769: What is the best type of skin incision for multiple prior cesarean deliveries?

Poster Session V

ajog.org 767 Racial/ethnic differences in maternal self-report and biomarkers of stress and stress biology in pregnancy

Ann Borders1, Jennifer Culhane2, Hyagriv Simhan4, Pathik Wadhwa5, Douglas Williamson6, Kwang-Youn Kim3, Daniel Mroczek3, William Grobman3

1 Evanston Hospital, NorthShore University HealthSystem, University of Chicago, Pritzker School of Medicine, Evanston, IL, 2Children’s Hospital of Philadelphia; University of Pennsylvania, School of Medicine, Philadelphia, PA, 3Northwestern University Feinberg School of Medicine, Chicago, IL, 4 Magee-Women’s Hospital, University of Pittsburgh Medical Center, Pittsburgh, PA, 5University of California -Irvine, School of Medicine, Irvine, CA, 6University of Texas Health Science Center at San Antonio, San Antonio, TX

OBJECTIVE: Maternal stress may contribute to racial disparities in adverse pregnancy and birth outcomes. The objective of this study is to determine whether self-report measures of maternal stress and related factors and biomarkers associated with stress biology vary by maternal race / ethnicity. STUDY DESIGN: This prospective cohort study enrolled participants from 4 geographically- and racially-diverse study sites. Between 12’0-20’6 weeks gestation participants provided blood for measures of systemic inflammation (C-Reactive Protein (CRP)) and cellmediated immunity (Epstein-Barr Virus antibodies (EBV)) and completed 11 validated self-reported measures of stress and stressrelated processes. Associations between maternal race/ethnicity, self-report scores, and CRP/EBV concentrations were assessed in univariable and multivariable analysis. RESULTS: Of the 764 women recruited, 56% were non-Hispanic White (NHW), 16% were non-Hispanic Black (NHB), 12% were Hispanic (H), and 15% were other/multiracial (O). NHB women reported higher childhood stress (p¼ 0.01), lower self-esteem (p ¼ < 0.001), and higher discrimination (p ¼ 0.001) compared to NHW women. These associations remained significant in multivariable analysis controlling for other significant demographic variables (education, income, BMI). In multivariable analysis, NHB women had significantly higher levels of EBV titer, a measure of cell-mediated immunity purposed to be altered by chronic stress, compared to NHW women. CRP was not associated with race/ethnicity. The other racial /ethnic groups (H and O) did not differ significantly from NHW. CONCLUSION: Racial /ethnic differences in EBV and in some self-reported measures related to maternal stress were identified. Future studies should further investigate associations with item-reduced measures of stress and determine the extent to which these differences may account for racial disparities in adverse pregnancy and birth outcomes.

768 Are there modifiable risk factors for early onset preeclampsia? A retrospective cohort study

Anna Natenzon1, Laura Reimers1, Peter Bernstein1, Diana Wolfe1 1

Montefiore Medical Center, OB-GYN, Bronx, NY

OBJECTIVE: To identify potentially modifiable preconception risk

factors for early PEC resulting in preterm delivery. STUDY DESIGN: We performed a cohort analysis utilizing the CDC

Pregnancy Risk Assessment Monitoring Survey (PRAMS) Phase 6 data. Early PEC was defined as delivery <32 weeks gestation and maternal high blood pressure. Respondents with early PEC were compared to those who reported delivery 32 weeks gestation and no maternal high blood pressure. Independent variables included were ones that could be addressed prior to conception. We calculated weighted two-way frequency tables for the association between early PEC and then conducted stepwise regression among those co-variates found to be significantly associated with disease. RESULTS: A total of 31,187 women met inclusion criteria for our study; the rate of early PEC was 2.10%. Univariate analysis demonstrated the following modifiable characteristics to be

significantly protective from early PEC: maternal education, prepregnancy teeth cleaning, and prenatal vitamin use. These did not, ultimately, remain significant in our final model. The final logistic regression model revealed the following potentially modifiable characteristics that had increased odds of disease: wanted to become pregnant sooner than actually conceived, partner stress, and having a pre-pregnancy high blood pressure check. Potentially modifiable risk factors that were found to be protective against early PEC were: adequate Prenatal Care (as measured by either the Kessner or Kotelchuck index) and normal BMI (Table 1). Other preconception variables that were not perceived as modifiable and that were associated with early PEC were: infant born with a birth defect, maternal fever, maternal race, prior termination of pregnancy, and no prior live births. CONCLUSION: This study suggests that there may be modifiable risk factors that are associated with the development of early PEC.

Modifiable and non-modifiable risk factors for early-onset pre-eclampsia

769 What is the best type of skin incision for multiple prior cesarean deliveries? Anna Palatnik1, William Grobman1

1 Northwestern University, Feinberg School of Medicine, Obstetrics and Gynecology, Chicago, IL

OBJECTIVE: In women with multiple prior cesarean deliveries (CD), vertical skin incisions are thought by some to result in better outcomes for both the mother and her neonate. The objective of this study was to compare maternal and neonatal outcomes among women with multiple prior CD according to their type of skin incisions. STUDY DESIGN: This was a secondary analysis of MFMU Cesarean Section Registry data. Women undergoing repeat CD with viable singleton gestation and history of at least 2 CD were included in this analysis. Women who had indications for emergent CD (e.g., cord prolapse, uterine rupture) or suspected placenta accreta were excluded. Maternal and neonatal outcomes of women with 2, 3 and 4 prior CD were compared by skin-incision type (transverse vs vertical) using univariable and multivariable analyses. Cox proportional hazard regression was used to compare incision-to-delivery intervals (IDI). RESULTS: 5007 women met the inclusion criteria. In univariable analysis, there was no difference based on skin incision type, regardless of the number of prior CD, in the frequency of ileus, blood transfusion, operative complications, wound complications, hysterectomy or intensive care unit admissions. In women with 2 prior CD, IDI was significantly shorter with vertical skin incision (12.9 min vs 14.1 min, p<0.001). Hospital admission >4 days (23.2% vs 9.3%, p¼0.005) and adverse neonatal outcomes (25.6% vs 13.7%, p¼0.03) were more common among women with 4 prior CD who underwent a vertical skin incision. In multivariable analyses, IDI remained significantly shorter in women with 2 and 3 prior CD

Supplement to JANUARY 2015 American Journal of Obstetrics & Gynecology

S373

Poster Session V and hospital admission > 4 days remained higher for women with 4 prior CD among women with vertical skin incision (Table). There were no differences in neonatal outcomes based on skin incision type (Table). CONCLUSION: In women with multiple prior CD, vertical skin incision shortened the interval to delivery slightly, but was not associated with improvement in neonatal outcome and was associated with prolonged maternal hospital stay.

Multivariable analysis of maternal and neonatal outcomes by skin incision type

*Adjusted for BMI, maternal age, race, history of smoking, GDM/ DM, presence of classical uterine incision, gestational age, male gender. HR ¼ hazard ratio; OR ¼ odds ratio.

770 Pharmacokinetics and tolerability of oral 17-hydroxyprogesterone caproate (HPC) relative to intramuscular (IM) HPC

Anthony DelConte1, Nachiappan Chidambaram2, Satish Nachaegari2, Mahesh Patel2, Srinivasan Venkateshwaran2 1

Saint Joseph’s University, Philadelphia, PA, 2Lipocine, Inc, Salt Lake City, UT

OBJECTIVE: To determine the pharmacokinetic profile and assess

tolerability of an oral HPC capsule (LPCN 1107) relative to an IM control in healthy non-pregnant women. STUDY DESIGN: This was an open-label, 3-period, active controlled study in ten healthy non-pregnant women 18-30 years of age. In Periods 1 and 2 volunteers were administered in a randomized, cross-over fashion, either one dose of LPCN 1107 400 mg (QD) or two doses of LPCN 1107 400 mg given 12 hours apart (Q12) with a standard meal. In Period 3 all subjects received a single dose of HPC 250 mg IM. There was a washout of one week between treatment Periods. Blood samples were collected over 24 hours following QD dosing, 36 hours following Q12 hour dosing and over 30 days following the IM dosing. HPC concentrations in plasma were analyzed using a validated LC-MS/MS method. Steady state simulations (SS) were modeled from single dose pharmacokinetic parameters using WinNonlin. RESULTS: Following administration of HPC the maximum concentration (Cmax, ng/mL) of HPC was 13.5, 23.1, 7.3 and area under the curve (AUC0-t, ng*h/mL) was 69, 173, 2101 for the QD, Q12 and IM treatments respectively. Given the intrinsic difference in dosing regimen between the oral and IM forms, SS was simulated based on single dose pharmacokinetic parameters for the 400 mg Q12 and 250 mg weekly IM doses. The simulated steady state pharmacokinetic parameters showed that 400 mg Q12 exposure was about 55% of weekly 250 mg IM product. LPCN 1107 was well tolerated with no SAEs. CONCLUSION: This study is the first to report significant oral absorption of HPC. Based on the steady state simulation, LPCN 1107 could provide serum exposures comparable to weekly IM injection at an appropriate dose and the oral treatments demonstrate good dose response. LPCN 1107 is currently in clinical development and if approved, has the potential to become the first oral HPC therapy for the prevention of recurrent preterm birth.

ajog.org 771 Short-term surgical and clinical outcomes with a novel method for open fetal surgery of myelomeningocele

Antonio Moron2, Mauricio Barbosa3, Herbene Milani2, Wagner Hisaba2, Natalia Carvalho2, Sergio Cavalheiro1 1

Universidade Federal de Sao Paulo, Neurocirurgia, Sao Paulo, Brazil, Universidade Federal de Sao Paulo-UNIFESP, Fetal Medicine, Sao Paulo, Brazil, 3Hospital Santa Joana, Fetal Madicine, Sao Paulo, Brazil 2

OBJECTIVE: This is a short-term evaluation of surgical and clinical outcomes with a novel method for open fetal surgery for myelomeningocele. STUDY DESIGN: Ninety-four fetal surgeries for myelomeningocele repair using a different surgical approach developed in our Institution during the last three years. The surgeries were undertaken at two centers with the same team with expertise in open fetal surgical and facilities to handle maternal and fetal complications. Inclusion criteria included singleton; less than complete 26 weeks’ gestation, upper MMC boundary at T1-S1; evidence of hindbrain herniation; normal karyotype and no others malformations; BMI < 35 and low risk for preterm birth. The variables analyzed were maternal demographics, gestational age at the time of surgery, hindbrain herniation, maternal complication, fetal and neonatal variables. RESULTS: Maternal age 31.1  4.9 years; White 87.2%; Married 92.5%; Years of schooling 14.0  1.9; Nullipara 58.3%; Fetal gender female 52.1%; Hindbrain herniation 98.9%; Gestational age at surgery 25.9  0.6 wks; Pulmonary edema 4.4%; Spontaneous rupture of membrane 31.8% Oligohydramnios 23.1%; Placental abruption 1.1%; Chorioamnionitis 4.4%; Blood transfusion at delivery 3.3%. Hysterotomy well-healed 63.7%; Very thin 30.8%; Area of dehiscence 3.3%; Complete dehiscence 2.2%; Perinatal death 3 (3.2%); Gestational age at birth 33.8  2.4 wks; < 30 wks 8.8%; Birth weight 2233  571g; Interval between fetal surgery and delivery 54.6 days; Dehiscence at repair site 4.2%; complete reversal of hindbrain herniation at birth 62.6%. CONCLUSION: This early experience using a novel surgical technique showed similar results with MOMS trial results without using the stapler device and can be useful when the costs and availability of medical supplies limit their application. However, further long-term follow-up is necessary to evaluate maternal and fetal outcomes.

772 Isolated abnormal glucose value on the 3-hour glucose tolerance test (OGTT) and subsequent adverse maternal and neonatal outcomes

Asal Fathian1, David Deschamps1, Ji Li2, Daniel Jackson1, Jennifer McIntosh1, Ravindu Gunatilake1, Eric Knudtson1, Jennifer Peck2, Marvin Williams1

1 University of Oklahoma, OB/GYN, MFM, Oklahoma City, OK, 2University of Oklahoma, School of Public Health, Department of Biostatistics and Epidemiology, Oklahoma City, OK

OBJECTIVE: To evaluate the association between large for gestational

age neonates weighing > 4000gms (LGA), hyperbilirubinemia, and cesarean delivery rates (CD) in pregnancies with a single abnormal value on the 3-hour OGTT (fasting, 1-hour, 2-hour, 3-hour). STUDY DESIGN: We performed a retrospective cohort study evaluating singleton pregnancies screened for gestational diabetes mellitus (GDM) and delivered between 01/2009- 12/2013 at our institution. A 50g glucose challenge test (GCT) was done between 24-0 and 300 weeks gestation with a value of 135 mg/dL used as the cutoff for administering the 3-hr oral glucose tolerance test (OGTT).GDM was diagnosed when two or more plasma values were elevated according to the Carpenter-Coustan criteria). LGA, hyperbilirubinemia, and CD rates were examined in comparison to those who passed the GCT using modified Poisson regression. RESULTS: Of the 3664 total pregnancies reviewed, 1107 singleton pregnancies failed the GCT. Of those who failed the initial GCT and completed an OGTT, 500 passed. A subset of 151 patients failed only one value on the OGTT (42 failed the fasting value and a 109 failed a

S374 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2015