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494: Positivity thresholds of HbA1c assay as a screening test for gestational diabetes mellitus in the first trimester in high-risk populations
Poster Session III
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alterations in inflammatory state. The aim of this study was to determine whether CT-associated inflammatory alterations persist in pregnancy. STUDY DESIGN: A multi-site prospective study was conducted in 654 pregnant women. Maternal CT was measured using the Childhood Trauma Questionnaire in the 2nd trimester of pregnancy. Women were classified based on the number of moderate to severe abuse/ neglect experiences during childhood. Interleukin-6 (IL-6) and interleukin-10 (IL-10) concentrations were measured at 12-20’6 weeks and 32-35’6 weeks of pregnancy. Linear mixed effect models were performed with adjustment for obstetric complications, maternal obesity, income, age, race/ethnicity, adult trauma exposure, depressive symptoms and abuse/neglect experience in the reference group. RESULTS: IL-6 concentrations as well as the IL-6/IL-10 ratio significantly increased over the course of gestation (IL-6: F(1,589.7)¼40.9, p<0.0001; IL-10: F(1,569.5)¼12.9, p<0.0001), while IL-10 concentrations did not significantly change from early to late gestation. Maternal CT was associated with average higher gestational IL-6 concentrations (F(3,653.1)¼4.59, p¼0.003) but not with altered average IL-10 concentrations or the IL-6/IL-10 ratio in the adjusted model. Maternal CT was not associated with the magnitude of change in any of the inflammatory outcomes from early to late gestation. Because only IL-6 but not Il-10 increased over the course of gestation, exploratory regression analyses tested whether there was a gestation-specific effect when CT was associated with the IL6/Il10 ratio. These analyses showed that maternal CT was associated with a higher IL6/Il10 ratio in late (b¼0.200.07, p¼0.006) but not in early pregnancy. CONCLUSION: The effects of maternal CT on inflammation persist during pregnancy, with a pro-/anti-inflammatory imbalance being especially pronounced in late gestation.
493 Maternal childhood trauma is associated with a pro-inflammatory state during pregnancy Claudia Buss1,2, Ann Borders3,4,5, Sonja Entringer1,2, Jennifer Culhane6,7, Greg Miller8,9, William Grobman3,10, Emma Adam9,11, Hyagriv Simhan12,13, Douglas Williamson14, Kwang-Youn Kim15, Lauren Keenan-Devlin4, Pathik D. Wadhwa1 1
University of California Irvine, Orange, CA, 2Charité Universitätsmedizin Berlin, Berlin, Germany, 3Center for Healthcare Studies e Institute for Public Health and Medicine, Chicago, IL, 4Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, NorthShore University Health System, University of Chicago Pritzker School of Medicine, Chicago, IL, 5Northwestern University Feinberg School of Medicine Department of Medical Social Sciences, Chicago, IL, 6Children’s Hospital of Philadelphia, Division of Adolescent Medicine, Philadelphia, PA, 7University of Pennsylvania Perelman School of Medicine, Department of Pediatrics, Philadelphia, PA, 8Northwestern University Department of Psychology, Chicago, IL, 9Institute for Policy Research, Chicago, IL, 10Northwestern University Feinberg School of Medicine, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Chicago, IL, 11 Northwestern University, School of Education and Social Policy, Chicago, IL, 12University of Pittsburgh School of Medicine, Division of Maternal-Fetal Medicine, Pittsburgh, PA, 13Magee Women’s Hospital, Division of Obstetrical Services, Pittsburgh, PA, 14Duke University, Department of Psychiatry and Behavioral Services, Durham, NC, 15Northwestern University Feinberg School of Medicine Department of Preventative Medicine, Biostatistics, Chicago, IL
OBJECTIVE: Exposure to childhood trauma (CT) is associated with adverse psychological and physiological outcomes including
494 Positivity thresholds of HbA1c assay as a screening test for gestational diabetes mellitus in the first trimester in high-risk populations Allison R. Walker, Amy Valent, Aaron B. Caughey Oregon Health and Science University, Portland, OR
OBJECTIVE: Gestational diabetes mellitus (GDM) is associated with
increased risks of preeclampsia, macrosomia, shoulder dystocia, and irreversible brachial plexus injury. Compared to the conventional second trimester oral glucose tolerance test (OGTT), screening with a HbA1C assay in the first trimester with a diagnostic second trimester OGTT has been shown to diagnose more cases of GDM earlier. Our study examined the effect of varied positivity thresholds in high-risk pregnancies. STUDY DESIGN: A decision analysis model was created using TreeAge 2016 software to compare the outcomes of screening with an HbA1C in the first trimester with a diagnostic OGTT in the second trimester, with positivity thresholds ranging from 5.9% to 6.4%. Outcomes examined included neonatal mortality, preeclampsia, preterm delivery, cerebral palsy, macrosomia, permanent brachial plexus injury, cost, and quality adjusted life years (QALY) of the mother and neonate. Probabilities, utilities, and costs were derived from the literature, and a cost-effectiveness threshold was set at $100,000/ QALY. Univariate analyses were used to investigate the impact of screening positivity. RESULTS: When comparing HbA1C positivity thresholds, a screening threshold of 5.9% resulted in 1,551 fewer cases of preeclampsia and 293 fewer preterm deliveries over the current standard of care. This
Supplement to JANUARY 2017 American Journal of Obstetrics & Gynecology
S291
Poster Session III threshold showed comparable neonatal outcomes. Univariate analysis demonstrated that the 5.9% threshold was the cost-effective and preferred threshold in regards to the cost of prenatal care for women with GDM when the additional cost of prenatal care with GDM ranges between $7,100 to $11,000. When treatment costs were more than $11,000 threshold of 6.4% was the most effective, though all all positivity thresholds were cost-effective versus the traditional OGTT and no HbA1C screen. CONCLUSION: Pregnancies at high risk of GDM should receive a firsttrimester HbA1c screen with a threshold for diagnosis of 5.9%.
ajog.org MFMU High-Risk Aspirin (HRA) trial did not report decreased SGA in LDA-treated PGDM pregnancies as a whole, we hypothesized a differential effect according to White classification (WC), with improved birth weight in those PGDM pregnancies with vascular complications at highest risk for SGA. Accordingly we sought to determine whether LDA’s impact on birth weight in PGDM pregnancies differed by WC. STUDY DESIGN: Secondary analysis of PGDM women enrolled in the MFMU HRA trial. Women were categorized according to WC into vascular (R, F, RF) or non-vascular (B, C, D) groups for further analysis. Normalized birth-weight percentiles were converted to Z-scores for comparison. Linear regression was used to model birth weight by WC group, LDA vs. placebo randomization, and the interaction of the two, adjusting for BMI, smoking, race and parity in multivariable analysis. The percentage of SGA and LGA newborns born to LDA vs. placebo-treated women was compared between groups using Pearson’s exact chisquare analysis, and an adjusted model was estimated by logistic regression. RESULTS: All 444 women with PGDM and complete outcome data were included in our analysis (53 vascular, 391 non-vascular). In the adjusted model, LDA was significantly associated with increased birth weight Z-score in non-vascular (p¼0.04) but not vascular gestations, and LDA had a significantly greater effect on birth weight Z-scores in non-vascular as compared with vascular PGDM gestations, p¼0.046, Figure 1. LDA-treated non-vascular PGDM women experienced more LGA births (40.2 vs 26.6%, p¼0.005) than those treated with placebo, Figure 2. There was no difference in SGA with LDA treatment in either group. These findings persisted in the adjusted analysis. CONCLUSION: LDA impacted birth weight differentially according to WC. LDA did not reduce SGA in the overall cohort or either group. The perhaps unexpected increased incidence of LGA infants in LDA-treated non-vascular PGDM gestations is of potential concern given increased neonatal and obstetrical morbidity related to LGA births and the preponderance of nonvascular PGDM.
495 Impact of low-dose aspirin on fetal growth in diabetic pregnancies: the importance of white classification Katlynn Adkins1, Amanda Allshouse2, Torri Metz1,3, Kent Heyborne1,3 1
University of Colorado School of Medicine, Aurora, CO, 2University of Colorado School of Public Health, Aurora, CO, 3Denver Health Medical Center, Denver, CO
OBJECTIVE: ACOG recently endorsed USPSTF guidelines recommending that low-dose aspirin (LDA) be given to all pregnant women with pregestational diabetes mellitus (PGDM) to prevent preeclampsia and small for gestational age (SGA) birth. Although the
S292 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2017
ajog.org
alterations in inflammatory state. The aim of this study was to determine whether CT-associated inflammatory alterations persist in pregnancy. STUDY DESIGN: A multi-site prospective study was conducted in 654 pregnant women. Maternal CT was measured using the Childhood Trauma Questionnaire in the 2nd trimester of pregnancy. Women were classified based on the number of moderate to severe abuse/ neglect experiences during childhood. Interleukin-6 (IL-6) and interleukin-10 (IL-10) concentrations were measured at 12-20’6 weeks and 32-35’6 weeks of pregnancy. Linear mixed effect models were performed with adjustment for obstetric complications, maternal obesity, income, age, race/ethnicity, adult trauma exposure, depressive symptoms and abuse/neglect experience in the reference group. RESULTS: IL-6 concentrations as well as the IL-6/IL-10 ratio significantly increased over the course of gestation (IL-6: F(1,589.7)¼40.9, p<0.0001; IL-10: F(1,569.5)¼12.9, p<0.0001), while IL-10 concentrations did not significantly change from early to late gestation. Maternal CT was associated with average higher gestational IL-6 concentrations (F(3,653.1)¼4.59, p¼0.003) but not with altered average IL-10 concentrations or the IL-6/IL-10 ratio in the adjusted model. Maternal CT was not associated with the magnitude of change in any of the inflammatory outcomes from early to late gestation. Because only IL-6 but not Il-10 increased over the course of gestation, exploratory regression analyses tested whether there was a gestation-specific effect when CT was associated with the IL6/Il10 ratio. These analyses showed that maternal CT was associated with a higher IL6/Il10 ratio in late (b¼0.200.07, p¼0.006) but not in early pregnancy. CONCLUSION: The effects of maternal CT on inflammation persist during pregnancy, with a pro-/anti-inflammatory imbalance being especially pronounced in late gestation.
493 Maternal childhood trauma is associated with a pro-inflammatory state during pregnancy Claudia Buss1,2, Ann Borders3,4,5, Sonja Entringer1,2, Jennifer Culhane6,7, Greg Miller8,9, William Grobman3,10, Emma Adam9,11, Hyagriv Simhan12,13, Douglas Williamson14, Kwang-Youn Kim15, Lauren Keenan-Devlin4, Pathik D. Wadhwa1 1
University of California Irvine, Orange, CA, 2Charité Universitätsmedizin Berlin, Berlin, Germany, 3Center for Healthcare Studies e Institute for Public Health and Medicine, Chicago, IL, 4Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, NorthShore University Health System, University of Chicago Pritzker School of Medicine, Chicago, IL, 5Northwestern University Feinberg School of Medicine Department of Medical Social Sciences, Chicago, IL, 6Children’s Hospital of Philadelphia, Division of Adolescent Medicine, Philadelphia, PA, 7University of Pennsylvania Perelman School of Medicine, Department of Pediatrics, Philadelphia, PA, 8Northwestern University Department of Psychology, Chicago, IL, 9Institute for Policy Research, Chicago, IL, 10Northwestern University Feinberg School of Medicine, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Chicago, IL, 11 Northwestern University, School of Education and Social Policy, Chicago, IL, 12University of Pittsburgh School of Medicine, Division of Maternal-Fetal Medicine, Pittsburgh, PA, 13Magee Women’s Hospital, Division of Obstetrical Services, Pittsburgh, PA, 14Duke University, Department of Psychiatry and Behavioral Services, Durham, NC, 15Northwestern University Feinberg School of Medicine Department of Preventative Medicine, Biostatistics, Chicago, IL
OBJECTIVE: Exposure to childhood trauma (CT) is associated with adverse psychological and physiological outcomes including
494 Positivity thresholds of HbA1c assay as a screening test for gestational diabetes mellitus in the first trimester in high-risk populations Allison R. Walker, Amy Valent, Aaron B. Caughey Oregon Health and Science University, Portland, OR
OBJECTIVE: Gestational diabetes mellitus (GDM) is associated with
increased risks of preeclampsia, macrosomia, shoulder dystocia, and irreversible brachial plexus injury. Compared to the conventional second trimester oral glucose tolerance test (OGTT), screening with a HbA1C assay in the first trimester with a diagnostic second trimester OGTT has been shown to diagnose more cases of GDM earlier. Our study examined the effect of varied positivity thresholds in high-risk pregnancies. STUDY DESIGN: A decision analysis model was created using TreeAge 2016 software to compare the outcomes of screening with an HbA1C in the first trimester with a diagnostic OGTT in the second trimester, with positivity thresholds ranging from 5.9% to 6.4%. Outcomes examined included neonatal mortality, preeclampsia, preterm delivery, cerebral palsy, macrosomia, permanent brachial plexus injury, cost, and quality adjusted life years (QALY) of the mother and neonate. Probabilities, utilities, and costs were derived from the literature, and a cost-effectiveness threshold was set at $100,000/ QALY. Univariate analyses were used to investigate the impact of screening positivity. RESULTS: When comparing HbA1C positivity thresholds, a screening threshold of 5.9% resulted in 1,551 fewer cases of preeclampsia and 293 fewer preterm deliveries over the current standard of care. This
Supplement to JANUARY 2017 American Journal of Obstetrics & Gynecology
S291
Poster Session III threshold showed comparable neonatal outcomes. Univariate analysis demonstrated that the 5.9% threshold was the cost-effective and preferred threshold in regards to the cost of prenatal care for women with GDM when the additional cost of prenatal care with GDM ranges between $7,100 to $11,000. When treatment costs were more than $11,000 threshold of 6.4% was the most effective, though all all positivity thresholds were cost-effective versus the traditional OGTT and no HbA1C screen. CONCLUSION: Pregnancies at high risk of GDM should receive a firsttrimester HbA1c screen with a threshold for diagnosis of 5.9%.
ajog.org MFMU High-Risk Aspirin (HRA) trial did not report decreased SGA in LDA-treated PGDM pregnancies as a whole, we hypothesized a differential effect according to White classification (WC), with improved birth weight in those PGDM pregnancies with vascular complications at highest risk for SGA. Accordingly we sought to determine whether LDA’s impact on birth weight in PGDM pregnancies differed by WC. STUDY DESIGN: Secondary analysis of PGDM women enrolled in the MFMU HRA trial. Women were categorized according to WC into vascular (R, F, RF) or non-vascular (B, C, D) groups for further analysis. Normalized birth-weight percentiles were converted to Z-scores for comparison. Linear regression was used to model birth weight by WC group, LDA vs. placebo randomization, and the interaction of the two, adjusting for BMI, smoking, race and parity in multivariable analysis. The percentage of SGA and LGA newborns born to LDA vs. placebo-treated women was compared between groups using Pearson’s exact chisquare analysis, and an adjusted model was estimated by logistic regression. RESULTS: All 444 women with PGDM and complete outcome data were included in our analysis (53 vascular, 391 non-vascular). In the adjusted model, LDA was significantly associated with increased birth weight Z-score in non-vascular (p¼0.04) but not vascular gestations, and LDA had a significantly greater effect on birth weight Z-scores in non-vascular as compared with vascular PGDM gestations, p¼0.046, Figure 1. LDA-treated non-vascular PGDM women experienced more LGA births (40.2 vs 26.6%, p¼0.005) than those treated with placebo, Figure 2. There was no difference in SGA with LDA treatment in either group. These findings persisted in the adjusted analysis. CONCLUSION: LDA impacted birth weight differentially according to WC. LDA did not reduce SGA in the overall cohort or either group. The perhaps unexpected increased incidence of LGA infants in LDA-treated non-vascular PGDM gestations is of potential concern given increased neonatal and obstetrical morbidity related to LGA births and the preponderance of nonvascular PGDM.
495 Impact of low-dose aspirin on fetal growth in diabetic pregnancies: the importance of white classification Katlynn Adkins1, Amanda Allshouse2, Torri Metz1,3, Kent Heyborne1,3 1
University of Colorado School of Medicine, Aurora, CO, 2University of Colorado School of Public Health, Aurora, CO, 3Denver Health Medical Center, Denver, CO
OBJECTIVE: ACOG recently endorsed USPSTF guidelines recommending that low-dose aspirin (LDA) be given to all pregnant women with pregestational diabetes mellitus (PGDM) to prevent preeclampsia and small for gestational age (SGA) birth. Although the
S292 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2017