- Email: [email protected]
171: Withdrawn
www.AJOG.org Clinical Obstetrics, Neonatology, Physiology-Endocrinology 168 Low PAPP-A and adverse pregnancy outcomes by gestational age Shira Fishman1, Stephen T. Chasen1 1
Weill Cornell Medical College, New York, NY
OBJECTIVE: Low PAPP-A is a marker for Down syndrome as well as
trisomies 18 and 13. In addition, low PAPP-A is associated with higher rates of adverse pregnancy outcomes (APO) including IUGR, preeclampsia, and stillbirth, though the positive predictive value is low. In screening for fetal aneuploidy, PAPP-A performs better earlier in gestation. Our objective was to determine if the association between low PAPP-A and APO is also gestational age dependent. STUDY DESIGN: All patients who underwent first-trimester risk assessment from January 2006 to December 2008 with PAPP-A level less than the 5th percentile were identified. Pregnancies with an abnormal fetal karyotype were excluded. Biochemical risk assessment was performed from 9 0/7 – 13 6/7 weeks. Pregnancy outcome was determined from electronic medical records. APO included growth restriction, preeclampsia, fetal demise, and spontaneous preterm delivery. Statistical analysis was performed with Kruskal-Wallis test, Fisher’s exact test and logistic regression. RESULTS: 283 women were included. Within this cohort of women with PAPP-A of 5th%ile or less, the PAPP-A values were lower earlier in gestation. The median PAPP-A level was at the 1st%ile at 9-9 6/7 weeks, and rose each week to a median of 5th%ile at 13-13 6/7 weeks (p⫽.01). APO was documented in 104 of 283 pregnancies (36.7%), with a higher rate seen in those at ⬍12 0/7 weeks compared to those 12 0/7 weeks and higher (43.4% vs. 29.0%; p⫽.01). Maternal age and weight were not associated with higher rates of APO. Logistic regression was performed to adjust for PAPP-A level, demonstrating an independent association between low PAPP-A prior to ⬍12 weeks and APO, OR 1.8 [1.1-3.0]. CONCLUSIONS: In addition to better screening performance for chromosomal abnormalities and more timely results, PAPP-A may be more predictive of APO prior to 12 weeks gestation.
Poster Session I
p⫽.05). Planned induction, regardless of mode of delivery, was associated with the lowest complication rate (1/9 vs 7/11 p⫽.03). CONCLUSIONS: Hemorrhagic complications occur more frequently than thrombotic in women receiving peripartum TA and may be related to supratherapeutic treatment. When vaginal delivery is not contraindicated, planned induction of labor appears to be preferable.
170 What factors are associated with postpartum urinary retention? Stephanie J. Handler1, Yvonne W. Cheng1, Sharon Knight1, Deirdre Lyell2, Aaron B. Caughey3 1 University of California, San Francisco, San Francisco, CA, 2Stanford University School of Medicine/Lucile Salter Packard Children’s Hospital, Stanford, CA, 3Oregon Health & Science University, Portland, OR
OBJECTIVE: To examine obstetric and demographic factors associated with postpartum urinary retention. STUDY DESIGN: This is a retrospective cohort study of 10,282 women delivered at an academic medical center from 2002-08. The primary outcome was urinary retention in the immediate postpartum period. A variety of maternal and obstetric factors were examined as predictors in univariate and multivariable analyses. RESULTS: Second stage longer than 4 hours, epidural anesthesia, operative vaginal delivery, episiotomy, nulliparity, and obesity were associated with urinary retention postpartum (Table). Maternal age, race/ethnicity, and neonatal birthweight were not associated with urinary retention. CONCLUSIONS: Several aspects of obstetric management increase the risk for postpartum urinary retention. Whether this condition is associated with long-term morbidity merits further research; meanwhile, such differences can be used in patient education and counseling. Table. Factors Associated with Postpartum Urinary Retention Risk Factor
No Risk Factor
p-value
2nd stage ⬎ 4 hrs
1.2% 0.6% 0.042 .......................................................................................................................................................................................... Epidural use 0.7% 0.3% 0.012 .......................................................................................................................................................................................... Op vag del 1.7% 0.5% ⬍0.001 ..........................................................................................................................................................................................
169 Complications of peripartum anticoagulation Shira Fishman , Kathleen Hong , Stephen T. Chasen
Episiotomy
1
Nulliparity 0.7% 0.4% 0.009 ..........................................................................................................................................................................................
1
1
1
1.7%
0.6%
0.016
..........................................................................................................................................................................................
Weill Cornell Medical Center, New York, NY
OBJECTIVE: In the peripartum period, the risk of venous thromboem-
bolism (VTE) from withholding therapeutic anticoagulation (TA) must be weighed against the risk of hemorrhagic complications from continued TA in women at high risk of VTE. Our objective was to review the outcomes of women at our institution treated with peripartum TA. STUDY DESIGN: All women who received TA within 72h of delivery from Jan 2006 to Jul 2010 were identified. TA was defined as anticoagulation sufficient for treatment of VTE. Those receiving prophylactic doses were excluded. Pregnancy and postpartum outcomes were obtained from electronic medical records. Statistical analysis was performed with Fisher’s exact test. RESULTS: 20 women received peripartum TA, the majority (16/20) for a history of DVT ⫹/- PE with rheumatologic disease or thrombophilia, and the remainder for mechanical heart valve or other cardiac risk factors. Delivery ranged from 26 0/7-39 3/7weeks. Prior to delivery, IV unfractionated heparin (UH) was started in 11 patients (55%), while the others received UH or low molecular weight heparin subcutaneously. The duration off anticoagulation ranged from 16-72 hours. Of the 45% (9/20) who experienced a postpartum complication, wound hematoma (6/9) was the most common. 6 patients (30%) were noted to have supratherapeutic anticoagulation, one of whom was on warfarin and required reoperation due to intra-abdominal hemorrhage. The only patient with an embolic complication had severe antiphospholipid antibody syndrome and ultimately required treatment with immunglobulin. There was a trend towards a higher rate of complications in women who were supratheraputic compared to those with appropriate levels of anticoagulation (56% vs 9%
Obesity 0.3% 0.8% 0.038 ..........................................................................................................................................................................................
171 Withdrawn 172 Is it really necessary to induce labor in cases of intra uterine growth restriction (IUGR) at term? Tal Shavit1, Eran Ashwal1, Rivka Regev1, Dana Sadeh1, Moshe D Fejgin1, Tal Biron-Shental1 1
Meir Medical Center, Tel Aviv University, Kfar Saba
OBJECTIVE: Intrauterine growth restricted (IUGR) infants have in-
creased perinatal morbidity and mortality. The decision whether to induce labor at term or to expectantly manage those pregnancies, with strict surveillance, is controversial. The aim of this study was to asses maternal and short term neonatal outcome of those two attitudes. STUDY DESIGN: This is a retrospective cohort study of singleton term neonates with birth-weight bellow the 10th percentile. Those who were diagnosed as IUGR, went through induction of labor at term, while those who were not diagnosed, were delivered spontaneously. Maternal and early neonatal outcomes were compared between induced and spontaneous labors. RESULTS: The epidemiologic background and the pregnancy course were similar among the two groups. The main results are shown in the attached table. CONCLUSIONS: Expectant management for term IUGR pregnancies seems to be safe with lower rates of cesarean deliveries. A large prospective randomized controlled trial with long term neonatal follow up is indicated.
Supplement to JANUARY 2011 American Journal of Obstetrics & Gynecology
S79
Weill Cornell Medical College, New York, NY
OBJECTIVE: Low PAPP-A is a marker for Down syndrome as well as
trisomies 18 and 13. In addition, low PAPP-A is associated with higher rates of adverse pregnancy outcomes (APO) including IUGR, preeclampsia, and stillbirth, though the positive predictive value is low. In screening for fetal aneuploidy, PAPP-A performs better earlier in gestation. Our objective was to determine if the association between low PAPP-A and APO is also gestational age dependent. STUDY DESIGN: All patients who underwent first-trimester risk assessment from January 2006 to December 2008 with PAPP-A level less than the 5th percentile were identified. Pregnancies with an abnormal fetal karyotype were excluded. Biochemical risk assessment was performed from 9 0/7 – 13 6/7 weeks. Pregnancy outcome was determined from electronic medical records. APO included growth restriction, preeclampsia, fetal demise, and spontaneous preterm delivery. Statistical analysis was performed with Kruskal-Wallis test, Fisher’s exact test and logistic regression. RESULTS: 283 women were included. Within this cohort of women with PAPP-A of 5th%ile or less, the PAPP-A values were lower earlier in gestation. The median PAPP-A level was at the 1st%ile at 9-9 6/7 weeks, and rose each week to a median of 5th%ile at 13-13 6/7 weeks (p⫽.01). APO was documented in 104 of 283 pregnancies (36.7%), with a higher rate seen in those at ⬍12 0/7 weeks compared to those 12 0/7 weeks and higher (43.4% vs. 29.0%; p⫽.01). Maternal age and weight were not associated with higher rates of APO. Logistic regression was performed to adjust for PAPP-A level, demonstrating an independent association between low PAPP-A prior to ⬍12 weeks and APO, OR 1.8 [1.1-3.0]. CONCLUSIONS: In addition to better screening performance for chromosomal abnormalities and more timely results, PAPP-A may be more predictive of APO prior to 12 weeks gestation.
Poster Session I
p⫽.05). Planned induction, regardless of mode of delivery, was associated with the lowest complication rate (1/9 vs 7/11 p⫽.03). CONCLUSIONS: Hemorrhagic complications occur more frequently than thrombotic in women receiving peripartum TA and may be related to supratherapeutic treatment. When vaginal delivery is not contraindicated, planned induction of labor appears to be preferable.
170 What factors are associated with postpartum urinary retention? Stephanie J. Handler1, Yvonne W. Cheng1, Sharon Knight1, Deirdre Lyell2, Aaron B. Caughey3 1 University of California, San Francisco, San Francisco, CA, 2Stanford University School of Medicine/Lucile Salter Packard Children’s Hospital, Stanford, CA, 3Oregon Health & Science University, Portland, OR
OBJECTIVE: To examine obstetric and demographic factors associated with postpartum urinary retention. STUDY DESIGN: This is a retrospective cohort study of 10,282 women delivered at an academic medical center from 2002-08. The primary outcome was urinary retention in the immediate postpartum period. A variety of maternal and obstetric factors were examined as predictors in univariate and multivariable analyses. RESULTS: Second stage longer than 4 hours, epidural anesthesia, operative vaginal delivery, episiotomy, nulliparity, and obesity were associated with urinary retention postpartum (Table). Maternal age, race/ethnicity, and neonatal birthweight were not associated with urinary retention. CONCLUSIONS: Several aspects of obstetric management increase the risk for postpartum urinary retention. Whether this condition is associated with long-term morbidity merits further research; meanwhile, such differences can be used in patient education and counseling. Table. Factors Associated with Postpartum Urinary Retention Risk Factor
No Risk Factor
p-value
2nd stage ⬎ 4 hrs
1.2% 0.6% 0.042 .......................................................................................................................................................................................... Epidural use 0.7% 0.3% 0.012 .......................................................................................................................................................................................... Op vag del 1.7% 0.5% ⬍0.001 ..........................................................................................................................................................................................
169 Complications of peripartum anticoagulation Shira Fishman , Kathleen Hong , Stephen T. Chasen
Episiotomy
1
Nulliparity 0.7% 0.4% 0.009 ..........................................................................................................................................................................................
1
1
1
1.7%
0.6%
0.016
..........................................................................................................................................................................................
Weill Cornell Medical Center, New York, NY
OBJECTIVE: In the peripartum period, the risk of venous thromboem-
bolism (VTE) from withholding therapeutic anticoagulation (TA) must be weighed against the risk of hemorrhagic complications from continued TA in women at high risk of VTE. Our objective was to review the outcomes of women at our institution treated with peripartum TA. STUDY DESIGN: All women who received TA within 72h of delivery from Jan 2006 to Jul 2010 were identified. TA was defined as anticoagulation sufficient for treatment of VTE. Those receiving prophylactic doses were excluded. Pregnancy and postpartum outcomes were obtained from electronic medical records. Statistical analysis was performed with Fisher’s exact test. RESULTS: 20 women received peripartum TA, the majority (16/20) for a history of DVT ⫹/- PE with rheumatologic disease or thrombophilia, and the remainder for mechanical heart valve or other cardiac risk factors. Delivery ranged from 26 0/7-39 3/7weeks. Prior to delivery, IV unfractionated heparin (UH) was started in 11 patients (55%), while the others received UH or low molecular weight heparin subcutaneously. The duration off anticoagulation ranged from 16-72 hours. Of the 45% (9/20) who experienced a postpartum complication, wound hematoma (6/9) was the most common. 6 patients (30%) were noted to have supratherapeutic anticoagulation, one of whom was on warfarin and required reoperation due to intra-abdominal hemorrhage. The only patient with an embolic complication had severe antiphospholipid antibody syndrome and ultimately required treatment with immunglobulin. There was a trend towards a higher rate of complications in women who were supratheraputic compared to those with appropriate levels of anticoagulation (56% vs 9%
Obesity 0.3% 0.8% 0.038 ..........................................................................................................................................................................................
171 Withdrawn 172 Is it really necessary to induce labor in cases of intra uterine growth restriction (IUGR) at term? Tal Shavit1, Eran Ashwal1, Rivka Regev1, Dana Sadeh1, Moshe D Fejgin1, Tal Biron-Shental1 1
Meir Medical Center, Tel Aviv University, Kfar Saba
OBJECTIVE: Intrauterine growth restricted (IUGR) infants have in-
creased perinatal morbidity and mortality. The decision whether to induce labor at term or to expectantly manage those pregnancies, with strict surveillance, is controversial. The aim of this study was to asses maternal and short term neonatal outcome of those two attitudes. STUDY DESIGN: This is a retrospective cohort study of singleton term neonates with birth-weight bellow the 10th percentile. Those who were diagnosed as IUGR, went through induction of labor at term, while those who were not diagnosed, were delivered spontaneously. Maternal and early neonatal outcomes were compared between induced and spontaneous labors. RESULTS: The epidemiologic background and the pregnancy course were similar among the two groups. The main results are shown in the attached table. CONCLUSIONS: Expectant management for term IUGR pregnancies seems to be safe with lower rates of cesarean deliveries. A large prospective randomized controlled trial with long term neonatal follow up is indicated.
Supplement to JANUARY 2011 American Journal of Obstetrics & Gynecology
S79