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306: Are women less likely to breast feed after pregnancy complications?
SMFM Abstracts
www.AJOG.org 304
EVIDENCE OF THE INVOLVEMENT OF CASPASE-1 UNDER PHYSIOLOGIC AND PATHOLOGIC CELLULAR STRESS DURING HUMAN PREGNANCY: A LINK BETWEEN THE INFLAMMASOME AND PARTURITION FRANCESCA GOTSCH1, ROBERTO ROMERO1, OFFER EREZ1, JIMMY ESPINOZA2, JUAN PEDRO KUSANOVIC1, POOJA MITTAL2, SHALI MAZAKI-TOVI2, CHONG JAI KIM3, JUNG-SUN KIM3, SAMUEL S EDWIN1, CHIA-LING NHAN-CHANG2, NEIL HAMILL2, LARA FRIEL2, EDI VAISBUCH1, NANDOR GABOR THAN1, BO HYUN YOON4, SONIA HASSAN2, 1Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, Michigan, 2Wayne State University School of Medicine, Department of Obstetrics and Gynecology, Detroit, Michigan, 3Wayne State University School of Medicine, Department of Pathology, Detroit, Michigan, 4Seoul National University Hospital, Seoul, South Korea OBJECTIVE: The “Inflammasome”, recently described in the placenta (Reprod Sci. 2007), is the first line of the immune response to cell stress (Cell 2006;126:659) and the “master switch of inflammation”. This complex can be activated by microorganisms and “danger signals”. The inflammasome stimulates caspase-1 activation to promote processing/secretion of proinflammatory cytokines (IL-1 and IL-18). Our objective was to determine caspase-1 expression in amniotic fluid (AF) under conditions of cellular stress. STUDY DESIGN: A cross-sectional study was conducted to determine AF concentrations of caspase-1 in 143 singleton pregnancies in the following groups: 1) mid-trimester (n⫽18); 2) term not in labor (n⫽25); 3) term in labor (n⫽28); 4) preterm labor who delivered at term (n⫽23); and 5) preterm labor who delivered preterm with (n⫽17) and without (n⫽32) intra-amniotic infection/inflammation (IAI). Caspase-1 was measured with ELISA.Non-parametric statistics were used for analysis. RESULTS: 1) Caspase-1 concentration was detected in AF at term, but not in the midtrimester; 2) Women in spontaneous labor at term had a higher median AF concentration of caspase-1 than patients not in labor at term [10.46 pg/ml, range (0.00-666.00) vs. 5.99 pg/ml, range (0.00-237.44);p⬍0.05]; 3) Among patients with preterm labor, those who delivered preterm with IAI had a significantly higher median caspase-1 concentration [41.39 pg/ml, range (0.00-515.00)] than those who delivered preterm without IAI [0.00 pg/ml, range (0.00-78.41)] and those who delivered at term [0.00 pg/ml, range (0.00-199.53)] (p⬍0.001 for both comparisons). CONCLUSION: 1) Amniotic fluid caspase-1 expression under physiologic conditions is developmentally regulated; 2) States of physiologic (labor) or pathologic (infection/inflammation) cellular stress are associated with an increased AF concentration of caspase-1; 3) We propose a central role for caspase-1 in the execution of pathophysiologic functions of the inflammasome, the first line of defense against microbial or “danger signals”.
306
Predictors of breastfeeding Maternal Age ⬎ 35 Teen mother Preeclampsia Diabetes Gestational diabetes Preterm birth Induction Cesarean Operative vaginal delivery Post-partum hemorrhage
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.319
305
Odds ratio
95% CI
1.59 0.58 0.98 0.90 1.05 0.56 0.87 0.80 0.83 0.84
1.38-1.82 0.50-0.66 0.80-1.22 0.51-1.61 0.84-1.31 0.47-0.67 0.77-0.98 0.69-0.92 0.72-0.96 0.75-0.94
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.321
COMPARISON OF ULTRASONOGRAPHIC CERVICAL LENGTH TO BISHOP SCORE IN DETERMINING THE ADMINISTRATION OF PROSTAGLANDIN FOR PRE-INDUCTION CERVICAL RIPENING IN TERM NULLIPARAS DONG-MYUNG SHIN, KYO HOON PARK, JOON-SEOK HONG, WOONG SUN KANG, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Department of Obstetrics and Gynecology, Seongnam-si, Gyeonggi-do, Republic of Korea, South Korea OBJECTIVE: The purpose of this study was to compare the clinical effectiveness of ultrasonographic cervical length with Bishop score in determining the admnistration of prostaglandin for pre-induction cervical ripening in term nulliparas. STUDY DESIGN: A prospective observational study of 105 nulliparas undergoing induction of labor with prostaglandin E2 (dinoprostone) and oxytocin was conducted over a 1-year period. From August 2006 through March 2007, seventy consecutive women were administered prostaglandin for pre-induction cervical ripening based on the Bishop score and from April to August 2007, thirty-five consecutive women were administered prostaglandin based on the sonographically measured cervical length. Unfavorable cervix to be treated with prostaglandin for pre-induction cervical ripening was defined as either a Bishop score ⬍6 for women included in the Bishop score group or a cervical length ⬎2.8 cm for women included in the transvaginal ultrasound group. Induction success was defined as entry into active phase within 12 hours of oxytocin infusion. RESULTS: The two groups were similar for maternal weight and height, cervical length, Bishop score and gestational age. The two groups were also similar for the rates of induction success, cesarean delivery and the interval from the start of oxytocin to active phase. However, in transvaginal ultrasound group, only 43% (15/35) were administered prostaglandin compared with 93% (65/70) in Bishop score group (p⫽0.001). CONCLUSION: In comparison with the Bishop score, the use of sonographically measured cervical length for preinduction cervical assessment to choose induction agent can reduce 50% of the need for prostaglandin administration without adversely affecting the induction outcome in term nulliparas. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.320
ARE WOMEN LESS LIKELY TO BREAST FEED AFTER PREGNANCY COMPLICATIONS? ROBYN LAMAR1, MARIA COURT2, PATRICIA ROBERTSON2, SHARON WEINER2, AARON CAUGHEY2, 1Kaiser Permanente Medical Center, San Francisco, San Francisco, California, 2University of California, San Francisco, San Francisco, California OBJECTIVE: The objective of this study was to determine if high-risk pregnancies and pregnancy complications were associated with rates of breast feeding upon hospital discharge. STUDY DESIGN: A retrospective cohort study of all women who delivered from 1986-2001 (N⫽26,781) was conducted. We examined diagnoses of preeclampsia, diabetes mellitus, gestational diabetes, chorioamnionitis, mode of delivery, postpartum hemorrhage, perineal lacerations and extremes of maternal age as predictors of breast feeding upon hospital discharge. Potential confounding was controlled for with maternal, neonatal, and obstetric characteristics included in the multivariable model. RESULTS: Women who had a preterm birth were significantly less likely to breastfeed (table). In terms of delivery data, cesarean (aOR 0.80, p⬍0.05) or operative vaginal deliveries (aOR, p⬍0.05) both predicted a lower rate of breastfeeding, while perineal lacerations and chorioamnionitis had no effect. Other high risk conditions including preeclampsia, diabetes, or multiple gestations predicted breastfeeding rates. CONCLUSION: Induction of labor, preterm birth, operative deliveries, and postpartum hemorrhage were all associated with lower rates of breast feeding even after controlling for maternal and neonatal characteristics. Additionally, special effort to encourage breast feeding in women with a preterm birth should be made, as their neonates may benefit the most from the benefits of breast milk.
307
WHAT PREDICT DURATION OF LATENCY PERIOD IN PRETERM PREMATURE RUPTURE OF MEMBRANES? NIR MELAMED1, AVI BEN-HAROUSH1, RONY CHEN1, BORIS KAPLAN1, MOSHE HOD1, YARIV YOGEV1, 1Helen Schneider Hospital for Women, Obstetrics and Gynecology, Tel Aviv, Israel OBJECTIVE: To identify factors that predict the duration of latency period in cases of preterm premature rupture of membranes (PPROM) STUDY DESIGN: A retrospective cohort study of all women with PPROM at 23-34 weeks during the years 1998-2006. Management of PPROM included the use of antibiotics, betamethasone if less than 34 weeks, and expectant management with induction at 34 weeks. Latency period was defined as the time elapsed between onset of PPROM to spontaneous delivery or to labor induction at 34 weeks. RESULTS: 1) Out of 66,775 deliveries, the rate of PPROM was 1.4 % 2) The overall median duration of the latency period was 6 days (interquartile-range 2.013.0) and was inversely related to gestational age at admission: 5 days (interquartilerange 2-9), 8 days (interquartile-range 2-24) and 14 days (interquartile-range 5-28) for women presenting at 30-33 weeks, 27-29 weeks, and 22-26 weeks, respectively. 3)Women with latency period⬍48 hours were characterized by a higher rate of twin gestations (25.3% vs. 11.8%,P⫽0.01), cervical dilatation ⬎1cm at admission (54.1% vs. 25.7%,P⫽0.03), amniotic fluid index (AFI)⬍5cm (46.8% vs. 35.9%,P⫽0.004), and were more likely to be nulliparous (47.1% vs. 35.9%,P⬍0.001). 4)Cox proportional hazards model analysis indicated that gestational age on admission (HR⫽1.29, 95%CI 1.22-1.37), oligohydramnios (HR⫽1.49, 95%CI1.18-1.87), cervical dilatation⬎1cm (HR⫽2.01, 95%CI 1.522.83), fetal growth restriction (HR⫽2.94, 95%CI 1.24-6.94), and nulliparity (HR⫽1.28, 95%CI 1.12-1.63) were significant and independent predictors for latency-period duration. Multifetal gestation and maternal age were unrelated to the latency period (P⫽0.8, P⫽0.65, respectively). CONCLUSION: Our data suggest the duration of the latency period is inversely related to gestational age, and is shorter in the presence of oligohydramnios, cervical dilatation, and fetal growth restriction. This information may be useful when counselling women regarding the available options in cases of PPROM. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.322
Supplement to DECEMBER 2007 American Journal of Obstetrics & Gynecology
S95
www.AJOG.org 304
EVIDENCE OF THE INVOLVEMENT OF CASPASE-1 UNDER PHYSIOLOGIC AND PATHOLOGIC CELLULAR STRESS DURING HUMAN PREGNANCY: A LINK BETWEEN THE INFLAMMASOME AND PARTURITION FRANCESCA GOTSCH1, ROBERTO ROMERO1, OFFER EREZ1, JIMMY ESPINOZA2, JUAN PEDRO KUSANOVIC1, POOJA MITTAL2, SHALI MAZAKI-TOVI2, CHONG JAI KIM3, JUNG-SUN KIM3, SAMUEL S EDWIN1, CHIA-LING NHAN-CHANG2, NEIL HAMILL2, LARA FRIEL2, EDI VAISBUCH1, NANDOR GABOR THAN1, BO HYUN YOON4, SONIA HASSAN2, 1Perinatology Research Branch, NICHD, NIH, DHHS, Detroit, Michigan, 2Wayne State University School of Medicine, Department of Obstetrics and Gynecology, Detroit, Michigan, 3Wayne State University School of Medicine, Department of Pathology, Detroit, Michigan, 4Seoul National University Hospital, Seoul, South Korea OBJECTIVE: The “Inflammasome”, recently described in the placenta (Reprod Sci. 2007), is the first line of the immune response to cell stress (Cell 2006;126:659) and the “master switch of inflammation”. This complex can be activated by microorganisms and “danger signals”. The inflammasome stimulates caspase-1 activation to promote processing/secretion of proinflammatory cytokines (IL-1 and IL-18). Our objective was to determine caspase-1 expression in amniotic fluid (AF) under conditions of cellular stress. STUDY DESIGN: A cross-sectional study was conducted to determine AF concentrations of caspase-1 in 143 singleton pregnancies in the following groups: 1) mid-trimester (n⫽18); 2) term not in labor (n⫽25); 3) term in labor (n⫽28); 4) preterm labor who delivered at term (n⫽23); and 5) preterm labor who delivered preterm with (n⫽17) and without (n⫽32) intra-amniotic infection/inflammation (IAI). Caspase-1 was measured with ELISA.Non-parametric statistics were used for analysis. RESULTS: 1) Caspase-1 concentration was detected in AF at term, but not in the midtrimester; 2) Women in spontaneous labor at term had a higher median AF concentration of caspase-1 than patients not in labor at term [10.46 pg/ml, range (0.00-666.00) vs. 5.99 pg/ml, range (0.00-237.44);p⬍0.05]; 3) Among patients with preterm labor, those who delivered preterm with IAI had a significantly higher median caspase-1 concentration [41.39 pg/ml, range (0.00-515.00)] than those who delivered preterm without IAI [0.00 pg/ml, range (0.00-78.41)] and those who delivered at term [0.00 pg/ml, range (0.00-199.53)] (p⬍0.001 for both comparisons). CONCLUSION: 1) Amniotic fluid caspase-1 expression under physiologic conditions is developmentally regulated; 2) States of physiologic (labor) or pathologic (infection/inflammation) cellular stress are associated with an increased AF concentration of caspase-1; 3) We propose a central role for caspase-1 in the execution of pathophysiologic functions of the inflammasome, the first line of defense against microbial or “danger signals”.
306
Predictors of breastfeeding Maternal Age ⬎ 35 Teen mother Preeclampsia Diabetes Gestational diabetes Preterm birth Induction Cesarean Operative vaginal delivery Post-partum hemorrhage
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.319
305
Odds ratio
95% CI
1.59 0.58 0.98 0.90 1.05 0.56 0.87 0.80 0.83 0.84
1.38-1.82 0.50-0.66 0.80-1.22 0.51-1.61 0.84-1.31 0.47-0.67 0.77-0.98 0.69-0.92 0.72-0.96 0.75-0.94
0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.321
COMPARISON OF ULTRASONOGRAPHIC CERVICAL LENGTH TO BISHOP SCORE IN DETERMINING THE ADMINISTRATION OF PROSTAGLANDIN FOR PRE-INDUCTION CERVICAL RIPENING IN TERM NULLIPARAS DONG-MYUNG SHIN, KYO HOON PARK, JOON-SEOK HONG, WOONG SUN KANG, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Department of Obstetrics and Gynecology, Seongnam-si, Gyeonggi-do, Republic of Korea, South Korea OBJECTIVE: The purpose of this study was to compare the clinical effectiveness of ultrasonographic cervical length with Bishop score in determining the admnistration of prostaglandin for pre-induction cervical ripening in term nulliparas. STUDY DESIGN: A prospective observational study of 105 nulliparas undergoing induction of labor with prostaglandin E2 (dinoprostone) and oxytocin was conducted over a 1-year period. From August 2006 through March 2007, seventy consecutive women were administered prostaglandin for pre-induction cervical ripening based on the Bishop score and from April to August 2007, thirty-five consecutive women were administered prostaglandin based on the sonographically measured cervical length. Unfavorable cervix to be treated with prostaglandin for pre-induction cervical ripening was defined as either a Bishop score ⬍6 for women included in the Bishop score group or a cervical length ⬎2.8 cm for women included in the transvaginal ultrasound group. Induction success was defined as entry into active phase within 12 hours of oxytocin infusion. RESULTS: The two groups were similar for maternal weight and height, cervical length, Bishop score and gestational age. The two groups were also similar for the rates of induction success, cesarean delivery and the interval from the start of oxytocin to active phase. However, in transvaginal ultrasound group, only 43% (15/35) were administered prostaglandin compared with 93% (65/70) in Bishop score group (p⫽0.001). CONCLUSION: In comparison with the Bishop score, the use of sonographically measured cervical length for preinduction cervical assessment to choose induction agent can reduce 50% of the need for prostaglandin administration without adversely affecting the induction outcome in term nulliparas. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.320
ARE WOMEN LESS LIKELY TO BREAST FEED AFTER PREGNANCY COMPLICATIONS? ROBYN LAMAR1, MARIA COURT2, PATRICIA ROBERTSON2, SHARON WEINER2, AARON CAUGHEY2, 1Kaiser Permanente Medical Center, San Francisco, San Francisco, California, 2University of California, San Francisco, San Francisco, California OBJECTIVE: The objective of this study was to determine if high-risk pregnancies and pregnancy complications were associated with rates of breast feeding upon hospital discharge. STUDY DESIGN: A retrospective cohort study of all women who delivered from 1986-2001 (N⫽26,781) was conducted. We examined diagnoses of preeclampsia, diabetes mellitus, gestational diabetes, chorioamnionitis, mode of delivery, postpartum hemorrhage, perineal lacerations and extremes of maternal age as predictors of breast feeding upon hospital discharge. Potential confounding was controlled for with maternal, neonatal, and obstetric characteristics included in the multivariable model. RESULTS: Women who had a preterm birth were significantly less likely to breastfeed (table). In terms of delivery data, cesarean (aOR 0.80, p⬍0.05) or operative vaginal deliveries (aOR, p⬍0.05) both predicted a lower rate of breastfeeding, while perineal lacerations and chorioamnionitis had no effect. Other high risk conditions including preeclampsia, diabetes, or multiple gestations predicted breastfeeding rates. CONCLUSION: Induction of labor, preterm birth, operative deliveries, and postpartum hemorrhage were all associated with lower rates of breast feeding even after controlling for maternal and neonatal characteristics. Additionally, special effort to encourage breast feeding in women with a preterm birth should be made, as their neonates may benefit the most from the benefits of breast milk.
307
WHAT PREDICT DURATION OF LATENCY PERIOD IN PRETERM PREMATURE RUPTURE OF MEMBRANES? NIR MELAMED1, AVI BEN-HAROUSH1, RONY CHEN1, BORIS KAPLAN1, MOSHE HOD1, YARIV YOGEV1, 1Helen Schneider Hospital for Women, Obstetrics and Gynecology, Tel Aviv, Israel OBJECTIVE: To identify factors that predict the duration of latency period in cases of preterm premature rupture of membranes (PPROM) STUDY DESIGN: A retrospective cohort study of all women with PPROM at 23-34 weeks during the years 1998-2006. Management of PPROM included the use of antibiotics, betamethasone if less than 34 weeks, and expectant management with induction at 34 weeks. Latency period was defined as the time elapsed between onset of PPROM to spontaneous delivery or to labor induction at 34 weeks. RESULTS: 1) Out of 66,775 deliveries, the rate of PPROM was 1.4 % 2) The overall median duration of the latency period was 6 days (interquartile-range 2.013.0) and was inversely related to gestational age at admission: 5 days (interquartilerange 2-9), 8 days (interquartile-range 2-24) and 14 days (interquartile-range 5-28) for women presenting at 30-33 weeks, 27-29 weeks, and 22-26 weeks, respectively. 3)Women with latency period⬍48 hours were characterized by a higher rate of twin gestations (25.3% vs. 11.8%,P⫽0.01), cervical dilatation ⬎1cm at admission (54.1% vs. 25.7%,P⫽0.03), amniotic fluid index (AFI)⬍5cm (46.8% vs. 35.9%,P⫽0.004), and were more likely to be nulliparous (47.1% vs. 35.9%,P⬍0.001). 4)Cox proportional hazards model analysis indicated that gestational age on admission (HR⫽1.29, 95%CI 1.22-1.37), oligohydramnios (HR⫽1.49, 95%CI1.18-1.87), cervical dilatation⬎1cm (HR⫽2.01, 95%CI 1.522.83), fetal growth restriction (HR⫽2.94, 95%CI 1.24-6.94), and nulliparity (HR⫽1.28, 95%CI 1.12-1.63) were significant and independent predictors for latency-period duration. Multifetal gestation and maternal age were unrelated to the latency period (P⫽0.8, P⫽0.65, respectively). CONCLUSION: Our data suggest the duration of the latency period is inversely related to gestational age, and is shorter in the presence of oligohydramnios, cervical dilatation, and fetal growth restriction. This information may be useful when counselling women regarding the available options in cases of PPROM. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2007.10.322
Supplement to DECEMBER 2007 American Journal of Obstetrics & Gynecology
S95