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Conception using IVF is associated with poorer perinatal outcomes in twin gestations
SMFM Abstracts S169
Volume 189, Number 6 Am J Obstet Gynecol 396
MIDTRIMESTER AMNIOTIC FLUID VITAMIN C LEVELS INVERSELY CORRELATE WITH INTERLEUKIN-6 LEVELS EVA PRESSMAN1, DEB PITTINARO1, JAMES WOODS1, 1University of Rochester, Obstetrics and Gynecology, Rochester, NY OBJECTIVE: To compare levels of vitamin C and interleukin-6 (IL-6) in pregnancies undergoing midtrimester amniocentesis for genetic indications. STUDY DESIGN: Women undergoing midtrimester genetic amniocentesis were prospectively enrolled. The initial 1 cc of amniotic fluid obtained was immediately refrigerated and processed within 24 hours for vitamin C and IL-6 analysis. Data were collected on maternal age, gestational age, and indication for amniocentesis. Demographic data, vitamin C levels, and IL-6 levels were analyzed with Pearson’s correlation and chi-square analysis. RESULTS: Data were available for 37 patients with normal karyotypes between the gestational ages of 16 and 21 weeks (mean 18.1 weeks). Mean maternal age was 35.1 years, with 66% of patients undergoing amniocentesis due to advanced maternal age. Vitamin C levels were noted to increase with advancing gestational age (r = 0.47, P = 0.003) but did not vary with maternal age or indication for amniocentesis. IL-6 values were not affected by these factors. A negative correlation was noted between vitamin C and IL-6 (r = -0.34, P = 0.034). CONCLUSION: Elevated levels of IL-6 in midtrimester amniotic fluid indicate intra-amniotic inflammation and have been associated with adverse pregnancy outcome. The inverse correlation between IL-6 and vitamin C suggests that consumption of vitamin C may occur as part of a chronic inflammatory process. Amniotic fluid vitamin C may also serve as a defense against chronic inflammation. Evaluation of the outcomes of these pregnancies may further clarify the potential role of vitamin C in the amniotic fluid.
398
CONTEMPORARY MANAGEMENT OF PRETERM PREMATURE RUPTURE OF MEMBRANES (PPROM): A SURVEY OF MATERNAL-FETAL MEDICINE PROVIDERS PATRICK RAMSEY1, FRANCIS NUTHALAPATY1, GEORGE LU2, SUSAN RAMIN3, ELIZEBETH NUTHALAPATY1, KIRK RAMIN4, 1University of Alabama at Birmingham, Obstetrics/Gynecology, Birmingham, AL 2Obstetrix Medical Group of Kansas & Missouri, Obstetrics/Gynecology, Kansas City, MO 3University of Texas Health Science Center at Houston, Obstetrics/Gynecology, Houston, TX 4University of Minnesota, Obstetrics/Gynecology, Minneapolis, MN OBJECTIVE: To characterize practice management variations for women with PPROM among maternal-fetal medicine (MFM) specialists. STUDY DESIGN: We performed a Web-based online survey of 1375 MFM providers. Participants were queried on practice characteristics and various management issues including use of tocolytics, antibiotics, and antenatal steroids and timing of delivery. RESULTS: Five-hundred three providers (37%), representing all 50 states and 13 countries, responded to the survey. Mean participant age was 45 ± 9 yr. The majority of study participants were in an academic university-based practice (53%). Only 30% reported a formal departmental protocol for managing PPROM. Consistent use of steroids (99.6%) and antibiotics (99.6%) was reported. Administration of steroids was confined to #32 wks by 37% and #34 wks by 51% of practitioners. Repeated dosing of steroids was uncommon (16%). The first-line antibiotic utilized and the rationale for use varied among practitioners. Tocolytic use in the setting of PPROM was reported by 75% of respondents, with magnesium sulfate the main agent used (98%). Tocolytic therapy generally was used for #48 hours for steroid benefit (85%). Amniocentesis, for a variety of disparate indications, was used by 66% of practitioners in the setting of PPROM. Fetal lung maturity testing (amniocentesis or vaginal pool) was reported by 78%, with inconsistency noted with respect to the test used. Outpatient management of women with PPROM after viability was noted by 43% of respondents. Gestational age at which expectant management is abandoned in women with PPROM varied significantly among respondents: $34 wks, 56%; $35 wks, 26%; $36 wks, 12%; $37 wks, 4.0%. CONCLUSION: Practice variations exist with respect to the management of PPROM among MFM providers. These disparate practices call for further research focused toward the optimization of the management for women with this pregnancy complication.
397
CONCEPTION USING IVF IS ASSOCIATED WITH POORER PERINATAL OUTCOMES IN TWIN GESTATIONS MATTHEW HOFFMAN1, ANTHONY SCISCIONE2, 1Christiana Hospital, Newark, DE 2None Given, Newark, DE OBJECTIVE: The use of assisted reproductive technology has led to a marked increase in the rates of multiple gestations. While twin gestations are at an increased risk of untoward pregnancy outcomes when compared to singleton gestations, the addition of being conceived by in vitro fertilization (IVF) may confer further risk. We sought to determine if twin gestations conceived by IVF had a higher risk of untoward pregnancy outcomes when compared to naturally occurring twin gestations. STUDY DESIGN: Using a contemporaneous collected database, we identified all women who delivered twin gestations at our institution from January 2000 till December of 2001. We compared women who conceived twins with IVF to naturally occurring twins. Twins were excluded if they delivered before 24 weeks, were monoamniotic, or if one of the fetuses died in utero. Univariate analysis was used using a P value of 0.05 as statistically significant. RESULTS: Two hundred fifty pregnancies resulting in 500 twins were identified. Of these, 76/500 (15%) were achieved through IVF. Women who conceived through the use of IVF were older (33.5 vs 20.8 years; P < 0.01) and of lower parity (1.7 vs 2.2; P < 0.01). Twins who were conceived with IVF had lower birthweights (2115 vs 2169 grams; P = 0.004), were born at earlier gestations (33.7 vs 34.9 weeks;P < 0.01), and were more likely to be born before 34 weeks (40.8% vs 23.1%; P < 0.001). Neonatal outcomes were similar. There was a trend towards a higher rate of sepsis and death in the IVF group (Table). CONCLUSION: Women with IVF twin gestations appear to deliver earlier than women with naturally occurring twins. The trend of an increased risk for neonatal death and sepsis in women with a twin gestation undergoing IVF needs to be corroborated in a larger study.
399
MIDTRIMESTER VAGINAL POLYMORPHONUCLEAR CELL (PMN) COUNTS COMPARED TO PMN TO EPITHELIAL CELL RATIOS FOR THE PREDICTION OF SPONTANEOUS PRETERM BIRTH (SPB) PATRICK RAMSEY1, M. DEE LYON1, ALICE GOEPFERT1, SUZANNE CLIVER1, WILLIAM ANDREWS1, JOHN HAUTH1, ROBERT GOLDENBERG1, 1University of Alabama at Birmingham, Obstetrics/Gynecology, Birmingham, AL OBJECTIVE: To compare the use of midtrimester vaginal PMN counts on Gram stain preparations with PMN to epithelial cell (EPI) ratios for the prediction of subsequent SPB. STUDY DESIGN: From a prospective cohort study, 83 women with a SPB < 35 wks (cases) were compared with a randomly selected control group of 108 women who delivered at term. Vaginal Gram stain preparations were obtained from all participants at the initial study visit (20-25 wks). Vaginal PMN and epithelial cell (EPI) counts were assessed on 5 non-adjacent oil immersion fields under 10003 magnification. Vaginal PMN:EPI ratios for each evaluated slide field were calculated to control for intraslide variation in cellular density. RESULTS: Mean delivery gestational age was 32 ± 3 wks for the cases and 40 ± 1 wks for the controls. Maternal age, race, and parity were similar between the groups. Mean PMN counts were higher in the cases (13 ± 20 cells per field [cpf]) when compared to the controls (10 ± 14 cpf, P = 0.17); however, this difference was not significant. The mean PMN/EPI ratio was significantly higher among the cases (3.4 ± 6.0) compared to the controls (1.8 ± 2.4, P = 0.01). PMN counts and PMN/EPI ratios were dichotomized by the 95th %ile cutoff (based on control values) to evaluate the association with SPB (Table). CONCLUSION: Midtrimester vaginal PMN counts on Gram stain preparations were not significantly associated with subsequent SPB in this population. However, the ratio of PMN to EPI counts, which provides internal standardization of variation in slide cellular density, was significantly higher in women with subsequent SPB < 35 wks.
Fetal outcomes
SGA < 2500 gm < 1500 gm RDS Sepsis Death
IVF
Non-IVF
P value
11.8% 69.7 10.5% 28.9% 5.3% 4.0%
11.3% 58.2 7.3% 27.1% 1.9% 0.9%
0.89 0.06 0.34 0.74 0.09 0.08
Volume 189, Number 6 Am J Obstet Gynecol 396
MIDTRIMESTER AMNIOTIC FLUID VITAMIN C LEVELS INVERSELY CORRELATE WITH INTERLEUKIN-6 LEVELS EVA PRESSMAN1, DEB PITTINARO1, JAMES WOODS1, 1University of Rochester, Obstetrics and Gynecology, Rochester, NY OBJECTIVE: To compare levels of vitamin C and interleukin-6 (IL-6) in pregnancies undergoing midtrimester amniocentesis for genetic indications. STUDY DESIGN: Women undergoing midtrimester genetic amniocentesis were prospectively enrolled. The initial 1 cc of amniotic fluid obtained was immediately refrigerated and processed within 24 hours for vitamin C and IL-6 analysis. Data were collected on maternal age, gestational age, and indication for amniocentesis. Demographic data, vitamin C levels, and IL-6 levels were analyzed with Pearson’s correlation and chi-square analysis. RESULTS: Data were available for 37 patients with normal karyotypes between the gestational ages of 16 and 21 weeks (mean 18.1 weeks). Mean maternal age was 35.1 years, with 66% of patients undergoing amniocentesis due to advanced maternal age. Vitamin C levels were noted to increase with advancing gestational age (r = 0.47, P = 0.003) but did not vary with maternal age or indication for amniocentesis. IL-6 values were not affected by these factors. A negative correlation was noted between vitamin C and IL-6 (r = -0.34, P = 0.034). CONCLUSION: Elevated levels of IL-6 in midtrimester amniotic fluid indicate intra-amniotic inflammation and have been associated with adverse pregnancy outcome. The inverse correlation between IL-6 and vitamin C suggests that consumption of vitamin C may occur as part of a chronic inflammatory process. Amniotic fluid vitamin C may also serve as a defense against chronic inflammation. Evaluation of the outcomes of these pregnancies may further clarify the potential role of vitamin C in the amniotic fluid.
398
CONTEMPORARY MANAGEMENT OF PRETERM PREMATURE RUPTURE OF MEMBRANES (PPROM): A SURVEY OF MATERNAL-FETAL MEDICINE PROVIDERS PATRICK RAMSEY1, FRANCIS NUTHALAPATY1, GEORGE LU2, SUSAN RAMIN3, ELIZEBETH NUTHALAPATY1, KIRK RAMIN4, 1University of Alabama at Birmingham, Obstetrics/Gynecology, Birmingham, AL 2Obstetrix Medical Group of Kansas & Missouri, Obstetrics/Gynecology, Kansas City, MO 3University of Texas Health Science Center at Houston, Obstetrics/Gynecology, Houston, TX 4University of Minnesota, Obstetrics/Gynecology, Minneapolis, MN OBJECTIVE: To characterize practice management variations for women with PPROM among maternal-fetal medicine (MFM) specialists. STUDY DESIGN: We performed a Web-based online survey of 1375 MFM providers. Participants were queried on practice characteristics and various management issues including use of tocolytics, antibiotics, and antenatal steroids and timing of delivery. RESULTS: Five-hundred three providers (37%), representing all 50 states and 13 countries, responded to the survey. Mean participant age was 45 ± 9 yr. The majority of study participants were in an academic university-based practice (53%). Only 30% reported a formal departmental protocol for managing PPROM. Consistent use of steroids (99.6%) and antibiotics (99.6%) was reported. Administration of steroids was confined to #32 wks by 37% and #34 wks by 51% of practitioners. Repeated dosing of steroids was uncommon (16%). The first-line antibiotic utilized and the rationale for use varied among practitioners. Tocolytic use in the setting of PPROM was reported by 75% of respondents, with magnesium sulfate the main agent used (98%). Tocolytic therapy generally was used for #48 hours for steroid benefit (85%). Amniocentesis, for a variety of disparate indications, was used by 66% of practitioners in the setting of PPROM. Fetal lung maturity testing (amniocentesis or vaginal pool) was reported by 78%, with inconsistency noted with respect to the test used. Outpatient management of women with PPROM after viability was noted by 43% of respondents. Gestational age at which expectant management is abandoned in women with PPROM varied significantly among respondents: $34 wks, 56%; $35 wks, 26%; $36 wks, 12%; $37 wks, 4.0%. CONCLUSION: Practice variations exist with respect to the management of PPROM among MFM providers. These disparate practices call for further research focused toward the optimization of the management for women with this pregnancy complication.
397
CONCEPTION USING IVF IS ASSOCIATED WITH POORER PERINATAL OUTCOMES IN TWIN GESTATIONS MATTHEW HOFFMAN1, ANTHONY SCISCIONE2, 1Christiana Hospital, Newark, DE 2None Given, Newark, DE OBJECTIVE: The use of assisted reproductive technology has led to a marked increase in the rates of multiple gestations. While twin gestations are at an increased risk of untoward pregnancy outcomes when compared to singleton gestations, the addition of being conceived by in vitro fertilization (IVF) may confer further risk. We sought to determine if twin gestations conceived by IVF had a higher risk of untoward pregnancy outcomes when compared to naturally occurring twin gestations. STUDY DESIGN: Using a contemporaneous collected database, we identified all women who delivered twin gestations at our institution from January 2000 till December of 2001. We compared women who conceived twins with IVF to naturally occurring twins. Twins were excluded if they delivered before 24 weeks, were monoamniotic, or if one of the fetuses died in utero. Univariate analysis was used using a P value of 0.05 as statistically significant. RESULTS: Two hundred fifty pregnancies resulting in 500 twins were identified. Of these, 76/500 (15%) were achieved through IVF. Women who conceived through the use of IVF were older (33.5 vs 20.8 years; P < 0.01) and of lower parity (1.7 vs 2.2; P < 0.01). Twins who were conceived with IVF had lower birthweights (2115 vs 2169 grams; P = 0.004), were born at earlier gestations (33.7 vs 34.9 weeks;P < 0.01), and were more likely to be born before 34 weeks (40.8% vs 23.1%; P < 0.001). Neonatal outcomes were similar. There was a trend towards a higher rate of sepsis and death in the IVF group (Table). CONCLUSION: Women with IVF twin gestations appear to deliver earlier than women with naturally occurring twins. The trend of an increased risk for neonatal death and sepsis in women with a twin gestation undergoing IVF needs to be corroborated in a larger study.
399
MIDTRIMESTER VAGINAL POLYMORPHONUCLEAR CELL (PMN) COUNTS COMPARED TO PMN TO EPITHELIAL CELL RATIOS FOR THE PREDICTION OF SPONTANEOUS PRETERM BIRTH (SPB) PATRICK RAMSEY1, M. DEE LYON1, ALICE GOEPFERT1, SUZANNE CLIVER1, WILLIAM ANDREWS1, JOHN HAUTH1, ROBERT GOLDENBERG1, 1University of Alabama at Birmingham, Obstetrics/Gynecology, Birmingham, AL OBJECTIVE: To compare the use of midtrimester vaginal PMN counts on Gram stain preparations with PMN to epithelial cell (EPI) ratios for the prediction of subsequent SPB. STUDY DESIGN: From a prospective cohort study, 83 women with a SPB < 35 wks (cases) were compared with a randomly selected control group of 108 women who delivered at term. Vaginal Gram stain preparations were obtained from all participants at the initial study visit (20-25 wks). Vaginal PMN and epithelial cell (EPI) counts were assessed on 5 non-adjacent oil immersion fields under 10003 magnification. Vaginal PMN:EPI ratios for each evaluated slide field were calculated to control for intraslide variation in cellular density. RESULTS: Mean delivery gestational age was 32 ± 3 wks for the cases and 40 ± 1 wks for the controls. Maternal age, race, and parity were similar between the groups. Mean PMN counts were higher in the cases (13 ± 20 cells per field [cpf]) when compared to the controls (10 ± 14 cpf, P = 0.17); however, this difference was not significant. The mean PMN/EPI ratio was significantly higher among the cases (3.4 ± 6.0) compared to the controls (1.8 ± 2.4, P = 0.01). PMN counts and PMN/EPI ratios were dichotomized by the 95th %ile cutoff (based on control values) to evaluate the association with SPB (Table). CONCLUSION: Midtrimester vaginal PMN counts on Gram stain preparations were not significantly associated with subsequent SPB in this population. However, the ratio of PMN to EPI counts, which provides internal standardization of variation in slide cellular density, was significantly higher in women with subsequent SPB < 35 wks.
Fetal outcomes
SGA < 2500 gm < 1500 gm RDS Sepsis Death
IVF
Non-IVF
P value
11.8% 69.7 10.5% 28.9% 5.3% 4.0%
11.3% 58.2 7.3% 27.1% 1.9% 0.9%
0.89 0.06 0.34 0.74 0.09 0.08