135 Second trimester serum screening and adverse pregnancy outcome in twin gestations

$118 SMFM Abstracts 133

SEVERE THIRD-TRIMESTER PREGNANCY COMPLICATIONS ARE ASSOCIATED WITH INHERITED THROMBOPHILIA ZOHAR NACHUM t , AMIR ~rEISSL YASSER HUJEIRAT'-', STAVIT SHALEV2, RONIT BECK-FRUCHTER t , ZOFNAT WEINER-MAGNEZ1 t, ZEEV WEINER l, ELIEZER SHALEV3; t H a ' E m e k Medical Center, Obstetrics a n d Gynecology, Afula; ~Ha'Emek Medical Center, H u m a n genetic unit, Afula; 3Technion-Israel Institute of Technolog); Rappaport Faculty of Medicine, Haifa OBJECTIVE: To d e t e r m i n e the frequency of inherited a n d acquired thrombophilia a m o n g wonlen with severe third-trimester complications of

December 2001 A m J Obstet Gynecol 135

SECOND TRIMESTER SERUM SCREENING AND ADVERSE PREGNANCY OUTCOME IN TWIN GESTATIONS RADEK BUKOWSKIt , BARBARA LUKE SCD 2, GEORGE SAADE 1, GAYLE OLSON 3, D1BE MARTIN 4, MARY O'SULLIVAN5, GARY HANKINSr; 1University of Texas Medical Branch, Obstetrics a n d Gynecology, Galveston, TX; 2University of Michigan, Obstetrics & Gynecology, Ann Arbor, MI; 3University of Texas Medical Branch at Galveston, Obstetrics a n d Gynecology, Galveston, TX; 4University of Miami, Obstetrics a n d Gynecology, Miami, FL; 5University of Mianti, Obstetrics a n d Gynecology, Miami, FL; 6University of Texas Medical Branch at Galveston, Obstetrics & Gynecology, Galveston, TX OBJECTIVE: To d e t e r m i n e the association between second trimester serum screening results a n d adverse pregnancy outcomes in twin gestations. STUDY DESIGN: Twin gestations followed longitudinally as p a r t of a multicenter study were included if they h a d established dates, second trimester serum screening, a n d no fetal anomalies (n = 68). The relationship between p r e g n a n c y outcomes a n d the MoM's for AFP, beta-hCG, a n d estriol, singly (MoM-A, MoM-H, a n d MoM-E, respectively) a n d as a composite (MoM-C), was d e t e r m i n e d using Mann-Whitney test, ROC curve, a n d multiple linear a n d logistic regression analyses. Data presented as median [interquartile range] or O R [95%CI]. RESULTS: Those with at least o n e twin with b i r t h w e i g h t <10%ile for gestation (corrected for twins, g e n d e r a n d race) had a higher MoM-H (3.2 [2.8-6.1] vs 2.1 [1.3-2.8]; P < .001) a n d MoM-C (4 [3-6.5] vs 2.7 [1.5-3.5]; P = .003) as c o m p a r e d with those with birthweights >_10%ile. This relationship persisted after controlling for confounders (MoM-H: 2.38 [1.1-5.3]; P = .03 a n d MoM-C: 1.9 [1.1-3.2]; P= .02). Logit model yielded an 80% sensitivity a n d 87% specificity in p r e d i c t i n g birthweight <10%lie in at least one twin. Percent discordance between the twins was significantly correlated with MoM-A, MoMH a n d MoM-E on muhiple linear regression analysis (R2 = 0.35; P < .05). Pregnancies with >20% discordance h a d higher MoM-H (3.2 [2.5-4.2] vs 2.2 [1.45-2.95]; P = .04) a n d MoM-C (7.1 [6.5-8.9] vs 6 [4.8-7.6]; P = .04) than those with -<20% discordance. The association r e m a i n e d significant in the multivariate analysis (MoM-H: 2.4 [1.04-5.5]: P = .04) a n d yielded a 71% sensitivity a n d 90% specificity. MoM-H (3.1 [2-4.2] vs 2.2 [1.2-2.9]; P = .014) a n d MoM-C (3.54 [2.7-5.8 vs 2.8 [1.6-3.5]; P = .03) were higher in gestations complicated by p r e t e r m labor, b u t there was no relationship with p r e t e r m delivery or preeclampsia. CONCLUSION: The results of second trimester screening can identify twin gestations at higher risk for adverse pregnancy outcomes.

136

PLACENTAL HISTOLOGY OF SPONTANEOUS SECOND TRIMESTER PREGNANCY LOSS CARLOS BENITO l, ELAINE VOSTROVSKY1, DEBRA DAY-SALVATORE 1, SU S,aZsTSHEN-SCHWARZ1, KIMBERLY CAPERS t, AGNES SULEWSKD, iUMDNJ-Robert Wood J o h n s o n Medical School/Saint Peter's University' Hospital, Obstetrics, Gynecology a n d Reproductive Sciences. New Brunswick, NJ OBJECTIVE: To determine what placental histologic lesions, if any, are associated with spontaneous second trimester loss. STUDY DESIGN: Patients presenting to the Pregnancy Loss Evaluation Selwice (PLES) from July 1994 to J u n e 2001 were included in the study. PLES patients were evaluated through medical history, review of medical charts a n d placental pathology, antiphospholipid antibody panel a n d evaluation of the uterine cavity. Placental slides were evaluated for: chorioamnionitis, chorionic vasculitis, necrosis of amnion, funisitis, chronic inflammatory lesions (decidual vasculitis, decidual plasma cell infiltrates, c h r o n i c villitis, intervillositis). S p o n t a n e o u s second trimester loss (SSTL) was defined as loss o c c u r r i n g between 14-24 weeks gestation associated with s p o n t a n e o u s r u p t u r e of membranes, contractions leading to loss or presenting with advanced cervical dilation. Patients with i n t r a u t e r i n e fetal demise (IUFD) were used as a comparison group. Significance was set a P < .05. RESULTS: A total of 226 patients h a d second trimester loss; 156 h a d SSTL a n d 70 h a d IUFD. Decidual vascular a n d coagulation related lesions were not associated with second trimester loss (P = .68 a n d .90 respectively). CONCLUSION: Placental histologic evidence of intrauterine infection a n d chronic inflammatory lesions were highly associated with SSTL. However, ascending infection, cervical incompetence as well as chronic inflammatory lesions have b e e n associated with cervical dilation which may lead to intrauterine infection. Table % SSTL % IUFD PVALUE

pregnancy, STUDY DESIGN: Women with severe preeclampsia, clinically significant placental abrnption a n d unexplained severe IUGR (<5th percentile) occurring after 24 weeks gestation, during a period of 3 years, were included. The study g r o u p consisted of 65 women who were matched for ethnicity with 53 healthy w o m e n with a n o r m a l obstetrical history. All women, in b o t h groups were tested for mutations of factor V Leiden, p r o t h r o m b i n gene, MTHFR, for the deficiencies of protein S, protein C, a n t i t h r o m b i n III a n d for lupusanticoagulant a n d anticardiolipin antibodies. RESULTS: The prevalence of any thrombophilia was 52% in the study g r o u p compared to 32% in the control g r o u p (OR 2.3; 95% CI 1.09 to 4.94; P < .04). Inherited thrombophilia was f o u n d in 42% of the study compared to 21% in the controls (OR 2.71; 95% CI 1.19 to 6.21; P < .02). The rate o f acquired t h r o m b o p h i l i a did not differ between the groups (20% vs. 19%, respectively). The rate o f combined thrombophilias was 17% vs. 7.5% (P= .16). CONCLUSION: Severe pregnancy complications of the third trimester are significantly associated with i n h e r i t e d thrombophilia. These findings suggest that a thrombophilia worknp should be part of investigation of these complications a n d may have therapeutic a n d prognostic implications in future pregnancies.

134

PRETERM PREMATURE RUPTURE OF MEMBRANES IS ASSOCIATED WITH FAILURE OF PHYSIOLOGIC TRANSFORMATION OF THE SPIRAL ARTERIES IN THE PLACENTAL BED YEON MEE KIM l, TINNAKORN C~ORAPONGSA 1, J U C H E O L KIM 1, RICARDO GOMEZ 1, BO HYUN YOON 2, SONIA HASSAN 3, ROBERTO ROMEROI; 1perinatology Research Branch, Detroit, M1; -~8eoul National University, Seoul 3Wayne State University, Obstetrics a n d Gynecology, Detroit, MI OBJECTIVE: Abnormal placentation, defined as failure of trophoblast invasion of the spiral arteries, has been considered central to the pathophysiology of preeelampsia a n d intrauterine growth retardation (Robertson et al, J Pathol Bact 1967;93:581) for the last 30 years. This study was c o n d u c t e d to determine if abnormal placentation was present in preterm premature rupture o f membranes (PROM). STUDY DESIGN: Placental bed biopsies were obtained at the time of Csection f r o m patients with preterxn P R O M . Biopsies were stained with cytokeratin 7 to determine the presence of trophoblast and PAS to identify fibrinoid deposits. A biopsy was considered to represent an adequate sample of the placental bed only if it h a d 1) interstitial trophoblast: 2) at least one spiral artery: a n d 3) a myometrial segment of the spiral arteries. The focus of the study was the diagnosis o f failure o f physiologic t r a n s f o r m a t i o n in the myometrial segment as described by Robertson a n d Brosens. RESULTS: Biopsies f r o m 18 patients met the inclusion criteria. The n u m b e r of spiral arteries ~aried widely a m o n g specimens (range 1-14). 50% (9/18) of patients h a d at least o n e spiral artery without evidence of trophoblast invasion of its vessel wall: failure of physiologic transformation. Complete transformation of at least one spiral artery was observed in 66% of cases (12/18). There was n o difference in the f r e q u e n c y of failure of physiologic t r a n s f o r m a t i o n of patients with i n f l a m m a t o r y lesions in the placental bed a n d those without inflammatory lesions [54% (6/11) vs. 43% (3/7), P > .05]. CONCLUSION: 1) Failure of physiologic t r a n s f o r m a t i o n of the myometrial segments of the spiral arteries is frequerlt in patients with preterm PROM, suggesting that a b n o r m a l placentation may he implicated in the pathogenesis of p r e t e r m PROM; 2) I n a d e q u a t e r e m o d e l i n g of the spiral arteries cannot be considered a lesion restricted to preeclampsia a n d small for gestational age.

Chorionic vasculitis Funlsitis Necrosis of amnion Decidual plasma cell infiltrates Deciduitis Decidual vasculitis Chronic villitis

82% 90% 89% 63% 69% 100% 100%

(32/39) (26/29) (31/35) (5/8) (16/23) (2/2) (3/3)

18% 10% 11% 37% 30% 0% 0%

(7/39) (3/29) (4/35) (3/8) (7/23) (0/2) (0/3)

.02 .002 .01 .01 .81 .01 .01