Multifetal Gestation Research Articles

An Unusual Monochorionic Pregnancy.

An Unusual Monochorionic Pregnancy.

Prevention of Preterm Birth with Progesterone.

Gestational age at birth is a critical factor for perinatal and adulthood outcomes, and even for transgenerational conditions’ effects. Preterm birth (PTB) (prematurity) is still the main determinant for infant mortality and morbidity leading cause of infant morbidity and mortality. Unfortunately, preterm birth (PTB) is a relevant public health issue worldwide and the global PTB rate is around 11%. The premature activation of labor is underlined by complex mechanisms, with a multifactorial origin influenced by numerous known and probably unknown triggers. The possible mechanisms involved in a too early labor activation have been partially explained, and involve chemokines, receptors, and imbalanced inflammatory paths. Strategies for the early detection and prevention of this obstetric condition were proposed in clinical settings with interesting results. Progesterone has been demonstrated to have a key role in PTB prevention, showing several positive effects, such as lower prostaglandin synthesis, the inhibition of cervical stromal degradation, modulating the inflammatory response, reducing gap junction formation, and decreasing myometrial activation. The available scientific knowledge, data and recommendations address multiple current areas of debate regarding the use of progesterone in multifetal gestation, including different formulations, doses and routes of administration and its safety profile in pregnancy.

Costs of Severe Maternal Morbidity in U.S. Commercially Insured and Medicaid Populations: An Updated Analysis.

Background: The most common reason for hospitalization in the United States is childbirth. The costs of childbirth are substantial.Materials and Methods: This was a retrospective cohort study of hospital deliveries identified in the MarketScan® Commercial and Medicaid health insurance claim databases. Women with an inpatient birth in the calendar year 2016 were included. Severe maternal morbidity (SMM) was identified using the Centers for Disease Control and Prevention algorithm of 21 International Classification of Diseases-10 codes. Mean costs and cost ratios for women with and without SMM were reported. Generalized linear models were used to analyze demographic and clinical variables influencing delivery costs.Results: We identified 1,486 women in the Commercial population, who had a birth in 2016 and met the criteria for SMM. The total mean per-patient costs of care for women with and without SMM were $50,212 and $23,795, respectively. In the Medicaid population there were 29,763 births, of which 342 met the criteria for SMM. The total mean per-patient costs of care for women with and without SMM were $26,513 and $9,652, respectively. A multifetal gestation, a cesarean delivery, maternal age, and pregnancy-related complications were independently predictive of increased delivery costs in both Commercial and Medicaid populations.Conclusions: The occurrence of SMM was associated with an increase in maternity-related costs of 111% in the Commercial and 175% in the Medicaid population. Some of the factors associated with increased delivery hospitalization costs could be treated or avoided.

COMPARING TRENDS IN ASSISTED REPRODUCTIVE THERAPY RELATED MULTI-FETAL GESTATION RATES FROM 2014-2019 BETWEEN AUTOLOGOUS AND DONOR EGG CYCLES

Various changes with the reporting systems and recommendations for elective single embryo transfer in 2014 and 2017 by SART and ASRM have attempted to decrease rates of multi-fetal gestations. This study was undertaken to determine the difference in the impact for autologous and donor egg cycles reported during 2014-2019.

Examining pre-term birth and cesarean section rates in gestational carrier pregnancies.

This study sought to report on the route and gestational age at delivery of gestational carrier (GC) pregnancies with respect to the GCs' prior obstetric history. A retrospective analysis of all GC pregnancies from one of the largest surrogacy agencies in California between 2008 and 2018 was performed. Available demographic data and obstetric history, including a history of prior cesarean section (CS) and preterm birth (PTB), were collected for each GC and correlated to outcomes of the index GC pregnancy. Primary outcomes for the index GC pregnancies included delivery route and gestational age at delivery. Eight-hundred-thirty-six GCs were included in our analysis. 319 (38.2%) delivered via CS, and 517 (61.8%) delivered vaginally. 60 (18.8%) of the CS deliveries were due to multifetal gestation. Primary CS rate in singleton GC pregnancies was 38.5%. In women without a history of CS, neither age, BMI, interpregnancy interval, prior parity, nor year of delivery impacted the primary singleton CS rate (all, P > 0.05). Of GCs with a history of a prior CS (n = 350, 41.9%), 218 (62.3%) had a vaginal delivery after CS (VBAC) and 132 (37.7%) had a repeat CS. Women who had successful VBACs were significantly younger than those who had repeat CS (mean 33.7 vs. 35.2years, P = .003). BMI was lower in patients who had a VBAC compared to those that had a repeat CS (mean BMI 24.6 vs. 25.5, P = 0.074), although this did not reach statistical significance. In GCs with a history of CS, interpregnancy interval, year of delivery, prior parity, and multiple gestation in the index GC pregnancy did not impact mode of delivery. VBAC rates did not change over the study period (P = 0.757). Overall PTB rate was 15.1%. Most PTB in GC pregnancies were in those with a history of PTB, and PTB was more likely in singletons rather than multifetal gestations (76.7% in singletons vs. 30% in multiples) in patients with history of PTB (P < 0.001). Those with no history of PTB and who carried multiples had a low rate of PTB; in fact, in this group, only 1 out of 35 patients had a PTB with multiples. Both primary CS and PTB rates in singleton GC pregnancies are higher than national averages. CS rates are independent of age, BMI, and interpregnancy interval. In GCs with a history of a CS, VBAC rates well exceed national averages and are higher in younger GCs with a lower BMI. PTB rates are impacted primarily by the GCs obstetric history. In those GCs without a history of PTB, rates of PTB are low, even in those with a multifetal gestation.

Acupressure and Acupuncture Use in the Peripartum Period.

Acupuncture is the procedure of inserting fine needles into specific points on the body for therapeutic purposes. Acupuncture and its derivatives (acupressure, moxibustion, electroacupuncture, and transcutaneous electric nerve stimulation on acupoints) are a popular treatment choice in the peripartum period (32 wk' gestation to 14 d postdelivery). There is substantial research evidence supporting acupuncture and its derivatives in the peripartum period. Benefits in the use of acupressure to reduce labor pain intensity and a reduction in the duration of labor with acupressure have been found. There is mixed evidence for the use of both moxibustion and moxibustion with acupuncture for noncephalic presentations and for acupressure for reducing intraoperative nausea. There is limited evidence available on acupuncture use in women with high-risk pregnancies or multifetal gestations.

Association between peripartum hysterectomy and venous thromboembolism

The risk of venous thromboembolism after delivery is modified by mode of delivery, with the risk of venous thromboembolism being higher after cesarean delivery than vaginal delivery. The risk of venous thromboembolism after peripartum hysterectomy is largely unknown. This study aimed to compare the incidence and risk of venous thromboembolism among women who had and did not have a peripartum hysterectomy. Furthermore, we sought to compare the risk of venous thromboembolism after hysterectomy with other patient, pregnancy, and delivery risk factors known to be associated with venous thromboembolism. This was a cross-sectional study of women with delivery encounters identified in the Nationwide Readmissions Database from October 2015 to December 2017. Delivery encounters and all variables of interest were identified using the International Classification of Diseases, Tenth Revision diagnosis and procedure codes. The incidence of venous thromboembolism during delivery and rehospitalizations within 6 weeks after discharge was compared among women who had and did not have a peripartum hysterectomy. Multivariable logistic regressions were used to estimate associations between venous thromboembolism and hysterectomy, adjusted for the following characteristics: maternal age, payer at time of delivery, obesity, hypertension, diabetes mellitus, tobacco use, multifetal gestation, peripartum infection, and peripartum hemorrhage. Similarly, venous thromboembolism risk was compared by mode of delivery, including hysterectomy. Diagnoses that may have been indications for peripartum hysterectomy were identified among patients who underwent a hysterectomy and compared between those who did and did not have venous thromboembolism. Analyses used survey weights to obtain population estimates. Of the 4,419,037 women with deliveries, 5098 (11.5 per 10,000 deliveries) underwent a hysterectomy. Moreover, 110 patients (215.8 per 10,000 deliveries) were diagnosed with venous thromboembolism after hysterectomy. The risk of venous thromboembolism was significantly higher in women who underwent a hysterectomy than in women who did not have a hysterectomy (unadjusted odds ratio, 25.1 [95% confidence interval, 20.0-31.5]; adjusted odds ratio, 11.2 [95% confidence interval, 8.7-14.5]; P<.001). Comparing the risk of venous thromboembolism by mode of delivery, the unadjusted and adjusted incidences of venous thromboembolism were 6.9 (95% confidence interval, 6.5-7.3) and 7.4 (95% confidence interval, 6.9-7.8) per 10,000 deliveries among women after vaginal delivery without peripartum hysterectomy, 12.5 (95% confidence interval, 11.8-13.1) and 11.3 (95% confidence interval, 10.7-12.0) per 10,000 deliveries after cesarean delivery without hysterectomy; and 217.2 (95% confidence interval, 169.1-265.2) and 96.9 (95% confidence interval 76.9-126.5) per 10,000 deliveries after hysterectomy, regardless of mode of delivery. Of the 110 diagnoses of venous thromboembolism with peripartum hysterectomy, 89 (81%) occurred during delivery admission. Of the remaining 21 cases, 50% occurred within the first 10 days after discharge from delivery, and 75% occurred within 25 days after discharge. These findings have demonstrated that peripartum hysterectomy is associated with a markedly increased risk of venous thromboembolism in the postpartum period, even when controlling for other known risk factors for postpartum thromboembolic events. Here, the incidence of venous thromboembolism after peripartum hysterectomy (2.2%) met some guideline-based risk thresholds for routine thromboprophylaxis, potentially for at least 2 weeks after delivery. Further investigation into the role of routine venous thromboembolism prophylaxis during and after delivery is needed.

Multifetal Gestations: Twin, Triplet, and Higher-Order Multifetal Pregnancies: ACOG Practice Bulletin, Number 231.

The incidence of multifetal gestations in the United States has increased dramatically over the past several decades. For example, the rate of twin births increased 76% between 1980 and 2009, from 18.9 to 33.3 per 1,000 births (1). However, after more than three decades of increases, the twin birth rate declined 4% during 2014-2018 to 32.6 twins per 1,000 total births in 2018 (2). The rate of triplet and higher-order multifetal gestations increased more than 400% during the 1980s and 1990s, peaking at 193.5 per 100,000 births in 1998, followed by a modest decrease to 153.4 per 100,000 births by 2009 (3). The triplet and higher-order multiple birth rate was 93.0 per 100,000 births for 2018, an 8% decline from 2017 (101.6) and a 52% decline from the 1998 peak (193.5) (4). The long-term changes in the incidence of multifetal gestations has been attributed to two main factors: 1) a shift toward an older maternal age at conception, when multifetal gestations are more likely to occur naturally, and 2) an increased use of assisted reproductive technology (ART), which is more likely to result in a multifetal gestation (5). A number of perinatal complications are increased with multiple gestations, including fetal anomalies, preeclampsia, and gestational diabetes. One of the most consequential complications encountered with multifetal gestations is preterm birth and the resultant infant morbidity and mortality. Although multiple interventions have been evaluated in the hope of prolonging these gestations and improving outcomes, none has had a substantial effect. The purpose of this document is to review the issues and complications associated with twin, triplet, and higher-order multifetal gestations and present an evidence-based approach to management.

Incidence of Severe Maternal Morbidity During Delivery Hospitalization in U.S. Commercially Insured and Medicaid Populations.

Objective: To estimate the incidence rate and associated risk factors of severe maternal morbidity (SMM) in commercially and Medicaid-insured women. Materials and Methods: This was a retrospective cohort study of women with a live inpatient delivery recorded in 2016 in the MarketScan® databases for commercially insured and Medicaid populations. The incidence of SMM, defined by the Center for Disease Control and Prevention's algorithm of International Classification of Diseases, 10th edition diagnostic and procedural codes, was determined. Measurements also included the association of SMM in bivariate analyses with patient characteristics and the association of SMM with delivery type, gestation type, maternal age, and race in multivariate logistic regression analysis, adjusted for pre-existing conditions and pregnancy-related complications. Results: The incidence of SMM per 10,000 deliveries was 111.4 in the Commercial and 109.6 in the Medicaid population. The most frequent SMM indicators were eclampsia and blood transfusion in the Commercial population (35.0 and 25.7 per 10,000 deliveries, respectively) and eclampsia and adult respiratory distress syndrome in the Medicaid population (45.5 and 14.9 per 10,000 deliveries, respectively). A cesarean delivery was associated with SMM in both Commercial (odds ratio [OR] 3.37; 95% confidence interval [CI] 1.51-1.84) and Medicaid populations (OR 1.99; 95% CI 1.80-2.17). A multifetal gestation was also associated with SMM in both Commercial (OR 3.37; 95% CI 2.80-4.10) and Medicaid populations (OR 2.26; 95% CI 1.86-2.75). Conclusion: SMM occurred in 1.1% of live inpatient deliveries. A cesarean delivery, multifetal gestation, race, region, and several pre-existing comorbidities and obstetric complications were associated with SMM.

Adequacy of prenatal care and stillbirth.

There is limited literature on adequacy of prenatal care during pregnancy especially in case of stillbirth. This retrospective study consisted of 103 patients with stillbirths and 197 patients with live births. The Adequacy of Prenatal Care Utilization Index (APNCU) was used to determine prenatal care adequacy (Canadian Task Force Classification II-2). Among high-risk patients, the APNCU categories of inadequate (OR=3.81, 95% CI: 1.16-12.57, P<0.05) and adequate plus (OR=2.58, 95% CI: 1.23-5.38, P<0.05) were each significantly associated with greater odds for stillbirth. Diabetes, multifetal gestations, and fetal anomalies were each significantly associated with increased odds for stillbirth. Our findings emphasize the importance of clinicians in the role of providing appropriate prenatal care in the prevention of stillbirth. Clinicians also should realize that even with the best care approach of adequate plus prenatal care, certain high-risk patients will still be at risk for stillbirth.

Evaluating Progestogens for Preventing Preterm birth International Collaborative (EPPPIC): meta-analysis of individual participant data from randomised controlled trials

Preterm birth is a global health priority. Using a progestogen during high-risk pregnancy could reduce preterm birth and adverse neonatal outcomes.We did a systematic review of randomised trials comparing vaginal progesterone, intramuscular 17-hydroxyprogesterone caproate (17-OHPC), or oral progesterone with control, or with each other, in asymptomatic women at risk of preterm birth. We identified published and unpublished trials that completed primary data collection before July 30, 2016, (12 months before data collection began), by searching MEDLINE, Embase, CINAHL, the Maternity and Infant Care Database, and relevant trial registers between inception and July 30, 2019. Trials of progestogen to prevent early miscarriage or immediately-threatened preterm birth were excluded. Individual participant data were requested from investigators of eligible trials. Outcomes included preterm birth, early preterm birth, and mid-trimester birth. Adverse neonatal sequelae associated with early births were assessed using a composite of serious neonatal complications, and individually. Adverse maternal outcomes were investigated as a composite and individually. Individual participant data were checked and risk of bias assessed independently by two researchers. Primary meta-analyses used one-stage generalised linear mixed models that incorporated random effects to allow for heterogeneity across trials. This meta-analysis is registered with PROSPERO, CRD42017068299.Initial searches identified 47 eligible trials. Individual participant data were available for 30 of these trials. An additional trial was later included in a targeted update. Data were therefore available from a total of 31 trials (11 644 women and 16185 offspring). Trials in singleton pregnancies included mostly women with previous spontaneous preterm birth or short cervix. Preterm birth before 34 weeks was reduced in such women who received vaginal progesterone (nine trials, 3769 women; relative risk [RR] 0·78, 95% CI 0·68-0·90), 17-OHPC (five trials, 3053 women; 0·83, 0·68-1·01), and oral progesterone (two trials, 181 women; 0·60, 0·40-0·90). Results for other birth and neonatal outcomes were consistently favourable, but less certain. A possible increase in maternal complications was suggested, but this was uncertain. We identified no consistent evidence of treatment interaction with any participant characteristics examined, although analyses within subpopulations questioned efficacy in women who did not have a short cervix. Trials in multifetal pregnancies mostly included women without additional risk factors. For twins, vaginal progesterone did not reduce preterm birth before 34 weeks (eight trials, 2046 women: RR 1·01, 95% CI 0·84-1·20) nor did 17-OHPC for twins or triplets (eight trials, 2253 women: 1·04, 0·92-1·18). Preterm premature rupture of membranes was increased with 17-OHPC exposure in multifetal gestations (rupture <34 weeks RR 1·59, 95% CI 1·15-2·22), but we found no consistent evidence of benefit or harm for other outcomes with either vaginal progesterone or 17-OHPC.Vaginal progesterone and 17-OHPC both reduced birth before 34 weeks' gestation in high-risk singleton pregnancies. Given increased underlying risk, absolute risk reduction is greater for women with a short cervix, hence treatment might be most useful for these women. Evidence for oral progesterone is insufficient to support its use. Shared decision making with woman with high-risk singleton pregnancies should discuss an individual's risk, potential benefits, harms and practicalities of intervention. Treatment of unselected multifetal pregnancies with a progestogen is not supported by the evidence.Patient-Centered Outcomes Research Institute.

A CROSS-SECTIONAL STUDY OF PREGNANCY AND ITS OUTCOME WITH SPECIAL REFERENCE TO OLIGOHYDRAMNIOS AND POLYHYDRAMNIOS AT JLNMCH, BHAGALPUR, BIHAR

Background: The importance of amniotic uid volume as an indicator of fetal wellbeing has made its assessment an important part of antenatal fetal surveillance, also the level of amniotic uid affect the fetal well being so the present study was conducted to study the pregnancy and its outcome with special reference to oligohydramnios and polyhydramnios. Methodology: We studied 200 clinically suspected cases of oligohydramnios and polyhydramnios of more than 28 weeks of gestational age at Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College &amp; Hospital, Bhagalpur, Bihar. All these clinically suspected patients were further examined by ultrasonography for fetal surveillance, AFI calculation and conrmation of amniotic uid level abnormality. Result: The study revealed that predisposing factors and complications associated with oligohydramnios were – post term pregnancies, PROM, PIH, chronic abruption placentae while for polyhydramnios they were preeclampsia, PROM, preterm labour, abruption placentae, malpresentation. There were no maternal high risk factors seen in oligohydramnios but polyhydramnios was observed with anemia, Rh factor incompatibility, PIH, gestational diabetes mellitus and multifetal gestation. The proportion of C-section for fetal distress was higher in oligohydramnios. Conclusion: We concluded from this study that there were many predisposing factors for both oligohydramnios and polyhydramnios they should be addressed judiciously to reduce their higher proportion. Hence it is essential to evaluate amniotic uid volume during ante partum fetal surveillance, while maternal examination should look for high risk factors to avoid untoward complications beforehand. Thus management of women with oligohydramnios and polyhydramnios should be indivisualised with careful monitoring during labour, judicious and active intervention timely gives margin of safety

Developing a Cerebral Palsy Risk Score for Newborns

Background: Cerebral palsy (CP) causes developmental delays, affecting quality of life. Many risk factors are theorized however, no total risks summary exists, nor a CP prediction score for newborns. The result is under surveillance, treatment delays, and non-rectifiable complications. Objective: To establish total risk factors and create a prediction score for assessing CP neonatal risk before discharge. A prediction score has great utility for medical professionals and parents in screening high-risk patients and developing adequate monitoring systems. Materials and Methods: Using a case-controlled retrospect of children aged 0 to 2 years, born at Thammasat University Hospital, Thailand between 2005 and 2014, prenatal, perinatal, and postnatal risks were compared between children without CP as control, and those diagnosed with CP as case, by multivariable logistic regression. Predictors were assessed with area under the receiver operating characteristic (AuROC), odds ratio (OR), 95% confidence interval (CI), p-value, and clinical predisposition. Logistic regression was applied, including calibration, validation, and categorization of risk. Results: Cerebral and non-cerebral malformations, multi-fetal gestation, low birthweight, and neonatal sepsis were found as potential predictors, scoring 3, 1.5, 1, 2, 2.5, respectively, AuROC being 0.86 (95% CI 0.79 to 0.92). Low, moderate, and high-risk groups were set with scores of less than 1, 1.5 to 3, and more than 3.5, respectively. Conclusion: The present predictive CP risks and scoring system shows excellent discrimination power. If newborns were categorized in the highrisk group, close monitoring and surveillance are needed. Keywords: Cerebral palsy, Risk score, Prenatal, Perinatal, Postnatal

The clinical relevance of luteal phase progesterone support in true natural cycle cryopreserved blastocyst stage embryo transfers: a retrospective cohort study

BackgroundMore than 67% of all embryos transferred in the United States involve frozen-thawed embryos. Progesterone supplementation is necessary in medicated cycles to luteinize the endometrium and prepare it for implantation, but little data is available to show if this is beneficial in true natural cycles. We evaluated the use of luteal phase progesterone supplementation for cryopreserved/warmed blastocyst transfers in true natural cycles not using an ovulatory trigger.MethodsRetrospective cohort study in a single academic medical center. We studied the use of luteal phase progesterone supplementation in patients undergoing true natural cycle cryopreserved blastocyst embryo transfers. Our primary outcome measure was ongoing pregnancy rate, with other pregnancy outcomes being evaluated (i.e. implantation rate, miscarriage rate, ectopic rate, and multifetal gestation). Categorical data were analyzed utilizing Fisher’s exact test and all binary variables were analyzed using log-binomial regression to produce a risk ratio.ResultsTwo hundred twenty-nine patients were included in the analysis with 149 receiving luteal phase progesterone supplementation and 80 receiving no luteal phase support. Patient demographic and cycle characteristics, and embryo quality were similar between the two groups. No difference was seen in ongoing pregnancy rate (49.0% vs. 47.5%, p = 0.8738), clinical pregnancy rate (50.3% vs. 47.5%, p = 0.7483), positive HCG rate (62.4% vs. 57.5%, p = 0.5965), miscarriage/abortion rate (5.4% vs. 2.5%, p = 0.2622), ectopic pregnancy rate (0% vs. 1.3%, p = 0.3493), or multifetal gestations (7.4% vs. 3.8%, p = 0.3166).Conclusion(s)The addition of luteal phase progesterone support in true natural cycle cryopreserved blastocyst embryo transfers did not improve pregnancy outcomes and therefore the routine use in practice cannot be recommended based on this study, but the utilization should not be discouraged without further studies.CapsuleProgesterone supplementation as luteal phase support in true natural cycle cryopreserved blastocyst transfers does not improve ongoing pregnancies.

796 Eclampsia and associated adverse outcomes in singleton versus multifetal gestations

Multifetal gestation is a known risk factor for pre-eclampsia, but the degree of increased risk for eclampsia has not been quantified. Our objectives were to: 1) compare rates of eclampsia in singleton versus twin and higher order multifetal gestations and 2) investigate whether eclampsia in multifetal gestations is associated with higher maternal morbidity. We conducted a cross-sectional study using the US Vital Statistics birth certificate data to identify cases of eclampsia in live-born singleton, twin and higher order multifetal gestations between 2014 and 2018. We excluded subjects with fetal anomalies, gestational age < 24 or > 42 weeks, or missing maternal comorbidity or outcome data. Multivariable Poisson regression with robust error variance was used to compare rates of eclampsia between pregnancies with singleton, twin, and higher order multifetal gestations. Similarly, rates of composite adverse maternal outcome (CMAO; includes any of the following: blood transfusion, ICU admission, unplanned cesarean hysterectomy, and uterine rupture) were compared between groups among pregnancies with eclampsia. Among the 18.8 million pregnancies identified that met inclusion criteria, the rates of eclampsia increased with increasing degree of multiple gestation (Table 1). Twin pregnancies were more than twice as likely (aRR 2.55, 95% CI 2.47-2.63) to be affected by eclampsia compared to singleton gestations, while triplets and higher order multiples were nearly four times as likely to be affected by eclampsia (RR 3.71, 95% CI 3.20-4.31). Among those with eclampsia, CMAO was higher in multifetal gestations compared to singletons (aRR 1.38, 95% CI 1.16-1.64; Table 2). Multifetal gestations are at increased risk of eclampsia compared to singletons, and risk is increased in higher order pregnancies. Among pregnancies affected by eclampsia, multifetal gestation is associated with higher rates of adverse maternal outcomes compared to singletons.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

316 Preeclampsia severity after spontaneous or IVF conception in women age 40 and over

Preeclampsia (PE) is more common in women who conceived by in vitro fertilization (IVF). However, it is unclear if PE severity is worse in IVF pregnancies as prior studies have not fully controlled for age and other confounding factors. We sought to determine if PE severity is worse in women age 40 and over with IVF compared to spontaneous conception. Cohort study of women age 40 and over, who had PE and delivered at our institution from 1/1/13 to 12/31/17. This cohort, chosen due to the high prevalence of IVF conception in women 40 and over, was identified using ICD-10 codes and chart validation. Exclusions were maternal age <40, fetal demise, and non-IVF fertility treatments. The primary exposure was IVF conception (vs. spontaneous) and the primary outcome was PE with severe features (vs. PE without severe features). Secondary outcomes included severe symptoms, laboratory measures, and adverse maternal outcomes (see footnote Table 2). Analyses by t-test, Chi-squared or Fisher’s exact test, and logistic regression (α=0.05). We identified 237 women age 40 and over with PE (mean 42±2 years); 138 (58%) conceived spontaneously and 99 (42%) conceived by IVF. Women with IVF pregnancy were more often older, nulliparous, White, with multifetal gestation and lower BMI (Table 1). Compared to women with spontaneous conception, those with IVF pregnancy were not more likely to have PE with severe features (90% vs. 82%, P=0.09) (Table 2). The odds of PE with severe features was not increased in IVF pregnancies even after adjustment for age, race, BMI, nulliparity and multifetal gestation (aOR 1.9, 95% CI 0.7-5.1). Adverse maternal outcomes were increased with IVF pregnancy (36% vs. 23%, P=0.03), but this was not significant after multivariable adjustment (aOR 0.64, 95% CI 0.3-1.4). In women 40 and over, IVF pregnancy was not independently associated with an increase in preeclampsia severity or adverse maternal outcomes. However, most women 40 and over had PE with severe features, suggesting that age may drive disease severity regardless of mode of conception.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

758 Hypertensive disease of pregnancy (HDP) among high risk women with stage 1 hypertension

To evaluate HDP in high risk women with stage 1 hypertension (SBP 130-139 mmHg or DBP 80-89 mmHg) as defined by the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Hypertension Guidelines. Previous investigations of low risk populations have correlated stage 1 hypertension with increased risk of poor obstetric outcomes, however high risk women have not been studied. We performed a secondary analysis of the "Low-dose aspirin to prevent preeclampsia in women at high risk" dataset, a multicenter randomized trial investigating aspirin (ASA) for the prevention of preeclampsia. High risk women with a diagnosis of insulin dependent diabetes (IDDM), chronic hypertension (CHTN), multifetal gestations (MG) or a history of preeclampsia (Hx Pre) who met criteria for stage 1 HTN at an initial prenatal visit between 13-26 weeks were randomized to baby aspirin (ASA) or placebo and compared to normotensive controls. The primary outcome was hypertensive disease in pregnancy (HDP) defined as gestational HTN, preeclampsia, and preeclampsia with severe features. Risk ratios and 95% CI were calculated. 2,053 high risk women were evaluated. 446 participants met criteria for stage 1 HTN and were compared to 1,309 normotensive controls. Among those in the placebo group, women with IDDM (RR 2.4 [1.6-3.5]), CHTN (RR 1.8 [1.1-3.0]) and Hx Pre (RR 2.0 [1.5-2.7]) demonstrated increased risk of HDP with a diagnosis of stage 1 HTN. Those with a history of preeclampsia and stage 1 HTN demonstrated increased risk for HDP in both the placebo and ASA group. ASA seemed to be effective in prevention of HDP for women with IDDM or CHTN. In patients with preexisting risk factors, stage 1 HTN at initial prenatal visit was an additive risk factor for hypertensive disease in pregnancy. ASA proves effective at preventing HDP in women with IDDM and CHTN who met criteria for stage 1 hypertension.

1046 Assessing compliance to daily low dose aspirin for preeclampsia prevention using a validated questionnaire

Adherence is essential to the efficacy of ASA in preventing preeclampsia (PE). Our objective was to evaluate and compare the adherence of pregnant women at high risk for PE to different regimens of ASA using a validated questionnaire, the simplified medication adherence questionnaire (SMAQ). 33 pregnant women identified as high risk for developing PE using the Unites States Preventative Services Task Force (USPSF) criteria were randomized in an open-label setting to either ASA 81mg daily or ASA 162mg daily, to be initiated before 16 weeks’ gestation. The USPSF criteria include: PE in a prior pregnancy, chronic hypertension, pregestational diabetes, renal disease, autoimmune disease or multifetal gestation. Compliance to therapy was ascertained using the validated SMAQ at 20, 26 and 36 ± 2 weeks’ gestation (Table 1). Non-adherence was defined as: a positive response to any of the qualitative questions, >2 missed doses over the past week, or >2 days of non-use in the past 3 months. Compliance rates were compared across treatment groups using Chi-square with an alpha error level set at <0.05. The mean age of participants was 36.0±4.9 years, 16/33 (48.5%) were primiparous. Age and parity were similar for both treatment groups. 18/33 (54.5%) women were randomized to the ASA 81mg group and 15/33 (45.5%) to ASA 162mg. The SMAQ was completed by 93.9% of participants at 20±2 weeks, 87.9% at 26±2 weeks and 75.8% at 36±2 weeks. Table 2 outlines compliance rates with daily low dose aspirin, stratified by treatment group. Overall, medication adherence was higher in the ASA 81mg group, particularly after the mid-trimester. Reasons for non-adherence included gastrointestinal side effects (6.1%), vaginal spotting (3%) and non-intentional omission (9.1%). Aspirin compliance appears to be elevated in women at high risk for PE who are prescribed ASA 81mg daily and to be significantly lower in women on 162mg. This should be taken into consideration when prescribing and counseling women about low dose ASA for PE prevention.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

1085 Maternal and neonatal outcomes of a subsequent pregnancy after stillbirth

Prior stillbirth is associated with increased risk of future stillbirth, but risks of adverse neonatal outcomes in a subsequent liveborn pregnancy are unknown. This is a secondary analysis of a large NIH-funded retrospective cohort study of women with diabetes, hypertensive disorders, and/or fetal growth restriction who delivered at a tertiary-care hospital from January 2002 to March 2013, excluding women with only severe preeclampsia or multifetal gestations. All women in the parent study were included in this analysis, comparing women with and without a history of stillbirth >20 weeks. The primary outcome is a neonatal morbidity composite: neonatal resuscitation (oxygen, CPAP, intubation, CPR), neonatal injury, RDS, TTN, hypoglycemia, sepsis. Secondary outcomes include a maternal morbidity composite (DVT/PE, ICU admission, DIC, sepsis, hysterectomy, pulmonary edema, renal failure, blood transfusion), neonatal death, and less severe neonatal and maternal outcomes. Log binomial and linear regression were performed controlling for maternal comorbidities. 191 women with and 11,725 women without prior stillbirth were included. Women with prior stillbirth were older (p<0.001), had higher BMI (p=0.001), and higher rates of chronic hypertension (p=0.007), autoimmune disease (p=0.02), and clotting disorder needing anticoagulation (p=0.03). After controlling for these factors, women with prior stillbirth had nearly 25% increased risk of composite neonatal morbidity (aRR 1.23; 95% CI 1.02-1.48), more than 50% increased risk of NICU admission (aRR 1.53; 95% CI 1.14-2.05), and nearly seven-fold increased risk of neonatal death (aRR 6.95; 95% CI 1.37-35.3), despite delivery at similar gestational age. Women with prior stillbirth were equally likely to have the maternal morbidity composite but nearly twice as likely to develop severe pre-eclampsia (aRR 1.88; 95% CI 1.09-3.31). Women with common obstetric comorbidities who have a prior stillbirth are at higher risk for severe neonatal complications, NICU admission and neonatal death when compared to women without prior stillbirth.

629 A new predictive model for periviable infant survival

Currently available survival calculators for periviable births do not account for fetal presentation and mode of delivery. We set out to develop and validate a predictive risk calculator for infant survival among women who delivered between 22 0/7 – 25 6/7 weeks of gestation which accounts for mode of delivery and fetal presentation. We performed a population-based cohort study of all women with livebirths between 22 0/7 – 25 6/7 weeks of gestation in the United States from 2009 through 2013. The primary objective was to build a predictive model estimating the probability of infant survival at 12 months of age using antenatal factors obtained from de-identified U.S livebirth records. Multivariable logistic regression estimated the association of these factors on risk of infant survival. A publicly available online calculator was developed after external validation and calibration were performed for individual risk assessment. The eight variables selected for inclusion in the model by magnitude of influence on infant survival were birthweight, gestational age, sex, antenatal steroid exposure, resuscitation, presentation at birth, mode of delivery and multifetal gestation From 2009-2013, there were 67,260 liveborn infants in the U.S. between 22 0/7 – 25 6/7 weeks of gestation, of which 51,352 were included in the study cohort. The receiver operator characteristic (ROC) curve for the 8-variable model achieved an area under the curve of 0.800 (95% CI 0.795-0.804). External validation demonstrated a consistent measure of discrimination with an AUC of 0.799 (95% CI 0.789-0.808). This validated predictive model accounts for new variables obtainable from the medical record and discriminates between infants at increased or decreased risk of survival after periviable birth. This risk calculator found at https://stage.ob.tools/calc/elbw (username: [email protected] , password: personalizeCare) and can utilized by health care providers in counseling women with threatening periviable birth.View Large Image Figure ViewerDownload Hi-res image Download (PPT)