500 g) ⫽ 0.002. ⬍ 37 weeks without preterm delivery) ⬍ 0.001 without abruption) ⬍ 0.001 without perinatal death) ⬍ 0.001
CONCLUSION: 1. Significant trauma-related perinatal morbidity and mortality occurred despite most patients having low AIS-Abdomen scores. 2. Spontaneous labor is the most common reason for delivery within 24 hours regardless of gestational age at injury. 3. Motor vehicle collisions account for most trauma-related preterm births, placental abruptions, and perinatal deaths.
295
NEONATAL OUTCOMES IN WOMEN WITH SONOGRAPHICALLY IDENTIFIED UTERINE LEIOMYOMATA JASMINE LAI, AARON CAUGHEY, G. IRAM QIDWAI, ALISON F. JACOBY, University of California, San Francisco, Department of Obstetrics & Gynecology, San Francisco, California OBJECTIVE: Although the association between leiomyomata and obstetric outcomes has been well-documented, little is known about the effect of leiomyomata on neonatal outcomes. STUDY DESIGN: This is a retrospective cohort study comparing neonatal outcomes in women with and without uterine leiomyomata discovered at routine second trimester obstetric ultrasonography [US], all delivering at a single institution. Potential confounders (maternal age, ethnicity, parity, labor induction, epidural use) were controlled for using multivariable logistic regression. RESULTS: From 1993-2003, 15,104 women underwent routine second trimester US, with 401 (2.7%) women identified with ⱖ1 leiomyomata. By univariate and multivariable analyses, presence of leiomyomata was associated with increased risks for preterm delivery [PTD] at ⬍34wks (adjusted odds ratio [AOR] 1.7, 95% confidence interval [CI] 1.1-2.6); ⬍32wks (AOR 1.9, CI 1.2-3.2); and ⬍28wks (AOR 2.0, CI 1.1-3.8). Association with increased risk for IUFD was also demonstrated (AOR 2.7, CI 1.0-6.9). Low birth weight [LBW], low Apgars, cord blood pH, sepsis, and RDS were not shown to be significantly associated with leiomyomata when controlling for gestational age. CONCLUSION: Regardless of maternal age, ethnicity, and parity, pregnant women with leiomyomata are at increased risk for preterm birth and IUFD. This did not translate to lower birth weight outcomes among term patients, suggesting that LBW is more likely due to PTD than growth restriction. These results may be useful for preconception and prenatal counseling of women with leiomyomata. Uterine leiomyomata and neonatal complications
PTD ⬍34 wks ⬍32 wks ⬍28 wks IUFD LBW, all pts LBW, term SGA
Control group
p-value
AOR
95% CI
8.9% 6.0% 3.8% 1.6% 15.6% 3.2% 6.7%
5.0% 3.2% 1.9% 0.5% 10.7% 2.6% 7.5%
⬍0.01 0.01 0.01 0.01 0.01 0.60 0.57
1.7 1.9 2.0 2.7 1.3 0.8 0.7
1.1–2.6 1.2–3.2 1.1–3.8 1.0–6.9 0.9–1.8 0.4–1.8 0.4–1.1
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.310
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.308
S92
Leiomyoma group
American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2007
www.AJOG.org
ALPHA HEMOGLOBIN STABILIZING PROTEIN (AHSP) IN RECURRENT MISCARRIAGE MONICA EMANUELLI1, PIERGIORGIO STORTONI2, DAVIDE SARTINI1, MONIA CECATI2, ALESSANDRA CORRADETTI2, STEFANO RAFFAELE GIANNUBILO2, ANDREA TRANQUILLI2, 1 Marche Polytechnic University, Biochemical biotechnologies, Ancona, Italy, 2 Marche Polytechnic University, Maternal and Child Sciences, Ancona, Italy OBJECTIVE: Alpha hemoglobin-stabilizing protein (AHSP) inhibits the production of reactive oxygen species in various cells, including erythrocytes. Reduced AHSP indicates reduced protection from oxidative stressors. Our objective was to investigate if and how AHSP varies in recurrent miscarriage. STUDY DESIGN: Forty specimens of trophoblast were collected from women at 10 weeks= gestation. Five were having recurrent miscarriage. Twenty women were experiencing a first spontaneous miscarriage. Those were followed up to their next pregnancy. Five of them experienced a repeated miscarriage. Ten women who had decided for voluntary abortion served as controls. At the end of the collection we had four groups: VA (Voluntary abortion-Controls; n⫽10); SA (Spontaneous first miscarriage with subsequent normal pregnancy, n⫽15); SASA (Spontaneous first miscarriage subsequent miscarriage; n⫽5); RSA (Recurrent miscarriage; not previously investigated n⫽5); RSAPS (Recurrent miscarriage previously studied, n⫽5). AHSP mRNA was determined using real time quantitative PCR. All statistical analyses were performed by using the GraphPad Prism Software. Differences were considered significant at p ⬍ 0.05. RESULTS: All patients had AHSP mRNA levels significantly lower than controls. AHSP mRNA levels were maximally reduced in RSA and RSAPS (8.0E10-6 ⫾ 1.3 and 8.1E10-6 ⫾ 0.7, respectively) when compared to first miscarriage and controls. (16.1E10-6 ⫾ 2.37 and 26.1E10-6 ⫾ 2.7, respectively). Women experiencing first spontaneous miscarriage followed by subsequent repeated miscarriage showed levels significantly reduced, as well (9.0.0E10-6 ⫾ 2.3). CONCLUSION: Recurrent miscarriage is charachterized by a status of reduced defense from oxifdative cell stressors. Such status may be evidenced already at a first miscarriage, thus identifying women who are at high risk for subsequent eventful pregnancy.
294
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.307
293
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.309
OUTCOMES AFTER TRAUMA IN PREGNANCY JOSIAH HAWKINS1, BRIAN CASEY1, JOSEPH MINEI2, DONALD MCINTIRE1, KENNETH LEVENO1, 1University of Texas Southwestern Medical Center, Department of Obstetrics and Gynecology, Dallas, Texas, 2 University of Texas Southwestern Medical Center, Trauma Surgery, Dallas, Texas OBJECTIVE: To describe outcomes in pregnant women evaluated in a large, urban Level I trauma center. STUDY DESIGN: This is an observational study completed after electronically linking databases for the obstetric service and the trauma unit at Parkland Hospital in Dallas. All pregnant women evaluated in the trauma unit between October 1995 and March 2004 were eligible for inclusion. Pregnancy outcomes for those women subsequently delivered at our hospital were evaluated, along with Abreviated Injury Severity scores for the abdomen (aAIS), which were assigned by trauma physicians in the Emergency Department and based on a scale of 1 to 5, with higher numbers indicating more severe injuries. RESULTS: A total of 1,328 pregnant women were evaluated during the study period, and 710 (53%) were Hispanic, 428 (32%) were black, 148 (11%) were white, and 42 (4%) were Asian or other ethnicity. Of these, 901 women (68%) delivered at our hospital. Of all women who delivered within 24 hours of injury, 64% labored spontaneously.
Mechanism of Injury n (%) Fail 407 (45) MVC 358 (40) Assault 92 (10) Other 44 (5) Total 901 (100) aAIS mean (range) 1
P-value 2 P-value 3 P-value 4 P-value
(compared (compared (compared (compared
to to to to
women women women women
SENSITIVITY OF TWO HOUR VERSUS FOUR HOUR MONITORING IN OBSTETRICAL PATIENTS FOLLOWING TRAUMA KELLY FOGLEMAN, MICHAEL PAGLIA, Brown University / Women & Infants’ Hospital of Rhode Island, Obstetrics and Gynecology, Providence, Rhode Island OBJECTIVE: To determine whether two hours of fetal monitoring after maternal trauma accurately predicts the need for admission when compared to four hours of monitoring. STUDY DESIGN: A retrospective chart analysis at a single, large academic institution was performed. Women with a singleton pregnancy greater than 24 weeks gestation presenting to an obstetric triage unit after experiencing trauma were included. The primary outcome was the ultimate disposition from triage. An investigator who was blinded to the ultimate disposition reviewed the first two hours of cardiotocographic monitoring and made a determination whether the patient should be admitted for further monitoring. The disposition decision made by the reviewer was compared with the actual disposition decision made after four hours of monitoring. The sample size was calculated to test the hypothesis that the sensitivity of the 2 hour test would be at least 92%. RESULTS: Between September 2004 through June 2006, 478 patients that met criteria were seen in the triage unit. 115 patients were admitted for further observation after four hours of monitoring. Based on the blinded reviewer=s decision, 63 of the admitted patients (54.8%) would have been discharged if the decision was based on only two hours of monitoring. Two hours of monitoring would have led to admission for 24 patients who were actually discharged from the triage unit. The sensitivity of two hours of monitoring was 45% (95% CI, 36-55%), significantly less than expected. The specificity, positive and negative predictive values of two versus four hours of monitoring is 93% (95% CI, 89-95%), 68% (95% CI, 57-79%), and 83% (95% CI, 78-86%) respectively. CONCLUSION: Two hours of fetal monitoring after maternal trauma does not accurately predict which patients will eventually be admitted for further observation after four hours of monitoring.
Delivery ⬍ 500 g
Preterm Delivery (⬍ 24 hrs of injury)
Abruption
Perinatal Death (⬍ 1 wk of injury
n (%)
n (%)
n (%)
n (%)
2 (0.2) 6 (0.7) 0 0 8 (0.9) 3 1.63 (0–5)
0 7 (0.8) 0 0 7 (0.8) 4 0.75 (0–4)
0 6 (0.7) 3 (0.3) 10 (1.1) 3 (0.3) 0 0 1 (0.1) 6 (0.7) 17 (1.9) 1 2 0.83 (0–5) 0.23 (0–2)
without delivery ⬍ 500 g) ⫽ 0.002. ⬍ 37 weeks without preterm delivery) ⬍ 0.001 without abruption) ⬍ 0.001 without perinatal death) ⬍ 0.001
CONCLUSION: 1. Significant trauma-related perinatal morbidity and mortality occurred despite most patients having low AIS-Abdomen scores. 2. Spontaneous labor is the most common reason for delivery within 24 hours regardless of gestational age at injury. 3. Motor vehicle collisions account for most trauma-related preterm births, placental abruptions, and perinatal deaths.
295
NEONATAL OUTCOMES IN WOMEN WITH SONOGRAPHICALLY IDENTIFIED UTERINE LEIOMYOMATA JASMINE LAI, AARON CAUGHEY, G. IRAM QIDWAI, ALISON F. JACOBY, University of California, San Francisco, Department of Obstetrics & Gynecology, San Francisco, California OBJECTIVE: Although the association between leiomyomata and obstetric outcomes has been well-documented, little is known about the effect of leiomyomata on neonatal outcomes. STUDY DESIGN: This is a retrospective cohort study comparing neonatal outcomes in women with and without uterine leiomyomata discovered at routine second trimester obstetric ultrasonography [US], all delivering at a single institution. Potential confounders (maternal age, ethnicity, parity, labor induction, epidural use) were controlled for using multivariable logistic regression. RESULTS: From 1993-2003, 15,104 women underwent routine second trimester US, with 401 (2.7%) women identified with ⱖ1 leiomyomata. By univariate and multivariable analyses, presence of leiomyomata was associated with increased risks for preterm delivery [PTD] at ⬍34wks (adjusted odds ratio [AOR] 1.7, 95% confidence interval [CI] 1.1-2.6); ⬍32wks (AOR 1.9, CI 1.2-3.2); and ⬍28wks (AOR 2.0, CI 1.1-3.8). Association with increased risk for IUFD was also demonstrated (AOR 2.7, CI 1.0-6.9). Low birth weight [LBW], low Apgars, cord blood pH, sepsis, and RDS were not shown to be significantly associated with leiomyomata when controlling for gestational age. CONCLUSION: Regardless of maternal age, ethnicity, and parity, pregnant women with leiomyomata are at increased risk for preterm birth and IUFD. This did not translate to lower birth weight outcomes among term patients, suggesting that LBW is more likely due to PTD than growth restriction. These results may be useful for preconception and prenatal counseling of women with leiomyomata. Uterine leiomyomata and neonatal complications
PTD ⬍34 wks ⬍32 wks ⬍28 wks IUFD LBW, all pts LBW, term SGA
Control group
p-value
AOR
95% CI
8.9% 6.0% 3.8% 1.6% 15.6% 3.2% 6.7%
5.0% 3.2% 1.9% 0.5% 10.7% 2.6% 7.5%
⬍0.01 0.01 0.01 0.01 0.01 0.60 0.57
1.7 1.9 2.0 2.7 1.3 0.8 0.7
1.1–2.6 1.2–3.2 1.1–3.8 1.0–6.9 0.9–1.8 0.4–1.8 0.4–1.1
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.310
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.308
S92
Leiomyoma group
American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2007