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Objectives To assess deviations in longitudinally measured cytokines with preterm birth (PTB). Methods Prospective longitudinal study targeting 80 subjects. Phlebotomy specimens for broad panel of cytokine analysis were obtained at three time (T) intervals: first trimester (T1: 8–14 weeks’ gestation), second trimester (T2: 18–22 weeks’ gestation), and third trimester (T3: 28–32 weeks’ gestation). Important demographics and outcomes were tracked. Data were stratified and the target groups were analyzed as follows: “Uncomplicated” (delivered ≥37 weeks) or “Preterm Birth” ( Results Complete data replete with phlebotomy at all three visits were obtained on 80 women. Birth outcomes were as follows: 11 Uncomplicated Term Birth (UTB), 28 PTB, 4 low birth weight (LBW), 16 OB complications (OBC), 11 current infections (IFN), and 10 mixed complications (MC=2 or more of the above). 28 PTB were compared to 11 uncomplicated term deliveries. In both groups, T helper type 1 (TH1) cytokine (IL-1β), pleiotrophic pro-inflammatory cytokine (IL-6), and counter-regulatory cytokine (IL-10) responses decreased over gestation, but rates of change in IL-1β, IL-6, and IL-10 were significantly different. Stratification of women by smoking status additionally demonstrated significant variance in immune status over the course of pregnancy Conclusions Women delivering PTB demonstrated significant differences in cytokine trajectory over pregnancy; these data further validate key role played by immune regulation in directing pregnancy outcome. Likewise, smoking impacts longitudinal trajectory of cytokines over pregnancy.

Objective To assess post-partum inflammation for patients delivering prior to 34 6/7 weeks by birth etiology. Methods This was an observational study of early preterm birth (PTB) occurring between 20 0/7 and 34 6/7 weeks of gestation. Serum C-reactive protein (CRP) levels were measured 1 month post-partum. CRP measurements were compared by birth etiology. Results A total of 399 women were analyzed. Distribution of birth etiology was 35% (n = 138) preterm labor (PTL), 28% (n = 115) preterm premature rupture of membranes (pPROM), and 37% (n = 141) indicated preterm birth (IPTB). Serum CRP varied by birth etiology (P = 0.036). Women with pPROM had elevated median CRP levels compared to women with PTL (P = 0.037). IPTB demonstrated elevated CRP levels when compared to PTL (P = 0.019). Pre-eclamptic/eclamptic subjects exhibited increased median CRP levels compared to PTL (P = 0.04). Conclusion Post-partum inflammation varies by birth etiology. Such variation may serve as identification of subjects whose future pregnancies and, ultimately, overall health status may benefit from inter-pregnancy interventions aimed at reducing inflammatory-associated risk factors.

In 2009, the Institute of Medicine (IOM) released revised pregnancy weight gain guidelines. There are limited data regarding the effect of maternal weight gain on newborn adiposity.The aim of this study was to estimate neonatal fat mass, lean body mass, and percentage body fat according to current Institute of Medicine (IOM) pregnancy weight gain guidelines.This is a secondary analysis of a prospective observational cohort study of neonates delivered at least 36 wk gestation and evaluated for fat mass, lean body mass, and percentage body fat. Women with abnormal glucose tolerance testing and other known medical disorders or pregnancies with known fetal anomalies were excluded. Pregravid body mass index (BMI) was categorized as normal weight (25 kg/m2), overweight (25-30 kg/m2), or obese (30 kg/m2). Maternal weight gain was quantified as less than, equal to, or greater than current IOM guidelines. Newborn body composition measurements were compared according to weight gain and BMI categories.A total of 439 maternal-newborn pairs were evaluated; 19.8% (n=87) of women gained less than IOM guidelines; 31.9% (n=140), equal to IOM guidelines; and 48.3% (n=212), greater than IOM guidelines. Significant differences for each component of body composition were found when evaluated by IOM weight gain categories (all ANOVA, P0.001). When controlling for pregravid BMI, only weight gain for women who were of normal weight before pregnancy remained significant.Maternal weight gain during pregnancy is a significant contributor to newborn body composition, particularly for women who are of normal weight before pregnancy.

To characterize immune modulation as expressed by cytokine assays at three time-points in human pregnancy.This is a prospective, longitudinal study of a broad panel of cytokine expression during singleton pregnancies resulting in an uncomplicated, full-term, live births. Peripheral blood was obtained at 8-14, 18-22, and 28-32 weeks gestation. Six cytokines - IFN-γ, IL-4, TNF-α, IL-1β, IL-6, and IL-10 - were measured in supernatants obtained from whole blood stimulations with PHA or LPS and were compared to unstimulated controls. Samples were processed by Luminex-100 MAP®. We used Generalized Linear Models (GLM) to evaluate cytokine trajectories.Complete data were obtained for 45 uncomplicated pregnancies. Overall, peripheral blood WBC's demonstrated dampened cytokine responses. However, over the course of pregnancy, we found enhanced counter-regulatory cytokine expression (e.g., shown by increased IL-10).The overall decrease in pro-inflammatory cytokines and increase in counter-regulatory cytokines as uncomplicated pregnancy progresses supports the evolving concepts of immunoregulation for the maintenance of a viable pregnancy.

We sought to compare two approaches to antenatal testing for their impact on the workforce. This is a prospective observational study of women who presented for antenatal testing. All women were given a survey upon presentation. As per hospital protocol, nonstress testing (NST) was performed semiweekly and biophysical profile (BPP) was performed weekly. The choice of testing was determined by the attending physician. χ2- and Student's t-tests were performed where appropriate. A P-value of

We sought to evaluate neonatal hearing assessment by the otoacoustic emission (OAE) test in very low birth weight (VLBW) infants exposed to antenatal steroids. This is a retrospective cohort study of infants

BACKGROUND: When tubal ligations cannot be performed because of dense postoperative adhesions, options for female sterilization are very limited. As the incidence of cesarean delivery rises and the occurrence of peritubal adhesions increases, tubal ligation using abdominal or laparoscopic surgery may become increasingly technically difficult. Hysteroscopic tubal occlusion provides a method of permanent sterilization when an abdominal or laparoscopic approach is unsuccessful. CASES: Three patients with failed tubal ligations by abdominal or laparoscopic approaches were referred to our institution. Their cases were complicated by technically difficult surgeries with dense intraabdominal adhesions. Hysteroscopic tubal occlusion was successfully performed in each patient. CONCLUSION: Hysteroscopic tubal occlusion can be used for permanent sterilization when abdominal or laparoscopic approaches are not possible.

To compare self-reported pre-pregnancy weightdelivery weight with documented pre-pregnancydelivery weight and determine whether there are differences compared with the Institute of Medicine's (IOM) guidelines.This is a retrospective analysis of 234 women. Inclusion criteria included documented height, self-reported pre-pregnancy weight, self-reported delivery weight, documented pre-pregnancy weight ± 12 weeks from last menstrual period, and documented delivery weight ± 2 weeks from delivery. We determined the difference between self-reported pre-pregnancy weight vs. documented pre-pregnancy weight and self-reported delivery weight vs. documented delivery weight. Using documented pre-pregnancy weight and documented delivery weight, we calculated gestational weight gain (GWG) relative to IOM criteria.Self-reported pre-pregnancy weight was 2.94 kg less than documented pre-pregnancy weight (p0.0001). Self-reported BMI was 1.11 mg/kg(2) less than documented BMI (p0.0001). Self-reported GWG was 3.01 kg greater than documented GWG (p0.0001). Ninety-eight percent of normal weight correctly classified pregravid BMI in contrast to 86% of obese (p0.005) and 73% of overweight (p0.001).Overweight and obese women underestimated self-reported pre-pregnancy weightoverestimated GWG, thereby mistakenly categorizing IOM guidelines.

Preterm premature rupture of the membranes remains difficult to predict accurately. The majority of those suffering preterm premature rupture of the membrane lack risk factors that might lead to preventative treatments. Its management is centered on an evaluation of the risks and benefits of attempted pregnancy prolongation compared with expeditious delivery. An understanding of the gestational age specific risks for newborn morbidity and mortality is essential to estimate the potential benefits of conservative management. Once the diagnosis of membrane rupture remote from term is made, conservative management to reduce neonatal complications is generally attempted while maintaining vigilance for complications such as infection, umbilical cord compression, or abruption. Concurrent antibiotic therapy and antenatal corticosteroid treatment are typically administered to prolong pregnancy, prevent infection, and reduce gestational age dependent morbidities. Near and at term, particularly if fetal pulmonary maturity has been confirmed, the patient is generally best served by expeditious delivery.

Obese pregnant women develop severe insulin resistance and enhanced systemic and placental inflammation, suggesting associated modifications of endocrine and immune functions. Activation of innate immunity by endotoxins/lipopolysaccharides (LPS) has been proposed as a mechanism for enhancing metabolic alterations in disorders with insulin resistance. The aim of this study was to characterize the immune responses developed by the adipose tissue (AT) and their potential links to maternal endotoxemia in pregnancy with obesity. Blood and subcutaneous abdominal AT were obtained from 120 lean and obese women (term pregnancy) recruited at delivery. Gene expression was assessed in AT and stromal vascular cells isolated from a subset of 24 subjects from the same cohort. Doubling of plasma endotoxin concentrations indicated subclinical endotoxemia in obese compared with lean women. This was associated with significant increase in systemic C-reactive protein and interleukin-6 (IL-6) but not tumor necrosis factor-α (TNF-α) concentrations. AT inflammation was characterized by accumulation of CD68(+) macrophages with a threefold increased gene expression of the macrophage markers CD68, EMR1, and CD14. Gene expression for cytokines IL-6, TNF-α, IL-8, and monocyte chemotactic protein-1 (MCP1) and for LPS-sensing CD14, toll-like receptor 4 (TLR4), translocating chain-associated membrane protein 2 was 2.5-5-fold higher in stromal cells of obese compared to lean. LPS-treated cultured stromal cells of obese women expressed a 5-16-fold stimulation of the same cytokines upregulated in vivo. Our data demonstrate that subclinical endotoxemia is associated with systemic and AT inflammation in obese pregnant women. Recognition of bacterial pathogens may contribute to the combined dysfunction of innate immunity and the metabolic systems in AT.

OBJECTIVE: To estimate whether 17alpha-hydroxyprogesterone caproate treatment in pregnancy increases the frequency of abnormal glucose screening and gestational diabetes mellitus (GDM). METHODS: This is a retrospective cohort study of women treated with weekly 17alpha-hydroxyprogesterone caproate. Women with pregestational diabetes and multiple gestations were excluded. 17alpha-hydroxyprogesterone caproate-exposed women were randomly matched with three unexposed controls by maternal age and prepregnancy body mass index (BMI). The main outcomes were an abnormal 1-hour 50-g glucose screen (at least 135 mg/dL) and GDM (a 1-hour 50-g glucose screen of at least 200 mg/dL or two or more abnormal values on a 3-hour 100-g oral glucose tolerance test). RESULTS: A total of 110 17alpha-hydroxyprogesterone caproate-exposed women were matched with 330 controls. Maternal race between exposed women and controls was similar (46% compared with 39% African American, 17% compared with 18% Hispanic, 36% compared with 40% white, P=.57). Abnormal 1-hour glucose screens were more frequent in the 17alpha-hydroxyprogesterone group (23.6% compared with 11.2%, P

Preterm premature rupture of the membranes near the limit of fetal viability is an uncommon complication of pregnancy, affecting approximately 4 in 1000 gravidas. However, maternal, fetal, and neonatal complications resulting from this condition are significant and include chorioamnionitis, pulmonary hypoplasia, restriction deformities, fetal loss, and complications of extreme prematurity among surviving infants. In this article, we review the literature regarding pregnancy outcomes after preterm premature rupture of the membranes near the limit of viability, and the data on traditional and nontraditional interventions to improve outcomes. An approach to patients who present with preterm premature rupture of the membranes near the limit of viability will be proposed.

Objective: Multifetal pregnancy as a result of ovulation induction (OI) and assisted reproductive technologies (ART) correlate with Board certification in reproductive endocrinology and infertility (REI). Design: Retrospective chart analysis of 304 patients referred to Wayne State University (WSU) and Thomas Jefferson University (TJU) for multifetal pregnancy reduction (MFPR) from March 1986 to January 1995 compared to 275 patients referred from January 1 to December 31, 2000 at MCP Hahnemann University. Material and Methods: Chart review for fetal number, pregnancy generation (OI or ART) and physician REI Board certification from the American Board of Specialties Obstetrics and Gynecology. Information was available on 296 of 304 patients studied in the 1986–1995 WSU cohort and 275 patients studied from the MCP Hahnemann 2000 cohort. Results: Analysis of 296 multifetal pregnancies at WSU and TJU for REI Board status showed non-REI Board-certified (NREI) physicians generated 174 pregnancies with quadruplets or more compared to 122 quadruplets or more by REI Board-certified physicians. Board certification did not impact quadruplet or more rates for OI or ART (p < 0.368). Of 275 patients with triplets or more at MCP Hahnemann, 156 (56.7%) were from ARTs versus 41.2% from 1986–1995 (χ2 = 13.1, p < 0.001). Quintuplets or more decreased from 18.5 to 9.7% (χ2 = 8.3, p = 0.004), and for REIs from 22.1 to 9.6% (χ2 = 4.7, p < 0.01), while 14.4% of cases coming from non-REIs had quintuplets versus 9.6% from REIs (p = NS). Conclusions: Cases of MFPR from ARTs have risen, while percentage of cases with quintuplets have fallen in half. We found no difference in quintuplets between REIs and non-REIs overall, but REI quintuplets fell significantly, and NREI has not.

singleton infants over 15 years at an urban tertiary center Kelly Gibson, Thaddeus P. Waters MetroHealth Medical Center-Case Western Reserve University, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Cleveland, OH, MetroHealth Medical Center Case Western Reserve University, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Cleveland, OH OBJECTIVE: To determine if there have been changes in birth weight (BW) and Ponderal Index (PI: gram/cm3) in preterm newborns across a fifteen year time period after controlling for population changes. STUDY DESIGN: This is a retrospective cohort analysis of data collected within a perinatal database at an urban tertiary center. We included liveborn singletons delivered between 28 0/7 and 36 6/7 weeks, and from 1/1995 to 12/2009. BW outliers (99th %ile for gestational age (GA) were excluded). Trends in BW and PI over time were evaluated. We divided the data into five year epochs. ANOVA, chi-squared, and linear stepwise regression analyses were used as appropriate. Regression analyses controlled for GA, maternal race, age, parity, smoking, BMI at delivery, diabetes (IDDM), hypertension (HTN), and delivery indication. RESULTS: 5,132 infants were included. Mean BW ( 118g), PI ( 0.13g/cm3), and GA ( 0.57wk) increased significantly over time (P 0.001 for each). Significant differences over time (p 0.001) were also found for maternal age ( 0.6yr), smoking ( 7.0%), IDDM ( 1.9%), nulliparity ( 4.9%), PROM ( 10.2%), and race (African Americans 7.4%), but not for BMI or HTN. Labor Inductions increased ( 5.0%; p 0.001) while spontaneous preterm labor decreased ( 5.6%; p 0.001). In stepwise regression (R2 0.52; Table), GA was the most highly associated factor affecting BW, followed by IDDM, HTN, infant gender, smoking, parity, and PROM. Year of delivery and maternal BMI were not significant factors. Regarding PI, stepwise regression (R2 0.025, p 0.045) found GA, year of delivery, HTN, and IDDM to be significantly associated factors. CONCLUSION: Over fifteen years, BW and PI of singleton infants born at 28-36 weeks GA have increased. The majority of this change is attributed to increased GA within this preterm cohort, and to changes in maternal social and medical demographic characteristics. PI, but not BW, has increased over time after controlling for factors likely to impact fetal growth. 572 Trends in severe obstetric morbidity Natalie Brooke Heath, Sean Esplin, Erick Henry, Cindy Weng, Michael Varner University of Utah School of Medicine, Obstetrics and Gynecology, SLC, UT, Intermountain Healthcare, Maternal-Fetal Medicine, Salt Lake City, UT, University of Utah, Biomedical Informatics, Salt Lake City, UT, University of Utah Health Sciences Center, Obstetrics and Gynecology, Salt Lake City, UT OBJECTIVE: To identify the contemporary occurrence and temporal trends of severe maternal morbidity in a large vertically integrated healthcare system. STUDY DESIGN: The data warehouse of a large vertically integrated healthcare system was searched for women delivering a singleton pregnancy delivered between July 2001 and December 2008. Severe maternal morbidity was defined as one or more of the following: ICU admission, cesarean hysterectomy, transfusion, uterine rupture, eclampsia, pulmonary embolism, cerebrovascular hemorrhage, intubation, cardiomyopathy or readmission within 6 weeks of discharge. Cases were identified by ICD-9 discharge diagnoses. Maternal demographic parameters, pregnancy outcome information and pre-existing conditions were also analyzed using univariate and multivariate logistic regression. RESULTS: 240,331 singleton births occurred during the study period. Severe maternal morbidity increased from 90.1 to 134.8 per 10,000 deliveries over the study period and was driven primarily by increased ICU admissions and transfusions (Figure). Overall cesarean delivery rates increased from 15.38% to 20.38%. However, rates of uterine rupture and pulmonary embolism decreased over the study period (Table). Each of the pre-existing medical conditions (chronic hypertension, chronic renal disease, diabetes and lupus) was associated with having a higher incidence of severe maternal morbidity. Women with pre-existing medical conditions were also more likely to be delivered abdominally. CONCLUSION: The rate of severe maternal morbidity increased over the study period primarily due to increased ICU admission and transfusion rates. Cesarean delivery rates also increased over the study period, and the increased incidence of transfusion is associated with this trend. PosterSessionIV Epidemiology, Infectious Disease, Intrapartum Fetal Assessment, Operative Obstetrics, Obstetric Quality & Safety, Public Health-Global Health www.AJOG.org

Objective This study was undertaken to characterize the course of bacterial vaginosis in pregnancy and to discern the bacterial morphotypes responsible for infection. Study Design Vaginal secretions were obtained in each trimester of pregnancy and were evaluated for bacterial vaginosis by Gram stain, categorized as normal or any of the following: Lactobacillus deficient, Gardnerella , Bacteroides , or Mobiluncus positive and by Nugent score. Results were evaluated for trends of bacterial vaginosis and Gram stain over pregnancy. Results One hundred forty-eight women were evaluated. Seventy-one women (48%) were bacterial vaginosis negative in all trimesters, compared with 14 (9.4%) who were positive throughout pregnancy. Among the 14 women who remained bacterial vaginosis positive, Gram stain findings were Gardnerella + Bacteroides + Lactobacillus , with approximately 50% harboring Mobiluncus . Few women become bacterial vaginosis positive as pregnancy progressed (6.1%). With each increasing week of pregnancy, the risk of becoming bacterial vaginosis positive decreased (0.93: 0.91-0.95; P Conclusion In this population, the majority of pregnant women trend toward bacterial vaginosis negative status. Few women are bacterial vaginosis positive across their pregnancy.

VS. SINGLETON PREGNANCIES WITH PRE-TERM PREMATURE RUPTURE OF MEMBRANES (PPROM) HIREN PATEL, MATTHEW HOFFMAN, THADDEUS WATERS, Christiana Hospital, Newark, Delaware, Drexel University, Obstetrics and Gynecology, Philadelphia, Pennsylvania OBJECTIVE: We sought to determine if there was a difference in latency between singleton and twin gestations following preterm premature rupture of the membranes (pPROM). STUDY DESIGN: Using a contemporaneously maintained database, we identified all women admitted between December 1996 and May 2003 with pPROM !32 weeks with either a singleton or twin gestation. Data abstracted included maternal demographic characteristics, gestational age at delivery, gestational age at rupture of membranes, mode of delivery, and neonatal outcomes. Our primary outcome was duration of latency. Secondary outcomes included gestational age at rupture and percentage of women delivering within 24 hours of pPROM. Univariate and multivariate analysis were used where appropriate. RESULTS: One thousand two hundred and four women had pPROM before 32 weeks (869 singletons and 354 twin gestations). Women with a singleton gestation were no more likely to deliver within 24 hours of presentation than those with multiple gestations (49.3% vs. 53.8%; p=0.264). Among women who did not deliver within the first 24 hours, latency was shorter for women with a singleton versus a twin gestation (11.2 days vs. 14.7 days; p!0.005). In both twins and singletons, length of latency was inversely proportional to gestational age at rupture (p!0.05). Additionally, women with twins were more likely to have pPROM at an earlier gestational age (26.2 weeks vs. 28.0 week-p!0.001). There was no difference in latency period between the groups when controlling for gestational age at pPROM (OR 1.01 95% CI 0.95 to 2.97). CONCLUSION: Women with a twin gestation are more likely to have pPROM at an earlier gestational age than women with a single gestation. There is no difference in latency until delivery between singleton and twin gestations after pPROM.

ANTENATAL STEROIDS JULIE SLOAN, THADDEUS WATERS, SEAN DALY, MARGARET SHERIDAN-PEREIRA, ROBERT GORMAN, ANTHONY SCISCIONE, RONALD WAPNER, Coombe Women’s Hospital, Dublin, Ireland, Ireland, Drexel University, Obstetrics and Gynecology, Philadelphia, Pennsylvania, Coombe Women’s Hospital, Dublin, Ireland, Ireland, Drexel University College of Medicine, Obstetrics and Gynecology, Philadelphia, Pennsylvania OBJECTIVE: Multiple doses of antenatal steroids have been associated with smaller head circumferences at birth. No study has addressed the long-term head growth of children exposed to antenatal steroids. We sought to determine the long-term effect of multiple courses of antenatal corticosteroids on head circumference. STUDY DESIGN: This is a retrospective case-cohort study performed at a tertiary care hospital. Our obstetrical database identified all singleton pregnancies >24 weeks gestation at risk for preterm birth between 1995-99. Data collected included maternal demographic characteristics, neonatal outcomes, number of steroid doses, gestational age at administration of steroids, gestational age at delivery, neonatal anthropometric measurements and serial anthropometric measurements. A full course of steroid therapy was defined as two doses of dexamethasone 12mg over 48 hours. An attending physician determined weekly steroid doses. We compared the neonates of mothers who received dexamethasone to neonates who were not exposed. Number of steroid courses and follow-up head circumferences were evaluated. Mantel-Haenszel test was used where appropriate. RESULTS: A total of 625 pregnancies were eligible for analysis with 469 infants (75.1%) having at least one follow-up exam for head circumference (HC). All 469 infants had a documented head circumference between 30 days of age and 3 years of age. Steroid dosing and HC at!10th percentile is presented in the table. Infants exposed to antenatal steroids were not more likely to have head circumferences below the 10th percentile than those that were unexposed (OR = 0.20 95% CI 0.007-5.4528). CONCLUSION: Infants exposed to multiple courses of antenatal steroids do not appear to have a higher risk of HC !10th percentile on interval evaluation.