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360: Intrahepatic cholestasis of pregnancy, outcomes related to bile acid levels
Poster Session II
ajog.org controls. There were no differences in CRP between groups. However, 2 of the 3 fetuses with reversed end-diastolic flow had the greatest CRP concentrations in the cohort. CONCLUSION: Singleton fetuses with FGR and abnormal UA Dopplers had greater concentrations of renin and lower concentrations of leptin when compared to controls. This is consistent with in-utero metabolic dysfunction. In multiple pregnancies, FGR fetuses with abnormal UA Dopplers and control fetuses exhibited different concentrations of leptin and renin compared to control fetuses from singleton pregnancies. This suggests that both the FGR fetus and the normal fetus in a multiple pregnancy have abnormal metabolic signaling.
360 Intrahepatic cholestasis of pregnancy, outcomes related to bile acid levels
Meirav Nezer1, Maayan Bas-Lando1, Rivka Farkash1, Nurit Algor1, Arnon Samueloff1, Hen Sela1 1 Shaare Zedek Medical Center in Jerusalem, Department of Obstetrics and Gynecology, Jerusalem, Israel
OBJECTIVE: Intrahepatic cholestasis of pregnancy (ICP), characterized by pruritus in the second half of pregnancy is associated with increased risk of intra uterine fetal death (IUFD). Some have suggested defining severe ICP by bile acid (BA) levels greater than 40 mol/L. We assessed whether this categorization is valid, by characterizing both groups and outcomes of such pregnancies. STUDY DESIGN: A Retrospective case control study, based on a computerized database at a single center between January 2006 and June 2014. All pregnancies in which BA was assessed were identified. Pregnancies were divided into 3 groups based on the maximal BA level during index pregnancy: normal BA (0-9.99 mol/L, group 1, G1), mildly elevated BA (10-39.99 mol/L, group 2, G2) and severely elevated BA (40 mol/L, group 3, G3). Statistics used: Descriptive, meansSDs, medians+IQR, Comparisons: chi-square, Fisher’s exact p<0.05, Kruskal-Wallis Test. RESULTS: During the study period 274 pregnancies had BA level tested out of 113,880 pregnancies. Pregnancies with normal BA level (G1) were used as control group. In 117 pregnancies ICP was diagnosed (1/1000 pregnancies). Among pregnancies complicated by ICP 87 (74%) were in G2 and 30 in G3 (26%). Overall there were 2 cases of IUFD at 32 and 34 weeks in the pregnancies assessed for BA level (2/274), all of which occurred in G3. Furthermore G3 presented at an earlier gestational age (334 weeks, p¼0.004), had a higher rate of induction of labor (53.3% p¼0.002), mostly delivered preterm (80%, p<0.0001), had lower Birth weight (2515 444gr p¼0.004) and had higher NICU admission rate (36.7% p<0.0001). Other Group characteristics and pregnancy outcomes according to groups is detailed in table. CONCLUSION: Severe ICP as defined by bile acid levels greater than 40 mol/L, is associated with increased risk of IUFD. In such cases even in the prematurity period delivery should be strongly considered, notwithstanding the cost of prematurity. Future studies should assess the timing of delivery in severe ICP cases to avoid IUFD.
Maternal and pregnancy characteristics and neonatal outcomes according to BA level.
361 The impact of a ban on trial of labor after cesarean (TOLAC) on primary cesarean delivery rates
Melissa Rosenstein1, Steven Gregorich2, Miriam Kuppermann1, Yvonne Cheng3, Aaron Caughey4, Mary Barger5
1 University of California, San Francisco, Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA, 2University of California, San Francisco, Department of Medicine, San Francisco, CA, 3California Pacific Medical Center, Department of Obstetrics and Gynecology, San Francisco, CA, 4Oregon Health and Science University, Department of Obstetrics and Gynecology, Portland, OR, 5 University of San Diego, Hahn School of Nursing and Health Science, San Diego, CA
OBJECTIVE: Many hospitals have stopped providing women with opportunity to undergo a trial of labor after cesarean (TOLAC). We performed a study to examine the impact of TOLAC bans on hospitals’ primary cesarean delivery (CD) rates. STUDY DESIGN: We conducted a cohort study of all California hospitals during 1999-2009 using the Birth Cohort File of linked birth certificates and maternal discharge diagnoses. We surveyed hospitals in 2012 to determine their TOLAC policy, and, if a policy change had been made, the year it took effect. Among hospitals that instituted a TOLAC ban between 2000-2008, we fit an interrupted time series-type model to estimate the effect the ban had on the primary CD rate among low-risk nulliparous term singleton vertex (NTSV) deliveries. We controlled for multiple hospital- and patientlevel factors as time-dependent covariates in a multivariable binomial regression model and a linear generalized estimating equation (GEE) model. RESULTS: There were 192,245 low-risk NTSV births during the study period at the 61 hospitals that banned TOLAC between
Supplement to JANUARY 2015 American Journal of Obstetrics & Gynecology
S189
ajog.org controls. There were no differences in CRP between groups. However, 2 of the 3 fetuses with reversed end-diastolic flow had the greatest CRP concentrations in the cohort. CONCLUSION: Singleton fetuses with FGR and abnormal UA Dopplers had greater concentrations of renin and lower concentrations of leptin when compared to controls. This is consistent with in-utero metabolic dysfunction. In multiple pregnancies, FGR fetuses with abnormal UA Dopplers and control fetuses exhibited different concentrations of leptin and renin compared to control fetuses from singleton pregnancies. This suggests that both the FGR fetus and the normal fetus in a multiple pregnancy have abnormal metabolic signaling.
360 Intrahepatic cholestasis of pregnancy, outcomes related to bile acid levels
Meirav Nezer1, Maayan Bas-Lando1, Rivka Farkash1, Nurit Algor1, Arnon Samueloff1, Hen Sela1 1 Shaare Zedek Medical Center in Jerusalem, Department of Obstetrics and Gynecology, Jerusalem, Israel
OBJECTIVE: Intrahepatic cholestasis of pregnancy (ICP), characterized by pruritus in the second half of pregnancy is associated with increased risk of intra uterine fetal death (IUFD). Some have suggested defining severe ICP by bile acid (BA) levels greater than 40 mol/L. We assessed whether this categorization is valid, by characterizing both groups and outcomes of such pregnancies. STUDY DESIGN: A Retrospective case control study, based on a computerized database at a single center between January 2006 and June 2014. All pregnancies in which BA was assessed were identified. Pregnancies were divided into 3 groups based on the maximal BA level during index pregnancy: normal BA (0-9.99 mol/L, group 1, G1), mildly elevated BA (10-39.99 mol/L, group 2, G2) and severely elevated BA (40 mol/L, group 3, G3). Statistics used: Descriptive, meansSDs, medians+IQR, Comparisons: chi-square, Fisher’s exact p<0.05, Kruskal-Wallis Test. RESULTS: During the study period 274 pregnancies had BA level tested out of 113,880 pregnancies. Pregnancies with normal BA level (G1) were used as control group. In 117 pregnancies ICP was diagnosed (1/1000 pregnancies). Among pregnancies complicated by ICP 87 (74%) were in G2 and 30 in G3 (26%). Overall there were 2 cases of IUFD at 32 and 34 weeks in the pregnancies assessed for BA level (2/274), all of which occurred in G3. Furthermore G3 presented at an earlier gestational age (334 weeks, p¼0.004), had a higher rate of induction of labor (53.3% p¼0.002), mostly delivered preterm (80%, p<0.0001), had lower Birth weight (2515 444gr p¼0.004) and had higher NICU admission rate (36.7% p<0.0001). Other Group characteristics and pregnancy outcomes according to groups is detailed in table. CONCLUSION: Severe ICP as defined by bile acid levels greater than 40 mol/L, is associated with increased risk of IUFD. In such cases even in the prematurity period delivery should be strongly considered, notwithstanding the cost of prematurity. Future studies should assess the timing of delivery in severe ICP cases to avoid IUFD.
Maternal and pregnancy characteristics and neonatal outcomes according to BA level.
361 The impact of a ban on trial of labor after cesarean (TOLAC) on primary cesarean delivery rates
Melissa Rosenstein1, Steven Gregorich2, Miriam Kuppermann1, Yvonne Cheng3, Aaron Caughey4, Mary Barger5
1 University of California, San Francisco, Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, San Francisco, CA, 2University of California, San Francisco, Department of Medicine, San Francisco, CA, 3California Pacific Medical Center, Department of Obstetrics and Gynecology, San Francisco, CA, 4Oregon Health and Science University, Department of Obstetrics and Gynecology, Portland, OR, 5 University of San Diego, Hahn School of Nursing and Health Science, San Diego, CA
OBJECTIVE: Many hospitals have stopped providing women with opportunity to undergo a trial of labor after cesarean (TOLAC). We performed a study to examine the impact of TOLAC bans on hospitals’ primary cesarean delivery (CD) rates. STUDY DESIGN: We conducted a cohort study of all California hospitals during 1999-2009 using the Birth Cohort File of linked birth certificates and maternal discharge diagnoses. We surveyed hospitals in 2012 to determine their TOLAC policy, and, if a policy change had been made, the year it took effect. Among hospitals that instituted a TOLAC ban between 2000-2008, we fit an interrupted time series-type model to estimate the effect the ban had on the primary CD rate among low-risk nulliparous term singleton vertex (NTSV) deliveries. We controlled for multiple hospital- and patientlevel factors as time-dependent covariates in a multivariable binomial regression model and a linear generalized estimating equation (GEE) model. RESULTS: There were 192,245 low-risk NTSV births during the study period at the 61 hospitals that banned TOLAC between
Supplement to JANUARY 2015 American Journal of Obstetrics & Gynecology
S189