Gestational Data Research Articles

Ultrasonographic measurement of the transcerebellar diameter for gestational age estimation in the third trimester.

Ultrasonographic estimation of gestational age is done routinely by using fetal biometric parameters, such as the biparietal diameter (BPD), femur length (FL), abdominal circumference (AC), and head circumference (HC). Gestational dating by ultrasound is reliable in the 1st trimester, but discrepancies increase to more than 3weeks in the 3rd trimester. To study the accuracy of gestational age estimation by the transcerebellar diameter (TCD) in the 3rd trimester of singleton pregnancies whose gestational age is known. A prospective study was carried out in the Department of Obstetrics and Gynecology at NDMC Medical College and Hindu Rao Hospital, Delhi, India, from October 2017 to May 2019 after obtaining clearance from the ethical committee. The study included 100 women aged 18-35years with singleton pregnancies in the 3rd trimester with a gestational age ≥ 28weeks; the women provided informed consent and filled in an F-form to rule out any sex determination of the baby. Only those women who had regular menstrual cycles 6months before conception, who were sure of their last menstrual period (LMP), who had a gestational dating scan done up to 14weeks, and for whom congenital malformation of the fetus had been ruled out by mid-trimester ultrasound were included. Gestational age was obtained for the measured BPD, HC, AC, FL, and TCD. A paired t-test was used for the comparison between the period of gestation (POG) by the 1st ultrasonography (USG) and that by the AC, BPD, FL, HC, and TCD. The estimation of gestational age by the BPD becomes gradually less reliable after 32weeks of pregnancy, that by the HC and FL after 36weeks, and that by the AC after 28weeks. Regression analysis was used to find a correlation of the various parameters, such as the POG by the 1st USG, BPD, HC, AC, FL, and TCD, with the POG by LMP. The correlation coefficient (r), coefficient of determination (R2), and p values were calculated. Of all the sonographic parameters for the estimation of gestational age, the TCD showed the highest correlation (r = 0.979; p < 0.0001) and the AC the lowest correlation. The mean difference between the estimate of gestational age by the TCD and that by the 1st trimester USG increased from ± 1day at weeks 28-32 to ± 1-2days at weeks 32-36 and further increased to ± 6days after 36weeks of pregnancy, which was statistically significant. This indicated that the TCD could estimate gestational age within 6days of near-term pregnancy. Thus, the TCD was a reliable parameter for the estimation of gestational age within 6days of near-term pregnancy along with routine biometry and an alternative parameter for the evaluation of gestational age when the LMP is not known.

Perinatal Counseling at the Margin of Gestational Viability: Where We’ve Been, Where We’re Going, and How to Navigate a Path Forward

Perinatal Counseling at the Margin of Gestational Viability: Where We’ve Been, Where We’re Going, and How to Navigate a Path Forward

Reinventing the Pregnancy Wheel to Improve Pregnancy Dating and Antenatal Care Visits: A Pilot Randomized Trial in Malawi.

Background and Objectives:The purpose of this study was to evaluate the feasibility of a customized, culturally sensitive pregnancy wheel given to pregnant women to improve gestational age dating accuracy at the time of delivery and to improve antenatal care attendance.Methods:This was a pilot randomized trial involving pregnant women presenting to a regional hospital in Lilongwe, Malawi. The primary outcome was accuracy of gestational age at the time of presentation to the hospital in labor. The secondary outcome was the number of antenatal visits.Results:At final analysis, 14 subjects were included in the pregnancy wheel (intervention) arm and 11 in the standard care arm. Fifty percent (n=7) of women in the intervention arm were accurately dated at the time of presentation for delivery, compared to only 9% (n=1) in the standard antenatal care arm (p=0.04). There was not a significant difference in the number of antenatal visits between the two study arms. No patients met the World Health Organization’s recommended eight antenatal care visits for prenatal care.Conclusion and Global Health Implications:The customized pregnancy wheel given to patients could improve gestational age dating accuracy, and as a result, clinical decision making. However, the barriers to greater antenatal care access are more complex and likely require a more complex solution. Significant attrition in this pilot trial limited statistical power, suggesting the need for future larger interventions. Accurate gestational dating requires access to ultrasonography and early antenatal care initiation, both of which are inadequate in Malawi. Although the customized pregnancy wheel did not improve antenatal care attendance, it improved gestational age dating accuracy in a pilot study at a central hospital in Lilongwe, Malawi.

Women's grief in induced abortion (IA) and later loss of pregnancy: Themes from a narrative literature review with implications for counselling.

This article is based on a review of literature on pregnancy losses at later gestational dates. The author, the head of counselling of a counselling team housed within an induced abortion (IA) clinic, undertook the review with the aim of compiling a fact sheet for clients to assist in their grief and loss associated specifically with IA. The research question was specifically exploring whether women's experience of IA during the first trimester of pregnancy differed from women's experiences during the second trimester of pregnancy, and therefore whether services and a resource needed to reflect this. A key theme in the literature reviewed was that loss by a later elective IA increased the likelihood of the parents' experiences of disenfranchised grief. Findings also showed that there were negative impacts to the women's health if grief and loss counselling was not offered. The experiences highlighted in the research literature were identifiable from other losses related to pregnancy caused by premature delivery, neonatal death, spontaneous abortion (miscarriage), and stillbirth. Recommendations for dealing with disenfranchised grief in the context of counselling in a women's IA clinic are explored with implications for assisting women and their partners post IA. [ABSTRACT FROM AUTHOR] Copyright of New Zealand Journal of Counselling is the property of New Zealand Association of Counsellors and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Quantitative results of an immunohistochemical study of metalloproteinase-2 in trophoblast at TORCH infection on abortion material in the gestation period 7-8 weeks.

Background. This study is a fragment of a series of immunohistochemical studies of trophoblast with TORCH infection, which are scheduled to be carried out at different gestational dates. This article is devoted to the results of studies of trophoblast during gestation of 7-8 weeks. Objective. Using the immunohistochemical method, to establish the features of the expression of metalloproteinase-2 in various types of trophoblast with TORCH infection compared with observations without an infectious process. Methods. The study examined abortion material 7-8 weeks of gestation. The main group of the study consisted of 18 observations of TORCH infection, and the control group - 17 observations of an aborted pregnancy without signs of an infectious process (abortion for social reasons). An immunohistochemical procedure was performed on metalloproteinase-2 with primary antibodies and a polymer antigen imaging system using DAKO diaminobenzidine. The method of microdensitometry in a specialized computer program ImageJ evaluated the optical density of the color. Results. According to the results of immunohistochemical studies using computer microdensitometry at a gestational age of 7-8 weeks, both with TORCH infection and without an infectious process, the very high expression of metalloproteinase-2 is observed in the invasive trophoblast, the smallest - in the syncytotrophoblast of the choric villi, and intermediate values are noted in chorionic villus cytotrophoblast and cell column cytotrophoblast. With TORCH infection, the expression of metalloproteinase-2 is reduced in all types of trophoblast (cytotrophoblast of chorionic villi, cytotrophoblast of cell columns, invasive cytotrophoblast in endometrial fragments), except for syncytotrophoblast of chorionic villi. Conclusion. According to the results of immunohistochemical studies, using computer microdensitometry at a gestational age of 7-8 weeks, both with TORCH infection and without an infectious process, the largest expression of metalloproteinase-2 is observed in invasive trophoblast, the smallest - in the syncytiotrophoblast of chorionic villi, and intermediate indices are noted in the cytotrophoblast of chorionic villi and the cytotrophoblast of cell columns. With TORCH infection, the expression of metalloproteinase-2 decreases in all types of trophoblast, excluding the syncytiotrophoblast of chorionic villi.

Implementation of the INTERGROWTH-21st gestational dating and fetal and newborn growth standards in Nairobi, Kenya: women’s experiences with ultrasound and newborn assessment

ABSTRACT Background In order to make further gains in preventing newborn deaths, effective interventions are needed. Ultrasounds and newborn anthropometry are proven interventions to identify preterm birth complications, the leading cause of newborn deaths. The INTERGROWTH-21st global gestational dating and fetal and newborn growth standards prescribe optimal growth in any population. Jacaranda Health in Kenya was the first low-resource health facility to implement the standards and evaluate their feasibility and acceptability. Objective To capture patients’ perceptions of ultrasound and newborn care before and during implementation of the INTERGROWTH-21st standards. Methods The study was conducted over two years before and during the introduction of the INTERGROWTH-21st standards. Fifty pregnant and/or newly delivered women were selected for in-depth interviews and focus group discussions using convenience and purposive sampling. Interviews were conducted by research assistants using semi-structured guides once in the pre-implementation phase and twice in the implementation phase. Interviews were transcribed, double-coded by two independent researchers and thematically analyzed together. Demographic information was obtained from hospital records. Results Patients reported being generally satisfied with ultrasound care when providers communicated effectively. Women reported a priority for ultrasound was that it allowed them to feel reassured. However, a clear need for better pre-screening information emerged consistently from patients. Women noted that factors facilitating their choosing to have an ultrasound included ensuring the well-being of the fetus and learning the sex. Barriers included wait times and financial constraints. Patients were generally satisfied with care using the newborn standards. Conclusions As the INTERGROWTH-21st standards are implemented worldwide, understanding ways to facilitate implementation is critical. Increased and standardized communication about ultrasound should be provided before the procedure to increase satisfaction and uptake. Considering patient perspectives when integrating new standards or guidelines into routine clinical care will inform effective strategies in care provision, thus improving maternal and newborn health and survival.

Characteristics and morbidity of prematurely born newborns conceived with assisted reproductive technologies

Introduction/Objective. The percentage of live-born infants conceived with assisted reproductive technologies (ART) in some European countries reaches 6% and in Serbia over 1%. The aim of this study was to analyze characteristics and morbidity of prematurely born newborns conceived with ART. Methods. The study included 154 prematurely born newborns from pregnancies conceived with ART and 154 prematurely born newborns conceived naturally, hospitalized at the Institute of Health Care of Children and Adolescents of Vojvodina. Participants from both groups were matched according to gestational age and date of birth. Results. Statistically significantly more newborns with very low birth weight have been in the group of newborns conceived by ART in comparison to newborns conceived naturally (?2 test, p = 0.0001). Morbidity of newborns conceived with ART is not higher in comparison to newborns of the same gestational age conceived naturally. Bronchopulmonary dysplasia, occurred more frequently in children from ART (?2 test, p = 0.006) and retinopathy of prematurity occurred more frequently in children conceived spontaneously (?2 test, p = 0.047). There was no difference in the frequency of birth defects, genetic syndromes, and inborn errors of metabolism between the two groups. Conclusion. Lower birth weight and intrauterine growth restriction are potential risk factors for worse postnatal outcome in newborns from pregnancies conceived with ART.

INVESTIGATION OF TROPHOBLAST IN TORCH INFECTION ON ABORTION MATERIAL IN THE FIRST TRIMESTER OF PREGNANCY

This study is a fragment of a series of immunohistochemical studies of trophoblast with TORCH infection, which are scheduled to be carried out at different gestational dates. This article deals with the results of trophoblast studies at the gestational age of 7-8 weeks. The study examined abortion material 7-8 weeks of gestation. The main group of the study consisted of 18 observations of TORCH infection, and the control group consisted of 17 observations of an aborted pregnancy without signs of an infectious process (abortion for social reasons). An immunohistochemical procedure was performed on metalloproteinases-2 with primary antibodies and polymer antigen imaging system using DAKO diaminobenzidine. The method of computer microdensitometry in a specialized computer program ImageJ evaluated the optical density of the color. According to the results of immunohistochemical studies using computer microdensitometry at the gestational age of 7-8 weeks, both with TORCH infection and without it an infectious process, strong expression of metalloproteinase-2 is observed in the invasive trophoblast, the smallest – in the syncytotrophoblast of the chorionic villi, and intermediate values are noted in chorionic villus cytotrophoblast and cell column cytotrophoblast. With TORCH infection the expression of metalloproteinase-2 decreases in all the four types of trophoblast (cytotrophoblast of chorionic villi; cytotrophoblast of cell columns; invasive cytotrophoblast in endometrial fragments), except for syncytotrophoblast of chorionic villi was found.

Thrombocytopenia in well small for gestational age neonates.

: Thrombocytopenia has been closely associated with small-for-gestational-age neonates (SGA; birthweight less than tenth percentile) admitted to the special care nursery or neonatal ICU. It is unclear if 'well' SGA neonates experience the same incidence of thrombocytopenia in the SGA population as compared to sick neonates. We conducted a retrospective cohort study from a health network in Melbourne, Australia, between 2012 and 2015 to identify SGA neonates (≥ 35 weeks' gestation at birth) that were otherwise well. Neonates with at least one platelet count within 7 days of life were matched to appropriate-for-gestational-age (AGA) neonates from the same birth centre, with the same sex, and closest gestational age and birth date, who were also considered otherwise well. 16.7% of matched neonates had thrombocytopenia (303/1814) and of these, a larger proportion of SGA neonates were thrombocytopenic, 21.7% (197/907), than AGA neonates, 11.7% (106/907, P < 0.01). The incidence of thrombocytopenia was greater in the SGA cohort regardless of admission destination (special care nursery/neonatal ICU 26.8 vs. 13.9%, P < 0.01; Postnatal Ward 16.5 vs. 9.4%, P < 0.01). Thrombocytopenia is more prevalent amongst constitutionally well SGA neonates than AGA neonates. SGA alone increases the risk of thrombocytopenia.

Implementing the INTERGROWTH-21st gestational dating and fetal and newborn growth standards in peri-urban Nairobi, Kenya: Provider experiences, uptake and clinical decision-making.

BackgroundPerinatal and newborn complications are major risk factors for unfavorable fetal and neonatal outcomes. Gestational dating and growth monitoring can be instrumental in the identification and management of high-risk pregnancies and births. The INTERGROWTH-21st Project developed the first global standards for gestational dating and fetal and newborn growth monitoring, supplying a toolkit for clinicians. This study aimed to assess the feasibility and acceptability of the first known implementation study of these standards in a low resource setting.MethodsThe study was performed in two 12-month phases from March 2016 to March 2018 at Jacaranda Health, a private maternity hospital in peri-urban Nairobi, Kenya. In-depth interviews, focus group discussions and a provider survey were utilized to evaluate providers’ experiences during implementation. Client chart data, for pregnant women attending antenatal care and/or delivering at Jacaranda Health along with their newborns, were captured to assess uptake and effect of the standards on clinical decision-making.ResultsFacility-level support and provider buy-in proved to be critical factors driving the success of implementing the standards. However, additional support was needed to strengthen capacity to conduct and interpret ultrasounds and maintain motivation among providers. We observed a significant increase in the uptake of obstetric ultrasounds, particularly gestational dating, during the implementation of the standards. Although no significant changes were detected in the identification of high-risk pregnancies, referrals and deliveries by Cesarean section during implementation, we did observe a significant reduction in inductions for post-date. No significant barriers were reported regarding the use of the newborn standards. Over 80% of providers advocated for the standards to remain in place with some enhancements related mainly to training, advocacy and procurement.ConclusionsThe findings are timely with increasing global adoption of the standards and the challenging and multi-faceted nature of translating new, evidence-based guidelines into routine clinical practice.

What is the Healthy Gut Microbiota Composition? A Changing Ecosystem across Age, Environment, Diet, and Diseases.

Each individual is provided with a unique gut microbiota profile that plays many specific functions in host nutrient metabolism, maintenance of structural integrity of the gut mucosal barrier, immunomodulation, and protection against pathogens. Gut microbiota are composed of different bacteria species taxonomically classified by genus, family, order, and phyla. Each human’s gut microbiota are shaped in early life as their composition depends on infant transitions (birth gestational date, type of delivery, methods of milk feeding, weaning period) and external factors such as antibiotic use. These personal and healthy core native microbiota remain relatively stable in adulthood but differ between individuals due to enterotypes, body mass index (BMI) level, exercise frequency, lifestyle, and cultural and dietary habits. Accordingly, there is not a unique optimal gut microbiota composition since it is different for each individual. However, a healthy host–microorganism balance must be respected in order to optimally perform metabolic and immune functions and prevent disease development. This review will provide an overview of the studies that focus on gut microbiota balances in the same individual and between individuals and highlight the close mutualistic relationship between gut microbiota variations and diseases. Indeed, dysbiosis of gut microbiota is associated not only with intestinal disorders but also with numerous extra-intestinal diseases such as metabolic and neurological disorders. Understanding the cause or consequence of these gut microbiota balances in health and disease and how to maintain or restore a healthy gut microbiota composition should be useful in developing promising therapeutic interventions.

Are Fetuses Affected by Gastroschisis Benefited from Prenatal Maternal Corticosteroid Use and Early Parturition?

Introduction: Gastroschisis (G) is a congenital defect of the abdominal walls through which intestinal herniation and permanent exposure to amniotic liquid (AL) and its components are developed at the end of gestation. G affects mostly fetuses from young mothers under 25 - 29 years old, but it occurs more often in fetuses of mothers’ ages between 12 - 15 years old. Some authors assert that it is not the low weight, nor the low gestational age that influences mortality. In addition to morphological alterations, histological alterations are characterized by disorganization, distribution and the degree of ganglia maturity and myenteric plexuses. The literature describes parturition anticipation of G disease carriers to minimize damages to intestinal loops. There are studies suggesting corticosteroids at the end of gestation in order to avoid morphological and histological damages to the intestinal loop. Objective: Identify if live newborn infants delivery anticipation, that is, gestational date less than 37 weeks and prenatal maternal use of corticosteroid were benefited from early enteral diet, namely, less than 10 post-surgery days. Material and Method: From 33 newborns researched in the period from 2010 to 2014; 28 newborns full records were included in the study with 15.2% mortality rate. These newborns were divided in 3 groups according to maternal age: 6 newborns from mothers’ age between 16 - 20 years old (Group 1); 14 newborns from mothers’ age between 21 - 25 years old (Group 2) and 8 newborns from mothers’ age between 26 - 29 years old (Group 3). Gestational age at birth and prenatal maternal usage of corticosteroid and beginning oral feeding were assessed. Results: From 28 newborns, 19 mothers ingested prenatal corticosteroid and 16 newborns received the first enteric diet 10 days before and 3 days later. The mothers of the other 9 newborns were not treated with corticosteroid; only 3 newborns were fed before 10 days and 6 were fed later (p = 0.0016). Regarding gestational age, 17 newborns were born before 37 weeks and their 1st enteral diet was offered before 10 days. From the 11 newborns born after 37 weeks, only 4 received the 1st enteral diet before 10 days (p = 0.015). Conclusion: Newborn infants born with gestational age below 37 weeks, whose mothers received prenatal corticosteroid, were benefited with the first enteral diet before 10 postoperative days.

Quantifying bias between reported last menstrual period and ultrasonography estimates of gestational age in Lusaka, Zambia.

To quantify differences in assessing preterm delivery when calculating gestational age from last menstrual period (LMP) versus ultrasonography biometry. The Zambian Preterm Birth Prevention Study is an ongoing prospective cohort study that commenced enrolment in August 2015 at Women and Newborn Hospital of University Teaching Hospital in Lusaka, Zambia. Women at less than 20weeks of pregnancy who were enrolled between August 17, 2015, and August 31, 2017, and underwent ultrasonography examination were included in the present analysis. The primary outcome was the difference between ultrasonography- and LMP-based estimated gestational age. Associations between baseline predictors and outcomes were assessed using simple regression. The proportion of preterm deliveries using LMP- and ultrasonography-derived gestational dating was calculated using Kaplan-Meier analysis. The analysis included 942 women. The discrepancy between estimating gestational age using ultrasonography and LMP increased with greater gestational age at presentation and among patients with no history of preterm delivery. In a Kaplan-Meier analysis of 692 deliveries, 140 (20.2%, 95% confidence interval [CI] 17.7-23.0) and 79 (11.4%, 95% CI 9.6-13.6) deliveries were classified as preterm by LMP and ultrasonography estimates, respectively. Taking ultrasonography as a standard, a bias was observed in LMP-based gestational age estimates, which increased with advancing gestation at presentation. This resulted in misclassification of term deliveries as preterm.

P08.02: Implementing INTERGROWTH‐21st standards in peri‐urban Nairobi, Kenya: translating global guidelines into clinical practice in a low‐resource setting

Growth restricted infants face the greatest risk of death and disability and detection of in-utero growth restriction can aid in early intervention. Accurate gestational dating, through a combination of last menstrual period and ultrasound (U/S), is the foundation of successful monitoring. However, few low-resource facilities or providers are equipped with the tools to successfully determine gestational age and accurately assess fetal growth. The recent INTERGROWTH-21st project produced a set of screening tools to combat these challenges. The tools include methods for accurate gestational dating, and detection of fetal/newborn growth disturbances by utilising routine prenatal U/S. Our study explores the acceptability and feasibility of implementing the INTERGROWTH-21st U/S standards over a one-year period at Jacaranda Health, a hospital that serves low and middle-income women in peri-urban Nairobi providing high quality affordable maternity care. Our implementation study included a six-month preimplementation phase which entailed procurement of supplies, updating ANC protocols to include gestational dating U/S, updating U/S forms to capture new parameters and training providers in U/S techniques. This was followed by a one-year implementation/observation phase. The acceptability and feasibility of implementation was assessed by using qualitative and quantitative clinical indicators. We will report on nurse/sonographer perceptions of the feasibility and acceptability of introducing new U/S techniques and tools for gestational dating. We will also report quantitative indicators of fidelity to the new protocol based on uptake of gestational dating U/S and completeness of documentation. As we navigate the successes and challenges related to implementing the INTERGROWTH-21st U/S tools into JH, we hope to contribute to a wider discussion regarding improvements in accurate gestational dating and fetal and newborn growth, specifically in other low resource settings. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

264. Prescription of Antihypertensive Drugs in Pregnancy: A study based on health insurance claims data

Introduction Hypertensive disorders of pregnancy occurs in 5–10% of pregnant women, but information about antihypertensive drugs prescribed to patients with hypertensive disorders of pregnancy is limited. Objective To clarify the prescription of antihypertensive drugs to pregnant women based on claims data. Methods Based on health insurance claim (claims) data at the Japan Medical Data Center, data were extracted about pregnant women with a hypertension-related diagnosis (ICD-10 classification: O10-O16) during pregnancy between January 1, 2008 and May 31, 2010. Information about gestational age and start date of medical care in claims for the mothers was extracted, and based on diagnostic information related to labor and delivery/miscarriage and records of treatment, pregnancy duration for each woman was estimated. Information on drug prescriptions during pregnancy was extracted from medical records or records of dispensed prescriptions. Results From among 2173 pregnant women, information about prescription status during the entire pregnancy could be obtained for 567 women, and of these, 160 women (28%) had been prescribed an antihypertensive drug during pregnancy. The most frequently prescribed antihypertensive drug was nifedipine tablets/capsules (41%), followed by methyldopa tablets (27%) and hydralazine HCl powder/tablets (22%). In addition, diuretics were used in 33%, and renin-angiotensin system drugs were used in 3% of cases. Discussion Safety has not been established for many of the antihypertensive drugs prescribed to women with hypertensive disorders of pregnancy based on our study results. This suggests an urgent need to establish a safety evaluation system for these drugs in Japan.

INTERGROWTH-21st Gestational Dating and Fetal and Newborn Growth Standards in Peri-Urban Nairobi, Kenya: Quasi-Experimental Implementation Study Protocol.

BackgroundThe burden of preterm birth, fetal growth impairment, and associated neonatal deaths disproportionately falls on low- and middle-income countries where modern obstetric tools are not available to date pregnancies and monitor fetal growth accurately. The INTERGROWTH-21st gestational dating, fetal growth monitoring, and newborn size at birth standards make this possible.ObjectiveTo scale up the INTERGROWTH-21st standards, it is essential to assess the feasibility and acceptability of their implementation and their effect on clinical decision-making in a low-resource clinical setting.MethodsThis study protocol describes a pre-post, quasi-experimental implementation study of the standards at Jacaranda Health, a maternity hospital in peri-urban Nairobi, Kenya. All women with viable fetuses receiving antenatal and delivery services, their resulting newborns, and the clinicians caring for them from March 2016 to March 2018 are included. The study comprises a 12-month preimplementation phase, a 12-month implementation phase, and a 5-month post-implementation phase to be completed in August 2018. Quantitative clinical and qualitative data collected during the preimplementation and implementation phases will be assessed. A clinician survey was administered eight months into the implementation phase, month 20 of the study. Implementation outcomes include quantitative and qualitative analyses of feasibility, acceptability, adoption, appropriateness, fidelity, and penetration of the standards. Clinical outcomes include appropriateness of referral and effect of the standards on clinical care and decision-making. Descriptive analyses will be conducted, and comparisons will be made between pre- and postimplementation outcomes. Qualitative data will be analyzed using thematic coding and compared across time. The study was approved by the Amref Ethics and Scientific Review Committee (Kenya) and the Harvard University Institutional Review Board. Study results will be shared with stakeholders through conferences, seminars, publications, and knowledge management platforms.ResultsFrom October 2016 to February 2017, over 90% of all full-time Jacaranda clinicians (26/28) received at least one of the three aspects of the INTERGROWTH-21st training: gestational dating ultrasound, fetal growth monitoring ultrasound, and neonatal anthropometry standards. Following the training, implementation and evaluation of the standards in Jacaranda Health’s clinical workflow will take place from March 2017 through March 5, 2018. Data analysis will be finalized, and results will be shared by August 2018.ConclusionsThe findings of this study will have major implications on the national and global scale up of the INTERGROWTH-21st standards and on the process of scaling up global standards in general, particularly in limited-resource settings.Registered Report IdentifierRR1-10.2196/10293

Gestational dating using last menstrual period and bimanual exam for medication abortion in pharmacies and health centers in Nepal

ObjectiveTo evaluate whether conducting a bimanual examination prior to medication abortion (MAB) provision results in meaningful changes in gestational age (GA) assessment after patient-reported last menstrual period (LMP) in Nepal. Study designWomen ages 16–45 (n=660) seeking MAB at twelve participating pharmacies and government health facilities, between October 2014 and September 2015, self-reported LMP. Trained auxiliary nurse midwives assessed GA using a bimanual exam after recording LMP. We compared GA assessments as measured via patient-reported LMP alone versus via LMP plus bimanual exam. ResultsOverall, 660 women (326 at pharmacies, 334 at health facilities) presented for MAB, and 95% were able to provide an LMP. Overall agreement between LMP alone and LMP with bimanual exam was 99.3%. If LMP alone had been used without bimanual exam, fewer than one in 200 women would have been given MAB beyond the legal gestational limit. Among the three women who were ≤63 days by LMP but >63 days by bimanual exam, only one would have received MAB beyond 70 days gestation. Fewer than one in 600 women would not have received MAB care when eligible by adding a bimanual exam. ConclusionThere was high agreement between LMP alone and LMP plus bimanual exam. Routine bimanual exam may not be essential for safe and effective MAB care for women who are able to report an LMP. Removing the bimanual exam requirement could decrease barriers to provision outside of currently approved clinical settings and allow for expanded abortion access through provision by providers without bimanual exam training or facilities. ImplicationsRoutine bimanual exams may not be essential for safe medication abortion provision by trained clinicians in pharmacies and health facilities in low resource settings like Nepal.

724: Interpregnancy BMI changes and offspring mortality following second pregnancy

Obesity in pregnancy is associated with increased risk of neonatal mortality, however the effect of interpregnancy weight change is less understood. We sought to understand the impact of maternal interpregnancy body mass index (BMI) change on second offspring mortality risk. We included 266,971 women with first and second singleton deliveries between 1989 and 2015 from the Utah Population Database. Our exposure was defined as interpregnancy BMI change from date of first delivery to conception date of second pregnancy, derived from best clinical gestational dating of second pregnancy. We categorized exposure as: <-1, [-1, 0], [0, <1 reference], [1, 2], [2-4], ≥4 BMI units (kg/m2). Our outcomes were all-cause age-specific mortality: neonatal (≤ 28 days), infant (≤1 year old) childhood (≤5 years old), and late childhood (5-<18 years old). Analyses were based on Cox proportional hazards stratified by full term (>37 weeks) and preterm (< 37 weeks) deliveries. We assessed all-cause mortality and death from congenital anomalies and early infancy. Cox regression was used to estimate hazard ratios of childhood mortality and all models were adjusted for maternal age, race/ethnicity, maternal education, smoking during pregnancy, diabetes, hypertension, assisted reproduction, interpregnancy interval, maternal BMI prior to first pregnancy, infant sex, gestational age (term or not) and small for gestational age. Among full term deliveries, women with BMI change of 4+ had increased risk of neonatal mortality in their second child (hazard ratio 1.63, 95% confidence interval 1.15, 2.31). There were no differences in infant, early or late childhood mortality by interpregnancy BMI change. Maternal interpregnancy BMI changes of 2 to 3.99 and ≥4 had increased risk of all-cause mortality and mortality associated with congenital anomalies or conditions originating in the perinatal period (ICD10 760-779) in their second child (Table 1). In a large U.S. population study, women with large interpregnancy BMI changes have a significant risk of mortality in their second term offspring. Further studies are needed to assess if maternal post-partum weight change are a modifiable risk factor for adverse childhood outcomes.

Relationship between air pollution exposure during pregnancy and birth weight of term singleton live-birth newborns

Objective: This study explored the association between air pollution exposure and birth weight by using the multilevel linear model, after controlling related meteorological factors and individual differences of both mothers and babies. Methods: Women of childbearing age who were pregnant in Xi'an from 2010 to 2013, were selected as objects of this study. Multistage random sampling method was used to select 4 631 subjects followed by a self-designed questionnaire survey. Data related to quality of air and meteorology were gathered from routine monitoring system. Gestational age and date of birth, together with the average levels of air pollution were calculated for each trimester on each mother, and then the impact of air pollution on birth weight was assessed. A multilevel linear model was employed to investigate the association between the levels of exposure to air pollution by birth weight. Confounding factors were under control. We established three models in this study: Model 1 which involving the variable of air pollution exposure. Model 2 was adjusted for variables in Model 1 plus some other individual differences of both mother and baby. Model 3 was adjusted for variables in Model 2 plus meteorological factors. Results: There were significant differences seen in birth weight within the subgroups of gender, gestational age, mother's reproductive age, maternal education, residential areas and family incomes (P<0.01) of the infants. However, there was no difference found in Model 1 (P>0.05). Data from Model 3 indicated that a decrease of 13.3 g(10.9 g in Model 2) and 6.6 g (5.9 g in Model 2) in birth weight that were associated with an increase of 10 μg/m(3) in the average level of NO(2) and PM(10) during the second trimester; A decrease of 13.7 g (9.8 g in Model 2) in birth weight was associated with an increase of 10 μg/m(3) in the average level of NO(2) during the third trimester. Conclusion: After controlling for meteorological factors, the levels of exposure to NO(2) and PM(10) during the second trimester and NO(2) during the third trimester were negatively associated with birth weight.

Evaluation of Progesterone Utilization and Birth Outcomes in a State Medicaid Plan.

Progesterone (hydroxyprogesterone caproate injection and vaginal progesterone) has been shown to reduce preterm birth (PTB) rates by a third among pregnant women at high risk. The purpose of this analysis is to report birth outcomes and medication adherence among Massachusetts Medicaid (MassHealth) members receiving progesterone, evaluate the association between member characteristics and birth outcomes and medication adherence, and compare cost of care with a prior preterm pregnancy. This retrospective cohort study used medical claims, pharmacy claims, and prior authorization (PA) request data for MassHealth members who had a PA submitted for progesterone between January 1, 2011, and March 31, 2015. Members were excluded due to breaks in coverage, progesterone was not indicated for prevention of PTB, and if current gestational week or date of delivery was unavailable. A total of 418 members were screened for inclusion of whom 190 met criteria and 169 filled progesterone. Mean age was 29.2 years (SD = 5.23), and clinical comorbidities were identified in 90.5% of members. Consistent with clinical trials on progesterone effectiveness, 62.1% of members had a term delivery (37 wks of gestation). Among members with prior gestational age at delivery available, the average difference in gestational age between pregnancies was 8.25 weeks (SD = 6.11). In addition, 66.3% of members were adherent to progesterone based on proportion of days covered (PDC) of 0.8 or higher. The overall mean PDC was 0.79 (SD = 0.26). Despite similar birth outcomes in clinical trials and national trends, medication adherence is low in this state Medicaid program. Therefore, members may benefit from adherence support.