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Is thrombophilia workup justified after two unexplained fetal losses?
S132 SMFM Abstracts 252
EFFECT OF EARLY MATERNAL WEIGHT GAIN IN MOTHERS OF TRIPLETS WITH A NORMAL PRE-PREGNANCY BODY MASS INDEX GEETA SHARMA1, ROBIN B. KALISH1, DEBBIE J. RHEA2, LOUIS G. KEITH3, ISAAC BLICKSTEIN4, 1Weill Medical College of Cornell University, Obstetrics and Gynecology, New York, NY 2Matria Healthcare, Inc, Clinical Research, Marietta, GA 3Northwestern University, Obstetrics and Gynecology, Chicago, IL 4Kaplan Medical Center and the Hadassah-Hebrew University School of Medicine, Obstetrics and Gynecology, Jerusalem, Israel OBJECTIVE: We investigated the influence of maternal weight gain on neonatal outcomes in triplet pregnancies. STUDY DESIGN: We performed a retrospective analysis of live-born triplet pregnancies with a normal pregravid body mass index in a group comprising 1195 (65.5%) nulliparas and 625 (34.5%) multiparas. Total triplet birth weight, gestational age at delivery, and frequency of very low birth weight neonates (VLBW) were compared in patients who gained weight below or above average per week. RESULTS: Compared with nulliparas, multiparas had significantly higher total triplet birth weight (5728 ± 1280 vs 5303 ± 1300 g, P < 0.001) and fewer VLBW infants (19.3% vs 27.8%, OR 0.62, 95% CI 0.5,0.7). Mothers who gained more than average weight had a significantly higher total triplet birth weight (multiparas: 5846 ± 1246 vs 5604 ± 1305 g, P = 0.02; nulliparas: 5487 ± 1307 vs 5118 ± 1268 g, P < 0.001) and fewer VLBW infants (multiparas: 17.1% vs 21.3% OR 0.76, 95% CI 0.6,0.96; nulliparas: 23.9% vs 31.8% OR 0.67, 95% CI 0.6,0.8). Total triplet birth weight significantly correlated with weight gain for both parity groups (R2 0.95 and 0.9, respectively). CONCLUSION: Above average weight gain in triplet pregnancies is causally related with improved neonatal outcomes in both nulliparas and multiparas.
December 2003 Am J Obstet Gynecol 254
CHANGES IN FETAL PRESENTATION IN TWIN PREGNANCIES STEPHEN T. CHASEN1, STACEY SPIRO1, FRANK CHERVENAK1, 1Weill Medical College of Cornell University, Obstetrics and Gynecology, New York, NY OBJECTIVE: Our objective was to describe the rate of spontaneous version in twins in the third trimester, as well as the correlation between antepartum and birth presentation. STUDY DESIGN: Twin pregnancies at $20 weeks evaluated in our ultrasound unit from 1998-2001 were identified. Gestational age was divided in 4 intervals: 20-23; 24-27; 28-31; and 32-36 weeks. Pregnancies evaluated in < 3 intervals or delivering at < 34 weeks were excluded. Fetal presentation was categorized as cephalic (C) or non-cephalic (NC). Records were reviewed for demographic information and birth presentation. Chi-square was used to compare distributions of presentations, and Cramer’s V measure of association was used to correlate presentations in individual pregnancies between antepartum intervals and birth. RESULTS: 207 pregnancies were included. Antepartum and birth presentations are seen below (Table). The distribution of fetal presentations changed significantly over time (P < 0.001), though they were similar between interval 4 and birth (P = 0.75). Correlation between antepartum and birth presentation in individual pregnancies increased throughout the 4 intervals, with V = 0.16 (P = 0.06) and V = 0.57 (P < 0.001) between birth and intervals 1 and 4, respectively. While all C/C pregnancies at $28 weeks delivered with a cephalic first twin, only 73% of pregnancies with an NC presenting twin at $28 weeks delivered with an NC presenting twin. No correlation was seen between parity, gender, birthweight, or mode of conception and fetal presentation or rate of spontaneous version. CONCLUSION: Many twins undergo spontaneous version in the third trimester, though there is excellent correlation between presentation at 32-36 weeks and birth. A cephalic presenting twin at $28 weeks is very unlikely to be noncephalic at birth, while noncephalic presentation is less stable. Presentation vs gestational age
20-23 24-27 28-31 32-36 Birth
253
IS THROMBOPHILIA WORKUP JUSTIFIED AFTER TWO UNEXPLAINED FETAL LOSSES? ZOHAR NACHUM1, AMIR WEISS1, YASER HUJEIRAT2, STAVIT SHALEV-ALON2, RAED SALIM1, ELIEZER SHALEV3, 1Ha’Emek Medical Center, Ob&Gyn Department, Afula, Israel 2Ha’Emek Medical Center, Human Genetic Lab, Afula, Israel 3Technion, Rappaport Faculty of Medicine, Haifa, Israel OBJECTIVE: To determine the frequency of thrombophilia among women with two unexplained fetal losses. STUDY DESIGN: A total of 144 women, study to control ratio of 2:1 (96:48), are needed to be screened in order to achieve power of 0.8 and alpha of 0.05, assuming a thrombophilia prevalence of 55% in study subjects and 30% in controls. All women with two fetal losses in the first or second trimester, in a 3-year period, were included. Of 97 women, 19 had at least one 2nd-trimester fetal loss. Women were excluded from the study if there were chromosomal, anatomic, or endocrine abnormalities. The study group was matched for ethnicity with 53 healthy women with a normal obstetrical history. All women, in both groups were tested for mutations of factor V Leiden, prothrombin gene, MTHFR; for the deficiencies of protein S, protein C, antithrombin III; and for lupus-anticoagulant and anticardiolipin antibodies. RESULTS: The prevalence of any form of thrombophilia was 43% in the study group compared to 32% in the control group (P = 0.22). Inherited thrombophilia was found in 36% of the study group compared to 21% of controls (P = 0.06). The rate of acquired thrombophilia did not differ between the groups (13% vs 19%, respectively), nor did the rate of combined thrombophilias (10.3% vs 7.5%). 13 out of 19 (68%) of the women who had second-trimester fetal loss had thrombophilia, a rate significantly higher than that of controls (OR 4.59; 95% CI 1.49 to 14.15; P < 0.01) and that of those with first-trimester fetal losses (37%) (OR 3.66; 95% CI 1.25 to 10.68; P < 0.02). Absence or existence of previous normal delivery did not change the results. CONCLUSION: Our findings suggest that a thrombophilia workup is justified in patients who have had two unexplained fetal losses only if at least one occurred during the second trimester.
255
weeks weeks weeks weeks
C/C
C/NC
NC/C
NC/NC
13.5% 25.3% 29.4% 40.4% 38.6%
50.0% 42.5% 33.5% 32.1% 34.8%
8.0% 9.7% 7.2% 11.4% 8.7%
28.5% 22.6% 29.9% 16.1% 17.9%
INCREASING BODY MASS INDEX RELATED TO FETAL AND MATERNAL COMPLICATIONS ROBERT K. SILVERMAN1, MARTHA WOJTOWYCZ1, JOHN T. NOSOVITCH, JR1, JOHN J. FOLK1, RICHARD H. AUBRY1, 1 Upstate Medical University, OB/GYN, Syracuse, NY OBJECTIVE: To use a population-based birth registry to study the statistical association between progressively increasing body mass index (BMI) and maternal and fetal morbidity. STUDY DESIGN: We identified 137,580 women who gave birth in central New York during 1996-2002. We retrospectively analyzed the association between progressively increasing BMI (not obese [BMI < 29.0], obese [BMI > 29.0 but < 35.0], morbid obesity [BMI $35.0]) and maternal and neonatal complications. Maternal medical conditions and complications included chronic hypertension, chronic lung disease, diabetes mellitus, hospitalization for a reason other than the delivery, preeclampsia, cesarean section, uterine atony, chorioamnionitis, and fever. Neonatal complications included low 5-minute Apgar scores, meconium aspiration, congenital anomalies, preterm delivery, and NICU admission. We used chi-square analyses and multiple logistic regression to determine statistical significance. RESULTS: We identified 21,121 women as obese and 12,319 as morbidly obese. These patients were at an increased risk for chronic hypertension (OR 2.2, 3.3, respectively, P < .001), chronic lung disease (OR 1.3, 1.4, P < .001), diabetes mellitus (OR 1.6, 2.7, P < .001), preeclampsia (OR 1.9, 2.1, P < .001), and cesarean section (OR 1.7, 2.3, P < .001). We found no significant association between obesity and morbid obesity and uterine atony, chorioamnionitis, and fever. Morbidly obese women were more likely to be hospitalized (OR 1.2, P < .001). Infants of morbidly obese women were more likely to have low Apgar scores at 5 minutes (OR 1.5, P < .001), to have meconium aspiration (OR 1.3, P < .05), to be preterm (OR 1.1, P < .01), and be admitted to a NICU (OR 1.4, P < .001). CONCLUSION: This large population-based analysis provides strong evidence that excessive maternal BMI is associated with significant maternal and fetal complications. These results argue strongly that BMIs in the obese and morbidly obese ranges should be independent factors when risk assessing a pregnancy.
EFFECT OF EARLY MATERNAL WEIGHT GAIN IN MOTHERS OF TRIPLETS WITH A NORMAL PRE-PREGNANCY BODY MASS INDEX GEETA SHARMA1, ROBIN B. KALISH1, DEBBIE J. RHEA2, LOUIS G. KEITH3, ISAAC BLICKSTEIN4, 1Weill Medical College of Cornell University, Obstetrics and Gynecology, New York, NY 2Matria Healthcare, Inc, Clinical Research, Marietta, GA 3Northwestern University, Obstetrics and Gynecology, Chicago, IL 4Kaplan Medical Center and the Hadassah-Hebrew University School of Medicine, Obstetrics and Gynecology, Jerusalem, Israel OBJECTIVE: We investigated the influence of maternal weight gain on neonatal outcomes in triplet pregnancies. STUDY DESIGN: We performed a retrospective analysis of live-born triplet pregnancies with a normal pregravid body mass index in a group comprising 1195 (65.5%) nulliparas and 625 (34.5%) multiparas. Total triplet birth weight, gestational age at delivery, and frequency of very low birth weight neonates (VLBW) were compared in patients who gained weight below or above average per week. RESULTS: Compared with nulliparas, multiparas had significantly higher total triplet birth weight (5728 ± 1280 vs 5303 ± 1300 g, P < 0.001) and fewer VLBW infants (19.3% vs 27.8%, OR 0.62, 95% CI 0.5,0.7). Mothers who gained more than average weight had a significantly higher total triplet birth weight (multiparas: 5846 ± 1246 vs 5604 ± 1305 g, P = 0.02; nulliparas: 5487 ± 1307 vs 5118 ± 1268 g, P < 0.001) and fewer VLBW infants (multiparas: 17.1% vs 21.3% OR 0.76, 95% CI 0.6,0.96; nulliparas: 23.9% vs 31.8% OR 0.67, 95% CI 0.6,0.8). Total triplet birth weight significantly correlated with weight gain for both parity groups (R2 0.95 and 0.9, respectively). CONCLUSION: Above average weight gain in triplet pregnancies is causally related with improved neonatal outcomes in both nulliparas and multiparas.
December 2003 Am J Obstet Gynecol 254
CHANGES IN FETAL PRESENTATION IN TWIN PREGNANCIES STEPHEN T. CHASEN1, STACEY SPIRO1, FRANK CHERVENAK1, 1Weill Medical College of Cornell University, Obstetrics and Gynecology, New York, NY OBJECTIVE: Our objective was to describe the rate of spontaneous version in twins in the third trimester, as well as the correlation between antepartum and birth presentation. STUDY DESIGN: Twin pregnancies at $20 weeks evaluated in our ultrasound unit from 1998-2001 were identified. Gestational age was divided in 4 intervals: 20-23; 24-27; 28-31; and 32-36 weeks. Pregnancies evaluated in < 3 intervals or delivering at < 34 weeks were excluded. Fetal presentation was categorized as cephalic (C) or non-cephalic (NC). Records were reviewed for demographic information and birth presentation. Chi-square was used to compare distributions of presentations, and Cramer’s V measure of association was used to correlate presentations in individual pregnancies between antepartum intervals and birth. RESULTS: 207 pregnancies were included. Antepartum and birth presentations are seen below (Table). The distribution of fetal presentations changed significantly over time (P < 0.001), though they were similar between interval 4 and birth (P = 0.75). Correlation between antepartum and birth presentation in individual pregnancies increased throughout the 4 intervals, with V = 0.16 (P = 0.06) and V = 0.57 (P < 0.001) between birth and intervals 1 and 4, respectively. While all C/C pregnancies at $28 weeks delivered with a cephalic first twin, only 73% of pregnancies with an NC presenting twin at $28 weeks delivered with an NC presenting twin. No correlation was seen between parity, gender, birthweight, or mode of conception and fetal presentation or rate of spontaneous version. CONCLUSION: Many twins undergo spontaneous version in the third trimester, though there is excellent correlation between presentation at 32-36 weeks and birth. A cephalic presenting twin at $28 weeks is very unlikely to be noncephalic at birth, while noncephalic presentation is less stable. Presentation vs gestational age
20-23 24-27 28-31 32-36 Birth
253
IS THROMBOPHILIA WORKUP JUSTIFIED AFTER TWO UNEXPLAINED FETAL LOSSES? ZOHAR NACHUM1, AMIR WEISS1, YASER HUJEIRAT2, STAVIT SHALEV-ALON2, RAED SALIM1, ELIEZER SHALEV3, 1Ha’Emek Medical Center, Ob&Gyn Department, Afula, Israel 2Ha’Emek Medical Center, Human Genetic Lab, Afula, Israel 3Technion, Rappaport Faculty of Medicine, Haifa, Israel OBJECTIVE: To determine the frequency of thrombophilia among women with two unexplained fetal losses. STUDY DESIGN: A total of 144 women, study to control ratio of 2:1 (96:48), are needed to be screened in order to achieve power of 0.8 and alpha of 0.05, assuming a thrombophilia prevalence of 55% in study subjects and 30% in controls. All women with two fetal losses in the first or second trimester, in a 3-year period, were included. Of 97 women, 19 had at least one 2nd-trimester fetal loss. Women were excluded from the study if there were chromosomal, anatomic, or endocrine abnormalities. The study group was matched for ethnicity with 53 healthy women with a normal obstetrical history. All women, in both groups were tested for mutations of factor V Leiden, prothrombin gene, MTHFR; for the deficiencies of protein S, protein C, antithrombin III; and for lupus-anticoagulant and anticardiolipin antibodies. RESULTS: The prevalence of any form of thrombophilia was 43% in the study group compared to 32% in the control group (P = 0.22). Inherited thrombophilia was found in 36% of the study group compared to 21% of controls (P = 0.06). The rate of acquired thrombophilia did not differ between the groups (13% vs 19%, respectively), nor did the rate of combined thrombophilias (10.3% vs 7.5%). 13 out of 19 (68%) of the women who had second-trimester fetal loss had thrombophilia, a rate significantly higher than that of controls (OR 4.59; 95% CI 1.49 to 14.15; P < 0.01) and that of those with first-trimester fetal losses (37%) (OR 3.66; 95% CI 1.25 to 10.68; P < 0.02). Absence or existence of previous normal delivery did not change the results. CONCLUSION: Our findings suggest that a thrombophilia workup is justified in patients who have had two unexplained fetal losses only if at least one occurred during the second trimester.
255
weeks weeks weeks weeks
C/C
C/NC
NC/C
NC/NC
13.5% 25.3% 29.4% 40.4% 38.6%
50.0% 42.5% 33.5% 32.1% 34.8%
8.0% 9.7% 7.2% 11.4% 8.7%
28.5% 22.6% 29.9% 16.1% 17.9%
INCREASING BODY MASS INDEX RELATED TO FETAL AND MATERNAL COMPLICATIONS ROBERT K. SILVERMAN1, MARTHA WOJTOWYCZ1, JOHN T. NOSOVITCH, JR1, JOHN J. FOLK1, RICHARD H. AUBRY1, 1 Upstate Medical University, OB/GYN, Syracuse, NY OBJECTIVE: To use a population-based birth registry to study the statistical association between progressively increasing body mass index (BMI) and maternal and fetal morbidity. STUDY DESIGN: We identified 137,580 women who gave birth in central New York during 1996-2002. We retrospectively analyzed the association between progressively increasing BMI (not obese [BMI < 29.0], obese [BMI > 29.0 but < 35.0], morbid obesity [BMI $35.0]) and maternal and neonatal complications. Maternal medical conditions and complications included chronic hypertension, chronic lung disease, diabetes mellitus, hospitalization for a reason other than the delivery, preeclampsia, cesarean section, uterine atony, chorioamnionitis, and fever. Neonatal complications included low 5-minute Apgar scores, meconium aspiration, congenital anomalies, preterm delivery, and NICU admission. We used chi-square analyses and multiple logistic regression to determine statistical significance. RESULTS: We identified 21,121 women as obese and 12,319 as morbidly obese. These patients were at an increased risk for chronic hypertension (OR 2.2, 3.3, respectively, P < .001), chronic lung disease (OR 1.3, 1.4, P < .001), diabetes mellitus (OR 1.6, 2.7, P < .001), preeclampsia (OR 1.9, 2.1, P < .001), and cesarean section (OR 1.7, 2.3, P < .001). We found no significant association between obesity and morbid obesity and uterine atony, chorioamnionitis, and fever. Morbidly obese women were more likely to be hospitalized (OR 1.2, P < .001). Infants of morbidly obese women were more likely to have low Apgar scores at 5 minutes (OR 1.5, P < .001), to have meconium aspiration (OR 1.3, P < .05), to be preterm (OR 1.1, P < .01), and be admitted to a NICU (OR 1.4, P < .001). CONCLUSION: This large population-based analysis provides strong evidence that excessive maternal BMI is associated with significant maternal and fetal complications. These results argue strongly that BMIs in the obese and morbidly obese ranges should be independent factors when risk assessing a pregnancy.