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728: Family history of diabetes mellitus as an independent risk factor for macrosomia and cesarean delivery
SMFM Abstracts
www.AJOG.org 725
FIRST TRIMESTER DETECTION OF FETAL ANOMALIES IN PREGESTATIONAL DIABETES JENA MILLER1, SIFA TURAN2, MARGARITA DE VECIANA3, CHRISTOPHER HARMAN1, AHMET BASCHAT1, 1University of Maryland, Baltimore, Department of OB/GYN and Reproductive Sciences, Baltimore, Maryland, 2University of Maryland, Maryland, 3Eastern Virginia Medical School, Norfolk, Virginia OBJECTIVE: First trimester abnormal nuchal translucency (NT), abnormal ductus venosus flow (DV) are risk factors for cardiac and extracardiac anomalies prevalent in pregestational diabetes (DM). The incidence of these anomalies is related to hemoglobin A1C (HbA1C) levels. We tested the performance of these screening tests to identify fetal anomalies in pregestational DM. STUDY DESIGN: Prospective observational study of patients with DM undergoing NT screening with DV Doppler between 11-14 weeks. Elevated NT, DV a-wave reversal and elevated HbA1C were tested for their ability to predict major fetal anomalies. Suspected anomalies were confirmed at postmortem or delivery. Chi square statistics were used. RESULTS: 154 patients had 11 anomalies (7.1%) (7 cardiac/4 extracardiac). 6 cardiac anomalies were identified prenatally (4 at fetal echocardiogram and 2 at anatomic survey). All cardiac anomalies and 3 of 4 extracardiac abnomalies occurred in patients with a HbA1C ⬎7 (p⬍0.05). 9.6% of patients with an HbA1C ⬎7 had an anomalous fetus. An abnormal NT did not predict anoamlies (9 anomalous fetuses had normal NT). DV a-wave reversal in 2 patients was associated with stillbirth and encephalocele. None of the 3 stillbirths were predicted by NT, DV Doppler or elevated HbA1C. CONCLUSION: The rate of fetal anomalies determined by perconceptional glycemic control. Even with early access to high resolution ultrasound screening the majority of these anomalies are not detected in the first trimester. This stresses overriding importance of counseling and glycemic control in these patients.
727
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.756
726
17-ALPHA HYDROXYPROGESTERONE CAPROATE (17-OHPC) AND CORTICOTROPIN RELEASING HORMONE (CRH) AMONG WOMEN WITH TWINS HYAGRIV SIMHAN1, STEVE CARITIS1, 1Eunice Kennedy Shriver NICHD MFMU Network, Bethesda, Maryland OBJECTIVE: We sought to determine if 17-OHPC exerts an effect on the fetalplacental endocrine stress response among women with twin pregnancies. The fetal-placental endocrine stress response is represented by maternal plasma corticotropin releasing hormone (CRH). STUDY DESIGN: This is a prespecified secondary analysis of a multicenter RCT of 17-OHPC for the prevention of preterm birth among women with twins. Women received either 17-OHPC intramuscularly 250 mg once weekly or placebo. A single maternal plasma sample was collected at 24-28 weeks and at 32-36 weeks and assayed for CRH in batch fashion. All samples were drawn more than 2 weeks prior to delivery. We only included women who had received all of their scheduled injections and had received at least 5 injections prior to the first blood sample to assure steady state concentrations. RESULTS: After adjustment for covariates, the difference in CRH concentration between treatment groups was not different at either time point. Likewise the change in CRH concentration between time points was not significantly different. CONCLUSION: Women with twin gestations who receive 17-OHPC therapy do not have different CRH concentrations from placebo-treated women. CRH concentration(mean⫾SD) (pg/mL) by treatment group Gestational age
Placebo
17-OHPC
p
24-28 weeks 32-36 weeks Change between time points
444⫾375, n⫽97 1224⫾792 n⫽69 15⫾23
420⫾191, n⫽81 1030⫾654 n⫽59 13⫾13
0.57 0.11 0.22
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.757
TRANSVAGINAL ULTRASONOGRAPHY TO PREDICT PRETERM BIRTH IN WOMEN WITH UTERINE ANOMALIES JOAN CRANE1, HEATHER SCOTT2, WENDY WHITTLE3, SUJATA CHANDRA4, DONNA HUTCHENS1, 1Memorial University, Eastern Health, Obstetrics and Gynecology, St. John’s, Newfoundland, Canada, 2Dalhousie University, Obstetrics and Gynecology, Halifax, Nova Scotia, Canada, 3University of Toronto, Obstetrics and Gynecology, Toronto, Ontario, Canada, 4University of Alberta, Obstetrics and Gynecology, Edmonton, Alberta, Canada OBJECTIVE: To estimate whether cervical length(CL) measured by transvaginal ultrasonography(TVUS) in women with uterine anomalies predicts spontaneous preterm birth(SPTB). STUDY DESIGN: Women with a uterine anomaly(bicornuate, didelphus, unicornuate or septate uterus) who were pregnant with singleton gestations and delivered August 2000 to April 2008 were compared with a low-risk control group. TVUS measuring CLs were performed 16-30weeks gestation. Primary outcomes included CL and SPTB⬍35weeks. Secondary outcomes were SPTB⬍37weeks, SPTB⬍32weeks, low birthweight, maternal and neonatal outcomes. ROC curves were generated to identify the best CL cut-off to identify women at risk for the outcomes of interest. RESULTS: Women with a bicornuate uterus(N ⫽37), didelphus uterus(N⫽17) or septum resected(N⫽9) had shorter cervical lengths(3.40cm, 3.72cm, 2.80cm) than the low-risk control group(N⫽122, 4.32cm, P⬍0.0001). Women with a bicornuate or didelphus uterus, compared with low-risk women, had higher rates of SPTB⬍35weeks(8.1% and 35.3% versus 0.8%, P⫽0.040 and P⬍0.0001), SPTB⬍37weeks(21.6% and 41.1% versus 3.3%, P⫽0.001 and P⬍0.0001), NICU admission(25.0% and 52.9% versus 7.5%, P⫽0.004 and P⫽0.001) and composite neonatal morbidity(30.6% and 64.7% versus 8.3%, P⫽0.001 and P⬍0.0001). Using a cutoff of 3.0cm, TVUS CL in women with a bicornuate uterus predicted SPTB⬍35weeks(PPV⫽33.3% and NPV⫽100%), birthweight ⬍2500g(PPV⫽ 44.4% and NPV 96.4%) and RDS(PPV⫽33.3% and NPV⫽100%). Women with a resected uterine septum did not have an increased risk of SPTB⬍35weeks(81% power to see 25% SPTB⬍35weeks in this group). CONCLUSION: The implications of TVUS CL measurements for women with a uterine anomaly depend on the type of anomaly, and whether it has been surgically resected. Women with a history of septum resected, bicornuate or didelphus uterus have shorter CLs than low-risk controls. Bicornuate and dildelphus uterus are associated with SPTB⬍35weeks, but resected uterine septum is not. TVUS CL predicts SPTB⬍35weeks, low birthweight and neonatal morbidity in women with a bicornuate uterus. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.758
728
FAMILY HISTORY OF DIABETES MELLITUS AS AN INDEPENDENT RISK FACTOR FOR MACROSOMIA AND CESAREAN DELIVERY EYAL SHEINER1, ARNON WIZNITZER1, GERSHON HOLCBERG1, MOSHE MAZOR1, AMALIA LEVY2, 1Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel, 2Epidemiology and Health Services Evaluation, Beer-Sheva, Israel OBJECTIVE: To test the association between familial history of diabetes mellitus and birth-weight as well as mode of delivery stratified for the presence of the disease. STUDY DESIGN: A population-based study, comparing birth outcome of patients with and without familial history of first degree relative with diabetes mellitus (type 1 or 2) was conducted. Patients lacking prenatal care were excluded from the analysis. Multiple logistic regression models were used to control for confounders. The Mantel-Haenszel procedure was used to obtain the weighted odds ratios while controlling for the presence of diabetes mellitus (either gestational or pre-gestational). RESULTS: Out of 181,479 deliveries, 7.6% (n⫽13,813) were in patients with familial history of diabetes mellitus. These patients had higher rates of diabetes mellitus (either gestational or pre-gestational) as compared to patients without familial history of diabetes mellitus (13.7% vs. 6.3%, OR⫽2.3; 95% CI 2.2-2.5, P⬍0.001). Patients with familial history of diabetes mellitus had higher rates of macrosomia (birth-weight⬎4 Kg; 5.7% vs. 4.6%, P⬍0.001). Also, a 1.3-fold increase in the risk for cesarean delivery (CD) was found in patients with familial history of diabetes mellitus as compared to the comparison group (17.1% vs. 13.8%, P⬍0.001). Using two different multiple logistic regression models, one with CD and the second with macrosomia as the outcome variable, the association between familial history of diabetes mellitus and these complications remained significant (OR⫽1.2; 95% CI 1.1-1.2; P⬍0.001 and OR⫽1.2; 95% CI 1.03-1.2; P⫽0.005, respectively). The two models controlled for important confounders such as diabetes mellitus and the year of delivery, in order to control for ascertainment bias. CONCLUSION: Family history of first degree relative with diabetes mellitus has a significant, independent association with the risk for macrosomia and cesarean delivery during pregnancy, regardless the presence of the disease. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.759
Supplement to DECEMBER 2008 American Journal of Obstetrics & Gynecology
S207
www.AJOG.org 725
FIRST TRIMESTER DETECTION OF FETAL ANOMALIES IN PREGESTATIONAL DIABETES JENA MILLER1, SIFA TURAN2, MARGARITA DE VECIANA3, CHRISTOPHER HARMAN1, AHMET BASCHAT1, 1University of Maryland, Baltimore, Department of OB/GYN and Reproductive Sciences, Baltimore, Maryland, 2University of Maryland, Maryland, 3Eastern Virginia Medical School, Norfolk, Virginia OBJECTIVE: First trimester abnormal nuchal translucency (NT), abnormal ductus venosus flow (DV) are risk factors for cardiac and extracardiac anomalies prevalent in pregestational diabetes (DM). The incidence of these anomalies is related to hemoglobin A1C (HbA1C) levels. We tested the performance of these screening tests to identify fetal anomalies in pregestational DM. STUDY DESIGN: Prospective observational study of patients with DM undergoing NT screening with DV Doppler between 11-14 weeks. Elevated NT, DV a-wave reversal and elevated HbA1C were tested for their ability to predict major fetal anomalies. Suspected anomalies were confirmed at postmortem or delivery. Chi square statistics were used. RESULTS: 154 patients had 11 anomalies (7.1%) (7 cardiac/4 extracardiac). 6 cardiac anomalies were identified prenatally (4 at fetal echocardiogram and 2 at anatomic survey). All cardiac anomalies and 3 of 4 extracardiac abnomalies occurred in patients with a HbA1C ⬎7 (p⬍0.05). 9.6% of patients with an HbA1C ⬎7 had an anomalous fetus. An abnormal NT did not predict anoamlies (9 anomalous fetuses had normal NT). DV a-wave reversal in 2 patients was associated with stillbirth and encephalocele. None of the 3 stillbirths were predicted by NT, DV Doppler or elevated HbA1C. CONCLUSION: The rate of fetal anomalies determined by perconceptional glycemic control. Even with early access to high resolution ultrasound screening the majority of these anomalies are not detected in the first trimester. This stresses overriding importance of counseling and glycemic control in these patients.
727
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.756
726
17-ALPHA HYDROXYPROGESTERONE CAPROATE (17-OHPC) AND CORTICOTROPIN RELEASING HORMONE (CRH) AMONG WOMEN WITH TWINS HYAGRIV SIMHAN1, STEVE CARITIS1, 1Eunice Kennedy Shriver NICHD MFMU Network, Bethesda, Maryland OBJECTIVE: We sought to determine if 17-OHPC exerts an effect on the fetalplacental endocrine stress response among women with twin pregnancies. The fetal-placental endocrine stress response is represented by maternal plasma corticotropin releasing hormone (CRH). STUDY DESIGN: This is a prespecified secondary analysis of a multicenter RCT of 17-OHPC for the prevention of preterm birth among women with twins. Women received either 17-OHPC intramuscularly 250 mg once weekly or placebo. A single maternal plasma sample was collected at 24-28 weeks and at 32-36 weeks and assayed for CRH in batch fashion. All samples were drawn more than 2 weeks prior to delivery. We only included women who had received all of their scheduled injections and had received at least 5 injections prior to the first blood sample to assure steady state concentrations. RESULTS: After adjustment for covariates, the difference in CRH concentration between treatment groups was not different at either time point. Likewise the change in CRH concentration between time points was not significantly different. CONCLUSION: Women with twin gestations who receive 17-OHPC therapy do not have different CRH concentrations from placebo-treated women. CRH concentration(mean⫾SD) (pg/mL) by treatment group Gestational age
Placebo
17-OHPC
p
24-28 weeks 32-36 weeks Change between time points
444⫾375, n⫽97 1224⫾792 n⫽69 15⫾23
420⫾191, n⫽81 1030⫾654 n⫽59 13⫾13
0.57 0.11 0.22
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.757
TRANSVAGINAL ULTRASONOGRAPHY TO PREDICT PRETERM BIRTH IN WOMEN WITH UTERINE ANOMALIES JOAN CRANE1, HEATHER SCOTT2, WENDY WHITTLE3, SUJATA CHANDRA4, DONNA HUTCHENS1, 1Memorial University, Eastern Health, Obstetrics and Gynecology, St. John’s, Newfoundland, Canada, 2Dalhousie University, Obstetrics and Gynecology, Halifax, Nova Scotia, Canada, 3University of Toronto, Obstetrics and Gynecology, Toronto, Ontario, Canada, 4University of Alberta, Obstetrics and Gynecology, Edmonton, Alberta, Canada OBJECTIVE: To estimate whether cervical length(CL) measured by transvaginal ultrasonography(TVUS) in women with uterine anomalies predicts spontaneous preterm birth(SPTB). STUDY DESIGN: Women with a uterine anomaly(bicornuate, didelphus, unicornuate or septate uterus) who were pregnant with singleton gestations and delivered August 2000 to April 2008 were compared with a low-risk control group. TVUS measuring CLs were performed 16-30weeks gestation. Primary outcomes included CL and SPTB⬍35weeks. Secondary outcomes were SPTB⬍37weeks, SPTB⬍32weeks, low birthweight, maternal and neonatal outcomes. ROC curves were generated to identify the best CL cut-off to identify women at risk for the outcomes of interest. RESULTS: Women with a bicornuate uterus(N ⫽37), didelphus uterus(N⫽17) or septum resected(N⫽9) had shorter cervical lengths(3.40cm, 3.72cm, 2.80cm) than the low-risk control group(N⫽122, 4.32cm, P⬍0.0001). Women with a bicornuate or didelphus uterus, compared with low-risk women, had higher rates of SPTB⬍35weeks(8.1% and 35.3% versus 0.8%, P⫽0.040 and P⬍0.0001), SPTB⬍37weeks(21.6% and 41.1% versus 3.3%, P⫽0.001 and P⬍0.0001), NICU admission(25.0% and 52.9% versus 7.5%, P⫽0.004 and P⫽0.001) and composite neonatal morbidity(30.6% and 64.7% versus 8.3%, P⫽0.001 and P⬍0.0001). Using a cutoff of 3.0cm, TVUS CL in women with a bicornuate uterus predicted SPTB⬍35weeks(PPV⫽33.3% and NPV⫽100%), birthweight ⬍2500g(PPV⫽ 44.4% and NPV 96.4%) and RDS(PPV⫽33.3% and NPV⫽100%). Women with a resected uterine septum did not have an increased risk of SPTB⬍35weeks(81% power to see 25% SPTB⬍35weeks in this group). CONCLUSION: The implications of TVUS CL measurements for women with a uterine anomaly depend on the type of anomaly, and whether it has been surgically resected. Women with a history of septum resected, bicornuate or didelphus uterus have shorter CLs than low-risk controls. Bicornuate and dildelphus uterus are associated with SPTB⬍35weeks, but resected uterine septum is not. TVUS CL predicts SPTB⬍35weeks, low birthweight and neonatal morbidity in women with a bicornuate uterus. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.758
728
FAMILY HISTORY OF DIABETES MELLITUS AS AN INDEPENDENT RISK FACTOR FOR MACROSOMIA AND CESAREAN DELIVERY EYAL SHEINER1, ARNON WIZNITZER1, GERSHON HOLCBERG1, MOSHE MAZOR1, AMALIA LEVY2, 1Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel, 2Epidemiology and Health Services Evaluation, Beer-Sheva, Israel OBJECTIVE: To test the association between familial history of diabetes mellitus and birth-weight as well as mode of delivery stratified for the presence of the disease. STUDY DESIGN: A population-based study, comparing birth outcome of patients with and without familial history of first degree relative with diabetes mellitus (type 1 or 2) was conducted. Patients lacking prenatal care were excluded from the analysis. Multiple logistic regression models were used to control for confounders. The Mantel-Haenszel procedure was used to obtain the weighted odds ratios while controlling for the presence of diabetes mellitus (either gestational or pre-gestational). RESULTS: Out of 181,479 deliveries, 7.6% (n⫽13,813) were in patients with familial history of diabetes mellitus. These patients had higher rates of diabetes mellitus (either gestational or pre-gestational) as compared to patients without familial history of diabetes mellitus (13.7% vs. 6.3%, OR⫽2.3; 95% CI 2.2-2.5, P⬍0.001). Patients with familial history of diabetes mellitus had higher rates of macrosomia (birth-weight⬎4 Kg; 5.7% vs. 4.6%, P⬍0.001). Also, a 1.3-fold increase in the risk for cesarean delivery (CD) was found in patients with familial history of diabetes mellitus as compared to the comparison group (17.1% vs. 13.8%, P⬍0.001). Using two different multiple logistic regression models, one with CD and the second with macrosomia as the outcome variable, the association between familial history of diabetes mellitus and these complications remained significant (OR⫽1.2; 95% CI 1.1-1.2; P⬍0.001 and OR⫽1.2; 95% CI 1.03-1.2; P⫽0.005, respectively). The two models controlled for important confounders such as diabetes mellitus and the year of delivery, in order to control for ascertainment bias. CONCLUSION: Family history of first degree relative with diabetes mellitus has a significant, independent association with the risk for macrosomia and cesarean delivery during pregnancy, regardless the presence of the disease. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.759
Supplement to DECEMBER 2008 American Journal of Obstetrics & Gynecology
S207