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Background Many women who intend to use long-acting, reversible contraceptives (LARCs) postpartum do not follow through with initiating use. The objectives of this study were to determine whether support from a contraceptive personal assistant could increase the uptake of LARCs by 3 months postpartum, and to identify risk factors for nonuptake of LARCs among women who planned LARC use. Study Design This is a randomized, controlled trial of 50 low-income postpartum women who desired LARC. The intervention group received telephone contact from a personal assistant who provided contraception education, facilitation of insurance coverage, appointment scheduling and assistance with childcare and transportation. The control group received routine follow up. Women were surveyed immediately and 3 months postpartum regarding contraceptive use and anticipated barriers to LARC use. Results A similar proportion of women in both groups received LARC [control 16/24 (67%), intervention 18/25 (72%), p= .76]. More primiparous (86.4%) than multiparous (55.5%) women obtained LARC (p=.04). In addition, women with more prenatal visits were more likely to have initiated LARC (odds ratio, 95% confidence interval for each increased visit: 1.50, 1.15–1.96). No other demographic factors were related to LARC uptake. Conclusions Providing telephone assistance to help navigate barriers did not increase postpartum uptake of LARCs. A personal history of clinic visit no-shows and/or infrequent prenatal visits were related to poor uptake of LARCs postpartum.

ObjectivesPeripherally inserted central catheters (PICCs) may be complicated by upper extremity (UE) superficial (SVT) or deep venous thrombosis (DVT). The purpose of this study was to determine current PICC insertion patterns and if any PICC or patient characteristics were associated with venous thrombotic complications.MethodsAll UE venous duplex scans during a 12-month period were reviewed, selecting patients with isolated SVT or DVT and PICCs placed ≤30 days. All UE PICC procedures during the same period were identified from an electronic medical record query. PICC-associated DVTs, categorized by insertion site, were compared with all first-time UE PICCs to determine the rate of UE DVT and isolated UE SVT. Technical and clinical variables in patients with PICC-associated UE DVT also were compared with 172 patients who received a PICC without developing DVT (univariable and multivariable analysis).ResultsWe identified 219 isolated UE SVTs and 154 UE DVTs, with 2056 first-time UE PICCs placed during the same period. A PICC was associated with 44 of 219 (20%) isolated UE SVTs and 54 of 154 UE DVTs (35%). The rates of PICC-associated symptomatic UE SVT were 1.9% for basilic, 7.2% for cephalic, and 0% for brachial vein PICCs. The rates of PICC-associated symptomatic UE DVT were 3.1% for basilic, 2.2% for brachial, and 0% for cephalic vein PICCs (χ2 P < .001). Univariate analysis of technical and patient variables demonstrated that larger PICC diameter, noncephalic insertion, smoking, concurrent malignancy, diabetes, and older age were associated with UE DVT (P < .05). Multivariable analysis showed larger catheter diameter and malignancy were the only variables associated with UE DVT (P < .05).ConclusionsThe incidence of symptomatic PICC-associated UE DVT is low, but given the number of PICCs placed each year, they account for up to 35% of all diagnosed UE DVTs. Larger-diameter PICCs and malignancy increase the risk for DVT, and further studies are needed to evaluate the optimal vein of first choice for PICC insertion.

Fibromyalgia is a difficult-to-treat chronic pain syndrome that affects 2% of the US population. Pregabalin is an antiepileptic recently FDA approved for fibromyalgia treatment. Other antiepileptics have been suggested for treatment. This systematic review examines the relative benefits and harms of antiepileptic drugs in the treatment of fibromyalgia. A literature search was conducted and 8 studies matched criteria (7 studies of pregabalin, 1 of gabapentin). Both drugs reduced mean pain scores more than placebo at a modest rate (pregabalin, 38% to 50%; gabapentin, 51%). In a 6-month trial of pregabalin responders, 32% continued to have response at 6 months, with a mean time to loss of response of 34 days. Compared to placebo, the drugs had similarly high rates of adverse events and withdrawals. Without a head-to-head trial it is not possible to conclude if 1 antiepileptic is more effective or harmful than the other, although limited evidence suggests potential differences. Future studies must directly compare the drugs, include a more broadly defined population, examine long term benefits and harms, and include cointerventions. We conclude that pregabalin and gabapentin are modestly effective for the treatment of fibromyalgia but that their long-term safety and efficacy remain unknown. Perspective This systematic review evaluates the benefits and harms of using the antiepileptic drugs gabapentin and pregabalin for the treatment of fibromyalgia. Conclusions from this paper can help clinicians to more effectively treat the pain associated with fibromyalgia.

The objective of the study was to examine the impact of chronic hypertension and pregestational diabetes on pregnancy outcomes.This was a retrospective cohort study of 532,088 women undergoing singleton births in California in 2006. Women were categorized into chronic hypertension, pregestational diabetes, both, or neither. Pregnancy outcomes were compared using the χ(2) test and multivariable logistic regression to control for potential confounders.We identified differences in perinatal outcomes between the groups. The rate of preterm birth in women with both conditions was 35.5% versus 25.5% in women with chronic hypertension versus 19.4% in women with pregestational diabetes (P.001). The rate of small for gestational age was 18.2% in women with both versus 18.3% in women with chronic hypertension versus 9.7% in women with pregestational diabetes (P.001).The impact of having both chronic hypertension and pregestational diabetes in pregnancy varies, depending on the outcome examined. Although some had an additive effect (eg, stillbirth), others did not (eg, preeclampsia).

2 hour glucose tolerance test vs the 1 hour glucose challenge test: a cost-effectiveness analysis John Mission, Mika Ohno, Keenan Yanit, Yvonne Cheng, Aaron Caughey Oregon Health & Science University, Obstetrics & Gynecology, Portland, OR, Santa Clara Valley Medical Center, Obstetrics and Gynecology, San Jose, CA, Oregon Health & Science University, Department of Obstetrics and Gynecology, Portland, OR, University of California, San Francisco, Department of Obstetrics, Gynecology & Reproductive Sciences, San Francisco, CA OBJECTIVE: The IADPSG recently recommended more inclusive screening criteria for gestational diabetes (GDM) using the 2-hour glucose tolerance test (2hGTT). This study examines the cost-effectiveness of screening with the 2hGTT using these criteria versus the 50g 1-hour glucose challenge test (GCT) with cutoff of 140 mg/dl, accounting for costs and benefits associated with GDM screening, diagnosis, and treatment. STUDY DESIGN: A decision analytic model was built using TreeAge software comparing routine screening using the new 2hGTT vs. the 1-hour GCT. Outcomes included preeclampsia, mode of delivery, maternal death, macrosomia, shoulder dystocia, brachial plexus injury (permanent and transient), hypoglycemia, hyperbilirubinemia, and neonatal death. All costs and benefits were derived from the literature. Less than $100,000 per QALY gained was considered costeffective. Baseline assumptions included a 4% incidence of GDM using the sequential regimen and an additional 15% of patients diagnosed with GDM under the new 2h GTT criteria. One-way sensitivity analyses were used to examine cost-efficacy over a wide range of baseline GDM rates as well as rates of new GDM diagnosis under the new 2h GTT criteria. RESULTS: Screening with the 2h GTT was cost-effective. This strategy was more costly ($2943.33 per patient for the 2h GTT vs $2818.83 per patient for the 1h GCT) but more effective (56.954185 QALYs for the 2h GTT vs 56.951726 for the 1h GCT), with an incremental costeffectiveness ratio of $50,630.34/QALY. In a one-way sensitivity analysis, the more inclusive IADPSG diagnostic approach remained costeffective as long an additional 1.7% or more of patients were diagnosed and treated for GDM. CONCLUSION: Screening at 24-28 weeks GA under the new IADPSG guidelines with the 2h GTT is cost-effective in improving maternal and neonatal outcomes. How the health care system will provide this expanded care to this group of women will need to be examined. 258 Treating patients in HAPO glucose category 5 to improve maternal and neonatal outcomes: a cost effectiveness analysis John Mission, Mika Ohno, Keenan Yanit, Rachel Pilliod, Yvonne Cheng, Aaron B Caughey Oregon Health & Science University, Obstetrics & Gynecology, Portland, OR, Santa Clara Valley Medical Center, Obstetrics and Gynecology, San Jose, CA, Oregon Health & Science University, Department of Obstetrics and Gynecology, Portland, OR, Oregon Health and Science University, Oregon Health and Science University School of Medicine, Portland, OR, University of California, San Francisco, Department of Obstetrics, Gynecology & Reproductive Sciences, San Francisco, CA OBJECTIVE: The HAPO study demonstrated a linear relationship between maternal hyperglycemia and adverse maternal and neonatal outcomes. Subjects were divided into seven categories according to fasting 2-hour glucose tolerance test results. Category 5 included patients between the top 3% and 12% of fasting glucose levels, consistent with marginal patients who would be diagnosed with Gestational Diabetes under the new IADPSG recommendations. This study examines the cost-effectiveness of treating patients in HAPO Category 5 as gestational diabetics, accounting for the costs and benefits associated with the consequences of hyperglycemia in pregnancy. STUDY DESIGN: A decision analytic model was built using TreeAge software that compared treating vs. not treating patients in HAPO Category 5. Outcomes included preeclampsia, mode of delivery, maternal death, macrosomia, shoulder dystocia, brachial plexus injury (permanent and transient), hypoglycemia, hyperbilirubinemia, and neonatal death. All costs and benefits were derived from the literature. Existing randomized controlled trials were used to estimate the effect of treatment on said outcomes. In addition, an index adjusting for treatment efficacy was used for sensitivity analysis. Utilities were applied to discounted life expectancy at a discount rate of 3% to generate Poster Session II Diabetes, Labor, Medical-Surgical-Disease, Obstetric Quality & Safety, Prematurity, Ultrasound-Imaging www.AJOG.org

additional factors increase risk of BPI? Katherine A Volpe, Yvonne W Cheng, Jonathan Snowden, Keenan E Yanit, Rachel Pilliod, Aaron Caughey Oregon Health & Science University, Department of Obstetrics and Gynecology, Portland, OR, University of California, San Francisco, Department of Obstetrics, Gynecology & Reproductive Sciences, San Francisco, CA, Oregon Health and Science University, Department of Obstetrics and Gynecology, Portland, OR OBJECTIVE: To examine birthweight and other predictors of brachial plexus injury (BPI) in women with shoulder dystocia. STUDY DESIGN: A retrospective cohort study of term pregnancies complicated by shoulder dystocia in California. Birthweight was the primary predictor examined. Univariate and multivariate analysis were performed on the relationship between birthweight and BPI, controlling for maternal race/ethnicity, age, parity, gestational diabetes and operative vaginal delivery. RESULTS: This study included 5,702 deliveries complicated by shoulder dystocia, of which 258(4.5%) resulted in BPI. The incidence of BPI with shoulder dystocia was 0% in neonates 25002999g, 2.8% in neonates 30003499g, 3.5% in neonates 35003999g, 5.4% in neonates 40004499g, 8.1% in neonates 45004999g and 12.8% in neonates 5000g (p 0.001). The association beween birthweight and BPI in women with a shoulder dystocia remained significant regardless of advanced maternal age (p 0.001), nulliparity(p 0.004) and operative delivery(p 0.009). Table 1 depicts a multivariate analyses of race, birtweight, and clinical risk factors for BPI in women with shoulder dystocia (n 5227). When controlling for potential confounders, increasing birthweight was associated with an increasing risk of BPI in women with a shoulder dystocia when compared to 3000-3499g birthweight (4000-4499, AOR 4.22, 95% CI 2.35-7.55, 4500-4999g AOR 6.51, 95% CI 3.41-12.41, 5000g AOR 8.92 95% CI 3.49-22.77). CONCLUSION: Increasing birthweight increases the risk of BPI in women with a shoulder dystocia independent of advanced maternal age, race, parity, induction of labor or operative vaginal delivery. 298 Factors influencing the accuracy of clinical estimation of fetal weight in term pregnancies Katherine Goetzinger, Anthony Odibo, Anthony Shanks, Kimberly Roehl, Alison Cahill Washington University in St. Louis, Department of Obstetrics and Gynecology, St. Louis, MO OBJECTIVE: The inherent subjective element of Leopold maneuvers for estimating fetal weight weakens it as a clinical tool. Clinical factors such as maternal discomfort in labor and progressive descent of the fetal head with advancing gestational age (GA) may further differentially impact the accuracy of clinical estimation of fetal weight (EFW). We aimed to evaluate whether clinical characteristics at the time of admission further reduce the accuracy of clinical EFW in term pregnancies. STUDY DESIGN: A retrospective cohort study of consecutive patients who presented for labor at 37 weeks gestation over a 4 year time period. Clinical EFW was performed using Leopold maneuvers at the time of admission. Patients with an ultrasound EFW were excluded. A Pearson correlation coefficient (r) was used to evaluate the linear relationship between clinical EFW and actual birth weight (BW). GA, fetal station, and admission diagnoses of spontaneous labor v. induction of labor (IOL) were evaluated with respect to their impact on clinical EFW. The primary outcome was defined as an absolute error between clinical EFW and actual BW 500 grams. Secondary outcomes included overall absolute error, absolute percent error [(EFWBW)/BW*100], and absolute percent error 10%. RESULTS: Of 4,121 patients, 3,797 (92.1%) had a clinical EFW performed at the time of admission. The overall correlation between clinical EFW and actual BW was weak. (r 0.4) The proportion fetal weight estimates with an absolute error 500 grams significantly decreased with increasing GA with a nadir at 40 weeks gestation (p10%. There was no difference in absolute error 500 grams when comparing patients admitted with spontaneous labor v. IOL (24.1% v. 26.3%; p 0.15) and comparing patients with fetal station 0 and 0 at the time of admission (24.8% v. 24.3%; p 0.84). CONCLUSION: The predictive value of Leopold estimates of fetal weight has a J-shaped relationship with increasing GA, reaching its best accuracy at 40 weeks. Despite this finding, the overall predictive value remains disappointing. www.AJOG.org Diabetes, Labor, Medical-Surgical-Disease, Obstetric Quality & Safety, Prematurity, Ultrasound-Imaging Poster Session II

31.8 / 3.0%. In addition maternal hypoproteinemia was present with mean albumin levels of 2.8 / 0.28 g/dL. Despite minimal fluid administration and blood loss during the procedure, significant decreases (p 0.0001) in mean hemoglobin (9.13 . 0.1 g/dL), hematocrit (26.4 / 2.8%), and albumin (2.5 / 0.22 g/dL) were seen 24 hours postoperatively. CONCLUSION: Significant maternal protein-calorie malnutrition and anemia were found in patients undergoing laser treatment for severe TTTS. These maternal abnormalities may help explain the risk of malnutrition related complications after laser treatment, including maternal pulmonary edema and fluid retention. They may also contribute to the amniotic fluid abnormalities seen in the donor and recipient fetus. Further studies are indicated to see if maternal protein supplementation can correct these abnormalities and perhaps affect the incidence and severity of maternal complications after laser treatment of the placenta. In addition, assessment of those patient not requiring treatment for lower stages of TTTS must be assessed to see if there is an association of protein-caloric malnutrition with more severe stages of TTTS.