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166: Prediction model of the integrated risk for emergent intrapartum cesarean delivery in growth restricted fetuses

2016, American Journal of Obstetrics and Gynecology

Poster Session I risk of cesarean delivery. Outcomes included stillbirth, late preterm birth, cesarean delivery, maternal death, shoulder dystocia, permanent brachial plexus injury, neonatal death, and cerebral palsy. All probabilities were derived from the literature. Quality-adjusted life years (QALYs) were calculated to compare strategies, accounting for maternal and neonatal utilities. RESULTS: Third-trimester US screening for growth abnormalities would prevent 43 stillbirths, 75 cases of shoulder dystocia, 3 permanent brachial plexus injuries, and 34 cases of cerebral palsy compared to fundal height screening. However, it would also increase late preterm births by 2,191 and cesarean deliveries by 4,831, ultimately leading to 6 more neonatal deaths. Further, it is not costeffective at $197,416.56 per QALY. Despite this, third-trimester US was ultimately the more effective strategy, as it maximized total QALYs. Multivariate sensitivity analyses showed that fundal height screening remained cost-effective until US sensitivities and specificities for LGA and SGA approached 80%. CONCLUSION: While third-trimester US screening for growth abnormalities prevents stillbirth in SGA and shoulder dystocia and its downstream injuries in LGA, due to increased risk of late preterm birth and cesarean deliveries it is not cost-effective compared to fundal height measurement. Further analyses, and ultimately a prospective trial, are needed to better elucidate these findings. ajog.org 166 Prediction model of the integrated risk for emergent intrapartum cesarean delivery in growth restricted fetuses Enav Yefet, Maisoon Badusi, Irit Davidzon-Friedman, Raed Salim, Eliezer Shalev, Zohar Nachum 1 Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel, 2Rappaport Faculty of Medicine, Technion, Haifa, Israel OBJECTIVE: To analyze risk factors and to develop a prediction model for emergent intrapartum cesarean delivery (ICD) due to non reassuring fetal heart rate monitoring (NRFHRM) in intrauterine growth restricted (IUGR) fetuses. STUDY DESIGN: All women from 34 weeks of gestation who delivered a singleton small for gestational age (SGA) neonate (below the 10thweight percentile) during 2005-2012 were retrospectively analyzed. Abnormal Doppler flows, contraindication for vaginal delivery, premature rupture of membranes, previous CS or NRFHRM before delivery were excluded. Risk factors were integrated using a multiple stepwise logistic regression model to predict the estimated risk for ICD due to NRFHRM. RESULTS: Four hundred and forty four SGA gestations were analyzed. Of them 387 (87%) women delivered vaginally and 57 women (13%) underwent ICD due to NRFHRM. The ICD due to NRFHRM group had a higher incidence of primiparity, preeclampsia, oligohydramnios and preterm delivery compared to the group delivered vaginally in a univariate analysis (table). Primiparity, preeclampsia and oligohydramnios were independent risk factors for ICD due to NRFHRM in stepwise multiple logistic regression model. A prediction model was calculated (C statistics 75%, P-value<0.001) according to which, when all 3 risk factors were present the estimated probability for ICD due to NRFHRM was as high as 78%, whereas the risk was only 4% when none of the risk factors was present (figure).Similar results were obtained when a group of suspected IUGR fetuses (i.e some of them were eventually appropriate for gestational age) was analysed in a similar way. CONCLUSION: The risk for ICD due to NRFHRM is significantly influenced by coexisting risk factors that act synergistically. This information should be shared with the patient and assists the physician in the management of pregnancies complicated with growth restriction. S106 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2016 Poster Session I ajog.org 168 Levels of adipokines in amniotic fluid at the time of delivery in dichorionic-diamniotic twins discordant for fetal growth Seung Mi Lee, Joong Shin Park, Errol R. Norwitz, Sumin Oh, Sun Hye Yang, Sun Young Jung, Sun Min Kim, JoonHo Lee, Chan-Wook Park, Byoung Jae Kim, Jong Kwan Jun 1 Seoul National University College of Medicine, Seoul, Korea, Republic of, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea, Republic of, 3Tufts University School of Medicine, Boston, MA 2 OBJECTIVE: Adipokines are cytokines secreted by adipose tissue that 167 What is the yield of the work-up done in cases of Intrauterine Growth Restriction? Rivka Sukenik Halevy, Adi Katz, Rivka Regev, Tal Biron Shantal 1 genetic Institute and OB-GYN department, Meir Medical Center. Sackler School of Medicine, Tel Aviv University, Kfar Saba, Israel, 2Sackler School of Medicine, Tel Aviv University, Sackler School of Medicine, Tel Aviv University, Israel, 3Department of pediatrics, Meir Medical Center. Sackler School of Medicine, Tel Aviv University, Kfar Saba, Israel OBJECTIVE: Intra-Uterine Growth Restriction (IUGR) is associated with different etiologies. The work-up preformed in these cases is targeted to determine the cause for IUGR and the existence of additional abnormalities. We opted to study the yield of tests performed as part of the routine work-up in IUGR pregnancies and the outcome of these pregnancies STUDY DESIGN: This retrospective study included a cohort of IUGR pregnancies (defined as estimated fetal eight below the 10th percentile) detected in Meir medical center during a two year period .Data regarding the work-up performed in these pregnancies including serology for infectious factors, genetic testing (karyotype, chromosomal microarray, FGFR3 mutations) and imaging (anatomical scan, fetal echocardiography) were retrieved from patient charts. We also evaluated data regarding medical problems which were diagnosed in the postnatal period. RESULTS: 198 IUGR pregnancies were included in our cohort; 72% were cases of isolated IUGR .The average gestational age at diagnosis was 33  5.6 weeks. In 80% at least some work-up done. Genetic counseling was performed in 42%; in 28% a karyotype was performed and in 2% CMA testing was done. No abnormalities were detected in genetic testing preformed prenatally. Echocardiogram preformed in 13.7% was abnormal in 4 cases (15.4%). Serological testing which was performed in 75.8% detected a CMV infection in one case (0.7%). Overall prenatal work-up was positive in 2.5% of pregnancies with IUGR. Ten newborns (5.1%) were diagnosed with a significant health problem after birth. There was one case of Down syndrome and one case Prader willi syndrome which were diagnosed postpartum. The rate of positive findings and the presence of significant problems after birth were not correlated with the severity of IUGR, the week of diagnosis, the symmetry or with obstetrical history. CONCLUSION: The cost-effectiveness of the tests performed as part of the work-up in IUGR pregnancies is not clear. The test with the highest yield is probably the fetal echocardiogram. The rate of significant problems after birth is increased in IUGR pregnancies. modulate metabolic processes. Although the role of adipokines in fetal growth is not well understood, we have previously reported that concentrations of adiponectin and leptin are elevated in midtrimester amniotic fluid(AF) collected from the smaller compared with the larger fetus in dichorionic-diamniotic(DCDA) twin pairs discordant for growth [Am J Obstet Gynecol 2015;212:S870]. To determine the longitudinal changes of adipokine concentrations throughout pregnancy, we compared the concentrations of adipokines in AF at birth of discordant DCDA twin pairs. STUDY DESIGN: The study population consisted of discordant DCDA twins (birth weight difference >10%) whose AF were retrieved at the time of cesarean delivery. Samples were analyzed for selected chemokines (Complement Factor D/Adipsin, Serpin E1/PAI-1, Adiponectin/Acrp30, C-Reactive Protein [CRP], CCL2/MCP-1, Leptin, Resistin) using LuminexÒ Performance Assay multiplex kits. Data were analyzed using Wilcoxon signed rank test. RESULTS: A total of 39 twin pairs were enrolled. Concentrations of adiponectin and leptin in AF at birth were not significantly different between discordant twin pairs (see Table); however, the concentration of serpin E1 was significantly higher in AF collected from the smaller compared with the larger twin. This difference remained significant after adjustment for birth order and fetal sex. CONCLUSION: In discordant DCDA twins (a model system that controls for confounding environmental factors affecting fetal growth such as maternal obesity and gestational diabetes), the concentration of serpin E1 was significantly elevated in the AF of the smaller babies at birth. Serpin E1 may be an important adipokine for fetal programming of subsequent metabolic complications, because prior data suggest that elevated levels of serpin E1 may lead to metabolic syndrome in adults. 169 Is a history of preeclampsia associated with an increased risk of small for gestational age in a future pregnancy? Anna Palatnik, William A. Grobman, Emily S. Miller 1 Northwestern University, Feinberg School of Medicine, Chicago, IL OBJECTIVE: A history of preeclampsia is associated with an increased risk of preeclampsia in future pregnancy. However it is unclear whether women with prior preeclampsia are at increased risk of small for gestational age (SGA) in a subsequent pregnancy without Supplement to JANUARY 2016 American Journal of Obstetrics & Gynecology S107