Oral Concurrent Session F OB Anesthesia and Pharmacology Medical Complications of Pregnancy

Oral Concurrent Session F OB Anesthesia and Pharmacology Medical Complications

Pregnancy of Friday, January 28,1994 1:00 p. m. - 3: 00 p. m. Moderator: Richard H. Paul, MD Past President, SPO

Ballroom C Abstract Numbers 61 - 68

Volume 170, Number Am J Obstet Gynecol

61

1, Part 2

SPO Abstracts

LOW-DOSE ASPIRININ NULLIPAROUS WOMEN:SAFETYOF EPIDURAL AND CORRELATION BETWEENBLEEDINGTIME AND MATERNAL-NEONATAL BLEEDING COMPLICATIONS. L IU, S. Carilis,E.Thom,x K.Shaw,D. McNelis, x Bethesda, Maryland. andtheNICHDMFMNetwork, OBJECTIVE: To determinethe frequencyand safety of the use of epidural betweenbleedingtimeandmaternal-neonatal anesthesia bleeding andthecorrelation in a groupof pregnantwomenwhoparticipated in a multicenter complications lowdoseaspirinin pregnancy trial. STUDYDESIGN:2985nufiparous womenfrom7 centerswererandomly assignedat 13-27weeksto receive60 mg/dof aspirinor a placebo.Data regardingt pe of anesthesia usedfor laboranddeliverywerecollectedin 5 centerswhoenrolled2579 women.Knowledgeregardinguse of epiduralwas knownin 1629(63%)of the women.891(55%)) epiduralanesthesia received

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RESULTS: Among the 891 women known to have received epidural, 451 received low-dose aspirin and 440 received a placebo. The frequency of epidural use among the 5 centers ranged from 27% to 94% There was no instance of bleeding related to epidural use One of the 5 centers also obtained bleeding times in 303 women (149 received aspirin and 154 received placebo). The mean±SD bleeding time in vanes receiving low-dose aspirin was significantly higher than in women receiving placebo (6.99±2.95 vs 5 99±2 43, p=0.002) In addition, the frequency of women having a bleedingtime >10 minuteswas higher in the aspirin group (14.1% vs 5.2%, pß. 01). Interestingly,women who receivedepidural had a lower bleeding time than those not receiving epidural (p=0.003) irrespective of the treatment used. Despite the difference in bleeding time between aspirin and placebo, we found no differences in maternal and neonatal bleeding complications (Table) No baby had excessive bleedingfrom circumcision,

Postpartum hemorrhage tl(%)

Estimatedbloodloss(ml)'

Change in hematocrit (%)

NeonatalbleedingN(%)

Aspirin (n=149)

Placebo (n=154)

6 (4.0)

7 (4 5)

5551196

546±163

4 43±3 5

4 43±3.2

3 (20)

4 (25)

'Powerof 99.7%to detecta differenceof 100ml, CONCLUSIONS: Epiduralanesthesiais safeto use in womenreceivinglow-dose bleedingtimein pregnantwomenreceiving aspirinin pregnancyDespitean increased low-dose bleedingcomplications aspirin,maternal-neonatal werenotincreased.

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EFFECT OF ASPIRIN AND INDOMETHACIN ON PROSTACYCLIN AND THROMBOXANE PRODUCTION BY PLACENTAL TISSUE INCUBATED I90 WITH FRACTIONS PATIENTS FROM WITH LUPUS ANTICOAGULANT. AM Peacemen, K Rehnberg'. Department of Ob/Gyn, Northwestern University Medical School, Chicago it. OBJECTIVE: We assessed the effect of aspirin (ASA) and indomethacin (1) on prostanoid production by placental tissue incubated with IgG fractions from patients with lupus anticoagulant (LAI. METHODS: IgG fractions were prepared using an ammonium sulfate precipitation method from the plasma of 5 non-pregnant patients with the antiphospholipid antibody (APA) syndrome and demonstrable LA. Fresh placentas were obtained from normal term pregnancies, and 350 mg explants of placental tissue were incubated with 3 mg of IoG from each For each patient, incubations were performed of the LA patients. in duplicate with final concentrations of 10 `M ASA, 10 'M I, and no added drug (NSAID). Aliquots were removed at nonsteroidal anti-inflammatory intervals up to 48 hr of incubation and assessed for placental prostecyclin (PGI) and thromboxene (TX) production by RIA of the stable metabolites PGF and TXB,. TX production RESULTS: by 20 hr of ýrr incubation is displayed in the figure. A 49aI % reduction in placental TX production was n seen with the addition of ASA (paired t-test, t p<. 01), to levels previously seen with 0 incubation of placental tissue alone. A similar decrease in TX production (34-76%, p<. 06) ; was noted with the addition of I. Decreased N x PGI production (26.46%, p<. 011 was also observed with the addition of I, but ASA at AU 0*1i" this dose did not affect PG1 production. Addition of both ASA and I at levels comparable to CONCLUSION: therapeutic plasma levels eliminates the increased TX production seen These data provide a with placental tissue incubated with LA-IgG. physiologic basis for treatment of APA related pregnancy loss with NSAID.

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WHY CAN'T GOOD GLYCEMIC CONTROL OF DIABETES IN PREGNANCY ELIMINATE 711E PROBLEM OF MACROSOMIA7 Raecnn. M. Miodovnik, G. Holcberg", J. Khoury, R. Jackie, T. A. Siddiqi. Dept. Ob/Gyn, University of Cincinnati, Cincinnati OH. BACKGROUND: Although macrosomla in infants of diabetic women is assumed to be related to poor glycemic control during pregnancy, a high rate of macrosomta persists in Type I (IDDM) diabetic pregnancies despite intensive insulin therapy. OBJECTIVE To test the hypothesis that macrosomia in IDDM is associated with poor glycemic control during pregnancy. DESIGN: 293 women with IDDM and 33 women with Type II (NIDDM, Maturity onset), diabetes who delivered viable singleton infants after 34 weeks gestation were included in the analysis. All received intensive insulin therapy during pregnancy, and sell-monitored blood glucose concentrations (BG) 4-6 times daily. Gestational age was verified by early sonogram. Birth weight percentiles were determined from local race and sex specific growth curves, and correlated with maternal glycemic control during pregnancy. RESULTS: Among infants of IDDM women, 39% were LGA (>901h%) and 64% of these were >95th%. Glycohemoglobin concentrations (Glib) were within normal range in 74% of IDDM mothers by the second trimester. Third trimester mean (±SD) preprandial BG was 113±25 mg/dL, and postprandial BG was 134 ±32mg/dL (interquartile ranges 95-125 and 110-151 respectively). The rate of LGA was related to weight gain in pregnancy, but was similar in women that had normal Glib (40%LGA) and in those that had higher Glib (36%LGA). LGA did not correlate with mean pre- or postprandial BG during any stage in pregnancy. In contrast, LGA in women with NIDDM was significantly associated with initial maternal weight and glucose control during pregnancy. CONCLUSION: Macrosomia is a persistent problem in IDDM pregnancies despite intensive insulin therapy and good glycemic control. We speculate that deficiency of counterregulatory hormonal responses in IDDM results in recurrent maternal hypoglycemic episodes with rebound excess of food intake, predisposing these infants to accelerated growth in utero. (Supported in part by NIH Grant HD 11725)

TOWARD UNIVERSAL CRITERIA FOR GESTATIONAL DIABETES: THE 75 GRAMGLUCOSE TEST IN PREGNANCY. TOLERANCE D. Sacks adik'. J. Greenspoon, S. Abu-FadilX H. Henry, G. Wolde- sT J. Yaox. Depts. Ob/Gyn, Kaiser Foundation Hospital, Bellflower, and Cedars-Sinai Medical Ctr, Los Angeles, Ca. OBJECTIVE: The Third Workshop-Conference International diabetes concluded that the 75 g, glucose on gestational tolerance test (GTT) was the test most likely to achieve international diabetes. consensus to define gestational The purpose of this study was to develop norms for that test in pregnancy, and to define glucose intolerance by the relationship between maternal glucose values and neonatal macrosomia.

STUDY DESIGN: 3063 unselected, hispanic predominantly known to have diabetes gravidas who were not previously GTT. Fasting, were given a 75 g. 2-hour one, and two hour Only having samples those were drawn. a fasting (FPG) >105 2-hour plasma glucose mg/dl and/or a (2hrPG) diet >200 mg/dl post-glucola value received insulin Birtliiweights therapy. liveborn and/or of only had FPG <105 mg/dl singletons whose mothers and 2hrPG <200 mg/dl between were used to calculate relationships levels Macrosomia and birthweights. glucose was defined >90%ile for gestational as a birthweight age. RESULTS: The mean+2S. D. values for fasting, 1, and 2 hours 102 mg/dl., 197 mg/dl., were respectively and In 160 mg/dl. logistic a multiple regression model, factors found to be significantly the associated with and their macrosomia odds ratios were maternal race (white/black 2.71; hispanic/black (2.59), 1.90), parity BMI (1.06), prepregnancy weight gain (4.20), gestational (0.95), (1.01). testing FPG (1.02). age at and lhrPG There was no single glucose value or combination of for the above values which macrosomia risk was increased. significantly

CONCLUSIONS:Within the range of GTT values studied: (1) Fetal macrosomia is influenced by factors other (2) There does not appear than maternal glucose levels. to be a threshhold that distinguises point women at increased risk for macrosomia.

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SPO Abstracts

January 1994 Am J Obstet Gynecol

IS IT COST EFFECTIVE TO SCREEN TEENAGERS FOR Kady Wilson: L. Hosma, ' GESTATIONAL DIABETES? AJohnso ,'S. K. Franko-Filipasic. L. Chamblise, Dept. of Ob/Gyn. Mariwpa Medical Center, & The Midwifery Service. Phoenix Memorial Hospital, Phil. AZ. OBJECTIVE: To determine the cost effectiveness of screening teenagers for gestational diabetes. STUDY DESIGN: We retrospectively reviewed the results of the prenatal testing for gestational diabetes in 350 women age 19 and younger who delivered at our institutions. The results of the 1' glucola and any 3' GTTs were recorded. Patients with an abnormal 3' GTT were identified and assigned a clan of gestational diabetes as described by White. The cost of a 1' glucola is $19 85 and for a 3' GTT is $52.00. The costs for testing this group of 350 patients was calculated. The cost to identify each patient with gestational diabetes was determined by dividing the number of cases identified by the total cost of testing. RESULTS: 9 of the 350 patients screened had a Is glucola > 140 mg% and had a 30 (TIT. 3 of these patients met criteria for diabetes All 3 were Class Al with normal fasting glucoaes throughout their pregnancies on diet alone.The total cost of 350 one hour glucolas was $6,947 50. The cost of the 9 three hour GTTs was $468.00 CONCLUSION: To screen 350 pregnant teenagers for gestational diabetes it cost $7.204 50 and identified only 3 gestational diabetics. All were Class Al and none required insulin. Lucas at al (I) reported that patients with Class Al gestational diabetes did not have significant obstetrical or perinatal morbidity. In 1991 533,483 patients 19 years and younger delivered in the U. S. (2) The cost of testing for gestational diabetes for this group would be approximately II million dollars. Given the low incidence of gestational diabetes in patients 19 years of age or younger coupled with the minimal morbidity reported for Class Al diabetes, it does not appear to be cost effective to screen teenagers for gestational diabetes. 1. Lucas, M. at. al. Class Al gestational diabetes: A Meaningful Diagnosis? Obstes Gynecol 1993;82: 260-265 2 Center for Disease Control yearly reports: 1991

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THE ASSOCIATION OF ABNORMAL FNR PATTERNS AND hýWendel, S. Cox, S. Roberts, M. Maberry, J. Deptt Ö6/6yn, Univ. Ned. of TX Southwestern

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CHORIOAMNIONITI: NEONATAL ACIDEMIA. Dax', L. Gilstrap. Dallas, TX Ctr.,

OBJECTIVE: It has been previously reported that the majority of do not have low Us pH's newborns with acute chorioaenionitis We sought to determine whether selected (<7.20). variables, in pregnancies by FHR abnormalities, complicated apecifically chorioaanionitis could predict neonatal scidenia (i. e., cord pN 7.20). METHODS: During a 6-month period, mothers diagnosed with identified in labor. were prospectively chorioaanionitis fetal monitor strips and hospital course were Following delivery, The Cox Proportional reviewed for both mother and neonate. Hazards Model weighs independent variables according to their included; Independent duration of exposure. variables heart rate loss of variability, birthweight, absence of fetal tachycardia, presence of fetal and absence of accelerations, heart rate decelerations. Duration of severe and late fetal to model was based upon diagnosis exposure for the statistical delivery. 197 consecutive RESULTS: cases of chorioaimionitis were for diagnosed of 2.1% in our an incidence prospectively Independent variables and their relative risks for population. neonatal acidemis are listed below. RR 1.3

P Cl (95X) 60 5-3.3 Birthweight (v2500 gms) . . 85 77 3-2.5 Loss of variability . . . 84 63 4-1.7 Absecce of severe/Late . . . ece era tons 2.8 01 1.3-6.1 No accelerations . 41 4-1.4 (160-180) Mild tachycardia . . .8 28 7-3.2 1.5 (5181) Mod/severe tachycardia . . The lack of fetal heart rate accelerations was the only variable associated with neonatal acidemia (pH < 7.20). significantly CONCLUSION: In pregnancies coaplicated by chorioamilonitis, only heart rate accelerations the absence of fetal could predict To our knowledge, this is the only report to neonatal scidemia. evaluate fetal heart rate patterns according to their length of exposure.

SULFATE MAGNESIUM SEIZURE PREVENTION

(PRY) FOR VERSUS PIIENYTOIN IN AMYGDALA KINDLED RATS. L. Stewaif, B. Mason, D. B. Cotton. C. A. Starnllev`, S. M. litenkauf', State University, Detroit, Dept of Ob/Gyn, Hutzel Hospital/Wayne MI. OBJECTIVES: in MgSO4 is widely used for seizure prophylaxis However, its anticonvulsant effects in other preeclampsia-eclampsia. types of seizures has not been proven. In the present study, we effects of therapeutic blood levels of compare the anticonvulsant M1SO4 and PHY in amygdala kindled rats. STUDY DESIGN: 18 male rats had a bipolar electrode stereotaxically implanted into the central nucleus of the amygdala. Following recovery, an afterdiscbarge (seizure) threshold was determined for Rats were stimulated until 3 consecutive Kindled occurred. rats randomly intravenous injections in a volume 60 or 90 mg/kg) or PHY (12.5,25 on preliminary data demonstrating

each rat. (=kindling)

daily

at their seizure thresholds seizures generalized tonic-clonic received one of the following of 1.5 ml/kg: saline, MgSO4 (30, Doses were based or 50 mg/kg). blood levels of 16.2 mg/dl for 25

mg/kg PHY and 4.2 mg/dl for 60 mg/kg MgSO4. Fifteen minutes following infection, rats were stimulated at their seizure thresholds and seizure activity was assessed. Statistical comparisons were done using ANOVA and post hoc comparisons where appropriate.

RESULTS: Magnesium sulfate had no effect on any of the seizure parameters assessed. PHY significantly reduced seizure duration (p<. 05), duration of postictal depression (p<. 05) and behavioral seizure stage (p<. 05). CONCLUSIONS: Amygdala kindled seizures are more potently inhibited by PHY than magnesium sulfate. This suggests that magnesium may not be a very effective treatment in situations where repetitive seizure activity has been experienced.

REFLECTRECENTGLYCEMICSTATUS AMNIOTICFLUID VOLUMEFLUCTUATIONS Y. IN GESTATIONAL DIABETICS. I. Bar-Haves, S. A. Scarpellix, Barnhardt, N. Y. Divon. Dept. Of Ob-Gyn. Albert Einstein College of Medicine, Bronx, N. Y. between the determine the OBJECTIVE: To association fluid index (AFI) and recent derived amniotic sonographically (GDM). diabetes mellitus glucose status in gestational STUDY DESIGN: The following were prospectively variables in 205 GDMs (who underwent 7 daily capillary glucose collected between 2/1/92 determinations with a memory glucaeeter) 1 day prior and 1 week prior to 7/31/93: AFI, mean blood glucose (MBG1-D and MBG1-W, respectively). the ultrasound examinations and percent hyperglycemia (1120 ag%) 1 day prior and 1 week prior (PHI-D and PHI-W. respectively). to the ultrasound examinations All patients demonstrating at least 1 AFI measurement within the 5cm < AFI S 20cm) and at least 1 elevated normal range (is, With measurement (is, AFI v 20ern) formed the study population. indices glucose as her own control, serving each patient (N-AFI E-AFI, AFIs and and elevated normal preceding t-test were compared with the use of Student's respectively) (n-39). In addition. APIs for each patient were plotted against age to determine whether there was a consistent gestational trend. RESULTS: PHI-W(8) N8G1-D(. g%) N8G1-V(mg%) PHI-D(%) API (ow) (MeantSD) (MeantSD) (Mean*SD) (MeantSD) (Mean: SD) 37: 21 37±17 116113 E-AFI 2212 118116 17: 18 18: 14 100,11 102: 12 N-AFI 13: 3 p-0.0094 p"0.0016 p<0.0008 P-0.0001 p-0.0032 No consistent of change in AFI was observed as a function age. gestational fluid the CONCLUSION: Amniotic reflect volume fluctuations preceding glycemic status in GDM.