- Email: [email protected]
HELLP syndrome ( < 34 weeks) in the first pregnancy: Maternal and fetal outcome in the next pregnancy
S106 SMFM Abstracts 347 PREGNANCY OUTCOME OF PATIENTS WITH PSORIASIS GILA BEN DAVID1, EYAL SHEINER1, MORDECHAI HALLAK1, AMALIA LEVI2, 1Soroka University Medical Center, Ob/Gyn, Beer-Sheva, Israel, 2Ben-Gurion University of the Negev, Faculty of Health Sciences, Epidemiology, Beer-Sheva, Israel OBJECTIVE: Psoriasis is one of the most common T cell-mediated autoimmune dermatologic diseases in humans. While immune disorders are known to have adverse effects on pregnancy, limited data exist regarding pregnancy outcome of women having psoriasis. The purpose of this study was to determine pregnancy outcome of patients with psoriasis. STUDY DESIGN: A case-control study of deliveries to women suffering from psoriasis (ICD-9 code 696.1; n=145) who delivered during the years 1988–2004 was conducted. For every birth, six births by non-psoriatic mothers (n=860) were randomly selected and adjusted for ethnicity and year of delivery. RESULTS: The following complications were significantly associated with pregnancies to psoriatic patients: recurrent abortions (6.9% vs. 3.3%; P!0.05), previous caesarean delivery (CD) (20.0% vs. 10.7%; P!0.01), severe preeclampsia (3.4% vs. 0.9%; P!0.05), chronic hypertension (4.8% vs. 1.5%; P!0.05), pre-gestational diabetes mellitus (4.1% vs. 1.2%; P!0.05), non-reassuring monitoring (5.5% vs. 1.7%; P!0.05), and labour dystocia (5.5% vs. 1.7%; P!0.05). Using a multivariable analysis, with backward elimination, only recurrent abortions (OR=2.1, 95% CI 1.1–4.9; P!0.05) and chronic hypertension (OR=2.9, 95% CI 1.01–8.3; P!0.05) were significantly associated with psoriasis.A higher rate of CD was found among the study group (35.2% vs. 15%; P!0.001). Another multivariable analysis was performed, with CD as the outcome variable, controlling for possible confounders such as previous CD, hypertensive disorders, labour dystocia etc. Psoriasis was found as an independent risk factor for CD (OR=4.1, 95% CI 2.3–7.5; P!0.001). No significant differences were noted between the groups regarding perinatal complications. CONCLUSION: Psoriasis was significantly associated with pregnancy complications such as recurrent abortions and chronic hypertension. Moreover, psoriasis was found to be an independent risk factor for CD. Thus, physicians should keep in mind that psoriasis might have non-dermatologic implications, which may adversely affect pregnancy.
348 FAILED EXTERNAL CEPHALIC VERSION – WHAT DO WE HAVE TO WAIT FOR? ASSAF BEN MEIR1, TAMAR ELRAM1, URIEL ELCHALAL1, YOSSEF EZRA1, 1The Hebrew University hadassah Medical Center, Obstetrics & Gynecology, Jerusalem, Israel OBJECTIVE: The object of external cephalic version (ECV) is to reduce the rate of cesarean sections, especially since the Term Breech Trial and the dramatic reduction in vaginal breech delivery rates. Up to date most of the studies have involved data regarding the chance to succeed in a trial of ECV, and have searched for parameters that may influence this goal. In our center, following a failed ECV, women are told to wait for spontaneous onset of labor, in hope that spontaneous version may occur. Many parturients return with breech presentation in labor and undergo an emergent cesarean section, a procedure involving a significantly higher complication rate compared to an elective cesarean section. We sought to learn how common these spontaneous versions really are. STUDY DESIGN: We prospectively collected data regarding all trials of ECV in our center between January 1997 and June 2005. Data collected included general and obstetric parameters and the mode of delivery after success or failed ECV. RESULTS: Six hundred and three women were included in the study. The success rates were 68% and 32% for multiparas and nulliparas, respectively. Prognostic factors included parity, BMI, AFI, placental location and type of breech. Since the introduction of the Term Breech Trial and the policy to prefer cesarean section for breech in labor, we performed 227 ECV trials with 91 failed ECV (40%). In the multiparous group only 1/43 cases (2.3%) underwent spontaneous version and delivered vaginally. In the nulliparas group none of the women underwent spontaneous version and all delivered by emergent cesarean section upon arrival in labor. CONCLUSION: The chance for spontaneous version after failed ECV is extremely low, especially in nulliparas. We recommend undertaking a trial of ECV at term in a setup prepared for elective cesarean section, which will be performed in case of failed ECV.
349 PERINATAL OUTCOMES IN WOMEN WITH A HISTORY OF SPONTANEOUS ABORTIONS KATHERINE BIANCO (F)1, SUSAN TRAN1, YVONNE CHENG1, MARY NORTON1, BRIAN SHAFFER1, AARON B. CAUGHEY1, 1University of California, San Francisco, Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California OBJECTIVE: To determine whether a history of spontaneous abortion (SAB) is associated with increases in obstetric and neonatal complications in subsequent pregnancies. STUDY DESIGN: This was a retrospective cohort study of all women who delivered at a single academic institution from 1980 to 2001. A history of an SAB and the number of SABs were examined in association with the following outcomes: placenta previa, abruption, preterm delivery (PTD), IUFD, and umbilical artery pH. Univariate and multivariate analyses were conducted. RESULTS: A total of 34,718 women met criteria. An increasing number of SABs and higher rates of placenta previa, abruptio, PTD !37, 32, and 28 weeks, IUFD, and umbilical artery pH !7.0 was found (Table). In multivariate analyses controlling for obstetric history, demographics, and medical history; 1 or more SABs was associated with a higher rate of PTD !32 weeks (OR 1.4, 95% CI 1.2-1.7); 2.R SABs was associated with an increase in abruption (OR 1.5, 95% CI 1.0-2.3) and umbilical artery pH !7.0 (OR 2.3, 95% CI 1.3-3.9); and .R 3 SABs was associated with an increase in placenta previa (OR 2.2, 95% CI 1.1-4.4), and IUFD (OR 3.7, 95% CI 1.9-7.2) as compared to women who had no prior SABs. CONCLUSION: An increasing number of SABs is associated with both obstetric and neonatal complications. The relationship between SAB and pregnancy complications requires further investigation. Theses findings can be used to counsel women regarding risks of pregnancy related complications. Number of sabs and perinatal complications SAB
Previa
Abruptio
PTD !37 wks
PTD !32 wks
IUFD
Cord Ph
0 1 2 3 p-value
1.15% 1.16% 1.58% 3.20% 0.001
0.86% 1.08% 1.46% 1.72% 0.006
8.13% 10.67% 14.06% 15.45% 0.001
2.38% 3.64% 5.01% 6.22% 0.001
0.51% 0.73% 0.53% 2.31% 0.001
0.86% 0.70% 2.35% 1.28% 0.001
350 ADVERSE PERINATAL OUTCOMES IN SUBSEQUENT PREGNANCIES IN WOMEN WITH PRIOR STILLBIRTH SEAN BLACKWELL1, JERRIE REFUERZO1, ISRAEL HENDLER2, SONIA HASSAN1, NAHLA KHALEK1, YORAM SOROKIN4, 1Wayne State University, Obstetrics & Gynecology, Detroit, Michigan, 2Wayne State University, Detroit, Michigan, 4Wayne State University, Ob/Gyn/Maternal Fetal Med, Detroit, Michigan OBJECTIVE: To study the frequency of adverse perinatal outcomes (APO) in subsequent pregnancies of women with a prior stillbirth (SB). STUDY DESIGN: A computerized perinatal database was used to study singleton pregnancies delivered from Jan 1, 1991 to Dec 31, 2004 at one tertiary care urban hospital. SB cases were identified through perinatal database and confirmed with medical records ICD-9 codes. SB was defined as fetal death at GA O 20 wks or birth weight (BW) O 400 grams at delivery. Demographic, clinical, and obstetric variables were studied for women who delivered a subsequent pregnancy O 20 wks at the same hospital during the study interval. Maternal race, parity, obesity, prior cesarean delivery, and gestational age at prior SB were studied for the impact on APO in subsequent pregnancies. APO was defined as preterm birth (PTB) ! 37 wks, small for gestational age (SGA) defined as neonatal ponderal index ! 5th %tile, severe preeclampsia, or recurrent stillbirth. RESULTS: We identified 644 women with singleton pregnancies whose first pregnancy at our institution was complicated by SB. These women had 259 subsequent pregnancies O 20 wks; there were 15 cases of recurrent SB (SB rate = 58 per 1,000 births). There was a high rate of other pregnancy complications including PTB ! 37 wks (24.3%), SGA (16.2%), and severe preeclampsia (1.5%). Overall, 30.9% of subsequent pregnancies had at least one APO. There were no differences in the rates of APO between African-American and Caucasian women (32.7% vs. 29.0%; p=0.27). CONCLUSION: Women with a prior SB have approximately 10! increased risk of recurrent SB and have APO in over 30% of subsequent pregnancies.
351 EARLY PREECLAMPSIA / HELLP SYNDROME (! 34 WEEKS) IN THE FIRST PREGNANCY: MATERNAL AND FETAL OUTCOME IN THE NEXT PREGNANCY L. B. E. A. HOEKS1, B. B. VAN RIJN1, A. FRANX1, H. W. BRUINSE1, 1University of Utrecht, Obstetrics and Gynecology, Utrecht, Netherlands OBJECTIVE: Data on maternal and fetal outcome of the next pregnancy after a first pregnancy complicated by early preeclampsia / HELLP syndrome are of extreme importance for counselling. Aim of the study: To evaluate the maternal and fetal outcome of the pregnancy after a first pregnancy with early preeclampsia / HELLP syndrome in a tertiary referral center. STUDY DESIGN: 120 women with a first pregnancy with early preeclampsia / HELLP syndrome and their next pregnancy. All women were treated in their second pregnancy with 80 mg ASA from the 12th week – 36th week of pregnancy or up to delivery, and preconceptionally and during pregnancy with folic acid and vitamine B6 if homocysteinaemia was diagnosed after the first pregancy.
SMFM Abstracts S107 RESULTS: Results are presented in Table 1. Preeclampsia reoccurred in the second pregnancy in 30 of the 120 women (25%). However, in 9 after 34 weeks and in 18 after 37 weeks. PIH occurred in 27 of the 120 cases but in all after 37 weeks. 41 Women had a completely normal pregnancy. CONCLUSION: The outcome of a pregnancy following a first pregnancy with an early preeclampsia/HELLP syndrome is in general favourable. First and second pregnancy (FP and SP) n [ 120
age (SD) gestational age at delivery (SD) gestational age !28 wks % gestational age O28 !34 wks % gestational age O34 !37 wks % gestational age O37 wks % HELLP syndrome % Cesarean Section % Mean birth weight g (SD) IUGR !p10 % Perinatal deaths %
FP
SP
29.0 (4) 29.2 (2) 25.9% 74.1% – – 52.5% 80.8% 1001 (439) 39.5% 34.5%
31.8 (4) 38 (4) 2.5% 2.5% 17% 78% 3% 43% 2961 (800) 10% 1.7%
352 MASS SPECTROMETRY (MS) - A NOVEL APPROACH IN DECIPHERING THE ORIGIN AND DURATION OF INTRA-AMNIOTIC BLEEDING IRINA A. BUHIMSCHI1, CATALIN S. BUHIMSCHI1, GUOMAO ZHAO1, CHRISTIAN M. PETTKER1, CARL P. WEINER2, 1 Yale University, Obstetrics, Gynecology & Reprod. Sciences, New Haven, Connecticut, 2University of Maryland, Obstetrics, Gynecology & Reprod. Sciences, Baltimore, Maryland OBJECTIVE: Intra-amniotic bleeding (e.g. abruption) and decidual hemorrhage are associated with preterm birth (PB). We sought a method based on SELDI technology that distinguishes the source of bleeding (maternal vs. fetal) and the timing of the blood loss (acute vs. chronic). STUDY DESIGN: During a ‘‘learning phase’’, paired maternal/fetal RBC lysates from 8 PB pregnancies were dried onto SELDI chips and analyzed by MS. The origin of Hb chain peaks [ chains (maternal Hb) vs. chains (fetal Hb)] were identified by their known masses. A identification profile was developed. The second phase tested the profile in amniotic fluid (AF) samples collected from women with clinical signs of abruption (25 retrieved by amniocentesis and 10 from the vagina after PPROM) to determine whether Hb peaks in paired abdominal/vaginal samples could be differentiated by MS. Signal intensities (S/N) were measured for the vs. chains. RESULTS: Hb chain peaks were located in the 14-17kDa mass section. SELDI permitted easily differentiation of fetal chain from maternal chain by a mass shift of C131Da [95%CI: 130-132]. The S/N ratio of / chains provided the relative contributions of maternal vs. fetal Hb. A mass shift for the chain was observed in AFs with old abruption. This peak (des–Arg141 Hb) also discriminated recent blood contamination [bloody tap] from older AF bleeds occurring in vivo. [Figure] Vaginal pooling provided similar insight. CONCLUSION: The presence of truncated Hb in AF on SELDI-MS separates acute from old bleeding. MS detection of the and chains allows identification of the bleeding source and can be used to assist the clinician in managing high risk pregnancies.
353 STILLBIRTH RISK PREDICTION RADEK BUKOWSKI1, GARY HANKINS1, FERGAL D. MALONE2, T. FLINT PORTER3, DAVID NYBERG4, CHRISTINE COMSTOCK5, KEITH EDDLEMAN6, SUSAN GROSS7, LORRAINE DUGOFF8, SABRINA CRAIGO9, ILAN TIMOR10, HONOR WOLFE11, KAREN TRAISTER12, MARY D’ALTON13, 1The University of Texas Medical Branch, Department of Obstetrics and Gynecology, Galveston, Texas, 2Royal College of Surgeons in Ireland, Dublin, Ireland, 3University of Utah, Obstetrics and Gynecology, Salt Lake, Utah, 4Swedish Medical Center, Perinatal Medicine, Seattle, Washington, 5William Beaumont Hospital, Royal
Oak, Michigan, 6Mount Sinai School of Medicine, Obstetrics, Gynecology and Reproductive Science, New York, New York, 7Montefiore Medical Center, Department of Obstetrics and Gynecology, Bronx, New York, 8University of Colorado Health Sciences Center, Obstetrics and Gynecology, Denver, Colorado, 9Tufts University, Obstetrics/Gynecology, Boston, Massachusetts, 10 New York University, Obstetrics and Gynecology, New York, New York, 11 University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina, 12DM-STAT, Medford, Massachusetts, 13Columbia University, Obstetrics and Gynecology, New York, New York OBJECTIVE: Stillbirth (SB) risk factors are identifiable only in a small subset of patients. Here we show a set of predictors that are associated with SB in a continuous and independent manner allowing calculation of adjusted likelihood ratios and stillbirth risk in every patient in a multiple marker test fashion. STUDY DESIGN: We conducted a prospective, non-interventional cohort study of 32,633 pregnancies which ended in live birth of a singleton infant without evidence of chromosomal abnormality and all data available. SB was defined as fetal demise of chromosomally normal fetus at R24 weeks. The relationships between SB and reported risk factors (maternal age, BMI, parity, diabetes, hypertension, smoking, number of prior miscarriages and preterm deliveries, PAPP-A, FbhCG, AFP, hCG, Estriol, Inhibin-A) were modeled using multivariate proportional hazard and logistic regressions. Calculated adjusted likelihood ratios were combined in a Bayesian formula to estimate individual risk for each patient. RESULTS: There were 101 SB (0.3%) without chromosomal abnormalities. Risk factors significantly associated with SB were as shown in Table 1. Combined estimated SB risk (SBR) ranged 0.01-350 / 1000 pregnancies and was on average 2.7 times higher among SB. SBR R5/1000 was associated with screen positive rate of 7 %, Detection Rate = 20.8%, SP = 93.1%, and correctly classified 92.9% of outcomes. Validity of prediction was confirmed by resampling-bootstraping. CONCLUSION: Our data demonstrate that risk factors associated with placental function and fetal growth are associated with SB in a continuous manner, independent of each other. We conclude that routine estimation of individual SB risk in pregnancy allows implementation of available effective methods of SB prevention in patients at risk and prevention of SB. (NIH-RO1HD-38652).
PAPP-A (MOM) AFP (MOM) INH-A (MOM) BMI (kg)
OR (95% CI)
adjLR (range)
0.68 1.34 1.09 1.06
0.002-1.55 0.75-166.2 0.007-84.2 0.45-10.4
(0.48-0.96) (1.14-1.59) (1.03-1.14) (1.03-1.09)
354 COMPARISON OF SELF-REPORTED SMOKING STATUS AND ANONYMOUS URINARY COTININE TESTING IN PREGNANCY KEISHA BURSEY-REDDICK1, GEETA K. SWAMY1, REBECCA N. BROUWER2, KATHRYN I. POLLAK2, EVAN R. MYERS1, FOR BABY STEPS INVESTIGATORS2, 1Duke University, Obstetrics & Gynecology, Durham, North Carolina, 2Duke University, Comprehensive Cancer Center and Department of Community and Family Medicine, Durham, North Carolina OBJECTIVE: Given the increasing societal pressures against smoking during pregnancy, women may be reluctant to disclose their smoking to prenatal care providers. If providers are unaware of women’s smoking, they cannot assist women in cessation or monitor for potential adverse birth outcomes. The objective of this study was to determine the true prevalence of cigarette smoking among pregnant women receiving prenatal care. STUDY DESIGN: Women receiving prenatal care at the Duke Obstetric clinic from February to August 2005 were eligible for anonymous evaluation. As part of standard practice, nurses asked women their smoking status at their first prenatal visit. A portion of the urine sample routinely obtained upon initiation of prenatal care was used for analysis. Identifying information and self-reported smoking status was recorded for all women to ensure that no woman was tested more than once. However, no identifying information was linked to the urine sample; thus, the laboratory analysis was performed in a blinded fashion. The NicCheck IÔ (Mossman Associates) semi-quantitative dipstick was used to detect the presence of urinary nicotine, cotinine, and 3hydroxycotinine. NicCheck IÔ correlates with a 200ng/mL cotinine discriminatory value by gas chromatography. A false positive result can occur in the setting of high niacin intake or excess second-hand smoke exposure. The difference, with 95% CI, between the proportions of smokers by self-report and urine testing was calculated. RESULTS: One hundred seventy-five urine samples were analyzed. The incidence of smoking based on self-report was 17.7% verses 37.7% based on positive urine dipstick. The absolute difference is 20%, 95% CI [0.11, 0.29]. CONCLUSION: There is a significant discrepancy in self-reported and actual smoking status among pregnant women. Universal urinary cotinine screening of pregnant women could aid clinicians in appropriately counseling and monitoring women at high risk for adverse birth outcomes. Smoking status by self-report and anonymous testing
Self-Report Anonymous Testing
Smoker
Non-Smoker
31 66
144 109
348 FAILED EXTERNAL CEPHALIC VERSION – WHAT DO WE HAVE TO WAIT FOR? ASSAF BEN MEIR1, TAMAR ELRAM1, URIEL ELCHALAL1, YOSSEF EZRA1, 1The Hebrew University hadassah Medical Center, Obstetrics & Gynecology, Jerusalem, Israel OBJECTIVE: The object of external cephalic version (ECV) is to reduce the rate of cesarean sections, especially since the Term Breech Trial and the dramatic reduction in vaginal breech delivery rates. Up to date most of the studies have involved data regarding the chance to succeed in a trial of ECV, and have searched for parameters that may influence this goal. In our center, following a failed ECV, women are told to wait for spontaneous onset of labor, in hope that spontaneous version may occur. Many parturients return with breech presentation in labor and undergo an emergent cesarean section, a procedure involving a significantly higher complication rate compared to an elective cesarean section. We sought to learn how common these spontaneous versions really are. STUDY DESIGN: We prospectively collected data regarding all trials of ECV in our center between January 1997 and June 2005. Data collected included general and obstetric parameters and the mode of delivery after success or failed ECV. RESULTS: Six hundred and three women were included in the study. The success rates were 68% and 32% for multiparas and nulliparas, respectively. Prognostic factors included parity, BMI, AFI, placental location and type of breech. Since the introduction of the Term Breech Trial and the policy to prefer cesarean section for breech in labor, we performed 227 ECV trials with 91 failed ECV (40%). In the multiparous group only 1/43 cases (2.3%) underwent spontaneous version and delivered vaginally. In the nulliparas group none of the women underwent spontaneous version and all delivered by emergent cesarean section upon arrival in labor. CONCLUSION: The chance for spontaneous version after failed ECV is extremely low, especially in nulliparas. We recommend undertaking a trial of ECV at term in a setup prepared for elective cesarean section, which will be performed in case of failed ECV.
349 PERINATAL OUTCOMES IN WOMEN WITH A HISTORY OF SPONTANEOUS ABORTIONS KATHERINE BIANCO (F)1, SUSAN TRAN1, YVONNE CHENG1, MARY NORTON1, BRIAN SHAFFER1, AARON B. CAUGHEY1, 1University of California, San Francisco, Obstetrics, Gynecology and Reproductive Sciences, San Francisco, California OBJECTIVE: To determine whether a history of spontaneous abortion (SAB) is associated with increases in obstetric and neonatal complications in subsequent pregnancies. STUDY DESIGN: This was a retrospective cohort study of all women who delivered at a single academic institution from 1980 to 2001. A history of an SAB and the number of SABs were examined in association with the following outcomes: placenta previa, abruption, preterm delivery (PTD), IUFD, and umbilical artery pH. Univariate and multivariate analyses were conducted. RESULTS: A total of 34,718 women met criteria. An increasing number of SABs and higher rates of placenta previa, abruptio, PTD !37, 32, and 28 weeks, IUFD, and umbilical artery pH !7.0 was found (Table). In multivariate analyses controlling for obstetric history, demographics, and medical history; 1 or more SABs was associated with a higher rate of PTD !32 weeks (OR 1.4, 95% CI 1.2-1.7); 2.R SABs was associated with an increase in abruption (OR 1.5, 95% CI 1.0-2.3) and umbilical artery pH !7.0 (OR 2.3, 95% CI 1.3-3.9); and .R 3 SABs was associated with an increase in placenta previa (OR 2.2, 95% CI 1.1-4.4), and IUFD (OR 3.7, 95% CI 1.9-7.2) as compared to women who had no prior SABs. CONCLUSION: An increasing number of SABs is associated with both obstetric and neonatal complications. The relationship between SAB and pregnancy complications requires further investigation. Theses findings can be used to counsel women regarding risks of pregnancy related complications. Number of sabs and perinatal complications SAB
Previa
Abruptio
PTD !37 wks
PTD !32 wks
IUFD
Cord Ph
0 1 2 3 p-value
1.15% 1.16% 1.58% 3.20% 0.001
0.86% 1.08% 1.46% 1.72% 0.006
8.13% 10.67% 14.06% 15.45% 0.001
2.38% 3.64% 5.01% 6.22% 0.001
0.51% 0.73% 0.53% 2.31% 0.001
0.86% 0.70% 2.35% 1.28% 0.001
350 ADVERSE PERINATAL OUTCOMES IN SUBSEQUENT PREGNANCIES IN WOMEN WITH PRIOR STILLBIRTH SEAN BLACKWELL1, JERRIE REFUERZO1, ISRAEL HENDLER2, SONIA HASSAN1, NAHLA KHALEK1, YORAM SOROKIN4, 1Wayne State University, Obstetrics & Gynecology, Detroit, Michigan, 2Wayne State University, Detroit, Michigan, 4Wayne State University, Ob/Gyn/Maternal Fetal Med, Detroit, Michigan OBJECTIVE: To study the frequency of adverse perinatal outcomes (APO) in subsequent pregnancies of women with a prior stillbirth (SB). STUDY DESIGN: A computerized perinatal database was used to study singleton pregnancies delivered from Jan 1, 1991 to Dec 31, 2004 at one tertiary care urban hospital. SB cases were identified through perinatal database and confirmed with medical records ICD-9 codes. SB was defined as fetal death at GA O 20 wks or birth weight (BW) O 400 grams at delivery. Demographic, clinical, and obstetric variables were studied for women who delivered a subsequent pregnancy O 20 wks at the same hospital during the study interval. Maternal race, parity, obesity, prior cesarean delivery, and gestational age at prior SB were studied for the impact on APO in subsequent pregnancies. APO was defined as preterm birth (PTB) ! 37 wks, small for gestational age (SGA) defined as neonatal ponderal index ! 5th %tile, severe preeclampsia, or recurrent stillbirth. RESULTS: We identified 644 women with singleton pregnancies whose first pregnancy at our institution was complicated by SB. These women had 259 subsequent pregnancies O 20 wks; there were 15 cases of recurrent SB (SB rate = 58 per 1,000 births). There was a high rate of other pregnancy complications including PTB ! 37 wks (24.3%), SGA (16.2%), and severe preeclampsia (1.5%). Overall, 30.9% of subsequent pregnancies had at least one APO. There were no differences in the rates of APO between African-American and Caucasian women (32.7% vs. 29.0%; p=0.27). CONCLUSION: Women with a prior SB have approximately 10! increased risk of recurrent SB and have APO in over 30% of subsequent pregnancies.
351 EARLY PREECLAMPSIA / HELLP SYNDROME (! 34 WEEKS) IN THE FIRST PREGNANCY: MATERNAL AND FETAL OUTCOME IN THE NEXT PREGNANCY L. B. E. A. HOEKS1, B. B. VAN RIJN1, A. FRANX1, H. W. BRUINSE1, 1University of Utrecht, Obstetrics and Gynecology, Utrecht, Netherlands OBJECTIVE: Data on maternal and fetal outcome of the next pregnancy after a first pregnancy complicated by early preeclampsia / HELLP syndrome are of extreme importance for counselling. Aim of the study: To evaluate the maternal and fetal outcome of the pregnancy after a first pregnancy with early preeclampsia / HELLP syndrome in a tertiary referral center. STUDY DESIGN: 120 women with a first pregnancy with early preeclampsia / HELLP syndrome and their next pregnancy. All women were treated in their second pregnancy with 80 mg ASA from the 12th week – 36th week of pregnancy or up to delivery, and preconceptionally and during pregnancy with folic acid and vitamine B6 if homocysteinaemia was diagnosed after the first pregancy.
SMFM Abstracts S107 RESULTS: Results are presented in Table 1. Preeclampsia reoccurred in the second pregnancy in 30 of the 120 women (25%). However, in 9 after 34 weeks and in 18 after 37 weeks. PIH occurred in 27 of the 120 cases but in all after 37 weeks. 41 Women had a completely normal pregnancy. CONCLUSION: The outcome of a pregnancy following a first pregnancy with an early preeclampsia/HELLP syndrome is in general favourable. First and second pregnancy (FP and SP) n [ 120
age (SD) gestational age at delivery (SD) gestational age !28 wks % gestational age O28 !34 wks % gestational age O34 !37 wks % gestational age O37 wks % HELLP syndrome % Cesarean Section % Mean birth weight g (SD) IUGR !p10 % Perinatal deaths %
FP
SP
29.0 (4) 29.2 (2) 25.9% 74.1% – – 52.5% 80.8% 1001 (439) 39.5% 34.5%
31.8 (4) 38 (4) 2.5% 2.5% 17% 78% 3% 43% 2961 (800) 10% 1.7%
352 MASS SPECTROMETRY (MS) - A NOVEL APPROACH IN DECIPHERING THE ORIGIN AND DURATION OF INTRA-AMNIOTIC BLEEDING IRINA A. BUHIMSCHI1, CATALIN S. BUHIMSCHI1, GUOMAO ZHAO1, CHRISTIAN M. PETTKER1, CARL P. WEINER2, 1 Yale University, Obstetrics, Gynecology & Reprod. Sciences, New Haven, Connecticut, 2University of Maryland, Obstetrics, Gynecology & Reprod. Sciences, Baltimore, Maryland OBJECTIVE: Intra-amniotic bleeding (e.g. abruption) and decidual hemorrhage are associated with preterm birth (PB). We sought a method based on SELDI technology that distinguishes the source of bleeding (maternal vs. fetal) and the timing of the blood loss (acute vs. chronic). STUDY DESIGN: During a ‘‘learning phase’’, paired maternal/fetal RBC lysates from 8 PB pregnancies were dried onto SELDI chips and analyzed by MS. The origin of Hb chain peaks [ chains (maternal Hb) vs. chains (fetal Hb)] were identified by their known masses. A identification profile was developed. The second phase tested the profile in amniotic fluid (AF) samples collected from women with clinical signs of abruption (25 retrieved by amniocentesis and 10 from the vagina after PPROM) to determine whether Hb peaks in paired abdominal/vaginal samples could be differentiated by MS. Signal intensities (S/N) were measured for the vs. chains. RESULTS: Hb chain peaks were located in the 14-17kDa mass section. SELDI permitted easily differentiation of fetal chain from maternal chain by a mass shift of C131Da [95%CI: 130-132]. The S/N ratio of / chains provided the relative contributions of maternal vs. fetal Hb. A mass shift for the chain was observed in AFs with old abruption. This peak (des–Arg141 Hb) also discriminated recent blood contamination [bloody tap] from older AF bleeds occurring in vivo. [Figure] Vaginal pooling provided similar insight. CONCLUSION: The presence of truncated Hb in AF on SELDI-MS separates acute from old bleeding. MS detection of the and chains allows identification of the bleeding source and can be used to assist the clinician in managing high risk pregnancies.
353 STILLBIRTH RISK PREDICTION RADEK BUKOWSKI1, GARY HANKINS1, FERGAL D. MALONE2, T. FLINT PORTER3, DAVID NYBERG4, CHRISTINE COMSTOCK5, KEITH EDDLEMAN6, SUSAN GROSS7, LORRAINE DUGOFF8, SABRINA CRAIGO9, ILAN TIMOR10, HONOR WOLFE11, KAREN TRAISTER12, MARY D’ALTON13, 1The University of Texas Medical Branch, Department of Obstetrics and Gynecology, Galveston, Texas, 2Royal College of Surgeons in Ireland, Dublin, Ireland, 3University of Utah, Obstetrics and Gynecology, Salt Lake, Utah, 4Swedish Medical Center, Perinatal Medicine, Seattle, Washington, 5William Beaumont Hospital, Royal
Oak, Michigan, 6Mount Sinai School of Medicine, Obstetrics, Gynecology and Reproductive Science, New York, New York, 7Montefiore Medical Center, Department of Obstetrics and Gynecology, Bronx, New York, 8University of Colorado Health Sciences Center, Obstetrics and Gynecology, Denver, Colorado, 9Tufts University, Obstetrics/Gynecology, Boston, Massachusetts, 10 New York University, Obstetrics and Gynecology, New York, New York, 11 University of North Carolina, Department of Obstetrics and Gynecology, Chapel Hill, North Carolina, 12DM-STAT, Medford, Massachusetts, 13Columbia University, Obstetrics and Gynecology, New York, New York OBJECTIVE: Stillbirth (SB) risk factors are identifiable only in a small subset of patients. Here we show a set of predictors that are associated with SB in a continuous and independent manner allowing calculation of adjusted likelihood ratios and stillbirth risk in every patient in a multiple marker test fashion. STUDY DESIGN: We conducted a prospective, non-interventional cohort study of 32,633 pregnancies which ended in live birth of a singleton infant without evidence of chromosomal abnormality and all data available. SB was defined as fetal demise of chromosomally normal fetus at R24 weeks. The relationships between SB and reported risk factors (maternal age, BMI, parity, diabetes, hypertension, smoking, number of prior miscarriages and preterm deliveries, PAPP-A, FbhCG, AFP, hCG, Estriol, Inhibin-A) were modeled using multivariate proportional hazard and logistic regressions. Calculated adjusted likelihood ratios were combined in a Bayesian formula to estimate individual risk for each patient. RESULTS: There were 101 SB (0.3%) without chromosomal abnormalities. Risk factors significantly associated with SB were as shown in Table 1. Combined estimated SB risk (SBR) ranged 0.01-350 / 1000 pregnancies and was on average 2.7 times higher among SB. SBR R5/1000 was associated with screen positive rate of 7 %, Detection Rate = 20.8%, SP = 93.1%, and correctly classified 92.9% of outcomes. Validity of prediction was confirmed by resampling-bootstraping. CONCLUSION: Our data demonstrate that risk factors associated with placental function and fetal growth are associated with SB in a continuous manner, independent of each other. We conclude that routine estimation of individual SB risk in pregnancy allows implementation of available effective methods of SB prevention in patients at risk and prevention of SB. (NIH-RO1HD-38652).
PAPP-A (MOM) AFP (MOM) INH-A (MOM) BMI (kg)
OR (95% CI)
adjLR (range)
0.68 1.34 1.09 1.06
0.002-1.55 0.75-166.2 0.007-84.2 0.45-10.4
(0.48-0.96) (1.14-1.59) (1.03-1.14) (1.03-1.09)
354 COMPARISON OF SELF-REPORTED SMOKING STATUS AND ANONYMOUS URINARY COTININE TESTING IN PREGNANCY KEISHA BURSEY-REDDICK1, GEETA K. SWAMY1, REBECCA N. BROUWER2, KATHRYN I. POLLAK2, EVAN R. MYERS1, FOR BABY STEPS INVESTIGATORS2, 1Duke University, Obstetrics & Gynecology, Durham, North Carolina, 2Duke University, Comprehensive Cancer Center and Department of Community and Family Medicine, Durham, North Carolina OBJECTIVE: Given the increasing societal pressures against smoking during pregnancy, women may be reluctant to disclose their smoking to prenatal care providers. If providers are unaware of women’s smoking, they cannot assist women in cessation or monitor for potential adverse birth outcomes. The objective of this study was to determine the true prevalence of cigarette smoking among pregnant women receiving prenatal care. STUDY DESIGN: Women receiving prenatal care at the Duke Obstetric clinic from February to August 2005 were eligible for anonymous evaluation. As part of standard practice, nurses asked women their smoking status at their first prenatal visit. A portion of the urine sample routinely obtained upon initiation of prenatal care was used for analysis. Identifying information and self-reported smoking status was recorded for all women to ensure that no woman was tested more than once. However, no identifying information was linked to the urine sample; thus, the laboratory analysis was performed in a blinded fashion. The NicCheck IÔ (Mossman Associates) semi-quantitative dipstick was used to detect the presence of urinary nicotine, cotinine, and 3hydroxycotinine. NicCheck IÔ correlates with a 200ng/mL cotinine discriminatory value by gas chromatography. A false positive result can occur in the setting of high niacin intake or excess second-hand smoke exposure. The difference, with 95% CI, between the proportions of smokers by self-report and urine testing was calculated. RESULTS: One hundred seventy-five urine samples were analyzed. The incidence of smoking based on self-report was 17.7% verses 37.7% based on positive urine dipstick. The absolute difference is 20%, 95% CI [0.11, 0.29]. CONCLUSION: There is a significant discrepancy in self-reported and actual smoking status among pregnant women. Universal urinary cotinine screening of pregnant women could aid clinicians in appropriately counseling and monitoring women at high risk for adverse birth outcomes. Smoking status by self-report and anonymous testing
Self-Report Anonymous Testing
Smoker
Non-Smoker
31 66
144 109