- Email: [email protected]
Oral concurrent session F
Oral Concurrent Session F
Medical Complications of Pregn a n cy Saturday, February 10, 1996 8:00 a.m.- 10:30 a.m. Kona Ballroom
M o d e r a t o r : David B. Cotton, MD Judges:
Steve N. Caritis, MD Sharon L. Dooley, MD Maurice L. Druzin, MD
ABSTRACT NUMBERS: 6 7-7 6
January 1996
330 SPOAbstracts
A m J Obstet Gynccol
67
ELEVATED AMNIOTIC FLUID INTERLEUKIN-6 PREDICTS NEONATAL PERIVENTRICULAR L E U K O M A L A C I A AND INTRAVENTRICULAR HEMORRHAGE. R. Fi~ueroa, E. Martinezx, P. Sehgal*, D. Garry*, K. PatelX, U. Verma, P. Visintainer x, M. RealC, S. Klein*, N. Tejani. New York Medical College, Valhalla, NY OBJECTIVE: Our purpose was to (1) investigate the relationship between elevated levels of amniotie flmd(AF) mterleukin-6(IL-6) and the development of periventricular leukomalacia(PVL) and intravenmcular hemorrhage(IVH) m the preterm neonate, and (2) compare the value of AFIL-6 to ammotic fluid culture(AFC) and histologlc chorioamnionitis (HCA) in the prediction of PVL and IVH STUDY DESIGN: Fifty-eight women in preterm labor with intact membranes underwent transabdominal amniocentesis. AF was cultured for aerobic and anaerobic bacteria and Mycoplasma species; IL-6 levels were determined by ELISA. The placentae were examined for histopathologic evidence of inflammation. Neonates were evaluated with transfontanelle cranial sonography for diagnosis of PVL and IVH on days 3 & 7. Student's t-'test, chi-square, ROC curve and logistic regression were used for analysis. RESULTS: Women with neonates who developed PVL and IVH(n=9) had higher AFIL-6 levels(p=0.002) than women(n=49) who delivered neonates without PVL or IVH. They also were at a lower gestatmnal age(GA) at admission(p=0.002), had a sborter median amniocentesls-to-delivery interval(p=0 03), a lower birth weight(p=0 00008), had more positive AFC (p=0.01), and more HCA(p=0.05). An AFIL-6 level > 12,000 pg/ml had a sensitivity(SENS) of 89% and speclficity(SPEC) of 88% compared to a SENS of 50% and SPEC of 92% for AFC, and a SENS of 56% and SPEC of 78% for HCA iu the prediction of PVL and IVH. Regression analysis demonstrated that AFIL-6 was an independent risk factor for the development of PVL and IVH(Odds Ratio 31.46, 95% CI 2.18 - 453.39; p--0.011) after controlling for GA, AFC, and HCA. CONCLUSIONS: AFIL-6 predicts neonatal PVL and 1VH in women in preterm labor with intact membranes.
69
POSTNATAL GROWTH AND COGNITIVE DEVELOPMENT IN THE VERY LOW BIRTH WEIGHT SMALL FOR GESTATIONAL AGE INFANT J M G~)lesx, M Y DIvan, C C Mc Carton*, I Wallacex Departments of OB/GYN and Pediatrics, Albert Einstein College of Medicine, Bronx, NY OBJECTIVE: To determine whether morphometnc measurements at bnth and growth are predctlve of cognibve development tn the preterm growth retarded infant STUDY DESIGN: 695 very low birth weight tnfants( BW < 1500gins) were studied between 1978 and 1993 Head ctrcumference, birth weight and height were measured Infantswere c l ~ as e~:herAppropriate for gestabonal age (AGA) or Small for gastabonalage ( SGA, BW < 10=hpercenble for gestetional age) The SGA Enfantswere further subdivided tnto Symmethc or Asymmetric SGA (sSGA and aSGA, respecbvely) All infants underwent serial evaluabons of cognlbve development by Mental development Index (MDI) or by Stanford Binet Intelhgent Quobent (IQ) Subsequent growth in the SGA mfante was catagor~ed by weght percantdes at 6, 12, 24 and at 36 months of age as. no change (<10u~,group I), mtnimal increase (le, 25~ > wetght > 10th, group ll), sizeable increase ( le ,weight > 25th, group III) Data were strabfied for gestational age at delivery as group A (24 to 29 weeks), group B (30 to 32 weeks) and group C (33 to 35 weeks) Analysm of Vanance and Cht Square testing were used for statistical analysis. RESULTS Within groups B and C, on the first evaluabon, AGA infants scored higher than those who were sSGA on MDI testing (p < 0.01) AGA infants whoso wetghts exceeded the 25th percenbis at 12 month scored s~gntfinantly higher than SGA infants of comparableweight on MDI at 12 month (p = 0 04) By 36 months postnatally there were no stgnlficant dtfferences among AGA, sSGA and aSGA infants on IQ Relative to other SGA mfante, group III infants scored slgntflcantly htgher on IQ at 36 months (p <0 05) CONCLUSIONS. Inibally AGA infants had a cogntbve developmental advantage over SGA infants By pre-school age, this advantage was lost SGA infants who demonstrated stzeable postnatal growth scored signrficantly higher on IQ Thts tmphes that s=zeablepostnatal growth improves cognrttve development In growth restricted neonates
68
AMNIOTIC FLUID CONCENTRATIONS OF INTERLEUKIN-6 IDENTIFY FETUSES AT RISK FOR THE DEVELOPMENT OF PERIVENTRICULAR LEUKOMALACIA. B.H. Yoon, R. Romero, J.K. Jun ~, K.H. Park~, S.H. Yang~, 1.O. Kim% H Munoz% LH. Chop Seoul National University, Seoul, Korea, the Perinatology Research Branch, NICHD, Bethesda, MD and Wayne State University/Hntzel Hospital, Detroit, MI. OBJECTIVE: Periventrienlar leukomalacia (PVL), a common brain white matter lesion of preterm neonates, is a major risk factor for cerebral palsy Recently, cytokines have been implicated as mediators for neuronal injury in PVL. The purpose of this study was to detcaTnine whether anmiotic fluid concentrations of eytokines are of value in the identification of infants at risk for PVL. STUDY DESIGN: The relationship between anmiotic fluid concentrations of interleuldu-6 (IL-6), interleukin-ll~ (IL-11~), tumor necrosis faetor-a C['NF-=) and interleukin-1 receptor antagonist (IL-lra) and the oeenrrenco of PVL lesions was examined in 118 patients who delivered preterm neonates within 72 hours after amnioeentesis. Amniotie fluid was cultured for aerobic and anaerobic bacteria and Myeoplasmas. Cytokines were measured by ELISA. Multiple logi~o regression and receiver-operating eharaeteristie (ROC) curve were used for analysis. RESULTS: 1) PVL lesions were present in 25% (30/118) of newborns; 2) ROC curve analysis demonstrated that an elevated concentration of amniofic fluid IL-6, IL-11L and TNF-= but not of IL-lra were significantly assoetated with the coctn'rc~ee of PVL (p < 0.05 for each); 3) An IL-6 ~ 6 5 ng/ml had the highest sensitivity (79%) and highest specificity (78%) m the identification of PVL of all tests performed; 4) Multivariate analysts indicated that amuiotic fluid IL-6 was an independent risk factor for PVL (odds ratio: 7.2, p < 0.02) adjustment of other confounding variables (i.e., gestatlonal age at hirth, anmiotic fluid culture, umbilical artcry pH, etc.), 5) Moreover, IL-lp and TNF-= did not add significant information to that already provided by IL-6 (p > o.t). CONCLUSIONS: 1) Anmiotic fluid IL-6 is the best antenatal predictor of PVL; 2) Our data provide strong support for the view that PVL is the result of cytokme-mediated neuronal injury.
70
A RANDOMIZED CONTROLLED TRIAL OF PREDNISONE AND ASA IN WOMEN WITH AUTOANTIBODIES AND UNEXPLAINED RECURRENT FETAL LOSS. C. Laskir~, C. Bombardier=, F. MandeP, K. Ritchla, M. Hannah, D. Farine. Univ. Of Toronto, Toconto, ON, Canada. V. Farewell'. Univ. Of Waterloo, Waterloo, ON, Canada. K. Spitzer~, L Fieldingx, M. Yeungx. Univ. Of Toronto, Toronto, ON, Canada OBJECTWE: The hypothetas under study is that prednisone and aspirin therapy will increase the live bir~ rate in women with autoantibedlas and unexplained recurrent fetal loss (U-RFL). STUDY DESIGN: 789 women with U-RFL (.~.2fetal leases) were screened for the presenoe of autoantibedies including antinuclear antibodies, antiDNA, anti-lymphocyte, anti-cardiolipin (aCL), and a lupus anticoagulant (LA). From this, 202 pregnant women with at least one autoantibedy, were randomized into a double-blind, controlled trial comparing therapy with predn=sona(0.5-0.8 mg/kg) and aspirin (100 rng) (n=101) to placebo (n=101). The primary outcome measure was a ~ t e logistic regression analy=s relating the probability of a successful pregnancy to the treatment effect, the pat~mt's age, and a previous history of sedy or late fetal loss. The study had 80% power to detect a 33% improvement in outcome, Continuous vanablse were analyzed by 2-tailed t-teste or chisquare as appropriate, RESULTS: In women with U-RFL, 49.4% were found to have at least one autoantibody. Live births in the treatment group was 65% whch was not sign~mantiy different than 54.6% found in the ¢onkol group (p=0.14). Specific analysis of the groups wrlh aCL and/or LA showed no benefit of the treatment (T) over the control (C) group (47.8% w 52.4% live birtils, p=0,50). Maternal side effects inc,luded an increase in hypertension =12.9% ve C=4%; F<0.02) and diabetes mellitus (T=14,9% ve C=5%; <0 02). Prernatunty was eegniflcantlymoce frequent in the treatment group than the control group, 58 5% vs 9 4% recpectivsiy (p
V,)lume 174, Number I, I'drt '2
SPO Abstracts 331
Am ] Ob,,tcr (,ynecol
71 ELECTIVE DELIVERY FOR MACROSOMIA IN THE DIABETIC
PREGNANCY: A CLINICAL COST-BENEFIT ANALYSIS. D Cqnway, O.Langer, Dept Ob-Gyn, UTHSC, San Antonio, TX OBJECTIVE: To test the hypothesis that elective dehvery for ultrasound diagnosis of macrosomm in diabetic pregnancies sigmficantly decreases the rate of shoulder dystocm, without a significant increase m maternal morbidity from cesarean section or reduction STUDY DESIGN: In a prospective study, we evaluated a protocol under which diabetic women with ultrasound EFW ~4250g underwent elective cesarean sectaon; and those with EF3/Vconsistent with LGA, but <4250g, underwent induction of labor. Women were stratified into four groups m accordance with the degree of agreement between the EFW and the actual blrthweight (eg EFW = macrosomia and actual blrthwelght = macrosomm). Maternal and neonatal outcomes were analyzed and compared for the penod pnor to and after initiation of this study protocol. Outcome variables included cesarean sectmn, shoulder dystocm, infectious morbidity, fetal morbidity, length of stay and overall cost. RESULTS: 4011 diabetic patients were included m this prospective study, with an overall rate of macrosomia of 8 5%. The overall rate of shoulder dystocia for the period prior to initiation of the protocol (1990-1992) was 3fold higher than the period (1993-1995) following mstztution of the protocol (2 20% vs 0 73%, ,o<0.05) resulting m a 67% reduction in shoulder dystocm rate Moreover, the overall C/B rate increased by only 1 6% (11 3% to 12 9% respectively) No shoulder dystocia occurred m patients induced for LGA or macrosomm based on our protocol Only 1% of our dmbetic populahon required intervention for ultrasound dmgnosis of LGA or macrosomm Of the patmnts who were dmgnosed as macrosomic (EFW), 45% had BW <4250g However, only 15.4% of C/S were done for the indication of EF'W >4250g. In contrast, only 4 3% of paUents were actually macrosomlc when EFW was <4000g ", CONCLUSIONS: The use of a weight threshold for electwe delivery m diabetic women wdl reduce the rate of shoulder dystocia without a significant increase in C/S rate. This practice m conjunction with intensified management approach in dmbetes will improve the outcome of these high rink women and their infants
72 A RE-EVALUATIONOF THE INOICATIONSFOR PULMONARYARTERYCATHETERS IN OBSTETRICS:THE ROLE OF2D ECHOCARDIOGRAPHY AND DOPPLERULTRASOUND. M. Belfort. A. Mares,x G. Saade, T. Wen, R. Rokeyx. Depts. Ob/Gyn,Anesthesiology, Medicine,BayinrCollegeof Med.,Houston,Tx, and MarzhfieldClinic, Marshfield,WI. OBJECTIVE:Frequentindications for pulmonaryartery catheterization (PAl in obstetrics are hypertensionunresponsiveto antihypertensives,oliguria unresponsiveto repeatedfluid boluses, and pulmonary edema. We prospectively tested the safety and utility of 2D echncardiogrephy(ECHO)and Dopplerultrasoundin the managementof suchpatients. STUDY DESIGN:Patientsfulfilling standardcriteria for PA were studiedusinga technique previouslyvalidatedat our institution. Patmntsthoughtto requirecontinuousmonitoringhad PA, otherwise monegenemt decisions were based on the non-invasive examination. Indicationsincluded4 patientswith persistentollguria, 2 wrth recalcitrant hypertensionand 2 with pulmonaryedema.LV filling pressure(LVFP),centralvenouspressure,cardiac output (CO), LV/RV duneesions, ejection fractmo, wall motion and chamber function were measured,calculated end/orassessedat the bedside. RESULTS: Only one patient required PA catheterization, and outcome was good in all cases. Of those with oliguria all 4 had hyperdynwnicLV function and low LVFPprior to volume expansion.One received 7.5i and one 41 of crystalinid before urine output was adequate. Noneof the 4 requiredPA and nonedevelopedpulmonaryedema.Two patients failed to respondto 2 dosesof hydralazine(lOmg). One had u high CO, normal LVFP,LV hypertrophyand a hyperdynemicLV • she respondedwell to labetaleL The secondpatient was shown to haveLV hypertrophyand intravescularcontraction. She respondedwell to volume expansionand further vesodllatatidn. One patient with pulmonary edema was diagnosedwith hypertensivecerdmmyopathybasedon ECHOand she had PA. The second patienthadterbutnlinetoxicitywith pulmonaryedemaand was managedwithout PA. CONCLUSIONS: 2D ECHOand Dopplerultrasoundcan be safelyusedto evaluatepatients who may otherwise requirePA catheterization.In manyinstances invesiveprocedurescan be avoidedby (1) knowingthe CO, LVFPand the potentialof the patientto toleratevolume expansion(2) determining the cardiac performanceprofile which may indicate whether a vasodilater or n ~, blocker is more appropriatefor lowering the blood pressure, and (3) diagnosingwhethnrLVfunction is impaired and if so whether or not there is systolic or diastolic dysfunction,and whetheror not continuousPA monitoringis needed.
73 BACTERIAL VAGINOSIS (BV) IN A POPULATION OF 3600 PREGNANT WOMEN AND RELATIONS TO PRETERM BIRTH EVALUATED FROM THE FIRST ANTENATAL VISIT. P Thorsen K Molsted, I P Jensen, M. Arpi, A. Bremrnelgaard, B. Jeune, B R M~ller. Department of Obstetrics and Gynecology, University Hospital, Odense, Denmark OBJECTIVE: The alms of this study were to determine the effects of common urogen~al tract infections and microbiological condttions among women ~n early pregnancy in regard to preterm labor, preterm premature rupture of membranes (PPROM), preterm birth (PTB) in a large prospectively followed cohort of Danish women. STUDY DESIGN: Three thousand and six hundred pregnant women were asked to participate m the study before 24 gestational weeks Samples were collected from the cervical os or vaginal vault for Chlamydia trachomatis, genital mycoplasmas, Tnchomonas vaginalis, yeasts and aerobe and anaerobic bacteria Amsels' cnteria (1983) were used for diagnosis of BV RESULTS: Mean gestatlonal age at enrollment was 17+1 (seventeen full gestat~onal weeks plus one day), [range 7+3 - 24+0] We found BV in the genital tract tn 13 7% (402/2927) of the pregnant women. We analyzed data of women entenng labor spontaneously and/or with rupture of membranes who did not have ewdence of severe congenital malformations Jn prewous pregnancy, placenta previa, cervical cerclage, sedous medical disease, preeclampsm, multiple pregnancy, isoimmunization or abruptlo placentae. Women w~th and without BV prior to 24 weeks of gestation had a simdar frequency of PPROM (before 37 full gestational weeks) [2 2% vs 2 1%; crude OR 1.0, 95% CI 0.4 - 2.3] and low birth weight (LBW) babies (< 2500 g) [3 6% vs 2 8%; crude OR 1 3, 95% CI 0 7 - 2 4] Rates of idiopathic PTB were similar among women with or without BV [3 4% vs 3 6%, OR 0 9, 95% CI 0 5 - 1.8] CONCLUSIONS: This prospective analysis of a stable Danish population shows low rates of PPROM, LBW, PTB and BV. There were no d~ferences for PPROM and LBW among pregnant women with or without BV prior to 24 full weeks of gestation.
74 WOMEN WITH SICKLE CELL TRAIT ARE AT INCREASED RISK FOR PREECLAMPSlk K.D. Larrebee', M.Monga. DepL Ob. Gyn. & Reprod. Scl. UTMSH, Houston, TX. OBJECTIVE: To determine the rate of presclampsla in women who are positive for sickle ceil trait. 8"rUDY DESIGN: All Nrican American women were tested for sidde cell trait using the sicldedex screen at their first prenatal visit and prospec~vely enrolled in this study from March, 1994 - June, 1995. Demographic data were collected at the time of enrotlmenL Outcome data, Including prasdarnpsla (as defined by ACOG criteria), gastatJonal age at delivery, b~r~eight and postpartum endometdtls were collected immediately postpartum. Assuming a 10% rata of posllfve sickle cell trait, 1199 peUents wore required to demonstrate 8 10% difference in the rete of prasclampsia wilh 80% power and p<0.05. Studenrs-t, Mann Whl~eyU, C,hl-square and Fishers Exact tests were used for statlstlcei analysis. RESULTS: 1584 women were enrolled; 162 were positive for sickle cell trait. Sickle cell traR podtive (SO+) women were older then sickle ceiJ trait negative (SO-) women (24.4 ± 4.6 vs 23.0 ± 4.4 years, p
332
SPO A b s t r a c t s
J~mu:H~ 1!)()(~ Am
75 THE EFFECT OF MATERNAL POSITION ON CARDIAC
OUTPUT WITH EPIDURAL ANALGESIA IN LABOR. DR Danilenko-Dixon, L Tefftx, B Haydonx, RA Cohen ~, MW Carpenter. Brown University, Depts Ob/Gyn & Anesthesia, Women & Infants Hospital, Providence, RI. OBJECTIVE: To test the hypothesis that supine vs. lateral position is associated with greater decrement in cardiac index after epidural analgesia (EA) in labor. STUDY DESIGN: Nineteen normal, term subjects were randomized to left lateral or supine position in early labor. Cardiac index (CI, measured by acetylene rebreathing), stroke volume index (SVI), heart rate (HR), mean arterial pressure (MAP), and systemic vascular resistance (SVR) were obtained at 5 minute intervals, beginning prior to 500 ml IV crystalloid (baseline), and ending 45 minutes after EA. RESULTS: Mean baseline supine vs. lateral group differences were significant for 21% lower CI, 21% lower SVI, 19% higher MAP, 50% higher SVR (all p<0.05), and equivalent HR. Fluid bolus in the supine group resulted in increments in CI and SVI (p<0.01), decrements in MAP and SVR (p<0.03), and unchanged HR. Relative to postfluid values, EA in the supine group resulted in decrements in CI and SVI (p<0.05). The lateral group exhibited no hemodynamic alterations following fluid bolus or EA. CONCLUSIONS: The supine U]n,~ Ev~v.a
significant post-EA decrement in CI, likely reflecting decreased preload volume. To our knowledge, this is thv flrst direct evidence of positional effects on maternal hemodynamic homeostasis after EA.
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76 The Effect of Dobutamine Hydmchloride on Ventricular Function and Oxygen Transport in Patients with Severe Preeclaml~in. C. Graves. T. Wheeler,H. Troiano. Dept. Ob/Gyn, Vanderbilt University, Nashville, TN. OBJECTIVE: Depressed left ventricolar function has been previously reported in patients with severe preeclampsia. In cntically ill patients, improvementofcasdias functionmay lead to increased oxygen deliver. This study reportsthe effect of dobutemine hydrochloride m a subset of patients with severe preeclampsia.Its use has not been previously reported in thts population. STUDY DESIGN: Pregnant patients in the third trimester with severe preectsmpsiawho required pulmonary artery catheter(PAC) monitoring for clinical management were evaluated for the study. Entry cntena included depressed left vcntricolar function after optimization of volume and no previoushistoryof cardiacdisease During the study period, 40 patients were diagnosed with severe preeclampsia and required PAC 8 pahents met criteria for dobuteminc administration. Dobutamme was initiated at 3 mcg/kg/min,then tittatedto the LVSWI. Values were compared pre and post infusion. Vanables were analyzed using the t-test. RESULTS: The outcome date is listed below : Mean Pulmonary Capdlary Wedge Pressure (PCWP) 18_+5.5 Mean Hemoglobin 10.2+ 3.2 Premfuslon Pustinfusion Cardiac Index (L.min'Lm2) 3.19 4.28 p=O.05 Left Ventncular Stroke Work Index (g-m/m2) 37 58 59.38 p=0.03 Oxygen Delivery Index (ml-mm'Lm2) 445.63 615.38 p=0.05 CONCLUSIONS: Dobutemme hydrochlonde can be used to improve oxygendehvenym patientswith severepreeclampsiawho have depressed left ventricular function.
Medical Complications of Pregn a n cy Saturday, February 10, 1996 8:00 a.m.- 10:30 a.m. Kona Ballroom
M o d e r a t o r : David B. Cotton, MD Judges:
Steve N. Caritis, MD Sharon L. Dooley, MD Maurice L. Druzin, MD
ABSTRACT NUMBERS: 6 7-7 6
January 1996
330 SPOAbstracts
A m J Obstet Gynccol
67
ELEVATED AMNIOTIC FLUID INTERLEUKIN-6 PREDICTS NEONATAL PERIVENTRICULAR L E U K O M A L A C I A AND INTRAVENTRICULAR HEMORRHAGE. R. Fi~ueroa, E. Martinezx, P. Sehgal*, D. Garry*, K. PatelX, U. Verma, P. Visintainer x, M. RealC, S. Klein*, N. Tejani. New York Medical College, Valhalla, NY OBJECTIVE: Our purpose was to (1) investigate the relationship between elevated levels of amniotie flmd(AF) mterleukin-6(IL-6) and the development of periventricular leukomalacia(PVL) and intravenmcular hemorrhage(IVH) m the preterm neonate, and (2) compare the value of AFIL-6 to ammotic fluid culture(AFC) and histologlc chorioamnionitis (HCA) in the prediction of PVL and IVH STUDY DESIGN: Fifty-eight women in preterm labor with intact membranes underwent transabdominal amniocentesis. AF was cultured for aerobic and anaerobic bacteria and Mycoplasma species; IL-6 levels were determined by ELISA. The placentae were examined for histopathologic evidence of inflammation. Neonates were evaluated with transfontanelle cranial sonography for diagnosis of PVL and IVH on days 3 & 7. Student's t-'test, chi-square, ROC curve and logistic regression were used for analysis. RESULTS: Women with neonates who developed PVL and IVH(n=9) had higher AFIL-6 levels(p=0.002) than women(n=49) who delivered neonates without PVL or IVH. They also were at a lower gestatmnal age(GA) at admission(p=0.002), had a sborter median amniocentesls-to-delivery interval(p=0 03), a lower birth weight(p=0 00008), had more positive AFC (p=0.01), and more HCA(p=0.05). An AFIL-6 level > 12,000 pg/ml had a sensitivity(SENS) of 89% and speclficity(SPEC) of 88% compared to a SENS of 50% and SPEC of 92% for AFC, and a SENS of 56% and SPEC of 78% for HCA iu the prediction of PVL and IVH. Regression analysis demonstrated that AFIL-6 was an independent risk factor for the development of PVL and IVH(Odds Ratio 31.46, 95% CI 2.18 - 453.39; p--0.011) after controlling for GA, AFC, and HCA. CONCLUSIONS: AFIL-6 predicts neonatal PVL and 1VH in women in preterm labor with intact membranes.
69
POSTNATAL GROWTH AND COGNITIVE DEVELOPMENT IN THE VERY LOW BIRTH WEIGHT SMALL FOR GESTATIONAL AGE INFANT J M G~)lesx, M Y DIvan, C C Mc Carton*, I Wallacex Departments of OB/GYN and Pediatrics, Albert Einstein College of Medicine, Bronx, NY OBJECTIVE: To determine whether morphometnc measurements at bnth and growth are predctlve of cognibve development tn the preterm growth retarded infant STUDY DESIGN: 695 very low birth weight tnfants( BW < 1500gins) were studied between 1978 and 1993 Head ctrcumference, birth weight and height were measured Infantswere c l ~ as e~:herAppropriate for gestabonal age (AGA) or Small for gastabonalage ( SGA, BW < 10=hpercenble for gestetional age) The SGA Enfantswere further subdivided tnto Symmethc or Asymmetric SGA (sSGA and aSGA, respecbvely) All infants underwent serial evaluabons of cognlbve development by Mental development Index (MDI) or by Stanford Binet Intelhgent Quobent (IQ) Subsequent growth in the SGA mfante was catagor~ed by weght percantdes at 6, 12, 24 and at 36 months of age as. no change (<10u~,group I), mtnimal increase (le, 25~ > wetght > 10th, group ll), sizeable increase ( le ,weight > 25th, group III) Data were strabfied for gestational age at delivery as group A (24 to 29 weeks), group B (30 to 32 weeks) and group C (33 to 35 weeks) Analysm of Vanance and Cht Square testing were used for statistical analysis. RESULTS Within groups B and C, on the first evaluabon, AGA infants scored higher than those who were sSGA on MDI testing (p < 0.01) AGA infants whoso wetghts exceeded the 25th percenbis at 12 month scored s~gntfinantly higher than SGA infants of comparableweight on MDI at 12 month (p = 0 04) By 36 months postnatally there were no stgnlficant dtfferences among AGA, sSGA and aSGA infants on IQ Relative to other SGA mfante, group III infants scored slgntflcantly htgher on IQ at 36 months (p <0 05) CONCLUSIONS. Inibally AGA infants had a cogntbve developmental advantage over SGA infants By pre-school age, this advantage was lost SGA infants who demonstrated stzeable postnatal growth scored signrficantly higher on IQ Thts tmphes that s=zeablepostnatal growth improves cognrttve development In growth restricted neonates
68
AMNIOTIC FLUID CONCENTRATIONS OF INTERLEUKIN-6 IDENTIFY FETUSES AT RISK FOR THE DEVELOPMENT OF PERIVENTRICULAR LEUKOMALACIA. B.H. Yoon, R. Romero, J.K. Jun ~, K.H. Park~, S.H. Yang~, 1.O. Kim% H Munoz% LH. Chop Seoul National University, Seoul, Korea, the Perinatology Research Branch, NICHD, Bethesda, MD and Wayne State University/Hntzel Hospital, Detroit, MI. OBJECTIVE: Periventrienlar leukomalacia (PVL), a common brain white matter lesion of preterm neonates, is a major risk factor for cerebral palsy Recently, cytokines have been implicated as mediators for neuronal injury in PVL. The purpose of this study was to detcaTnine whether anmiotic fluid concentrations of eytokines are of value in the identification of infants at risk for PVL. STUDY DESIGN: The relationship between anmiotic fluid concentrations of interleuldu-6 (IL-6), interleukin-ll~ (IL-11~), tumor necrosis faetor-a C['NF-=) and interleukin-1 receptor antagonist (IL-lra) and the oeenrrenco of PVL lesions was examined in 118 patients who delivered preterm neonates within 72 hours after amnioeentesis. Amniotie fluid was cultured for aerobic and anaerobic bacteria and Myeoplasmas. Cytokines were measured by ELISA. Multiple logi~o regression and receiver-operating eharaeteristie (ROC) curve were used for analysis. RESULTS: 1) PVL lesions were present in 25% (30/118) of newborns; 2) ROC curve analysis demonstrated that an elevated concentration of amniofic fluid IL-6, IL-11L and TNF-= but not of IL-lra were significantly assoetated with the coctn'rc~ee of PVL (p < 0.05 for each); 3) An IL-6 ~ 6 5 ng/ml had the highest sensitivity (79%) and highest specificity (78%) m the identification of PVL of all tests performed; 4) Multivariate analysts indicated that amuiotic fluid IL-6 was an independent risk factor for PVL (odds ratio: 7.2, p < 0.02) adjustment of other confounding variables (i.e., gestatlonal age at hirth, anmiotic fluid culture, umbilical artcry pH, etc.), 5) Moreover, IL-lp and TNF-= did not add significant information to that already provided by IL-6 (p > o.t). CONCLUSIONS: 1) Anmiotic fluid IL-6 is the best antenatal predictor of PVL; 2) Our data provide strong support for the view that PVL is the result of cytokme-mediated neuronal injury.
70
A RANDOMIZED CONTROLLED TRIAL OF PREDNISONE AND ASA IN WOMEN WITH AUTOANTIBODIES AND UNEXPLAINED RECURRENT FETAL LOSS. C. Laskir~, C. Bombardier=, F. MandeP, K. Ritchla, M. Hannah, D. Farine. Univ. Of Toronto, Toconto, ON, Canada. V. Farewell'. Univ. Of Waterloo, Waterloo, ON, Canada. K. Spitzer~, L Fieldingx, M. Yeungx. Univ. Of Toronto, Toronto, ON, Canada OBJECTWE: The hypothetas under study is that prednisone and aspirin therapy will increase the live bir~ rate in women with autoantibedlas and unexplained recurrent fetal loss (U-RFL). STUDY DESIGN: 789 women with U-RFL (.~.2fetal leases) were screened for the presenoe of autoantibedies including antinuclear antibodies, antiDNA, anti-lymphocyte, anti-cardiolipin (aCL), and a lupus anticoagulant (LA). From this, 202 pregnant women with at least one autoantibedy, were randomized into a double-blind, controlled trial comparing therapy with predn=sona(0.5-0.8 mg/kg) and aspirin (100 rng) (n=101) to placebo (n=101). The primary outcome measure was a ~ t e logistic regression analy=s relating the probability of a successful pregnancy to the treatment effect, the pat~mt's age, and a previous history of sedy or late fetal loss. The study had 80% power to detect a 33% improvement in outcome, Continuous vanablse were analyzed by 2-tailed t-teste or chisquare as appropriate, RESULTS: In women with U-RFL, 49.4% were found to have at least one autoantibody. Live births in the treatment group was 65% whch was not sign~mantiy different than 54.6% found in the ¢onkol group (p=0.14). Specific analysis of the groups wrlh aCL and/or LA showed no benefit of the treatment (T) over the control (C) group (47.8% w 52.4% live birtils, p=0,50). Maternal side effects inc,luded an increase in hypertension =12.9% ve C=4%; F<0.02) and diabetes mellitus (T=14,9% ve C=5%; <0 02). Prernatunty was eegniflcantlymoce frequent in the treatment group than the control group, 58 5% vs 9 4% recpectivsiy (p
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Am ] Ob,,tcr (,ynecol
71 ELECTIVE DELIVERY FOR MACROSOMIA IN THE DIABETIC
PREGNANCY: A CLINICAL COST-BENEFIT ANALYSIS. D Cqnway, O.Langer, Dept Ob-Gyn, UTHSC, San Antonio, TX OBJECTIVE: To test the hypothesis that elective dehvery for ultrasound diagnosis of macrosomm in diabetic pregnancies sigmficantly decreases the rate of shoulder dystocm, without a significant increase m maternal morbidity from cesarean section or reduction STUDY DESIGN: In a prospective study, we evaluated a protocol under which diabetic women with ultrasound EFW ~4250g underwent elective cesarean sectaon; and those with EF3/Vconsistent with LGA, but <4250g, underwent induction of labor. Women were stratified into four groups m accordance with the degree of agreement between the EFW and the actual blrthweight (eg EFW = macrosomia and actual blrthwelght = macrosomm). Maternal and neonatal outcomes were analyzed and compared for the penod pnor to and after initiation of this study protocol. Outcome variables included cesarean sectmn, shoulder dystocm, infectious morbidity, fetal morbidity, length of stay and overall cost. RESULTS: 4011 diabetic patients were included m this prospective study, with an overall rate of macrosomia of 8 5%. The overall rate of shoulder dystocia for the period prior to initiation of the protocol (1990-1992) was 3fold higher than the period (1993-1995) following mstztution of the protocol (2 20% vs 0 73%, ,o<0.05) resulting m a 67% reduction in shoulder dystocm rate Moreover, the overall C/B rate increased by only 1 6% (11 3% to 12 9% respectively) No shoulder dystocia occurred m patients induced for LGA or macrosomm based on our protocol Only 1% of our dmbetic populahon required intervention for ultrasound dmgnosis of LGA or macrosomm Of the patmnts who were dmgnosed as macrosomic (EFW), 45% had BW <4250g However, only 15.4% of C/S were done for the indication of EF'W >4250g. In contrast, only 4 3% of paUents were actually macrosomlc when EFW was <4000g ", CONCLUSIONS: The use of a weight threshold for electwe delivery m diabetic women wdl reduce the rate of shoulder dystocia without a significant increase in C/S rate. This practice m conjunction with intensified management approach in dmbetes will improve the outcome of these high rink women and their infants
72 A RE-EVALUATIONOF THE INOICATIONSFOR PULMONARYARTERYCATHETERS IN OBSTETRICS:THE ROLE OF2D ECHOCARDIOGRAPHY AND DOPPLERULTRASOUND. M. Belfort. A. Mares,x G. Saade, T. Wen, R. Rokeyx. Depts. Ob/Gyn,Anesthesiology, Medicine,BayinrCollegeof Med.,Houston,Tx, and MarzhfieldClinic, Marshfield,WI. OBJECTIVE:Frequentindications for pulmonaryartery catheterization (PAl in obstetrics are hypertensionunresponsiveto antihypertensives,oliguria unresponsiveto repeatedfluid boluses, and pulmonary edema. We prospectively tested the safety and utility of 2D echncardiogrephy(ECHO)and Dopplerultrasoundin the managementof suchpatients. STUDY DESIGN:Patientsfulfilling standardcriteria for PA were studiedusinga technique previouslyvalidatedat our institution. Patmntsthoughtto requirecontinuousmonitoringhad PA, otherwise monegenemt decisions were based on the non-invasive examination. Indicationsincluded4 patientswith persistentollguria, 2 wrth recalcitrant hypertensionand 2 with pulmonaryedema.LV filling pressure(LVFP),centralvenouspressure,cardiac output (CO), LV/RV duneesions, ejection fractmo, wall motion and chamber function were measured,calculated end/orassessedat the bedside. RESULTS: Only one patient required PA catheterization, and outcome was good in all cases. Of those with oliguria all 4 had hyperdynwnicLV function and low LVFPprior to volume expansion.One received 7.5i and one 41 of crystalinid before urine output was adequate. Noneof the 4 requiredPA and nonedevelopedpulmonaryedema.Two patients failed to respondto 2 dosesof hydralazine(lOmg). One had u high CO, normal LVFP,LV hypertrophyand a hyperdynemicLV • she respondedwell to labetaleL The secondpatient was shown to haveLV hypertrophyand intravescularcontraction. She respondedwell to volume expansionand further vesodllatatidn. One patient with pulmonary edema was diagnosedwith hypertensivecerdmmyopathybasedon ECHOand she had PA. The second patienthadterbutnlinetoxicitywith pulmonaryedemaand was managedwithout PA. CONCLUSIONS: 2D ECHOand Dopplerultrasoundcan be safelyusedto evaluatepatients who may otherwise requirePA catheterization.In manyinstances invesiveprocedurescan be avoidedby (1) knowingthe CO, LVFPand the potentialof the patientto toleratevolume expansion(2) determining the cardiac performanceprofile which may indicate whether a vasodilater or n ~, blocker is more appropriatefor lowering the blood pressure, and (3) diagnosingwhethnrLVfunction is impaired and if so whether or not there is systolic or diastolic dysfunction,and whetheror not continuousPA monitoringis needed.
73 BACTERIAL VAGINOSIS (BV) IN A POPULATION OF 3600 PREGNANT WOMEN AND RELATIONS TO PRETERM BIRTH EVALUATED FROM THE FIRST ANTENATAL VISIT. P Thorsen K Molsted, I P Jensen, M. Arpi, A. Bremrnelgaard, B. Jeune, B R M~ller. Department of Obstetrics and Gynecology, University Hospital, Odense, Denmark OBJECTIVE: The alms of this study were to determine the effects of common urogen~al tract infections and microbiological condttions among women ~n early pregnancy in regard to preterm labor, preterm premature rupture of membranes (PPROM), preterm birth (PTB) in a large prospectively followed cohort of Danish women. STUDY DESIGN: Three thousand and six hundred pregnant women were asked to participate m the study before 24 gestational weeks Samples were collected from the cervical os or vaginal vault for Chlamydia trachomatis, genital mycoplasmas, Tnchomonas vaginalis, yeasts and aerobe and anaerobic bacteria Amsels' cnteria (1983) were used for diagnosis of BV RESULTS: Mean gestatlonal age at enrollment was 17+1 (seventeen full gestat~onal weeks plus one day), [range 7+3 - 24+0] We found BV in the genital tract tn 13 7% (402/2927) of the pregnant women. We analyzed data of women entenng labor spontaneously and/or with rupture of membranes who did not have ewdence of severe congenital malformations Jn prewous pregnancy, placenta previa, cervical cerclage, sedous medical disease, preeclampsm, multiple pregnancy, isoimmunization or abruptlo placentae. Women w~th and without BV prior to 24 weeks of gestation had a simdar frequency of PPROM (before 37 full gestational weeks) [2 2% vs 2 1%; crude OR 1.0, 95% CI 0.4 - 2.3] and low birth weight (LBW) babies (< 2500 g) [3 6% vs 2 8%; crude OR 1 3, 95% CI 0 7 - 2 4] Rates of idiopathic PTB were similar among women with or without BV [3 4% vs 3 6%, OR 0 9, 95% CI 0 5 - 1.8] CONCLUSIONS: This prospective analysis of a stable Danish population shows low rates of PPROM, LBW, PTB and BV. There were no d~ferences for PPROM and LBW among pregnant women with or without BV prior to 24 full weeks of gestation.
74 WOMEN WITH SICKLE CELL TRAIT ARE AT INCREASED RISK FOR PREECLAMPSlk K.D. Larrebee', M.Monga. DepL Ob. Gyn. & Reprod. Scl. UTMSH, Houston, TX. OBJECTIVE: To determine the rate of presclampsla in women who are positive for sickle ceil trait. 8"rUDY DESIGN: All Nrican American women were tested for sidde cell trait using the sicldedex screen at their first prenatal visit and prospec~vely enrolled in this study from March, 1994 - June, 1995. Demographic data were collected at the time of enrotlmenL Outcome data, Including prasdarnpsla (as defined by ACOG criteria), gastatJonal age at delivery, b~r~eight and postpartum endometdtls were collected immediately postpartum. Assuming a 10% rata of posllfve sickle cell trait, 1199 peUents wore required to demonstrate 8 10% difference in the rete of prasclampsia wilh 80% power and p<0.05. Studenrs-t, Mann Whl~eyU, C,hl-square and Fishers Exact tests were used for statlstlcei analysis. RESULTS: 1584 women were enrolled; 162 were positive for sickle cell trait. Sickle cell traR podtive (SO+) women were older then sickle ceiJ trait negative (SO-) women (24.4 ± 4.6 vs 23.0 ± 4.4 years, p
332
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75 THE EFFECT OF MATERNAL POSITION ON CARDIAC
OUTPUT WITH EPIDURAL ANALGESIA IN LABOR. DR Danilenko-Dixon, L Tefftx, B Haydonx, RA Cohen ~, MW Carpenter. Brown University, Depts Ob/Gyn & Anesthesia, Women & Infants Hospital, Providence, RI. OBJECTIVE: To test the hypothesis that supine vs. lateral position is associated with greater decrement in cardiac index after epidural analgesia (EA) in labor. STUDY DESIGN: Nineteen normal, term subjects were randomized to left lateral or supine position in early labor. Cardiac index (CI, measured by acetylene rebreathing), stroke volume index (SVI), heart rate (HR), mean arterial pressure (MAP), and systemic vascular resistance (SVR) were obtained at 5 minute intervals, beginning prior to 500 ml IV crystalloid (baseline), and ending 45 minutes after EA. RESULTS: Mean baseline supine vs. lateral group differences were significant for 21% lower CI, 21% lower SVI, 19% higher MAP, 50% higher SVR (all p<0.05), and equivalent HR. Fluid bolus in the supine group resulted in increments in CI and SVI (p<0.01), decrements in MAP and SVR (p<0.03), and unchanged HR. Relative to postfluid values, EA in the supine group resulted in decrements in CI and SVI (p<0.05). The lateral group exhibited no hemodynamic alterations following fluid bolus or EA. CONCLUSIONS: The supine U]n,~ Ev~v.a
significant post-EA decrement in CI, likely reflecting decreased preload volume. To our knowledge, this is thv flrst direct evidence of positional effects on maternal hemodynamic homeostasis after EA.
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76 The Effect of Dobutamine Hydmchloride on Ventricular Function and Oxygen Transport in Patients with Severe Preeclaml~in. C. Graves. T. Wheeler,H. Troiano. Dept. Ob/Gyn, Vanderbilt University, Nashville, TN. OBJECTIVE: Depressed left ventricolar function has been previously reported in patients with severe preeclampsia. In cntically ill patients, improvementofcasdias functionmay lead to increased oxygen deliver. This study reportsthe effect of dobutemine hydrochloride m a subset of patients with severe preeclampsia.Its use has not been previously reported in thts population. STUDY DESIGN: Pregnant patients in the third trimester with severe preectsmpsiawho required pulmonary artery catheter(PAC) monitoring for clinical management were evaluated for the study. Entry cntena included depressed left vcntricolar function after optimization of volume and no previoushistoryof cardiacdisease During the study period, 40 patients were diagnosed with severe preeclampsia and required PAC 8 pahents met criteria for dobuteminc administration. Dobutamme was initiated at 3 mcg/kg/min,then tittatedto the LVSWI. Values were compared pre and post infusion. Vanables were analyzed using the t-test. RESULTS: The outcome date is listed below : Mean Pulmonary Capdlary Wedge Pressure (PCWP) 18_+5.5 Mean Hemoglobin 10.2+ 3.2 Premfuslon Pustinfusion Cardiac Index (L.min'Lm2) 3.19 4.28 p=O.05 Left Ventncular Stroke Work Index (g-m/m2) 37 58 59.38 p=0.03 Oxygen Delivery Index (ml-mm'Lm2) 445.63 615.38 p=0.05 CONCLUSIONS: Dobutemme hydrochlonde can be used to improve oxygendehvenym patientswith severepreeclampsiawho have depressed left ventricular function.