- Email: [email protected]
314: Association between an abnormal cerebroplacental ratio and the development of severe pre-eclampsia
Poster Session II
Hypertension, Diabetes, Prematurity, Physiology
OBJECTIVE: A substantial portion of intrauterine fetal demise (IUFD) in low resource settings is attributed to maternal complications, including hypertension in pregnancy. The aim of this study is to describe the prevalence of IUFD in pregnant women with hypertension in a rural Haitian hospital and compare characteristics of women with hypertension who had an IUFD to those who had a live birth. Recognizing risk factors for IUFD can optimize management plans in low resource settings. STUDY DESIGN: This was a retrospective cohort study of women with hypertension in pregnancy admitted to the maternity ward of Hôpital Albert Schweitzer (HAS) in Deschapelles, Haiti from January 1, 2011 through December 31, 2012. Medical charts were reviewed to obtain data. Data are presented as mean standard deviation, median (interquartile range) or proportion. RESULTS: During the study period 1743 women were admitted to the HAS maternity service with 176 IUFDs (10.1%). There were 300 women (17.2%) with singleton pregnancies affected by hypertension. Thirty-two women were excluded due to lack of documented outcomes. Of the remaining 268 women, 23.1% (n¼62) had an IUFD. Severe preeclampsia was diagnosed in 75.8% of women with an IUFD and 89.8% with a live birth (p¼0.005). Placental abruption was more common in the IUFD group (32.3%) compared with the live birth group (4.9%; p<0.0001). Neonates in the IUFD group were delivered earlier than in the live birth group (p<0.0001) and had a lower birth weight (p<0.0001). After adjusting birth weight for gestational age, the difference was not statistically significant (p¼0.07). The incidence of maternal death was 6.5% in the IUFD group and 0.5% in the live birth group (p<0.0001). CONCLUSION: Nearly one quarter of women admitted with hypertension in pregnancy experienced an IUFD; abruption accounted for a large proportion of IUFD. IUFD was associated with a significantly higher incidence of maternal death. Early diagnosis of hypertension and abruption may allow for well-timed intervention to prevent fetal and maternal mortality.
www.AJOG.org
OBJECTIVE: To determine the risk of gestational diabetes (GDM)
associated with the geographic distribution of healthy and unhealthy community resources. STUDY DESIGN: A retrospective study was performed involving zip codes in Los Angeles and Orange counties in southern California. Fast food restaurants, supermarkets, grocery stores, gyms and health clubs were first identified using Google Maps Extractor software and then aggregated by zip code. Green space (beach, parks and golf courses) was obtained through the Southern California Association of Government. California Birth Certificate data were used to obtain zip code level data for the number of patients with GDM as well as maternal age, race/ethnicity and body mass index (BMI). Measures of socioeconomic status were also collected using zip code level data from Census 2010 and the American Community Survey (20072011). Unadjusted and adjusted risk ratios were calculated using negative binomial regression. Regression models were generated for each geographic measure accounting for maternal age, BMI, race/ ethnicity and median household income. RESULTS: There were 364 zip codes included in the study, including 9,692 cases of GDM. The adjusted risk of GDM was reduced in zip codes with greater concentration of grocery stores [relative risk (RR) ¼ 0.95, 95% confidence interval (CI) 0.92-0.98] and supermarkets (RR¼0.94,, 95% CI 0.90-0.98). There was no significant relationship between the risk of GDM and the spatial distribution of fast food, gyms, health clubs and green space. CONCLUSION: The role of resource allocation cannot be underestimated when counseling patients regarding their risk of developing GDM. However, our ecological risks might not reflect individual behavior patterns which greatly impact individual risk of GDM. Further study at the individual level may help to further characterize the findings in this study.
Adjusted Risk of GDM (Adjusted for maternal age, BMI, race, ethnicity and median household income)
Clinical characteristics of patients with hypertension in pregnancy
* ¼ per 10,000 individuals.
314 Association between an abnormal cerebroplacental ratio and the development of severe pre-eclampsia Jodi Regan1, Heather Masters1, Carri Warshak1 1
University of Cincinnati College of Medicine, Maternal Fetal Medicine, Cincinnati, OH
OBJECTIVE: Evaluate the association between an abnormal cere-
Data are presented as n (%), median (interquartile range) and mean standard deviation. IUFD: Intrauterine fetal demise. *Comparing IUFD to live birth.
313 Geographic distribution of resources and the risk of gestational diabetes Christopher Young1, Olivier Laurent2, Judith Chung1, Jun Wu2 1
University of California, Irvine, Obstetrics and Gynecology, Orange, CA, University of California, Irvine, Population Health and Disease Prevention, Program in Public Health, Irvine, CA 2
broplacental ratio (CPR) and the subsequent development of severe preeclampsia, with subanalysis of other markers of maternal and neonatal morbidity. STUDY DESIGN: We identified a cohort with FGR defined as an estimated fetal weight less than the 10th percentile and/or an abdominal circumference less than the 5th percentile. We reviewed Doppler findings and calculated the CPR by dividing the middle cerebral pulsatility index by the UA pulsatility index . We compared outcomes in three study groups: (1) normal UA (referent), (2) abnormal UA, but normal CPR>1.08, and (3) abnormal UA and abnormal CPR<1.08. The primary outcome was the development of severe pre-eclampsia. Logistic regression was performed, with adjustment
S164 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2014
www.AJOG.org
Hypertension, Diabetes, Prematurity, Physiology
for age, parity, race, BMI, chronic hypertension, and tobacco. Sensitivity and specificity analysis was performed. RESULTS: We included 167 patients in this analysis: 111, 25 and 31 in Group 1,2 and 3 respectively. The rate of development of severe preeclampsia was strongly associated with an abnormal CPR, with Group 1,2, and 3 having a 6.3, 12 and 35.5% rate respectively (p<0.01). The aOR for the development of severe preeclampsia in Group 3 was 2.65 (1.5-4.7) compared to referent. Secondary outcome measures were significantly more common in Group 3 (Table). Sensitivity of CPR for the development of severe preeclampsia was 52%, specificity 86%. CONCLUSION: In patients with FGR, the CPR is a useful marker for the prediction of those patients that will develop severe preeclampsia. In addition, an abnormal CPR was also highly predictive of cesarean delivery, delivery prior to 32 weeks, development of nonreassuring fetal status, NICU admission and perinatal mortality.
Poster Session II
Probability of GDM adjusted for confounders by month of conception
Secondary outcomes in CPR and severe pre-eclampsia 316 Emergent therapy using either labetalol or hydralazine for acute-onset persistent severe hypertension in recommended dosages does not achieve an optimal hemodynamic profile James Martin1, Marie Darby1, Imran Sunesara2, Luissa Kiprono1, Leody Bautista1, Rachael Morris1, Javier Castillo1, James Bofill1 GA-gestational age, NRFHTs-nonreassuring fetal heart tones, NICU- Neonatal intensive care unit.
315 Seasonality of gestational diabetes mellitus based on date of conception in South Australiaea retrospective population study 2006-2011 Petra Verburg1, Graeme Tucker1, Wendy Scheil1, Claire Roberts2, Gus Dekker3 1
Epidemiology branch, SA Health, Adelaide, SA, Australia, 2Lyell McEwin Hospital, Elizabeth Vale, SA, Australia, 3School of Paediatrics and Reproductive Health, Robinson Institute, University of Adelaide, Adelaide, SA, Australia
OBJECTIVE: The objective of this study was to assess the seasonal vari-
ation of GDM in an Australian population. It has been suggested that the incidence of gestational diabetes mellitus (GDM) may vary with different seasons of the year. However, the literature is ambiguous. STUDY DESIGN: Retrospective population-based cohort study of 70,262 South Australian singleton liveborn births, for whom a Body Mass Index (BMI) of the mother and sex of the baby were recorded, during 2006-2011 in the South Australian Perinatal Statistics Collection. The incidence of GDM in relation to date of conception was assessed. Fourier series analysis was used to model seasonal trends. RESULTS: Of a total of 70,262 births recorded during the study period 4,280 (6.1%) women were diagnosed with GDM. Seasonal modelling shows a strong relation between GDM and date of conception (p<0.000). When adjusted for confounders (age, BMI, ethnicity) the model still shows a strong relation between GDM and date of conception (p<0.000, Fig 1). The peak prevalence occurred among conceptions in winter (Jun/Jul/Aug), with a trough in pregnancies conceived in summer (Dec/Jan/Feb). CONCLUSION: The highest incidence of GDM was associated with conception in the winter months(Jun/Jul/Aug). Deficiency in vitamin D has previously been associated with both GDM and Type 2 Diabetes. It is likely that winter conception when maternal vitamin D status is at its nadir, exacerbates the insulin resistant state characteristic of pregnancy.
1
University of Mississippi Medical Center, Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Jackson, MS, 2University of Mississippi Medical Center, Biostatistics, Jackson, MS
OBJECTIVE: Acute-onset persistent severe hypertension with preeclampsia is associated with high maternal morbidity and even mortality. ACOG offers two order sets using either hydralazine or labetalol as first-line drug. We sought to determine if maternal hemodynamics are improved using these order sets. STUDY DESIGN: Patients with acute severe hypertension were prospectively randomized to either IV labetalol (L) or hydralazine (H) to reduce maternal BP to 140-155/90-99 mm Hg in this IRBapproved pilot study. Thoracic impedance cardiography (ICG) was undertaken immediately prior to treatment and after the target blood pressures were achieved. Longitudinal data analysis used mixed models to compare the mean differences between treatments and times. The final model was fitted using Restricted maximum likelihood (REML). Mean arterial pressure (MAP), cardiac output (CO) and systemic vascular resistance (SVR) were plotted relative to the target optimal hemodynamic zone for pregnancy. RESULTS: Twenty-nine patients completed the study. Between groups, there was no significant difference in MAP (H 119.4, L 117.7, mean difference 1.73). The estimated mean difference between baseline and follow-up ICG was -9.17 (p¼0.001, 95%CI -14.39 - -3.95).There was no significant difference in SVR between groups (H 1771.3, L 1976.9, mean difference 205.62). There was no significant difference in CO (H 5.7, L 5.1, mean difference 0.64). There was no significant mean difference between baseline and follow-up ICG for SVR and CO. CONCLUSION: Using current protocols, neither drug enabled any patient in the study to achieve an ideal hemodynamic profile for pregnancy. Either drug in higher doses, with longer duration of therapy, and frequent hemodynamic reassessment may be required to safely achieve an optimal hemodynamic profile. Further study is required to determine whether such efforts lead to better patient outcomes without maternal or fetal risk.
Supplement to JANUARY 2014 American Journal of Obstetrics & Gynecology
S165
Hypertension, Diabetes, Prematurity, Physiology
OBJECTIVE: A substantial portion of intrauterine fetal demise (IUFD) in low resource settings is attributed to maternal complications, including hypertension in pregnancy. The aim of this study is to describe the prevalence of IUFD in pregnant women with hypertension in a rural Haitian hospital and compare characteristics of women with hypertension who had an IUFD to those who had a live birth. Recognizing risk factors for IUFD can optimize management plans in low resource settings. STUDY DESIGN: This was a retrospective cohort study of women with hypertension in pregnancy admitted to the maternity ward of Hôpital Albert Schweitzer (HAS) in Deschapelles, Haiti from January 1, 2011 through December 31, 2012. Medical charts were reviewed to obtain data. Data are presented as mean standard deviation, median (interquartile range) or proportion. RESULTS: During the study period 1743 women were admitted to the HAS maternity service with 176 IUFDs (10.1%). There were 300 women (17.2%) with singleton pregnancies affected by hypertension. Thirty-two women were excluded due to lack of documented outcomes. Of the remaining 268 women, 23.1% (n¼62) had an IUFD. Severe preeclampsia was diagnosed in 75.8% of women with an IUFD and 89.8% with a live birth (p¼0.005). Placental abruption was more common in the IUFD group (32.3%) compared with the live birth group (4.9%; p<0.0001). Neonates in the IUFD group were delivered earlier than in the live birth group (p<0.0001) and had a lower birth weight (p<0.0001). After adjusting birth weight for gestational age, the difference was not statistically significant (p¼0.07). The incidence of maternal death was 6.5% in the IUFD group and 0.5% in the live birth group (p<0.0001). CONCLUSION: Nearly one quarter of women admitted with hypertension in pregnancy experienced an IUFD; abruption accounted for a large proportion of IUFD. IUFD was associated with a significantly higher incidence of maternal death. Early diagnosis of hypertension and abruption may allow for well-timed intervention to prevent fetal and maternal mortality.
www.AJOG.org
OBJECTIVE: To determine the risk of gestational diabetes (GDM)
associated with the geographic distribution of healthy and unhealthy community resources. STUDY DESIGN: A retrospective study was performed involving zip codes in Los Angeles and Orange counties in southern California. Fast food restaurants, supermarkets, grocery stores, gyms and health clubs were first identified using Google Maps Extractor software and then aggregated by zip code. Green space (beach, parks and golf courses) was obtained through the Southern California Association of Government. California Birth Certificate data were used to obtain zip code level data for the number of patients with GDM as well as maternal age, race/ethnicity and body mass index (BMI). Measures of socioeconomic status were also collected using zip code level data from Census 2010 and the American Community Survey (20072011). Unadjusted and adjusted risk ratios were calculated using negative binomial regression. Regression models were generated for each geographic measure accounting for maternal age, BMI, race/ ethnicity and median household income. RESULTS: There were 364 zip codes included in the study, including 9,692 cases of GDM. The adjusted risk of GDM was reduced in zip codes with greater concentration of grocery stores [relative risk (RR) ¼ 0.95, 95% confidence interval (CI) 0.92-0.98] and supermarkets (RR¼0.94,, 95% CI 0.90-0.98). There was no significant relationship between the risk of GDM and the spatial distribution of fast food, gyms, health clubs and green space. CONCLUSION: The role of resource allocation cannot be underestimated when counseling patients regarding their risk of developing GDM. However, our ecological risks might not reflect individual behavior patterns which greatly impact individual risk of GDM. Further study at the individual level may help to further characterize the findings in this study.
Adjusted Risk of GDM (Adjusted for maternal age, BMI, race, ethnicity and median household income)
Clinical characteristics of patients with hypertension in pregnancy
* ¼ per 10,000 individuals.
314 Association between an abnormal cerebroplacental ratio and the development of severe pre-eclampsia Jodi Regan1, Heather Masters1, Carri Warshak1 1
University of Cincinnati College of Medicine, Maternal Fetal Medicine, Cincinnati, OH
OBJECTIVE: Evaluate the association between an abnormal cere-
Data are presented as n (%), median (interquartile range) and mean standard deviation. IUFD: Intrauterine fetal demise. *Comparing IUFD to live birth.
313 Geographic distribution of resources and the risk of gestational diabetes Christopher Young1, Olivier Laurent2, Judith Chung1, Jun Wu2 1
University of California, Irvine, Obstetrics and Gynecology, Orange, CA, University of California, Irvine, Population Health and Disease Prevention, Program in Public Health, Irvine, CA 2
broplacental ratio (CPR) and the subsequent development of severe preeclampsia, with subanalysis of other markers of maternal and neonatal morbidity. STUDY DESIGN: We identified a cohort with FGR defined as an estimated fetal weight less than the 10th percentile and/or an abdominal circumference less than the 5th percentile. We reviewed Doppler findings and calculated the CPR by dividing the middle cerebral pulsatility index by the UA pulsatility index . We compared outcomes in three study groups: (1) normal UA (referent), (2) abnormal UA, but normal CPR>1.08, and (3) abnormal UA and abnormal CPR<1.08. The primary outcome was the development of severe pre-eclampsia. Logistic regression was performed, with adjustment
S164 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2014
www.AJOG.org
Hypertension, Diabetes, Prematurity, Physiology
for age, parity, race, BMI, chronic hypertension, and tobacco. Sensitivity and specificity analysis was performed. RESULTS: We included 167 patients in this analysis: 111, 25 and 31 in Group 1,2 and 3 respectively. The rate of development of severe preeclampsia was strongly associated with an abnormal CPR, with Group 1,2, and 3 having a 6.3, 12 and 35.5% rate respectively (p<0.01). The aOR for the development of severe preeclampsia in Group 3 was 2.65 (1.5-4.7) compared to referent. Secondary outcome measures were significantly more common in Group 3 (Table). Sensitivity of CPR for the development of severe preeclampsia was 52%, specificity 86%. CONCLUSION: In patients with FGR, the CPR is a useful marker for the prediction of those patients that will develop severe preeclampsia. In addition, an abnormal CPR was also highly predictive of cesarean delivery, delivery prior to 32 weeks, development of nonreassuring fetal status, NICU admission and perinatal mortality.
Poster Session II
Probability of GDM adjusted for confounders by month of conception
Secondary outcomes in CPR and severe pre-eclampsia 316 Emergent therapy using either labetalol or hydralazine for acute-onset persistent severe hypertension in recommended dosages does not achieve an optimal hemodynamic profile James Martin1, Marie Darby1, Imran Sunesara2, Luissa Kiprono1, Leody Bautista1, Rachael Morris1, Javier Castillo1, James Bofill1 GA-gestational age, NRFHTs-nonreassuring fetal heart tones, NICU- Neonatal intensive care unit.
315 Seasonality of gestational diabetes mellitus based on date of conception in South Australiaea retrospective population study 2006-2011 Petra Verburg1, Graeme Tucker1, Wendy Scheil1, Claire Roberts2, Gus Dekker3 1
Epidemiology branch, SA Health, Adelaide, SA, Australia, 2Lyell McEwin Hospital, Elizabeth Vale, SA, Australia, 3School of Paediatrics and Reproductive Health, Robinson Institute, University of Adelaide, Adelaide, SA, Australia
OBJECTIVE: The objective of this study was to assess the seasonal vari-
ation of GDM in an Australian population. It has been suggested that the incidence of gestational diabetes mellitus (GDM) may vary with different seasons of the year. However, the literature is ambiguous. STUDY DESIGN: Retrospective population-based cohort study of 70,262 South Australian singleton liveborn births, for whom a Body Mass Index (BMI) of the mother and sex of the baby were recorded, during 2006-2011 in the South Australian Perinatal Statistics Collection. The incidence of GDM in relation to date of conception was assessed. Fourier series analysis was used to model seasonal trends. RESULTS: Of a total of 70,262 births recorded during the study period 4,280 (6.1%) women were diagnosed with GDM. Seasonal modelling shows a strong relation between GDM and date of conception (p<0.000). When adjusted for confounders (age, BMI, ethnicity) the model still shows a strong relation between GDM and date of conception (p<0.000, Fig 1). The peak prevalence occurred among conceptions in winter (Jun/Jul/Aug), with a trough in pregnancies conceived in summer (Dec/Jan/Feb). CONCLUSION: The highest incidence of GDM was associated with conception in the winter months(Jun/Jul/Aug). Deficiency in vitamin D has previously been associated with both GDM and Type 2 Diabetes. It is likely that winter conception when maternal vitamin D status is at its nadir, exacerbates the insulin resistant state characteristic of pregnancy.
1
University of Mississippi Medical Center, Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Jackson, MS, 2University of Mississippi Medical Center, Biostatistics, Jackson, MS
OBJECTIVE: Acute-onset persistent severe hypertension with preeclampsia is associated with high maternal morbidity and even mortality. ACOG offers two order sets using either hydralazine or labetalol as first-line drug. We sought to determine if maternal hemodynamics are improved using these order sets. STUDY DESIGN: Patients with acute severe hypertension were prospectively randomized to either IV labetalol (L) or hydralazine (H) to reduce maternal BP to 140-155/90-99 mm Hg in this IRBapproved pilot study. Thoracic impedance cardiography (ICG) was undertaken immediately prior to treatment and after the target blood pressures were achieved. Longitudinal data analysis used mixed models to compare the mean differences between treatments and times. The final model was fitted using Restricted maximum likelihood (REML). Mean arterial pressure (MAP), cardiac output (CO) and systemic vascular resistance (SVR) were plotted relative to the target optimal hemodynamic zone for pregnancy. RESULTS: Twenty-nine patients completed the study. Between groups, there was no significant difference in MAP (H 119.4, L 117.7, mean difference 1.73). The estimated mean difference between baseline and follow-up ICG was -9.17 (p¼0.001, 95%CI -14.39 - -3.95).There was no significant difference in SVR between groups (H 1771.3, L 1976.9, mean difference 205.62). There was no significant difference in CO (H 5.7, L 5.1, mean difference 0.64). There was no significant mean difference between baseline and follow-up ICG for SVR and CO. CONCLUSION: Using current protocols, neither drug enabled any patient in the study to achieve an ideal hemodynamic profile for pregnancy. Either drug in higher doses, with longer duration of therapy, and frequent hemodynamic reassessment may be required to safely achieve an optimal hemodynamic profile. Further study is required to determine whether such efforts lead to better patient outcomes without maternal or fetal risk.
Supplement to JANUARY 2014 American Journal of Obstetrics & Gynecology
S165