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833: Evaluation of the clinical use of magnesium sulfate for cerebral palsy prevention
Poster Session V
Prematurity, Physiology
Neonatal characteristics and primary outcomes
*A 13th infant in the control group died in the delivery room and was excluded from analysis.
831 Feasibility of shear wave speed to evaluate cervical softness Stephanie Romero1, Lindsey Carlson2, Timothy Hall2, Mark Palmeri3, M. Sean Esplin1, Cara Heuser1, Helen Feltovich1 1
Intermountain Healthcare, Maternal-Fetal Medicine, Salt Lake City, UT, University of Wisconsin, Medical Physics, Madison, WI, 3Duke University, Biomedical Engineering, Durham, NC 2
OBJECTIVE: The cervix softens in gestation as its microstructure changes. Premature change may cause preterm birth. Bishop score can only subjectively describe softening, which motivates development of objective methods. Our goal was to determine whether shear wave speeds (SWS) can detect cervical softening. STUDY DESIGN: Nulliparous patients requiring prostaglandin ripening at 37-41 weeks were recruited (n ¼ 16). The study was approved by IHC and UW IRBs. Exams consisted of Bishop score, cervical length, and SWS measurement by a single operator (STR). Siemens Acuson S2000 ultrasound system was used. For SWS, a prototype transducer (128 elements, 14mm aperture, 3mm diameter), operated in linear array mode, was affixed to the operator’s finger in a sterile glove filled with gel, and placed on the anterior cervix. 10 measurements were made. Exams were done pre-ripening and w4 hours later. Subjects were divided into “Not in Labor” [n¼8, contractions >q3m allowing enough time for SWS/fetal head not well applied (no pressure on cervix)] and “Marked Progression” [n¼4, contractions
www.AJOG.org
OBJECTIVE: Obstetric history is often used to guide subsequent
pregnancy management. However, some seemingly ‘low risk’ women will have a preterm birth (PTB). We sought to identify whether adverse changes in social risk factors between a woman’s 1st and 2nd delivery increase the risk of PTB among women with a prior term delivery. STUDY DESIGN: Retrospective case-control cohort of women with their first 2 consecutive pregnancies carried to 20.0 wks gestation within a large healthcare system, 2002-2012. Women whose 1st delivery was <37 weeks, required a cerclage, or was complicated by multiple gestation and/or a fetal anomalies/aneuploidy were excluded. Those delivering G1 at term and G2 preterm 20.0 & <37.0 wks (term-preterm cases) were compared to women with a term birth for both G1 and G2 (term-term controls). Risk factors with the potential to change between pregnancies, such as tobacco, alcohol, and illicit drug use, insurance, and marital status, were compared between cases and controls. Data were extracted from computerized point-of-care programs; a portion manually verified. Analysis was by Chi2, Student’s t-test, and logistic regression. RESULTS: 38215 women met inclusion criteria. 1735 (4.5%) were term-preterm cases. Cases and controls were similar with regards to race/ethnicity and maternal age. Cases delivered their 2nd pregnancy earlier (35.5 vs. 39.0, p<0.001). Social risk factors were compared between groups (table). Women who initiated tobacco use after their 1st pregnancy were at significantly increased risk for PTB. In multivariable models accounting for known PTB risk factors, only women with new tobacco use (OR 2.3, 95% CI 1.6-3.2) and an interpregnancy interval < 12 months (OR 3.5, 95% CI 2.6-4.6) were at increased risk of term-preterm sequence. CONCLUSION: Tobacco use is a significant risk factor for PTB, even among women with a prior term delivery and no previous PTB. These women should be targeted for tobacco cessation programs, and may warrant a lower threshold for PTB screening.
Changes in social risk factors among women delivering term-preterm and those delivering term-term
Data are given as n(%).
833 Evaluation of the clinical use of magnesium sulfate for cerebral palsy prevention Pierre-Emmanuel Bouet1, Anne-Laure Baisson1, Veronique Courtay1, Ge´raldine Gascoin-Lachambre2, Philippe Gillard1, Sigismond Lasocki3, Philippe Descamps1, Loı¨c Sentilhes1 1
832 Newly acquired social risk factors among women with a prior term delivery who subsequently deliver preterm Luchin Wong1, Jacob Wilkes2, Kent Korgenski2, Michael Varner1, Tracy Manuck1 1
Intermountain Healthcare and the University of Utah, Department of Obstetrics and Gynecology, Salt Lake City, UT, 2Intermountain Healthcare and the University of Utah, Pediatrics, Salt Lake City, UT
Angers University Hospital, Obstetrics and Gynecology, Angers, France, Angers University Hospital, Neonatology, Angers, France, 3Angers University Hospital, Anesthesia, Angers, France 2
OBJECTIVE: To evaluate the implementation of a clinical protocol for the use of magnesium for cerebral palsy prevention, focusing on uptake, indications and safety. STUDY DESIGN: This retrospective and unicentred study included all women with fetuses of gestational age < 33 weeks whose birth was
S404 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2014
www.AJOG.org
Prematurity, Physiology
planned or expected within 24 hours from September 2011 (starting of implementation of magnesium sulfate in our department) to December 2012. We assigned women to receive magnesium sulfate, administered intravenously as a 4g bolus followed by a constant infusion of 1g per hour. If delivery had not occurred after 12 hours and was no longer considered imminent, the infusion was discontinued. The primary study outcome was to assess the rate of predelivery administration of magnesium sulfate over this time period. RESULTS: Among the 5610 patients who delivered during the study period, 110 were eligible for the protocol. 73% of eligible gravidas (95% CI : 61.1 - 87.6) received magnesium sulfate before delivery. Among patients eligible for the protocol who received magnesium sulfate, 87.5% delivered within 24 hours. In 2011, at the beginning of magnesium sulfate implementation, 82,3% of eligible gravidas received magnesium before delivery. The reasons that indicated treatment did not occur were staff error (40%), urgent delivery (56.7%) and past history of heart rhythm disorder (3.3%). The mean gestational age of the protocol’s implementation was 29.6 +/- 2.1 weeks. The mean duration of magnesium sulfate treatment was 285 +/- 40 minutes. Bolus and constant infusion were respectively administered during 34 +/- 11 minutes and 333 +/- 79 minutes. Four patients (4%) received magnesium sulfate during more than 12 hours. The mean dose administered was 8 +/- 6.7 g. No major maternal side effects were observed. CONCLUSION: It is feasible to implement a magnesium sulfate cerebral palsy prevention protocol into clinical practice.
Baseline characteristics of women who received magnesium sulfate
Poster Session V
OBJECTIVE: Bacterial vaginosis (BV) is a polymicrobial infection
associated with preterm birth (PTB). Conventional microbiological approaches have limited ability to comprehensively study this heterogenous condition. We sought to determine whether increases or decreases of microbial loads as assessed by qPCR could better describe the relationship between BV associated bacteria and PTB. STUDY DESIGN: We conducted a secondary analysis of stored vaginal samples from a prior trial in which women were randomized in the mid-trimester to metronidazole and azithromycin or placebo to prevent PTB. All women had risk factors for PTB including: positive fetal fibronectin, BV and a prior PTB, or BV and a prepregnancy weight <50 kg. Vaginal bacterial counts for total microbial load, Atopobium species, Gardnerella vaginalis, and BV-associated bacteria (BVAB) 1, 2, and 3 were measured using qPCR for 16S rRNA with absolute quantitation. Rates of PTB (<37 weeks) were calculated based on increase or decrease of microbial load after treatment and further analyzed by presence (Nugent 7-10) or absence (Nugent 0-6) of BV. RESULTS: 243 paired pre- and post-treatment vaginal samples were evaluated: 123 in the antibiotic group and 120 in the placebo. The rate of PTB <37 weeks was 18.1% (n¼44) and groups did not differ by risk factors for or rate of PTB (p¼0.24). Baseline bacterial load did not differ by treatment group (p¼0.87). Rates for PTB based on increase or decrease of bacterial counts stratified by BV status are depicted in the Table. There was no difference in the rate of PTB regardless of whether the bacterial count increased or decreased post-treatment and regardless of receipt of antibiotics or placebo. CONCLUSION: Although qPCR can assess changes in bacterial loads in the setting of BV, changes in the organisms examined and total bacterial load were not associated with the rate of PTB. Explanations for associations between BV and PTB are quite complex and require further investigation with comprehensive molecular bacteriology techniques.
835 Subsequent pregnancy outcomes among women with a history of preterm premature rupture of membranes (PPROM) <24.0 weeks gestation
*Values are given as mean +/- standard deviation; **Some patients had more than one reason for preterm birth; ***Respiratory rate of < 10/min, diastolic blood pressure decrease of > 30 mmHg, areflexia, coma, lung and heart failure.
834 Quantitative PCR microbial load assessment over time and preterm birth Adi Abramovici1, Elena Lobashevsky1, Suzanne Cliver1, Rodney Edwards1, Akila Subramaniam1, John Hauth1, Joseph Biggio1 1
University of Alabama at Birmingham, Obstetrics & Gynecology, Birmignham, AL
Karen Gibbins1, M. Sean Esplin1, Michael Varner1, Alexandra Eller1, Tracy Manuck1 1
Intermountain Healthcare and The University of Utah, Obstetrics and Gynecology, Salt Lake City, UT
OBJECTIVE: Early PPROM (prior to 24.0 wks gestation) is rare but is associated with high rates of neonatal morbidity and mortality. Some clinicians may not consider the early PPROM event as a significant preterm birth (PTB) history, particularly if it occurs <20 wks. We sought to characterize subsequent pregnancy outcomes among women with history of early PPROM. STUDY DESIGN: Retrospective cohort of women with documentation of 1 singleton pregnancy complicated by PPROM 14.0-24.0 wks at a single large tertiary referral center, 2002-2013. Women with PPROM were identified from ICD9 codes and obstetric databases.
Supplement to JANUARY 2014 American Journal of Obstetrics & Gynecology
S405
Prematurity, Physiology
Neonatal characteristics and primary outcomes
*A 13th infant in the control group died in the delivery room and was excluded from analysis.
831 Feasibility of shear wave speed to evaluate cervical softness Stephanie Romero1, Lindsey Carlson2, Timothy Hall2, Mark Palmeri3, M. Sean Esplin1, Cara Heuser1, Helen Feltovich1 1
Intermountain Healthcare, Maternal-Fetal Medicine, Salt Lake City, UT, University of Wisconsin, Medical Physics, Madison, WI, 3Duke University, Biomedical Engineering, Durham, NC 2
OBJECTIVE: The cervix softens in gestation as its microstructure changes. Premature change may cause preterm birth. Bishop score can only subjectively describe softening, which motivates development of objective methods. Our goal was to determine whether shear wave speeds (SWS) can detect cervical softening. STUDY DESIGN: Nulliparous patients requiring prostaglandin ripening at 37-41 weeks were recruited (n ¼ 16). The study was approved by IHC and UW IRBs. Exams consisted of Bishop score, cervical length, and SWS measurement by a single operator (STR). Siemens Acuson S2000 ultrasound system was used. For SWS, a prototype transducer (128 elements, 14mm aperture, 3mm diameter), operated in linear array mode, was affixed to the operator’s finger in a sterile glove filled with gel, and placed on the anterior cervix. 10 measurements were made. Exams were done pre-ripening and w4 hours later. Subjects were divided into “Not in Labor” [n¼8, contractions >q3m allowing enough time for SWS/fetal head not well applied (no pressure on cervix)] and “Marked Progression” [n¼4, contractions
www.AJOG.org
OBJECTIVE: Obstetric history is often used to guide subsequent
pregnancy management. However, some seemingly ‘low risk’ women will have a preterm birth (PTB). We sought to identify whether adverse changes in social risk factors between a woman’s 1st and 2nd delivery increase the risk of PTB among women with a prior term delivery. STUDY DESIGN: Retrospective case-control cohort of women with their first 2 consecutive pregnancies carried to 20.0 wks gestation within a large healthcare system, 2002-2012. Women whose 1st delivery was <37 weeks, required a cerclage, or was complicated by multiple gestation and/or a fetal anomalies/aneuploidy were excluded. Those delivering G1 at term and G2 preterm 20.0 & <37.0 wks (term-preterm cases) were compared to women with a term birth for both G1 and G2 (term-term controls). Risk factors with the potential to change between pregnancies, such as tobacco, alcohol, and illicit drug use, insurance, and marital status, were compared between cases and controls. Data were extracted from computerized point-of-care programs; a portion manually verified. Analysis was by Chi2, Student’s t-test, and logistic regression. RESULTS: 38215 women met inclusion criteria. 1735 (4.5%) were term-preterm cases. Cases and controls were similar with regards to race/ethnicity and maternal age. Cases delivered their 2nd pregnancy earlier (35.5 vs. 39.0, p<0.001). Social risk factors were compared between groups (table). Women who initiated tobacco use after their 1st pregnancy were at significantly increased risk for PTB. In multivariable models accounting for known PTB risk factors, only women with new tobacco use (OR 2.3, 95% CI 1.6-3.2) and an interpregnancy interval < 12 months (OR 3.5, 95% CI 2.6-4.6) were at increased risk of term-preterm sequence. CONCLUSION: Tobacco use is a significant risk factor for PTB, even among women with a prior term delivery and no previous PTB. These women should be targeted for tobacco cessation programs, and may warrant a lower threshold for PTB screening.
Changes in social risk factors among women delivering term-preterm and those delivering term-term
Data are given as n(%).
833 Evaluation of the clinical use of magnesium sulfate for cerebral palsy prevention Pierre-Emmanuel Bouet1, Anne-Laure Baisson1, Veronique Courtay1, Ge´raldine Gascoin-Lachambre2, Philippe Gillard1, Sigismond Lasocki3, Philippe Descamps1, Loı¨c Sentilhes1 1
832 Newly acquired social risk factors among women with a prior term delivery who subsequently deliver preterm Luchin Wong1, Jacob Wilkes2, Kent Korgenski2, Michael Varner1, Tracy Manuck1 1
Intermountain Healthcare and the University of Utah, Department of Obstetrics and Gynecology, Salt Lake City, UT, 2Intermountain Healthcare and the University of Utah, Pediatrics, Salt Lake City, UT
Angers University Hospital, Obstetrics and Gynecology, Angers, France, Angers University Hospital, Neonatology, Angers, France, 3Angers University Hospital, Anesthesia, Angers, France 2
OBJECTIVE: To evaluate the implementation of a clinical protocol for the use of magnesium for cerebral palsy prevention, focusing on uptake, indications and safety. STUDY DESIGN: This retrospective and unicentred study included all women with fetuses of gestational age < 33 weeks whose birth was
S404 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2014
www.AJOG.org
Prematurity, Physiology
planned or expected within 24 hours from September 2011 (starting of implementation of magnesium sulfate in our department) to December 2012. We assigned women to receive magnesium sulfate, administered intravenously as a 4g bolus followed by a constant infusion of 1g per hour. If delivery had not occurred after 12 hours and was no longer considered imminent, the infusion was discontinued. The primary study outcome was to assess the rate of predelivery administration of magnesium sulfate over this time period. RESULTS: Among the 5610 patients who delivered during the study period, 110 were eligible for the protocol. 73% of eligible gravidas (95% CI : 61.1 - 87.6) received magnesium sulfate before delivery. Among patients eligible for the protocol who received magnesium sulfate, 87.5% delivered within 24 hours. In 2011, at the beginning of magnesium sulfate implementation, 82,3% of eligible gravidas received magnesium before delivery. The reasons that indicated treatment did not occur were staff error (40%), urgent delivery (56.7%) and past history of heart rhythm disorder (3.3%). The mean gestational age of the protocol’s implementation was 29.6 +/- 2.1 weeks. The mean duration of magnesium sulfate treatment was 285 +/- 40 minutes. Bolus and constant infusion were respectively administered during 34 +/- 11 minutes and 333 +/- 79 minutes. Four patients (4%) received magnesium sulfate during more than 12 hours. The mean dose administered was 8 +/- 6.7 g. No major maternal side effects were observed. CONCLUSION: It is feasible to implement a magnesium sulfate cerebral palsy prevention protocol into clinical practice.
Baseline characteristics of women who received magnesium sulfate
Poster Session V
OBJECTIVE: Bacterial vaginosis (BV) is a polymicrobial infection
associated with preterm birth (PTB). Conventional microbiological approaches have limited ability to comprehensively study this heterogenous condition. We sought to determine whether increases or decreases of microbial loads as assessed by qPCR could better describe the relationship between BV associated bacteria and PTB. STUDY DESIGN: We conducted a secondary analysis of stored vaginal samples from a prior trial in which women were randomized in the mid-trimester to metronidazole and azithromycin or placebo to prevent PTB. All women had risk factors for PTB including: positive fetal fibronectin, BV and a prior PTB, or BV and a prepregnancy weight <50 kg. Vaginal bacterial counts for total microbial load, Atopobium species, Gardnerella vaginalis, and BV-associated bacteria (BVAB) 1, 2, and 3 were measured using qPCR for 16S rRNA with absolute quantitation. Rates of PTB (<37 weeks) were calculated based on increase or decrease of microbial load after treatment and further analyzed by presence (Nugent 7-10) or absence (Nugent 0-6) of BV. RESULTS: 243 paired pre- and post-treatment vaginal samples were evaluated: 123 in the antibiotic group and 120 in the placebo. The rate of PTB <37 weeks was 18.1% (n¼44) and groups did not differ by risk factors for or rate of PTB (p¼0.24). Baseline bacterial load did not differ by treatment group (p¼0.87). Rates for PTB based on increase or decrease of bacterial counts stratified by BV status are depicted in the Table. There was no difference in the rate of PTB regardless of whether the bacterial count increased or decreased post-treatment and regardless of receipt of antibiotics or placebo. CONCLUSION: Although qPCR can assess changes in bacterial loads in the setting of BV, changes in the organisms examined and total bacterial load were not associated with the rate of PTB. Explanations for associations between BV and PTB are quite complex and require further investigation with comprehensive molecular bacteriology techniques.
835 Subsequent pregnancy outcomes among women with a history of preterm premature rupture of membranes (PPROM) <24.0 weeks gestation
*Values are given as mean +/- standard deviation; **Some patients had more than one reason for preterm birth; ***Respiratory rate of < 10/min, diastolic blood pressure decrease of > 30 mmHg, areflexia, coma, lung and heart failure.
834 Quantitative PCR microbial load assessment over time and preterm birth Adi Abramovici1, Elena Lobashevsky1, Suzanne Cliver1, Rodney Edwards1, Akila Subramaniam1, John Hauth1, Joseph Biggio1 1
University of Alabama at Birmingham, Obstetrics & Gynecology, Birmignham, AL
Karen Gibbins1, M. Sean Esplin1, Michael Varner1, Alexandra Eller1, Tracy Manuck1 1
Intermountain Healthcare and The University of Utah, Obstetrics and Gynecology, Salt Lake City, UT
OBJECTIVE: Early PPROM (prior to 24.0 wks gestation) is rare but is associated with high rates of neonatal morbidity and mortality. Some clinicians may not consider the early PPROM event as a significant preterm birth (PTB) history, particularly if it occurs <20 wks. We sought to characterize subsequent pregnancy outcomes among women with history of early PPROM. STUDY DESIGN: Retrospective cohort of women with documentation of 1 singleton pregnancy complicated by PPROM 14.0-24.0 wks at a single large tertiary referral center, 2002-2013. Women with PPROM were identified from ICD9 codes and obstetric databases.
Supplement to JANUARY 2014 American Journal of Obstetrics & Gynecology
S405