Trimester Visit Research Articles

Starting Early Program Impacts on Feeding at Infant 10 Months Age: A Randomized Controlled Trial.

Background: Disparities in obesity-promoting feeding patterns begin in pregnancy and infancy, underscoring the need for early primary prevention in high-risk groups. We sought to determine the impact of a primary care-based child obesity prevention intervention beginning during pregnancy on maternal infant feeding practices, knowledge, and styles at 10 months in low-income Hispanic families. Methods: The Starting Early Program (StEP) randomized controlled trial enrolled pregnant women at a third trimester visit. Women (n = 533) were randomized to standard care or an intervention with prenatal/postpartum individual nutrition counseling and nutrition and parenting support groups coordinated with pediatric visits. Feeding practices (breastfeeding, family meals, juice, and cereal in the bottle) were assessed using questions from the Infant Feeding Practices Study II. Feeding styles were assessed using the Infant Feeding Style Questionnaire. We analyzed impacts on feeding practices, knowledge, and styles using regression analyses adjusting for covariates. Results: Four hundred twelve mothers completed 10-month assessments. Intervention mothers were more likely to give breast milk as the only milk source [adjusted odds ratio (AOR) 1.65, 95% confidence interval (CI) 1.06-2.58] and have daily family meals (AOR 1.91, 95% CI 1.19-3.05), and less likely to give juice (AOR 0.60, 95% CI 0.39-0.92) or cereal in the bottle (AOR 0.54, 95% CI 0.30-0.97) compared to controls. Intervention mothers were more likely to exhibit lower pressuring, indulgent and laissez-faire feeding styles, and to have higher knowledge. Attending a greater number of group sessions increased intervention impacts. Conclusions: StEP led to reduced obesity-promoting feeding practices and styles, and increased knowledge and provides great potential for population-scalability.

Midwives’ role in drop-out antenatal care at second visit: Therapeutic and interactive communication in the Lombok Tengah District, Indonesia

Visiting health center for getting ANC service, at least four times during pregnancy consisting of the first visit (K1) during the first trimester, the second visit (K2) during the second trimester, and K3 and K4 visit during the third trimester must be done by pregnant women in Indonesia. The objective of this research is to analyze therapeutic and interactive communication by midwives during ANC service. This observational research used cross sectional design. The sample size is 30 women with babies under six months old from 3 PHCs working areas in Lombok Tengah District. Among all therapeutic and interactive communication indicators performed by the midwives, only responsive indicator in therapeutic communication showed insignificant influence on K4 of pregnant women. The other indicators showed significant impact. More than 50% of respondents said that midwives providing ANC had poor attending skill, respect, responsiveness, empathy, informing, persuading, and reminding. The conclusion is that the worse the pregnant women perception of midwives communication behavior is, the higher the chance for the pregnant women to drop-out during K4 is.

Factors Influencing Quality of Life during the First Trimester of Pregnancy: A Prospective Cohort Study.

Introduction: Pregnancy, delivery and postpartum periods are associated with fast changes leading to decreased self-confidence, anxiety, stress or even maternal depression impairing their quality of life (QOL). Although considered important, QOL of women during pregnancy is poorly understood. The aim of our study was to assess factors influencing QOL during first trimester of pregnancy. The secondary goal of our study was to evaluate whether QOL during first trimester of pregnancy is associated with newborn weight. Materials and methods: A prospective cohort study was performed including pregnant women during the first trimester visit. Our questionnaire consisted of the SF-36 QOL questionnaire, Wexner fecal incontinence scale, and other additional information. The SF-36 questionnaire mental (MCS) and physical (PCS) health scores were used in order to evaluate QOL of women during first trimester of pregnancy. Two multiple logistic regression models were created in order to determine independent variables that influence the QOL. Results: 440 pregnant women were included in the study. The two main domains that were used in the study were MCS and PCS, their medians were 50.0 (25.0; 50.0) and 50.1 (39.4; 59.0) points respectively. From the two logistic regression models we determined several independent factors that influence QOL of women during the first trimester of pregnancy. Additionally, we determined that women who reported worse QOL tended to give birth to newborns large for their gestational age. Conclusions: We found several significant variables that influence QOL of women during the first trimester of pregnancy. We also found that that lower MCS and PCS scores during the first trimester are associated with newborns large for gestational age.

Human Papillomavirus (HPV) Infection in Early Pregnancy: Prevalence and Implications.

Introduction Young women (20-35 years) are at high risk of HPV infection, although the majority of the infections are asymptomatic and are cleared spontaneously by the host immune system. These are also the group of women who are sexually active and are in the population of pregnant women. During pregnancy, the changes in the hormonal milieu and immune response may favor persistence of HPV infection and may aid in transgenerational transmission thereby furthering the cancer risk. In the present study, we determined the prevalence of vaginal HPV infection in early pregnancy and attempted to relate with pregnancy outcome. Material and Methods Vaginal cytology samples were collected from the condoms used to cover the vaginal sonography probe during a routine first trimester visit to the hospital. All women were followed up throughout pregnancy and childbirth. Maternal and neonatal outcomes were recorded. Results We found a prevalence of HPV infection around 39.4% in our population. Interestingly all HPV positive women were infected with one or more high risk HPV viruses with an overlap of intermediate and low risk in 43% and 7.3%, respectively. Women with preterm prelabor rupture of membranes (PPROM) showed a statistically higher incidence in HPV positive (7.3%) group as compared to the HPV negative (3.2%) group. Conclusion The prevalence of genital HPV infection is high during pregnancy (around 40%) and was associated with higher incidence of PPROM.

Clear cell carcinoma of ovary in pregnancy

Clear cell carcinoma in pregnancy is a rare event, accounts for less than 1%. Here we present a 29year old women who was incidentally diagnosed to have an abdominal mass corresponding to 24 week size on her first trimester visit, Ca 125 was 49, MRI pelvis showed large complex ovarian cyst probably cystic ovarian neoplasm. Patient underwent fertility preserving staging laparotomy. Intraoperative right salphingo-ovariotomy was performed. Histopathology reported as Clear cell carcinoma of ovary. The couple decided to undergo Medical termination of pregnancy after multidisciplinary team counselling provided by Medical oncologist and obstetrician. After six months of adjuvant chemotherapy with paclitaxel and carboplatin patient improved symptomatically better and is on regular follow up. Keywords: Clear cell carcinoma of ovary.

THE PREVALENCE OF UNDERWEIGHT, OVERWEIGHT AND OBESITY IN A ROMANIAN POPULATION IN THE FIRST TRIMESTER OF PREGNANCY - CLINICAL IMPLICATIONS.

Underweight, overweight and obesity are important global public health issues and risk factors for adverse perinatal outcomes. To assess the distribution of the body mass index (BMI) in the Romanian obstetric population in the first trimester of pregnancy and its correlation with pregnancy outcomes. We also report the distribution of blood pressure (BP) parameters and their correlation with BMI. This retrospective study includes 9,064 women attending routine first trimester visit and ultrasound scan at 12.8(±0.6) gestational weeks. Characteristics, parity, method of conception, blood pressure (from 3,650 women), maternal weight and height, BMI and foetal ultrasound were recorded. Pregnancy outcomes were available for 1,607 deliveries. The Pearson correlation coefficient was assessed for each BMI group vs. blood pressure parameters, gestational age and birth weight. ANOVA analysis and post hoc tests were used to determine group differences. Linear regression was applied to estimate the contribution of BMI and gestational age to birth weight variance. In our population, 66.37% pregnant women had a normal BMI, 19.29% were overweight, and 7.56% were obese. There was a weak-to-medium positive correlation between BMI and blood pressure parameters, for all weight categories. The correlation between maternal BMI and birth weight was positive for normal and overweight. Our findings highlight the need for more effective health strategies targeting reduction of weight-related problems in women of childbearing age.

640: Does first-trimester clean catch urine reflect the microbiome of the vagina or lower urinary tract?

Assess if microbes in clean catch urine of pregnant women resemble those of the vagina or the lower urinary tract. This is a prospective IRB-approved cohort study of 29 pregnant women with a singleton pregnancy <14 weeks. Exclusion criteria included recurrent UTI, antibiotic use since conception, and urinary tract anomalies. During their 1st trimester visit, consented subjects provided paired clean catch urine and vaginal swab samples. Samples were assessed by an Expanded Quantitative Culture (EQC) method that - compared to the standard urine culture method - uses more types of media and atmospheric conditions with a longer incubation period. Colony forming units (CFU) were counted for each morphologically distinct colony type; representative colonies were purified for identification using MALDI-TOF Mass Spectroscopy. Species identification and CFU counts were combined for analysis using the Bray-Curtis dissimilarity index (BC). A BC value of 0.5 was used to sort paired vaginal and urine samples as similar (<0.5) or different (≥0.5). For descriptive purposes, samples were hierarchically clustered with complete-linkage agglomeration by their vaginal culture results. The majority of the subjects were multiparous (n=20) with a mean age of 29.6 years. EQC detected live microbes in both urine and vaginal samples of all subjects. The vaginal samples clustered into 4 distinct community state structures (Figure). Based on BC indices, paired urine and vaginal samples were dissimilar (BC≥0.5) for 72% (n=21) of subjects. Of the 8 subjects with similar urine and vaginal microbiomes (BC<0.5), Lactobacillus was dominant in 88% of vaginal samples (n=7) and 100% of urine samples (n=8). In contrast, of the 21 subjects with dissimilar microbiomes (BC>0.5), a minority (24%, n=5) had a Lactobacillus-dominant urine sample (p<0.01). The clean catch urine microbiome of pregnant women in their 1st trimester is most often distinct from their vaginal microbiome, evidence that their lower urinary tract contains a unique microbiome. Women with dissimilar urine and vaginal microbiomes were less likely to have Lactobacillus-dominant urine. Given these findings, the vaginal microbiome should not be assumed to represent the lower urinary tract microbiome.

Hemostatic Activation and Glycocalyx Shedding during Pregnancy

Background: Pregnancy has been described as a hypercoagulable state and is characterized by an increased risk of thrombotic events; yet the absolute incidence is low. The glycocalyx is a network of proteoglycans and glycoproteins projecting from the endothelial cell surface that plays a key role in maintaining endothelial integrity. Syndecan-1 is a component of the endothelial glycocalyx and is substituted with heparan sulfate chains which promote its interactions with key anticoagulants such as tissue factor pathway inhibitor and antithrombin. Proteolytic release of components of the glycocalyx (i.e. shedding) has been shown to occur in response to a number of physiologic challenges. Thrombomodulin, another endothelial cell transmembrane protein, is a key component of the primary dynamic anticoagulant mechanism limiting thrombus growth and is also subject to proteolytic release. In this study, we longitudinally evaluate hemostatic activation (D-dimer), glycocalyx shedding (syndecan-1) and thrombomodulin release in healthy women who became pregnant.Methods: Healthy nulliparous women (N=26) were prospectively enrolled in a longitudinal study at the University of Vermont Medical Center in a protocol approved by the Institutional Review Board. Study visits were conducted prior to pregnancy in the follicular phase (Visit 1), at the end of the first trimester (Visit 2), and the mid-third trimester (Visit 3). Blood was collected into citrate, and platelet poor plasma aliquots were prepared. Syndecan-1 and soluble thrombomodulin were measured on all samples by ELISA, and D-dimer was measured at Visits 1 and 3. For analyses, comparisons were made across Visits using a paired Student's t-test. Data are expressed as mean ± SD.Results: D-dimer levels were increased (3-13 fold across all women) significantly at Visit 3 (7.6 ± 3.9 μg/mL) compared to Visit 1 (1.2 ± 0.5 μg/mL), p < 0.001. Syndecan-1 levels were elevated at Visit 2 relative to Visit 1 in 25 of the 26 women; Visit 2 levels (43.7 ± 12.7 ng/mL) were significantly higher than Visit 1 (25.6 ± 18.0 ng/mL), p < 0.001. At Visit 3, an average 20-fold increase (range of 2.7 - 52.9-fold) in syndecan-1 levels (Visit 3, 518.5 ± 248.5 ng/mL) compared to Visit 1, p < 0.001 was observed. Soluble thrombomodulin did not change between Visit 1 (2.93 ± 0.5 μg/mL) and Visit 2 (2.88 ± 0.6 μg/mL); however there was a significant increase by Visit 3 (3.59 ± 0.7 μg/mL), p<0.001. Correlation analyses relating syndecan-1 and D-dimer levels and syndecan-1 and soluble thrombomodulin levels at each visit or relating fold changes in these markers between Visit 1 and Visit 3 showed no significant associations.Conclusions: By Visit 3 (the third trimester) women show significant increases in hemostatic activation, glycocalyx shedding and the release of another endothelial cell membrane protein. Increasing the levels of syndecan-1 in circulation may have a heparin-like effect on antithrombin activity while increasing soluble thrombomodulin levels may increase systemic protein C activation. However, the release of two potent anticoagulants from the endothelial surface can reduce the ability of the endothelial surface to help mediate and restrict thrombus growth at the site of injury. Future studies are needed to address whether there may be a prothrombotic contribution from the degraded endothelial surface that is offset by the release of anticoagulants into the circulatory system. DisclosuresNo relevant conflicts of interest to declare.

Association between Maternal Psychosocial Stress during Pregnancy and Gestational Age in Puerto Rico

Preterm birth (PTB), the leading cause of infant morbidity and mortality worldwide, disproportionally impacts infants in Puerto Rico (PR). Psychosocial stress may be an important risk factor for PTB and hasn&amp;#8217;t been examined in PR. We examined associations between stress and gestational age continuously and PTB (&amp;lt;37 weeks gestation) using multiple dimensions of stress in order to optimally define exposure. Stress was measured using the Perceived Stress Scale (PSS), Life Experiences Survey (LES), Center for Epidemiologic Studies-Depression (CES-D), and ENRICHD Social Support Instrument (ESSI). We included 922 mother-infant pairs of the Puerto Rico Testsite for Exploring Contamination Threats (PROTECT) Cohort, which examines environmental risk factors for PTB in the Northern Karst region of PR. Data on stress measures was collected during the 3rd trimester visit, except for LES, which was collected at the 2nd trimester. Responses on each scale were scored to create a continuous measure. Higher scores on each scale, except the ESSI, were indicative of increased stress. There were 93 PTBs in this analysis. Lower maternal education, unemployment, and public insurance were more common among women who delivered preterm and were associated with higher scores on all stress measures. Higher scores on the PSS (ß: 0.00; 95% CI (confidence interval): -0.02, 0.01), LES (ß: 0.01; 95% CI: -0.02, 0.04), ESSI (ß: 0.01; 95% CI: -0.02, 0.04), and CES-D scales (ß: -0.01; 95% CI: -0.02, 0.01) were not associated with gestational age or PTB. Although our findings show that stress as measured by these scales is not associated PTB, there are other facets of stress, such as anxiety and neighborhood perceptions, that were not captured in our scales but may be important. Our study indicates that stress in pregnancy is not a major risk factor for PTB in our population. Other environmental exposures, such as chemical exposures in pregnancy, will be investigated in this population in the future.

Innate immune activation and depressive and anxious symptoms across the peripartum: An exploratory study

BackgroundThere are complex associations between immune function and mental illness, yet studies in the perinatal period focus primarily on individual inflammatory markers and depressive symptoms only, cross-sectionally. We sought to examine associations between both depressive and anxious symptoms and immune activation longitudinally across the peripartum. MethodsWe measured mood (Beck Depression Inventory, BDI-1 A) and anxiety (State-Trait Anxiety Inventory, STATE) and levels of 23 cytokines at 5 points in pregnancy and postpartum in 51 women. Within subject cytokine trajectories over time by depressive and anxious symptom grouping were assessed using linear mixed effects models with random intercept and slope. We also undertook an exploratory cluster analysis based on third trimester cytokine values. ResultsBased on categorical BDI scores, IL-6 (p < 0.001), IL-15 (p = 0.047), GCSF (p = 0.003), and CCL3 (p < .001) were significantly different across time, with IL-6 (p < 0.001), IL-15 (p = 0.003), and CCL3 (p < 0.001) higher at the third trimester visit in more depressed subjects. Based on categorical STATE scores, GM-CSF significantly decreased across pregnancy for the less anxious group (p = 0.016), but not for the more anxious, and CCL3 (p = 0.017), CXCL8 (p = 0.011), and IL-6 (p < 0.001) were higher at the third trimester visit for more anxious subjects. In exploratory cluster analysis based on cytokine level, there were no differences in mood or anxiety scores, but significant differences by race/ethnicity and overweight/obesity status. Women with higher pro-inflammatory cytokine values are more likely to be Hispanics (69.2% vs. 21.4%, p = 0.015), but less likely to be African American (23.1% vs. 60.7%, p = 0.015) or overweight/obese (25% vs. 69.2%, p = 0.016) compared to women with lower pro-inflammatory cytokine values. ConclusionWe identified a pro-inflammatory burst at the third trimester, indicative of innate immune activation, in women with higher levels of both depressive and anxious symptoms, as well as differences in pro-inflammatory changes across time. We also found significant differences in cytokine levels by race, ethnicity, and overweight/obesity status. These results point the way toward future longitudinal work that considers race/ethnicity, timing, and weight status, and evaluates perinatal mood and anxiety disorders in the context of changing immune functioning across the peripartum.

Association of the Affordable Care Act Dependent Coverage Provision With Prenatal Care Use and Birth Outcomes

The effect of the Affordable Care Act (ACA) dependent coverage provision on pregnancy-related health care and health outcomes is unknown. To determine whether the dependent coverage provision was associated with changes in payment for birth, prenatal care, and birth outcomes. Retrospective cohort study, using a differences-in-differences analysis of individual-level birth certificate data comparing live births among US women aged 24 to 25 years (exposure group) and women aged 27 to 28 years (control group) before (2009) and after (2011-2013) enactment of the dependent coverage provision. Results were stratified by marital status. The dependent coverage provision of the ACA, which allowed young adults to stay on their parent's health insurance until age 26 years. Primary outcomes were payment source for birth, early prenatal care (first visit in first trimester), and adequate prenatal care (a first trimester visit and 80% of expected visits). Secondary outcomes were cesarean delivery, premature birth, low birth weight, and infant neonatal intensive care unit (NICU) admission. The study population included 1 379 005 births among women aged 24-25 years (exposure group; 299 024 in 2009; 1 079 981 in 2011-2013), and 1 551 192 births among women aged 27-28 years (control group; 325 564 in 2009; 1 225 628 in 2011-2013). From 2011-2013, compared with 2009, private insurance payment for births increased in the exposure group (36.9% to 35.9% [difference, -1.0%]) compared with the control group (52.4% to 51.1% [difference, -1.3%]), adjusted difference-in-differences, 1.9 percentage points (95% CI, 1.6 to 2.1). Medicaid payment decreased in the exposure group (51.6% to 53.6% [difference, 2.0%]) compared with the control group (37.4% to 39.4% [difference, 1.9%]), adjusted difference-in-differences, -1.4 percentage points (95% CI, -1.7 to -1.2). Self-payment for births decreased in the exposure group (5.2% to 4.3% [difference, -0.9%]) compared with the control group (4.9% to 4.3% [difference, -0.5%]), adjusted difference-in-differences, -0.3 percentage points (95% CI, -0.4 to -0.1). Early prenatal care increased from 70% to 71.6% (difference, 1.6%) in the exposure group and from 75.7% to 76.8% (difference, 0.6%) in the control group (adjusted difference-in-differences, 0.6 percentage points [95% CI, 0.3 to 0.8]). Adequate prenatal care increased from 73.5% to 74.8% (difference, 1.3%) in the exposure group and from 77.5% to 78.8% (difference, 1.3%) in the control group (adjusted difference-in-differences, 0.4 percentage points [95% CI, 0.2 to 0.6]). Preterm birth decreased from 9.4% to 9.1% in the exposure group (difference, -0.3%) and from 9.1% to 8.9% in the control group (difference, -0.2%) (adjusted difference-in-differences, -0.2 percentage points (95% CI, -0.3 to -0.03). Overall, there were no significant changes in low birth weight, NICU admission, or cesarean delivery. In stratified analyses, changes in payment for birth, prenatal care, and preterm birth were concentrated among unmarried women. In this study of nearly 3 million births among women aged 24 to 25 years vs those aged 27 to 28 years, the Affordable Care Act dependent coverage provision was associated with increased private insurance payment for birth, increased use of prenatal care, and modest reduction in preterm births, but was not associated with changes in cesarean delivery rates, low birth weight, or NICU admission.

1006: Fasting glucose checkpoints during gestation: is timing related to level of glycemic control?

Since glycemic control is usually achieved through a trial-and-error methods, we aimed to evaluate the glycemic control prediction ability of fasting glucose and insulin levels at different time points. We performed a prospective study of women diagnosed with GDM, with singleton gestations, in a tertiary medical center. Laboratory workup which included fasting blood samples for blood count, chemistry, glucose and insulin. We calculated insulin resistance and sensitivity using the HOMA-IR and QUICKI models, respectively. Each patient was given nutritional consult and was instructed to measure glucose levels 6 times daily. Level of glycemic control was evaluated one week later, and women with more than 20% of measurements exceeding 95mg/dL at fasting or 120mg/dL 2-hours postprandial, or mean capillary glucose≥105mg/dL (poor glycemic control), were given medical treatment (insulin or Glyburide). We compared women with poor glycemic control with women with good glycemic control. We recruited 75 women, of which 26 (34.7%) were poorly controlled. Poorly controlled women had higher mean maternal age, and higher first trimester, OGTT and first visit fasting glucose levels, as well as higher first visit fasting insulin level. They also had higher HOMA-IR and lower QUICKI. Using a multivariate logistics regression model, HOMA-IR, QUICKI, first trimester fasting glucose, and first visit fasting insulin and glucose were found to be independently associated with poor glycemic control. We also calculated a ROC curve, which demonstrated that for a fixed specificity of 91%, first visit fasting glucose of 94.5mg/dL achieved the greatest sensitivity, PPV and NPV. Fasting glucose in the first trimester, OGTT and first visit, as well as first visit fasting insulin are all significantly higher among women with poorly controlled GDM. First visit fasting glucose have the best test performance measures to predict poor glycemic control.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

First-Trimester Serum Fatty Acid-Binding Protein 4 and Subsequent Gestational Diabetes Mellitus.

To examine whether plasma fatty acid-binding protein 4 concentrations, measured in the first trimester, are associated with gestational diabetes mellitus (GDM). This prospective, multicenter cohort study was conducted at three maternity centers in two cities (Harbin and Beijing) in China from July 2015 to June 2016. Data for fasting plasma glucose and fatty acid-binding protein 4 concentrations in the first trimester and one-step GDM screening with a 75-g oral glucose tolerance test performed between 24 and 28 weeks of gestation were collected and analyzed. Plasma from women in the first trimester was available for 1,150 women, of whom 135 (11.7%) developed GDM. The GDM distribution across the fatty acid-binding protein 4 quartiles ranged from 3.8% (first quartile) to 21.6% (fourth quartile). In multivariate models comparing the second (quartile 2), third, and fourth quartiles against the first quartile of fatty acid-binding protein 4, concentrations of fatty acid-binding protein 4 in quartile 2, quartile 3, and quartile 4 were associated with the development of GDM with respective associated adjusted odds ratios (95% CIs) of 1.76 (1.21-2.58), 2.36 (1.55-4.29), and 3.57 (1.99-6.11). A significant difference in the area under receiver operating characteristic curve between established risk factors alone and the addition of fatty acid-binding protein 4 concentrations was observed (difference 0.042 [95% CI 0.028-0.055]; P=.03). Higher fatty acid-binding protein 4 concentrations in the first trimester visit were associated with increased risk of GDM and might be useful in identifying women at risk for GDM for early prevention strategies.

Randomized Controlled Trial of a Primary Care-Based Child Obesity Prevention Intervention on Infant Feeding Practices

To determine the effects of a child obesity prevention intervention, beginning in pregnancy, on infant feeding practices in low-income Hispanic families. The Starting Early randomized controlled trial enrolled pregnant women at a third trimester visit. Women (n=533) were randomly allocated to a standard care control group or an intervention group participating in prenatal and postpartum individual nutrition/breastfeeding counseling and subsequent nutrition and parenting support groups coordinated with well-child visits. Outcome measures included infant feeding practices and maternal infant feeding knowledge at infant age 3months, using questions adapted from the Infant Feeding Practices Study II and an infant 24-hour diet recall. A total of 456 families completed 3-month assessments. The intervention group had higher prevalence of exclusive breastfeeding on the 24-hour diet recall (42.7% vs 33.0%, P=.04) compared with controls. The intervention group reported a higher percentage of breastfeeding vs formula feeding per day (mean [SD] 67.7 [39.3] vs 59.7 [39.7], P=.03) and was less likely to introduce complementary foods and liquids compared with controls (6.3% vs 16.7%, P=.001). The intervention group had higher maternal infant feeding knowledge scores (Cohen d, 0.29, 95% CI .10-.48). The effect of Starting Early on breastfeeding was mediated by maternal infant feeding knowledge (Sobel test 2.86, P=.004). Starting Early led to increased exclusive breastfeeding and reduced complementary foods and liquids in 3-month-old infants. Findings document a feasible and effective infrastructure for promoting breastfeeding in families at high risk for obesity in the context of a comprehensive obesity prevention intervention. ClinicalTrials.gov: NCT01541761.

Diagnostic Accuracy of Routine Antenatal Determination of Fetal RHD Status Across Gestation

The RhD (RH1) antigen of the rhesus system is the most commonly implicated antigen for hemolytic disease of the fetus. Postnatal prophylaxis with anti-RhD immunoglobulin in RhD− women with an RhD+ child has been shown to reduce the risk of becoming alloimmunized. Subsequent introduction of routine antenatal prophylaxis with anti-RhD immunoglobulin in the third trimester for all RhD− women is now standard in many countries. Cell-free fetal DNA in maternal plasma can be tested for the presence or absence of the RHD gene, essentially screening for fetal Rh status. This prospective, multicenter cohort study was performed to determine the diagnostic accuracy of RHD genotyping in RhD− parturients and the optimal gestation for implementation into practice. From 2009 to 2012, consenting parturients had blood samples obtained at their initial appointment, at Down syndrome screening (11–21 weeks’ gestation), and at routine anomaly scanning (18–23 weeks’ gestation). At the third trimester visit (∼28 weeks), women were given the results of molecular testing, and an additional blood sample was obtained to confirm fetal RHD status. When this testing confirmed that the fetus was RHD−, women were allowed to opt out of receiving anti-RhD immunoglobulin. All women predicted to be carrying an RhD+ baby, or if the genotyping result was inconclusive, were offered anti-RhD immunoglobulin. All women who had a sensitizing event at less than 28 weeks were also offered anti-RhD immunoglobulin. RhD typing on cord blood samples was performed using routine serologic methods. Genotyping results were interpreted as RHD+, RHD−, or inconclusive. The final analysis included 2288 women and 4913 fetal genotype results with 4 analyses or less per parturient. Genotyping results were inconclusive for 393 samples (8.0%; 95% confidence interval, 7.3%–8.8%). Based on cord blood analyses, 2023 samples were from RhD− babies, of which 18 had been falsely predicted antenatally to be genotypically RHD+, and 85 were inconclusive; 2890 were RhD+, of which 308 were inconclusive on fetal RHD genotyping, and 19 were falsely predicted to be genotypically RHD−. The odds of correctly identifying RHD+ and RHD− fetuses increased significantly with gestational age, with low levels of false-negative results after 11 weeks’ gestation. At less than 11, 11 to 13, 14 to 17, 18 to 23, and more than 23 weeks, the sensitivities for detecting fetal RHD positivity were 96.85% (94.95%–98.05%), 99.83% (99.06%–99.97%), 99.67% (98.17%–99.94%), 99.82% (98.96%–99.97%), and 100% (99.59%–100%). At less than 11 weeks, 16 (1.9%) of 865 babies tested were falsely predicted to be RHD−. Massive throughput fetal RHD genotyping can be performed as soon as possible at 11 weeks or more. After 11 weeks, the incidence of false-negative results was considerably lower and did not decrease between 11 and 24 weeks, in agreement with evidence that concentrations of cell-free fetal DNA increase only minimally at 10 to 20 weeks’ gestation. The small number of false RHD− results after 11 weeks would lead to a small increase in the risk of alloimmunization. The tradeoffs between treating fewer women with antepartum immunoglobulin versus a few women becoming alloimmunized need to be considered carefully.

Thyroid and Pregnancy: A Systematic Review

ABSTRACT Pregnancy acts, like a stress test for the thyroid gland and results in hypothyroidism in women who are iodine deficient or have limited thyroid reserve, and postpartum thyroiditis in previously euthyroid women with underlying Hashimoto's thyroiditis. However, there is inconclusive evidence to recommend for or against the universal serum TSH screening at the 1st trimester visit of a pregnant woman and trimester specific cut-off values should be used for monitoring the thyroid function (whenever performed). Nonspecific complaints, like irritability or anxiety in a postpartum lady should be investigated to rule out postpartum thyroiditis and not merely considered as maladjustment on the part of the lady. Thyroid nodules can grow in size during pregnancy but usually are well tolerated and can be operated postpartum. If deemed necessary during pregnancy, surgery should be carried out in the 2nd trimester for the same.

Strategies of testing for syphilis during pregnancy.

Strategies of testing for syphilis during pregnancy.

Prediction of pre‐pregnancy weight from first trimester visit (1031.2)

Introduction: Gaining weight within the Institute of Medicine (IOM) guidelines leads to healthy pregnancy outcomes. In order to calculate weight gain during pregnancy, clinicians require an accurate measurement of pre‐pregnancy weight. Unfortunately, in most cases, pregravid weight is self‐reported which can be an unreliable measure.Purpose: To develop and validate a mathematical model to estimate pre‐pregnancy weight from weight measured during a first trimester prenatal visit.Methods: After testing the validity of self‐reported pregravid weight, four models were constructed using two comprehensive clinical databases containing weight directly measured before pregnancy and during the first trimester. Maternal age, race, height, and both gestational age and measured weight at the earliest first trimester visit, were used to predict pregravid weight. Each model was validated on independent data not used for model development. Bland‐Altman analysis was performed to test the validity of each model.Results: Although self‐reported pregravid weight correlated well with measured weight (R2=0.98), the Bland‐Altman analysis suggested a negative bias (‐0.62 kg), confidence intervals [‐4.4, 3.1]), indicating increased under‐reporting of pregravid weight with higher BMI classifications. The developed predictive models validated well, demonstrating good agreement and low bias: (R2=0.96, Bias =0.06, confidence intervals [‐5.46,5.58 kg]).Conclusions: The developed models provide an alternative method for health care providers and researchers to determine pregravid weight and appropriately classify women into the correct set of BMI‐specific IOM gestational weight gain guidelines.

PP067. Third trimester prediction of late PE

It is well known that a multiparametric model including epidemiological maternal factors, uterine Doppler and biochemical parameters could be useful at 1st and 2nd Trimester for the prediction of early PE (<34 weeks of gestation) but less accurate for late PE (⩾34 weeks of gestation). Different physiopathologies have been suggested for these two entities. A new approach based in a 3rd trimester screening has been suggested for the predicton of late PE. To define the prediction capacity of maternal characteristics at 3rd trimester for late PE. 4724 pregnancies followed up and delivered in our centre from July 2010 to December 2012 were included in a cross sectional study. Out of these, 59 cases developed a late preeclampsia (1.2%). Controls were gestations with no diagnosis of PE nor gestational hypertension. All patients made a 3rd trimester visit at 31-33 weeks, where systolic and diastolic blood pressure and the absolute weight gain since the beginning of pregnancy were measured. Parity, maternal age and body mass index at the beginning of the pregnancy were also recorded. A multivariate logistic regression analysis was made to define the predictive capacity of these variables for late PE. MAP was significantly higher in those patients who developped PE (78.8 vs 88.8 mmHg, p<0.05). Although cases had a higher BMI at first visit ( BMI 25.9 vs 23, p<0.05), the total weight gain during pregnancy up to the 3rd trimester was similar among groups (9.3 vs 10.3kg, p>0.05). The mean GA at delivery of cases was 38 (range 35-41 weeks) and of controls 39.1 (range 34-42 weeks). In a multivariate logistic regression analysis, MAP and BMI were independent and significant predictors of late PE at 3rd Trimester. The model including BMI and MAP has an AUC of 0.76 (0.683-0.837). A 3rd trimester screening could be useful in the prediction of late-onset PE.

Anti-angiogenic factors and pre-eclampsia in type 1 diabetic women

Elevated anti-angiogenic factors such as soluble fms-like tyrosine kinase 1 (sFlt1), a soluble form of vascular endothelial growth factor receptor, and endoglin, a co-receptor for TGFbeta1, confer high risk of pre-eclampsia in healthy pregnant women. In this multicentre prospective study, we determined levels of these and related factors in pregnant women with type 1 diabetes, a condition associated with a fourfold increase in pre-eclampsia. Maternal serum sFlt1, endoglin, placental growth factor (PlGF) and pigment epithelial derived factor were measured in 151 type 1 diabetic and 24 healthy non-diabetic women at each trimester and at term. Approximately 22% of the diabetic women developed pre-eclampsia, primarily after their third trimester visit. In women with pre-eclampsia (diabetic pre-eclampsia, n = 26) vs those without hypertensive complications (diabetic normotensive, n = 95), significant changes in angiogenic factors were observed, predominantly in the early third trimester and prior to clinical manifestation of pre-eclampsia. Serum sFlt1 levels were increased approximately twofold in type 1 diabetic pre-eclampsia vs type 1 diabetic normotensive women at the third trimester visit (p < 0.05) and the normal rise of PlGF during pregnancy was blunted (p < 0.05). Among type 1 diabetic women, third trimester sFlt1 and PlGF were inversely related (r(2) = 42%, p < 0.0001). Endoglin levels were increased significantly in the diabetic group as a whole vs the non-diabetic group (p < 0.0001). Higher sFlt1 levels, a blunted PlGF rise and an elevated sFlt1/PlGF ratio are predictive of pre-eclampsia in pregnant women with type 1 diabetes. Elevated endoglin levels in women with type 1 diabetes may confer a predisposition to pre-eclampsia and may contribute to the high incidence of pre-eclampsia in this patient group.