The active management of risk in nulliparous patients at term: An association between a higher...
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391 EVALUATION OF ABNORMAL WEIGHT GAIN BY INSTITUTE OF MEDICINE GESTA- TIONAL WEIGHT GAIN GUIDELINES AMONG WOMEN WITH NORMAL PRE-PREG- NANCY BMI THOMAS MYLES 1 , SHANNON LINES 2 , HEATHER NEELEY 2 , TERRY LEET 2 , 1 Saint Louis University, Obstetrics, Gynecology, and Women’s Health, St. Louis, Missouri, 2 Saint Louis University, School of Public Health, St. Louis, Missouri OBJECTIVE: In 1990, the Institute of Medicine (IOM) released new gestational weight gain guidelines, which increased the recommended weight gain of normal weight women to 25-35 pounds. Few studies have investigated the effect of these guidelines for normal weight women on pregnancy out- comes. The purpose of this study was to investigate the relationship between gestational weight gain in women with normal pre-pregnancy body mass index (BMI) and small-for-gestational age (SGA), large-for-gestational age (LGA), gestational diabetes (GDM), and cesarean delivery. STUDY DESIGN: This is a population-based cohort study using Missouri birth certificate data. Data were obtained from women who delivered full term singletons between 1999 and 2001. Women were divided into 3 groups: those who gained less than the recommended (!25 pounds, n=14,344), recom- mended (25-35 pounds, n=32,152), and more than recommended (O35 pounds, n=35, 225) gestational weight gain. RESULTS: We found a protective effect for LGA (relative risk 0.6, 95% confidence interval 0.6-0.7) and cesarean delivery (0.9, 0.86-0.95) among women who gained less than the recommended weight compared to those who gained the recommended amount of weight while pregnant. The relative risk was 1.5, (1.3-1.8) and 1.7, (1.6-1.8) for GDM (regardless of insulin usage) and SGA, respectively. We found a protective effect for SGA (0.6, 0.6-0.7)among women who gained more than the recommended amount of weight compared to those who gained the recommended amount of weight), but relative risks of 1.3, (1.2-1.3) and 2.0, (1.9-2.1) for cesarean delivery and LGA, respectively. CONCLUSION: Women who had a normal prepregnancy BMI who gain weight outside the IOM guidelines are at an increased risk of adverse pregnancy and birth outcomes. Adherance to the IOM’s guideline’s ideal weight gain may improve pregnancy outcome for patients with a normal prepregnancy BMI. 392 FIRST TRIMESTER TROPHOBLAST SECRETE TISSUE FACTOR DONNA NEALE 1 , REBECCA CASE 2 , VIKKI ABRAHAMS 2 , GRACIELA KRIKUN 3 , GIL MOR 2 , 1 Yale Univer- sity, Maternal-Fetal Medicine, New Haven, Connecticut, 2 Yale University, Ob/Gyn, New Haven, Connecticut, 3 Yale University, Obstetrics and Gynecol- ogy & Reproductive Sciences, New Haven, Connecticut OBJECTIVE: Successful implantation relies on the blastocyst attaining a state of immune privilege allowing it to invade into the decidua and eventually establishing contact with the maternal circulation via the extravillous tropho- blast. These invasive processes must occur without the presence of hemorrhage. We previously reported that 1st trimester trophoblast secrete Fas Ligand via microvesicles which serves as mechanism by which the trophoblast promotes a state of immune privilege. A major component of microvesicles derived from other tissue types is Tissue Factor (TF), and TF is a main mediator of homeostasis via the production of thrombin. The aim of this study was to determine whether microvesicles from 1st trimester trophoblast cells contain Tissue Factor (TF). STUDY DESIGN: First trimester trophoblast cells were cultured and grown to 80% confluency. The supernatants from the cell cultures were collected and microvesicles were isolated using an ultracentrifugation technique. Microves- icles were disrupted by treating them with 2% Triton X-100 at 40C for 30 min followed by centrifugation of the microvesicle suspension at 16,000 g at 40C for 1 hour. Tissue Factor was determined by ELISA. RESULTS: Tissue Factor was isolated from the microvesicles of first trimester trophoblast cells. 1623 pg/nl of TF was identified in intact micro- vesicles while 3794 pg/nl of TF was identified from disrupted microvesicles. CONCLUSION: This study yielded the novel observation that first trimester trophoblast cells secrete TF via microvesicles. Our study indicate that Tissue Factor is contained inside of the microvesicles since disruption of the integrity of the microvesicles promote TF release to the supernatant. This may serve as a mechanism whereby the developing blastocyts is able to invade the decidua without causing catastrophic hemorrhage. 393 WOMEN WITH PLACENTA PREVIA OR LOW-LYING PLACENTA WHICH RESOLVES LATER IN PREGNANCY HAVE A HIGH RATES OF UTERINE ATONY. AMEN NESS (F) 1 , JOLENE SEIBEL-SEAMON 1 , CAROLYN SELMER 2 , JOHN VISINTINE 1 , EMILY RICCI 1 , VINCENZO BERGHELLA 1 , 1 Thomas Jefferson University, Obstetrics and Gynecol- ogy, Philadelphia, Pennsylvania, 2 Lankenau Hospital, Obstetrics and Gyne- cology, Wynnewood, Pennsylvania OBJECTIVE: To determine the obstetrical outcome of pregnancies compli- cated by a second trimester placenta previa or low-lying placenta which resolved prior to delivery. STUDY DESIGN: We identified all women who had a placenta previa or low- lying placenta on routine second trimester ultrasound, between 2001 and 2005 which subsequently resolved. An equal number of women with no evidence of placenta previa or low-lying placenta at the same gestational age at index ultrasound served as controls. Statistical methods included Chi square or Fisher’s exact test. RESULTS: 148 cases of resolved placenta previa or low-lying placenta were identified, together with 148 matched controls. There were no differences be- tween cases and controls for age (P=.055), race (P=.603), parity (P=.629), prior uterine surgery (P=.391), uterine anomalies (P=1.0), or cesarean deliv- ery rate (P=.308). There were also no differences in the frequency of preterm delivery (9.5% vs. 10.8%, P=.798), or IUGR (5.4% vs. 2.7%, P=.378). Although gestational age at delivery were similar (38.7 vs. 38.6 weeks, P=.655), birth weights were significantly greater in the cases (3418 vs.3223 gm, P=.008).The rate of antepartum bleeding was greater in cases compared to controls but this did not reach statistical significance (6.8% vs. 2.0%, P=.085). However, uterine atony was significantly more frequent in cases compared to controls (6.8% vs. 0.7%, P=.005). CONCLUSION: Despite resolution, women who initially were noted to have a placenta previa or low-lying placenta in the second trimester are at significantly greater risk of uterine atony. 394 THE ACTIVE MANAGEMENT OF RISK IN NULLIPAROUS PATIENTS AT TERM: AN ASSOCIATION BETWEEN A HIGHER PREVENTIVE LABOR INDUCTION RATE AND A LOWER CESAREAN DELIVERY RATE JAMES NICHOLSON 1 , MORGHAN HOLT 2 , AARON CAUGHEY 3 , GEORGE MACONES 4 , 1 University of Pennsylvania, Family Practice and Community Medicine, Philadelphia, Pennsylvania, 2 University of Pennsylvania, Graduate Nursing, Philadelphia, Pennsylvania, 3 University of California, San Francisco, San Francisco, California, 4 University of Pennsylvania, Obstetrics and Gynecology, Philadelphia, Pennsylvania OBJECTIVE: Objective: National primary cesarean delivery rates continue to increase. A recent study reported the association, in a population of mixed parity, between a new method of care and a very low cesarean delivery rate. We wished to re-examine this association in a study involving only nulliparous patients. STUDY DESIGN: Methods: One hundred sequentially delivered nulliparous subjects that had been exposed to the active management of risk in pregnancy at term were identified. The risk profile of each subject was used to estimate an optimal time of delivery, and delivery by the upper limit of that gestational age range was encouraged by offering labor induction. For patients with a modified Bishops score !6 PGE2 was also offered prior to induction. Random numbers techniques were used to identify three hundred fifty-two patients that had received standard treatment. Levels of salient birth outcomes in the two study groups were then determined and compared. Logistic regression was used to adjust for possible confounding. RESULTS: Results: The active management group had a significantly higher labor induction rate (53% vs., 22.2%, OR 2.39 [1.83-3.13]) and a significantly lower cesarean delivery rate (9% vs. 25.9%, OR 0.35 [0.18-0.67]). In addition, rates of NICU admission and major perineal trauma were lower in the exposed group, and other salient outcomes were not increased. CONCLUSION: Conclusions: Nulliparous patients exposed to the active management of risk in pregnancy at term experienced better outcomes than those that received the standard of care. These findings conflict with the long- standing belief that labor induction promotes adverse outcomes. This discrep- ancy is perhaps explained by the use, in this investigation, of labor induction in a ‘‘preventive’’ rather than ‘‘indicated’’ mode. A randomized controlled study is needed to evaluate this new method of care. SMFM Abstracts S117
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Transcript of The active management of risk in nulliparous patients at term: An association between a higher...
391 EVALUATION OF ABNORMAL WEIGHT GAIN BY INSTITUTE OF MEDICINE GESTA-TIONAL WEIGHT GAIN GUIDELINES AMONG WOMEN WITH NORMAL PRE-PREG-NANCY BMI THOMAS MYLES1, SHANNON LINES2, HEATHER NEELEY2, TERRY LEET2,1SaintLouisUniversity,Obstetrics,Gynecology, andWomen’sHealth, St.Louis,Missouri, 2Saint Louis University, School of Public Health, St. Louis, Missouri
OBJECTIVE: In 1990, the Institute of Medicine (IOM) released newgestational weight gain guidelines, which increased the recommended weightgain of normal weight women to 25-35 pounds. Few studies have investigatedthe effect of these guidelines for normal weight women on pregnancy out-comes. The purpose of this study was to investigate the relationship betweengestational weight gain in women with normal pre-pregnancy body mass index(BMI) and small-for-gestational age (SGA), large-for-gestational age (LGA),gestational diabetes (GDM), and cesarean delivery.
STUDY DESIGN: This is a population-based cohort study using Missouribirth certificate data. Data were obtained from women who delivered full termsingletons between 1999 and 2001. Women were divided into 3 groups: thosewho gained less than the recommended (!25 pounds, n=14,344), recom-mended (25-35 pounds, n=32,152), and more than recommended (O35pounds, n=35, 225) gestational weight gain.
RESULTS: We found a protective effect for LGA (relative risk 0.6, 95%confidence interval 0.6-0.7) and cesarean delivery (0.9, 0.86-0.95) amongwomen who gained less than the recommended weight compared to those whogained the recommended amount of weight while pregnant. The relative riskwas 1.5, (1.3-1.8) and 1.7, (1.6-1.8) for GDM (regardless of insulin usage) andSGA, respectively. We found a protective effect for SGA (0.6, 0.6-0.7)amongwomen who gained more than the recommended amount of weight comparedto those who gained the recommended amount of weight), but relative risks of1.3, (1.2-1.3) and 2.0, (1.9-2.1) for cesarean delivery and LGA, respectively.
CONCLUSION: Women who had a normal prepregnancy BMI who gainweight outside the IOM guidelines are at an increased risk of adverse pregnancyand birth outcomes. Adherance to the IOM’s guideline’s ideal weight gain mayimprove pregnancy outcome for patients with a normal prepregnancy BMI.
392 FIRST TRIMESTER TROPHOBLAST SECRETE TISSUE FACTOR DONNA NEALE1,REBECCA CASE2, VIKKI ABRAHAMS2, GRACIELA KRIKUN3, GIL MOR2, 1Yale Univer-sity, Maternal-Fetal Medicine, New Haven, Connecticut, 2Yale University,Ob/Gyn, New Haven, Connecticut, 3Yale University, Obstetrics and Gynecol-ogy & Reproductive Sciences, New Haven, Connecticut
OBJECTIVE: Successful implantation relies on the blastocyst attaining a stateof immune privilege allowing it to invade into the decidua and eventuallyestablishing contact with the maternal circulation via the extravillous tropho-blast. These invasive processes must occur without the presence of hemorrhage.We previously reported that 1st trimester trophoblast secrete Fas Ligand viamicrovesicles which serves as mechanism by which the trophoblast promotes astate of immune privilege. A major component of microvesicles derived fromother tissue types isTissueFactor (TF), andTF is amainmediatorof homeostasisvia the production of thrombin. The aim of this study was to determine whethermicrovesicles from 1st trimester trophoblast cells contain Tissue Factor (TF).
STUDY DESIGN: First trimester trophoblast cells were cultured and grownto 80% confluency. The supernatants from the cell cultures were collected andmicrovesicles were isolated using an ultracentrifugation technique. Microves-icles were disrupted by treating them with 2% Triton X-100 at 40C for 30 minfollowed by centrifugation of the microvesicle suspension at 16,000 g at 40Cfor 1 hour. Tissue Factor was determined by ELISA.
RESULTS: Tissue Factor was isolated from the microvesicles of firsttrimester trophoblast cells. 1623 pg/nl of TF was identified in intact micro-vesicles while 3794 pg/nl of TF was identified from disrupted microvesicles.
CONCLUSION: This study yielded the novel observation that first trimestertrophoblast cells secrete TF via microvesicles. Our study indicate that TissueFactor is contained inside of the microvesicles since disruption of the integrityof the microvesicles promote TF release to the supernatant. This may serve asa mechanism whereby the developing blastocyts is able to invade the deciduawithout causing catastrophic hemorrhage.
393 WOMEN WITH PLACENTA PREVIA OR LOW-LYING PLACENTA WHICH RESOLVESLATER IN PREGNANCY HAVE A HIGH RATES OF UTERINE ATONY. AMEN NESS (F)1,JOLENE SEIBEL-SEAMON1, CAROLYN SELMER2, JOHN VISINTINE1, EMILY RICCI1,VINCENZO BERGHELLA1, 1Thomas Jefferson University, Obstetrics and Gynecol-ogy, Philadelphia, Pennsylvania, 2Lankenau Hospital, Obstetrics and Gyne-cology, Wynnewood, Pennsylvania
OBJECTIVE: To determine the obstetrical outcome of pregnancies compli-cated by a second trimester placenta previa or low-lying placenta whichresolved prior to delivery.
STUDY DESIGN: We identified all women who had a placenta previa or low-lying placenta on routine second trimester ultrasound, between 2001 and 2005which subsequently resolved. An equal number of women with no evidence ofplacenta previa or low-lying placenta at the same gestational age at indexultrasound served as controls. Statistical methods included Chi square orFisher’s exact test.
RESULTS: 148 cases of resolved placenta previa or low-lying placenta wereidentified, together with 148 matched controls. There were no differences be-tween cases and controls for age (P=.055), race (P=.603), parity (P=.629),prior uterine surgery (P=.391), uterine anomalies (P=1.0), or cesarean deliv-ery rate (P=.308). There were also no differences in the frequency of pretermdelivery (9.5% vs. 10.8%, P=.798), or IUGR (5.4% vs. 2.7%, P=.378).Although gestational age at delivery were similar (38.7 vs. 38.6 weeks,P=.655), birth weights were significantly greater in the cases (3418 vs.3223gm, P=.008).The rate of antepartum bleeding was greater in cases comparedto controls but this did not reach statistical significance (6.8% vs. 2.0%,P=.085). However, uterine atony was significantly more frequent in casescompared to controls (6.8% vs. 0.7%, P=.005).
CONCLUSION: Despite resolution, women who initially were noted to havea placenta previa or low-lying placenta in the second trimester are atsignificantly greater risk of uterine atony.
SMFM Abstracts S117
394 THE ACTIVE MANAGEMENT OF RISK IN NULLIPAROUS PATIENTS AT TERM: ANASSOCIATION BETWEEN A HIGHER PREVENTIVE LABOR INDUCTION RATE ANDA LOWER CESAREAN DELIVERY RATE JAMES NICHOLSON1, MORGHAN HOLT2,AARON CAUGHEY3, GEORGE MACONES4, 1University of Pennsylvania, FamilyPractice and Community Medicine, Philadelphia, Pennsylvania, 2Universityof Pennsylvania, Graduate Nursing, Philadelphia, Pennsylvania, 3Universityof California, San Francisco, San Francisco, California, 4University ofPennsylvania, Obstetrics and Gynecology, Philadelphia, Pennsylvania
OBJECTIVE: Objective: National primary cesarean delivery rates continueto increase. A recent study reported the association, in a population of mixedparity, between a new method of care and a very low cesarean delivery rate.We wished to re-examine this association in a study involving only nulliparouspatients.
STUDY DESIGN: Methods: One hundred sequentially delivered nulliparoussubjects that had been exposed to the active management of risk in pregnancyat term were identified. The risk profile of each subject was used to estimate anoptimal time of delivery, and delivery by the upper limit of that gestational agerange was encouraged by offering labor induction. For patients with a modifiedBishops score !6 PGE2 was also offered prior to induction. Random numberstechniques were used to identify three hundred fifty-two patients that hadreceived standard treatment. Levels of salient birth outcomes in the two studygroups were then determined and compared. Logistic regression was used toadjust for possible confounding.
RESULTS: Results: The active management group had a significantly higherlabor induction rate (53% vs., 22.2%, OR 2.39 [1.83-3.13]) and a significantlylower cesarean delivery rate (9% vs. 25.9%, OR 0.35 [0.18-0.67]). In addition,rates of NICU admission and major perineal trauma were lower in the exposedgroup, and other salient outcomes were not increased.
CONCLUSION: Conclusions: Nulliparous patients exposed to the activemanagement of risk in pregnancy at term experienced better outcomes thanthose that received the standard of care. These findings conflict with the long-standing belief that labor induction promotes adverse outcomes. This discrep-ancy is perhaps explained by the use, in this investigation, of labor induction ina ‘‘preventive’’ rather than ‘‘indicated’’ mode. A randomized controlled studyis needed to evaluate this new method of care.
