STUDY DESIGN: We did a case control study enrolling 4498 normal pregnan- cies, of whom 346 delivered before 37 weeks (cases) and the remaining at term.
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LONG TERM MATERNAL OUTCOME OF HELLP SYNDROME MOUNIRA HABLI1, NAHID EFTEKHARI2, EMILY WIEBRACH2, MARAM KHABBAZ3, ANNETTE BOMBRYS1, HELEN HOW1, BAHA SIBAI1, 1University of Cincinnati, Cincinnati, Ohio, 2University of Cincinnati, College of Medicine, Cincinnati, Ohio, 3Bethesda North Hospital, Departement of Family Medicine, Ohio OBJECTIVE: To evaluate subsequent pregnancy outcome and long-term prognosis after HELLP syndrome. STUDY DESIGN: 128 patients with a history of HELLP syndrome were followed from 1-31 years (average 5). These patients were asked to fill out questionnaires and send their medical records. Outcome variables included maternal demographics, results of index pregnancy, outcomes of subsequent pregnancies and long-term maternal morbidity. Data are presented as mean standard deviation or as n(%). RESULTS: Among 128 patients, 82% were Caucasian with a mean age 30.5⫾4.4 years(range 18-41) at index pregnancy. 81% had cesarean at mean gestational age (GA) 32.6⫾5.1 weeks. 34% had blood products transfusion,38% were admitted to ICU,2% had liver failure and 3% required dialysis at index pregnancy. On follow up 50 women had subsequent pregnancies: table below summarizes outcome in subsequent pregnancy and maternal long term outcome. Birth control pills (27%) was the most common method of contraception followed by vasectomy(14%). During follow up, 5% of infants had attention deficit disorder and 8% had developmental delay. CONCLUSION: Patients with a history of HELLP syndrome are at increased risk for recurrent preeclampsia and HELLP syndrome as well as increased long-term morbidities particularly depression and chronic hypertension. This data is important for patient counseling.
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BIOCHEMICAL AND ULTRASOUND MARKERS TO PREDICT FETAL OUTCOME IN PREGNANCIES COMPLICATED BY GESTATIONAL DIABETES MELLITUS STEFANO CECCHI1, STEFANORAFFAELE GIANNUBILO2, VALERIA BEZZECCHERI1, ELISA CARBONI3, BEATRICE LANDI4, GIOVANNA BATTISTONI5, ANDREA TRANQUILLI6, 1Marche Polytechnic University, Maternal and Child Sciences, Ancona, Italy, Italy, 2Marche Polytechnic University, Maternal and Child Sciences, Ancona, Marche, Italy, 3Marche Polytechnic University, Institute of Maternal and Child Sciences, Ancona, Italy, 4 Marche Polytechnic University, Maternal and Child Sciences, Ancona, Italy, 5 Marche Polytechnic University, Maternal and Child Sciences, Italy, 6Society for Maternal-Fetal Medicine, Ancona, Italy OBJECTIVE: To investigate the risk of perinatal outcomes based on metabolic and ultrasound markers in women with Gestational Diabetes Mellitus (GDM). STUDY DESIGN: Sixty women affected by GDM (34 women on diet only treatment and 26 women with on insulin treatment), were compared to 30 pregnant controls normoglycemic and comparable for age and gestational age at delivery. Neonatal plasma samples were performed to measure baby insulin levels. Multivariate analysis was performed for intrapartum complications, neonatal polycythemia, itterus and hypoglycemia; independent variables included: prepregnancy BMI, fasting glycaemia, the oral glucose tolerance test - area under the curve (OGTT-AUC), weight gain during pregnancy, ultrasound fetal abdominal thickness and need for insulin therapy. All the women recruited had a normal 24-h glucose profile. RESULTS: Neonatal insulin levels were higher in GDM than in controls (9.2 ⫾ 2 vs 5.8 ⫾ 1.4 microUI/ml; p⬍0.001) but were significantly lower in diet-treated GDM versus insulin-treated GDM (6.4 ⫾ 2.7 vs 11.2 ⫾ 1.6 microUI/ml; p⬍0.001 ). In multivariate analysis the factors significantly contributing to perinatal outcomes were the OGTT-AUC ⬎ 320 (OR: 2.4; 1.2-4.8 CI), fetal abdominal thickness ⬎ 95°percentile (OR: 4.2; 2.2-8.3 CI), the need of insulin therapy (OR: 6.1; 4.1-9.4 CI). CONCLUSION: During gestational diabetes although in presence of a normal 24-h glucose profile, other parameters, achievable in a noninvasive and reproducible fashion, may predict the fetal metabolism status and the potential resulting perinatal morbidity. 0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.796
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.794 766 764
IS ULTRASOUND FETAL WEIGHT ESTIMATION USEFUL TO PREDICT PRETERM BIRTH? FILIBERTO M. SEVERI1, CATERINA BOCCHI1, MICHELA TORRICELLI1, CHIARA FERRATA1, CHIARA CANCEMI1, PASQUALE FLORIO1, FELICE PETRAGLIA1, 1University of Siena, Department of Pediatrics, Obstetrics & Reproductive Medicine, Siena, Italy, Italy OBJECTIVE: The correlation between prematurity and low fetal growth, as occurs in intrauterine growth retardation (IUGR) fetuses, has been widely investigated. It was suggested that sub-optimal intrauterine growth is associated to preterm delivery and therefore that fetuses at risk of preterm labor are smaller than gestational age (GA) matched controls. We evaluated whether in pregnancies not affected by diseases impacting fetal growth, a fetal weight estimation (EFW) lower than a ROC curve established cut-off, could be a useful clinical predictor of preterm birth. STUDY DESIGN: We did a case control study enrolling 4498 normal pregnancies, of whom 346 delivered before 37 weeks (cases) and the remaining at term (control group, 1:12 ratio). Inclusion criteria: singleton pregnancy, 1st trimester dating, spontaneous delivery. Exclusion criteria: IUGR, fetal anomalies, any preexistent/pregnancy-induced maternal pathology. EFW was calculated by ultrasounds using the Hadlock formula, and converted to multiple of median (MoM) for each gestational age. The Receiving Operator Characteristic Curve (ROC curve) analysis was used to determine the best predictive cut-offs. RESULTS: EFW MoM was significantly lower in fetuses delivered preterm than in who did not (P ⬍0.0001). At a cut-off of 0.90 MoM (AUC 0.695, 95% CI 0.6810.708) EFW achieved a sensitivity of 51.2% (95% CI 45.8-56.5), a specificity of 82.9% (95% CI 81.7-84.0), LR⫹ of 2.98 (95% CI 2.7-3.3), LR- of 0.59 (95% CI 0.5-0.7) as single marker for preterm birth. The pre-test probability of preterm delivery was 7.7%, whilst after EFW cut-off computation the probability of the disease (positive predictive value) was 19.9% with a negative predictive value (i.e. the probability to be free of the disease) of 95.2%. CONCLUSION: Fetuses delivered prematurely have a low EFW: at the cut-off of 0.90 MoM EFW determination allowed to detect, with good specificity, a group of fetuses more susceptible to be born prematurely, but mainly patients at low-risk of the disease.
EVIDENCE FOR PARTICIPATION OF HIGH MOBILITY GROUP BOX 1 PROTEIN (HMGB1) IN ACTIVATION OF RECEPTOR FOR ADVANCED GLYCATION END-PRODUCTS (RAGE) AND TOLL-LIKE RECEPTOR (TLR) SYSTEMS IN WOMEN WITH SEVERE PREECLAMPSIA MARGARET A. BAUMBUSCH1, CATALIN S. BUHIMSCHI1, GUOMAO ZHAO1, STEPHEN THUNG1, EMILY A. OLIVER2, IRINA A. BUHIMSCHI1, 1Yale University, Ob/Gyn & Reprod Sci, New Haven, Connecticut, 2King’s College London, Women’s Health, London, United Kingdom, United Kingdom OBJECTIVE: HMGB1 is a pleiotropic, non-histone nuclear protein. Intracellular HMGB1 binds DNA and regulates transcription. Compelling evidence suggests that extracellular HMGB1 engages RAGE as well as TLR2 & 4 to activate innate immunity, elevate cytokine levels and induce cell death. The objective of this study was to evaluate changes in maternal blood and urine HMGB1 concentrations in women with severe preeclampsia (sPE), a condition characterized by both RAGE and TLR activation. STUDY DESIGN: In a case control study we analyzed time-matched serum and urine samples from 118 women with either sPE (n⫽79, GA: 31 [22-36] wks) or uncomplicated pregnancies delivered at term (CRL n⫽39, GA: 30 [21-34] wks). Levels of HMGB1, TNF (marker of TLR activation) and soluble RAGE (marker of RAGE activation) were measured by sensitive and specific immunoassays. Fractional excretion of HMGB1 was calculated and urinary analytes normalized for creatinine or fractional excretion of total protein. Data was further analyzed by presence or absence of end-organ disease: eclampsia (n⫽5), HELLP (n⫽20) and/or IUGR (n⫽18). Non-parametric statistics were used. RESULTS: 1) Urine but not serum HMGB1 levels were significantly elevated in sPE (P⬍0.001), independent of GA; 2) The fractional excretion of HMGB1 was significantly increased in sPE as compared to CRLs (P⬍0.001), after correction for proteinuria; 3) HMGB1 urinary excretion correlated with circulating soluble RAGE (r⫽0.402, P⬍0.001) and TNF (r⫽0.336, P⫽0.003); 4) Women with eclampsia and/or HELLP had elevated urine HMGB1 concentrations and fractional excretions compared to those with sPE but no end-organ disease or IUGR (P⬍0.001). CONCLUSION: Our results suggest HMGB1 may play a role in RAGE and TLR systems activation in women with sPE. The fractional excretion of HMGB1 is significantly increased in sPE and relates to disease severity. The elevated excretion but lack of detectable change in serum may be consequent to HMGB1=s increased nephritic production or its hydrophobic nature and adherence to vascular endothelium.
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.795
0002-9378/$ - see front matter doi:10.1016/j.ajog.2008.09.797
Supplement to DECEMBER 2008 American Journal of Obstetrics & Gynecology
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