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OBJECTIVE: The purpose of this study was to monitor the introduction of the STAN-methodology (Noventa Medical, Moelndal, Sweden). STUDY DESIGN: This was a prospective observational study covering the total population of deliveries at term during 2 years. Four thousand eight hundred and thirty out of 14,687 term pregnancies were monitored using the STAN S 21 fetal heart monitor and the associated clinical guidelines. Cord artery metabolic acidosis, neonatal outcome, and rates of operative deliveries for fetal distress were assessed. RESULTS: The annual rate of STAN usage increased from 28.1% to 37.7% and was associated with a significant reduction in metabolic acidosis rate in the total population from 0.76% to 0.44% (P < .05). The compliance with the clinical guidelines increased in cases requiring intervention. The rates for moderate/severe hypoxic neonatal encephalopathy were consistently low, 0.55 and 0.68 per 1000 deliveries, respectively, and corresponding to previous findings. The rate of operative delivery did not change during the 2 years in the total population. CONCLUSION: Increasing STAN usage provided consistent improvements in fetal outcome equalling those noted in the Swedish randomized controlled trial (RCT) without increasing operative interventions for fetal distress.

Objective The purpose of this study was to evaluate the role of monocyte chemotactic protein-1 in cervical and amniotic fluid in women in preterm labor and with preterm premature rupture of membranes. Study design Women with singleton pregnancies (≤34 weeks) in preterm labor (n = 75 women), with preterm premature rupture of membranes (n = 47 women), and at term (n = 45 women) who were undergoing elective cesarean delivery were included. Cervical and amniotic fluid were sampled. Results Monocyte chemotactic protein-1 in cervical and amniotic fluid was higher in women in preterm labor than in women at term. Cervical monocyte chemotactic protein-1 in women in preterm labor was associated with microbial invasion of the amniotic cavity, intra-amniotic inflammation, delivery within 7 days, and at ≤34 weeks. Amniotic monocyte chemotactic protein-1 correlated to microbial invasion of the amniotic cavity in women with preterm premature rupture of membranes, intra-amniotic inflammation in preterm labor, preterm premature rupture of membranes, delivery within 7 days, and delivery at ≤34 weeks in women in preterm labor. Conclusion Monocyte chemotactic protein-1 in cervical and amniotic fluid levels are elevated in preterm labor and preterm premature rupture of membranes and correlate to intra-amniotic infection/inflammation.

OBJECTIVE: Cardiotocography plus automatic ST analysis of the fetal electrocardiography has been shown recently to reduce both the operative delivery rate for fetal distress and the cord artery metabolic acidosis rate. The purpose of this study was to analyze findings that were related to cases with a complicated/adverse neonatal outcome in the Swedish randomized controlled trial. STUDY DESIGN: Of the 4966 term fetuses that were included in the trial, all 351 newborn infants who required special neonatal care were identified. Cases of perinatal death, neonatal encephalopathy, or metabolic acidosis at birth were reviewed. RESULTS: Of the 29 fetuses with adverse/complicated neonatal outcome, 22 fetuses had cardiotocography and ST patterns that indicated a need for intervention, according to the cardiotocography plus ST clinical guidelines. The number of live-born with moderate or severe neonatal encephalopathy showed a significant decrease from 0.33% (8/2447 fetuses) in the cardiotocography-only group to 0.04% (1/2519 fetuses) in the cardiotocography plus ST group. CONCLUSION: Cardiotocography plus ST analysis provides accurate information about intrapartum hypoxia and may prevent intrapartum asphyxia and neonatal encephalopathy by giving a clear alert to the staff members who are in charge.

delivery in women with preterm labor: analysis of multiple proteins in maternal serum Panagiotis Tsiartas, Rose-Marie Holst, Ulla-Britt Wennerholm, Henrik Hagberg, David Hougaard, Kristin Skogstrand, Brad Pearce, Marian Kacerovsky, Bo Jacobsson Papageorgiou University Hospital of Thessaloniki, Obstetrics and Gynecology, Thessaloniki, Greece, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Gothenburg, Sweden, Sahlgrenska University Hospital, East, Obstetrics and Gynecology, Gothenburg, Sweden, Queen Charlottes and Chelsea Hospital, Institute of Reproductive and Developmental Biology, London, United Kingdom, Statens Serum Institut, Department of Clinical Biochemistry and Immunology, Copenhagen, Denmark, Statens Serum Institut, 3Department of Clinical Biochemistry and Immunology, Copenhagen, Denmark, Rollins School of Public Health, Epidemiology, Atlanta, GA, Univerzita Karlova Praha, Porodnicka a gynekologicka klinika FN Hradec Kralova, Praha, Czech Republic OBJECTIVE: To analyze whether specific proteins in maternal serum and the cervical length, alone or in combination, can identify the likelihood that women in preterm labor with intact membranes will deliver spontaneously within 7 days of sampling. STUDY DESIGN: We used in our study two independent cohorts of women, an exploratory cohort from 1995-2005 and a confirmatory cohort from 2008-2010 admitted to the Sahlgrenska University Hospital, Gothenburg, Sweden in preterm labor. In the exploratory cohort of 142 women in preterm labor between 22 and 33 weeks of gestation, maternal serum was collected and tested for twenty-seven proteins using multiplex xMAP technology. The women in the study provided serum samples at admission to the hospital for xMAP analysis. Individual levels of each protein were compared and calculations performed to find associations among different proteins, cervical length, and spontaneous preterm delivery within 7 days of sampling. Prediction models were created based on stepwise logistic regression. We have in a second stage applied our multivariable model in order to confirm its predictive capacity to an independent confirmatory cohort of 42 women between 23 and 33 weeks of gestation, who were admitted to the hospital in preterm labor and provided serum samples for xMAP analysis. RESULTS: We found one multivariable model through the data analysis of the exploratory cohort of women that predicts spontaneous preterm delivery within 7 days. This model was based on serum IL-10, RANTES and cervical length (sensitivity 73.8%, specificity 87.3%, positive predictive value 75.6%, negative predictive value 86.3%, likelihood ratio 5.8 and area under the curve 0.89). From the application of the multivariable model to the confirmatory cohort we found that the model had a sensitivity of 66.6%, specificity 66.6%, positive predictive value 35.3%, negative predictive value 88%, likelihood ratio 2 and area under the curve 0.66. CONCLUSION: A combination of maternal serum proteins and cervical length might help to determine whether women with preterm labor will deliver within 7 days.

Objective The purpose of this study was to investigate alterations in brain metabolism in fetuses with intrauterine growth restriction (IUGR) and evidence of cerebral redistribution of blood flow. Study Design Biometry and Doppler assessment of blood flow was assessed with ultrasound in 28 fetuses with IUGR and cerebral redistribution and in 41 appropriately grown control subjects. Proton magnetic resonance spectroscopy of the fetal brain was then performed to determine the presence of choline (Cho), creatine (Cr), N-acetylaspartate (NAA), and lactate and to generate ratios for NAA:Cho, NAA:Cr, and Cho:Cr. Results Sixty-five percent of spectra were interpretable: N-acetylaspartate, choline, and creatine peaks were identified in all these spectra; lactate was present in 5 IUGR fetuses and in 3 appropriately grown fetuses. NAA:Cr and NAA:Cho ratios were significantly lower in IUGR fetuses with cerebral redistribution. Conclusion Cerebral redistribution is associated with altered brain metabolism that is evidenced by a reduction in NAA:Cho and NAA:Cr ratios.

DETECT BIOMARKERS RELEASED IN RESPONSE TO INTRA-AMNIOTIC INFLAMMATION BO JACOBSSON, ULLA RUESCHI, ASA ROSEN, LARS RYMO, HENRIK HAGBERG, Perinatal Center, Dept Obstetrics and Gynecology, Goteborg, Sweden, Department of Clinical Chemistry and Transfusion Medicine, Department of Clinical Chemistry and Transfusion Medicine, Goteborg, Sweden OBJECTIVE: There is an urgent need to understand the pathophysiological mechanisms behind preterm birth in order to develop therapeutic and preventive strategies. Lately, evidence has grown strong for an association between intrauterine inflammation (IAI) and preterm birth in women with preterm labor (PTL) or preterm premature rupture of membranes (pPROM). In that perspective identification of novel biomarkers is of great importance. Our objective was to use a proteomic strategy, SELDI-TOF-MS, to determine whether protein profiling could reveal novel biomarkers present in cervical and amniotic fluid of PTL/pPROM patients with IAI (defined as elevated amniotic IL-6) compared to non-IAI cases. STUDY DESIGN: The study-material included amniotic fluid samples from 27 individuals with either PTL (n = 13) or pPROM (n = 14) before 34 weeks of gestation. Cervical fluid were present from those in PTL. Fourteen of the 27 women had IAI defined as elevated concentrations of IL-6 in amniotic fluid. Cervical and amniotic fluid proteins were analyzed by SELDI-TOF-MS using a strong anion array surface (Q 10) using sinapinic acid as the energy-absorbing molecule. RESULTS: Protein profiles revealed large individual variation in the amniotic fluid protein composition. However, we detected five peaks that were strongly over-expressed (P ! .0002) in amniotic fluid in IAI samples compared non-IAI samples. Four of the peaks were detected in the mass range 3400-4100 Da, the fifth peak was detected at 24 600 Da. The difference was not present regarding these five peaks in cervical fluid. CONCLUSION: Preliminary data suggest that novel biomarkers could be detected with proteomic analysis using SELDI-TOF and these proteins might S108 SMFM Abstracts

WITH PREGNANCY-RELATED PELVIC PAIN: A RANDOMISED SINGLE BLIND CONTROLLED TRIAL LARS LADFORS, HELEN ELDEN, MONIKA FAGEVIK OLSEN, HANS-CHRISTIAN OSTGAARD, HENRIK HAGBERG, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Perinatal Center, Gothenburg, Sweden, Sahlgrenska University Hospital, Department of Physiotherapy, Gothenburg, Sweden, Sahlgrenska University Hospital, Department of Orthopaedics, Gothenburg, Sweden, Sahlgrenska University Hospital, Department of Obstetrics and Gynecology, Perinatal Center, Gothenburg, Sweden, Sweden OBJECTIVE: At present, there is no cure for pelvic girdle pain (PGP) during pregnancy. The aim was to evaluate short and long-term efficacy of acupuncture and specific stabilizing exercises as adjunct to standard treatment compared to standard treatment alone on pain, days of sick leave and disability. STUDY DESIGN: In all, 386 pregnant women entered the trial after physical examination by an independent observer to confirm isolated PGP. The women were randomly assigned to standard treatment plus acupuncture (ACU), standard treatment plus specific stabilizing exercise (SSE) or to a control group (C). The main outcome measures were pain and days of sick leave. Analysis were performed by intention to treat. RESULTS: The ACU group had less pain (VAS scores) than controls in the morning (P = .0003) and in the evening (P= .0003). The differences remained during follow-up and were even more pronounced 3 months after treatment. The ACU group had lower rates in VAS compared to the SSE group (P = .0114). The SSE group, in turn, had lower rates in VAS than controls in the morning (P = .0186) and in the evening (P = .0432). We found no differences regarding sick leave at any time. No adverse effects of the treatments were recorded. CONCLUSION: Acupuncture as well as specific stabilizing exercises constitutes efficient complements to standard treatment to reduce pain and discomfort and improve the ability to perform daily activities among pregnant women with isolated PGP. Acupuncture alleviates PGP more effectively than specific stabilizing exercise or standard treatment.

ULATION-BASED STUDY JUN ZHANG, BRADY HAMILTON, JOYCE MARTIN, ANN TRUMBLE, National Institutes of Health, Epidemiology Branch, Bethesda, MD National Center for Health Statistics, Hyattsville, MD National Institutes of Health, Bethesda, MD OBJECTIVE: The number of multifetal pregnancies has increased dramatically. Cases such as premature rupture of the membranes of one fetus, single fetal demise, and premature labor in extreme preterm are encountered more often than before. Delaying delivery of the remaining fetus(es) is feasible in some cases. However, benefits and risks of this procedure have yet to be established. STUDY DESIGN: We used the U.S. 1995-98 Matched Multiple Birth File to examine infant survival after delayed interval delivery. We identified 200 twin pregnancies in which the first twin was delivered between 17 and 29 weeks of gestation and the second twin was delivered at least 24 hours later. We individually matched the delayed deliveries with 374 twin pregnancies in which delivery of second twin was not delayed. Perinatal outcomes and infant survival were compared between the delayed and non-delayed twins. RESULTS: Among the 200 pregnancies with delayed delivery, the mean gestational age at first delivery was 23 weeks and the median duration of delay was 6 days (ranging from 2 to 107 calendar days). With every week of delay in delivery, the fetus gained 131 grams on average (95% CI: 115-147 g). 56% of the delayed second twins survived to 1 year of age (95% CI: 50-64%) while only 24% of the non-delayed second twins did so (95% CI: 20-29%) (P < 0.001). The delayed twins also had significantly higher Apgar scores at 5 minutes. However, delayed delivery was also associated with 11% of risk (95% CI: 6-16%) for fetal death of the remaining twin before 24 weeks. CONCLUSION: Delaying delivery of the remaining fetus(es) before 30 weeks of gestation improves infant survival by more than twofold and, probably, reduces long-term child morbidity by increasing birthweight and Apgar score at 5 minutes.

45 46 CEREBRAL PALSY IS STRONGLY ASSOCIATED WITH SEVERE INTRAUTERINE GROWTH RESTRICTION IN TERM BUT NOT IN PRETERM CASES BO JACOBSSON, ANDRE FRANCIS, GUDRUN HAGBERG, HENRIK HAGBERG, JASON GARDOSI, Perinatal Center, Goteborg, Sweden West Midlands Perinatal Institute, Birmingham, United Kingdom Dept. of Pediatrics, Goteborg, Sweden OBJECTIVE: To evaluate the association between fetal growth and the development of cerebral palsy (CP) in term and preterm infants. STUDY DESIGN: We studied a population-based cohort of singleton children with CP (n = 334) and a matched (gender, gestational age, delivery ward) control group (n = 668) born between 1983 and 1990. Gestational age was determined on the basis of an early ultrasound scan in 97% of the patients. Growth status was assessed by using customized percentiles based on Swedish population, and cut-off values of < 1st centile and 1st to 5th centiles were used to define intrauterine growth restriction (IUGR) . RESULTS: Out of a total of 334 cases, 116 (35%) were preterm ( < 37 weeks) and 218 (65%) were born at term. Children with CP who were preterm did not have an increased risk of IUGR ( < 1st centile: OR 0.9, CI 0.4-2.0). In contrast, children with CP who were born at term were more likely to have a history of severe IUGR ( < 1st centile: OR 8.2, CI 3.0-22.6). The association applied in similar measure to the two main diagnostic CP categories at term: hemiplegia (n = 98), OR 11.7 (2.5-54.8) and diplegia (n = 66), OR 12.1 (CI 1.4-107.1). For IUGR cases between the 1st and 5th centiles, the association with CP in term births was not as strong but was significant (OR 1.9, CI 1.0-3.6). CONCLUSION: Children with severe IUGR at term have an 8-fold higher risk of CP. In contrast, preterm infants suffering from IUGR were not at risk. These findings highlight the need for close antenatal monitoring of fetal growth. December 2003 Am J Obstet Gynecol S74 SMFM Abstracts

WITH PERIVENTRICULAR LEUCOMALACIA BO JACOBSSON, GUDRUN HAGBERG, HENRIK HAGBERG, Perinatal Center, Goteborg, Sweden Dept. of Pediatrics, Goteborg, Sweden OBJECTIVE: Previous studies have investigated maternal infection during delivery as a possible risk factor for cerebral palsy (CP) in term infants. Infants born at term with diagnosed CP and periventricular leukomalacia (PVL) have, however, been excluded. The aim of this study was to investigate the relationship between maternal infections during pregnancy and PVL combined with CP in the offspring. STUDY DESIGN: A population-based case-control study. Term infants with CP and PVL (CP/PVL) (n = 44) born in 1983-94 were included and matched with a control group (n = 88). All records were scrutinized for any infectious disease or use of antibiotics during pregnancy. Cystic and atrophic PVL were diagnosed by a computed tomographic scan. RESULTS: Mothers with any event of infectious disease noted in their records had an increased risk of having a child with CP/PVL (19/44 cases, 21/88 controls [OR 2.42 {1.12-5.25}]), and if the mothers had suffered any event of amore serious infectious disease during pregnancy, they had an even higher risk (6/44 cases, 1/88 controls [OR 13.74 {1.60-118}]). Apgar score < 7 at 1, 5, or 10 minutes did not constitute a risk factor for CP in this particular subgroup of infants. CONCLUSION: Infection in pregnant women was significantly associated with CP/PVL in term infants, especially in those pregnancies complicated by a more severe maternal infection. In spite of a previously demonstrated close correlation between Apgar score at birth and unexplained CP in term infants, depressed viability at birth did not confer an increased risk of CP/PVL. Speculatively, maternal infection during late mid-pregnancy may inflict fetal white matter injury, but not preterm birth, resulting in PVL/CP in infants born at term without signs of intrapartal asphyxia.

A prospective study was undertaken to evaluate the risk of uterine rupture or dehiscence after cesarean section. During the 10 years of the study, 24,644 patients were delivered of infants. Of these women, 2036 (8.3%) had previously undergone cesarean section. A trial of labor was allowed in 1008 of these patients, and 92.2% were delivered vaginally. The incidence of uterine rupture in this trial of labor group was 0.6%, compared with 0.4% in the total group. Cesarean section scar rupture caused no serious complications in either the mothers or the offspring in the trial of labor group. Uterine rupture in this group was not associated with use of oxytocin or epidural analgesia. Patients with lower-segment scar rupture had no history of puerperal pyrexia. The incidence of uterine dehiscence was 4%. In summary, the risk of uterine rupture in patients who have previously undergone cesarean section but are allowed a trial of labor is low and not associated with serious complications. Vaginal delivery is therefore considered the safest route of delivery in these patients. (Am J Obstet Gynecol 1989;160:569-73.)