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org

Clinical Obstetrics, Epidemiology, Fetus, Medical-Surgical Complications, Neonatology, Physiology/Endocrinology, Prematurity

no differences in estimated fetal weight, birthweight, or gestational

age at delivery.
CONCLUSION: Unlike non-pregnant populations, sleep duration during pregnancy, when measured in the 3rd trimester, is not associated
with excessive GWG. This is likely due to altered physiology in pregnancy and additional factors contributing to sleep disruption. Additional data, especially sleep characteristics in the 1st and 2nd trimesters, is needed to further evaluate a possible association between sleep
duration and weight gain in pregnancy.

112 Is there a difference in the risk profile of women

who develop thrombo-embolic events in the
puerperium or later in life?
Maor Waldman1, Eyal Sheiner1, Ilana Shoham Vardi2
1
Soroka University Medical Center, Department of Obstetrics and
Gynecology, Beer-Sheva, Israel, 2Ben Gurion University of the Negev,
Department of Epidemiology and Health Services Evaluation, Beer-Sheva,
Israel

OBJECTIVE: Venous thrombo-embolic events (VTE) (mainly pulmonary embolism [PE] and deep vein thrombosis [DVT]) are currently
the primary cause for maternal death in the developed world. The
study objective was to identify whether risk factors for VTE during the
puerperium are different from these of thrombo-embolic events developed later in life during more than 10 years of follow-up.
STUDY DESIGN: A nested case-case study was designed, comparing
women who experienced VTE in the puerperium period to women
who experienced such an event over a period of a more than a decade.
The study included women (n316) with VTE from a cohort of
48,319 women that gave birth between the years 1987-1998 and had a
follow up period until 2011. Multiple logistic regression model was
constructed in order to define independent risk factors associated
with early (6 weeks) vs. late thrombo-embolic events.
RESULTS: VTE during puerperium occurred in 81 women, and in 235
within at least 10 years after the puerperium. Patients encountered
VTE during the puerperium had more PE events (n16, 19.8%) and
less DVT events (n42, 51.9%), compared with the late VTE group
(PE n15, 6.4%; DVT n159, 67.7%; p 0.001).
While baseline characteristics of the two VTE groups were similar
(table), women undergoing cesarean section (CS) in the delivery preceding the VTE were more likely to develop early VTE (OR1.8, 95%
Cl1.05-3.2, P0.032). Using a multivariate analysis, controlling for
confounders such as maternal age, CS was noted as an independent
risk factor for early vs. late VTE (adjusted OR1.9; 95% CI 1.1-3.5;
p0.023).
CONCLUSION: The risk profile of both earlier and late VTE are similar,
except for cesarean section which is an independent risk factor for
early (vs. late) VTE. Women encountered venous thrombo-embolic
event during the puerperium are more likely to suffer from pulmonary emboli than women encountering VTE after the puerperium.

Index pregnancy characteristics by

time of VTE occurrence

Poster Session I

113 Placenta accreta in a previous pregnancy

and its significance on subsequent births
Tamar Eshkoli1, Eyal Sheiner1, Adi Y Weintraub1,
Gershon Holcberg1, Fernanda Press1
1
Soroka University Medical Center, Ben-Gurion University of the Negev,
Obstetrics and Gynecology, Faculty of Health Sciences, Beer-Sheva, Israel

OBJECTIVE: To investigate the perinatal outcomes of women that had

a placenta accreta in a previous pregnancy.
STUDY DESIGN: We retrospectively compared all subsequent singleton
cesarean deliveries (CD) of women with a previous placenta accreta,
with CD of women with no such history, during the years 1988-2011.
RESULTS: Out of 34,567 singleton CD that occurred during the study
period, 0.1% (n30) were of women with a previous placenta accreta.
Recurrent placenta accreta occurred in 23.3% (7/30) of patients with
placenta accreta in their previous pregnancy. Previous placenta accreta was significantly associated with uterine rupture, peripartum
hysterectomy and the need for blood transfusions. Nevertheless, increased risk for adverse perinatal outcomes such as low Apgar scores at
5 minutes and perinatal mortality was not found in these patients
(table).
CONCLUSION: A pregnancy following a previous placenta accreta is at
increased risk for adverse maternal outcomes such as recurrent accreta, uterine rupture and peripartum hysterectomy. However, adverse perinatal outcomes are not demonstrated.

Selected pregnancy and perinatal outcomes

of patients with and without a
previous placenta accrete

Data are presented as percentages.

114 A proportion score of pelvic and neonatal head

circumference is highly predictive of instrumental delivery
and cesarean section due to cephalo-pelvic disproportion
Gadi Liberty1, Lina Linov2, Irena Sionov1, Alona Koval2, Bord
Ilia1, Eyal Anteby1
1

Barzilai Medical Center, Obstetrics and Gynecology, Ashkelon, Israel,

Barzilai Medical Center, Radiology, Ashkelon, Israel

OBJECTIVE: To evaluate the risk for instrumental delivery (ID) and

cesarean section due to cephalo-pelvic disproportion (CS-CPD), according to maternal pelvic CT parameters, and neonate weight and
head circumference.
STUDY DESIGN: We studied patients who delivered at term a singleton
fetus in vertex presentation, and had underwent an abdominal CT in
our institution. Pelvimetry was performed retrospectively. We analyzed the relation between maternal pelvic parameters, neonatal
weight and head circumference (HC), and the mode of delivery.
RESULTS: We enrolled 111 cases: 84 patients had NVD, 7 had ID and
20 had CS-CPD. The neonatal HC was significantly larger in ID and
CS-CPD in comparison to NVD (34.91.1, 34.92.5 and 33.81.7
cm, respectively, p0.03). The transverse diameter of the mid pelvis
was significantly smaller in ID and CS-CPD in comparison to NVD
(9.51.1, 9.80.9 and 10.40.8 cm respectively, p0.002). We expressed the composed A-P and lateral parameters of the pelvic inlet,
mid and outlet, with a naive formula of estimated ellipse circumference (EEC). The mid pelvic EEC was significantly smaller in ID and
CS-CPD in comparison to NVD (322.6, 33.53.5 and 34.82.3 cm

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Clinical Obstetrics, Epidemiology, Fetus, Medical-Surgical Complications, Neonatology, Physiology/Endocrinology, Prematurity

respectively, p0.034). We used the ratio between the pelvic EEC and
HC to express a proportion score (PS) for CPD. The PS was significantly smaller in ID and CS-CPD, in comparison to NVD, in all pelvic
levels: inlet (1.080.1 and 1.090.1 VS 1.150.08, p0.006); mid
(0.920.09 and 0.970.1 VS 1.030.08, p0.0003); and outlet
(0.770.04 and 0.810.07 VS 0.840.08 p0.011). ROC analysis
showed that a mid pelvis PS of 1 had a 68% sensitivity, 58% specificity
and a positive predictive value of 89% for CS-CPD.
CONCLUSION: Low proportion score of maternal pelvic parameters and
neonate head circumference, is highly correlated with ID and CSCPD.

115 Placental abruption as a marker for long

term cardiovascular mortality: a follow up period
of more than a decade
Gali Pariente1, Ilana Shoham-Vardi2, Roy Kessous1, Eyal Sheiner1
1
Soroka University Medical Center, Department of Obstetrics and
Gynecology, Beer sheva, Israel, 2Soroka University Medical Center, Faculty of
Health Sciences, Beer sheva, Israel

OBJECTIVE: To investigate the risk for subsequent cardiovascular

events in women having placental abruption, during a follow-up period of more than 10 years.
STUDY DESIGN: A population-based study comparing consecutive
pregnancies of women with and without placental abruption was conducted. Deliveries occurred during the years 1988-1999 and had a
follow up until the year 2010. Associations between placental abruption and maternal long-term cardiovascular hospitalizations, morbidity and mortality were investigated. Multivariable analysis was
used to control for confounders.
RESULTS: During the study period, there were 47,909 deliveries who
met the inclusion criteria, of these 1.4% (n653) occurred in patients
with placental abruption. No significant differences were noted regarding subsequent long term hospitalizations due to cardiovascular
causes during at least a decade of follow-up (OR 1.2, 95% CI 0.8-1.8,
P0.314), as well as regarding invasive procedures (OR1.5 95% CI
0.7-3.3, P0.312; table). However, placental abruption was noted as a
risk factor for long term cardiovascular mortality (OR 6.6, 95% CI
2.3-18.4, P0.004). The case fatality rate for placental abruption was
13.0% vs. 2.5% in the comparison group. ( P0.001). In a multivariate logistic regression model, after controlling for confounders such
as ethnicity and maternal age, placental abruption was noted as an
independent risk factor for maternal long-term cardiovascular mortality (adjusted OR 4.5; 95% CI-1.1-19.1, P 0.041).
CONCLUSION: Placental abruption is a significant risk factor for longterm cardiovascular mortality in a follow-up period of more than a
decade.

Subsequent cardiovascular events in

women having placental abruption

116 Giving birth to a small for gestational age infant is a

risk factor for long-term maternal cardiovascular morbidity
Gali Pariente1, Roy Kessous1, Ilana Shoham-Vardi2, Eyal Sheiner1
1
Soroka University Medical Center, Ben-Gurion University of the Negev,
Department of Obstetrics and Gynecology, Beer-Sheva, Israel, 2Soroka
University Medical Center, Ben-Gurion University of the Negev, Faculty of
Health Sciences, Beer-Sheva, Israel

OBJECTIVE: To investigate whether women with a prior occurrence of

small-for-gestational-age (SGA) are at an increased risk for subsequent long term maternal cardiovascular morbidity.

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STUDY DESIGN: A population-based study comparing consecutive

pregnancies of women with and without a previous delivery of a SGA

neonate was conducted. Deliveries occurred during the years 19881999, with a follow-up period until 2010. Incidence of long-term cardiovascular morbidity was compared between women with SGA neonate and women who gave birth at the same period to an appropriate
for gestational age neonate. Logistic regression was conducted to obtain adjusted odds ratios (AOR) and 95 % confidence intervals (CI)
for the association between SGA and subsequent cardiovascular
morbidity.
RESULTS: During the study period 47612 deliveries met the inclusion
criteria; 9.3% (n4411) occurred in patients with a prior occurrence
of SGA. Women with a prior occurrence of SGA had higher rates of
long term complex cardiovascular events such as congestive heart failure, cardiac arrest etc. (OR2.3; 95% CI 1.3-4.4, P0.006) and long
term cardiovascular mortality (OR 3.4; 95% CI 1.5-7.6, P0.006;
table). Using a multivariable logistic regression model, controlling for
confounders such as maternal age and ethnicity, having delivered a
SGA neonate was noted as an independent risk factor for long-term
maternal cardiovascular hospitalizations (AOR 1.4; 95% CI-1.11.6, P 0.001).
CONCLUSION: Delivery of a previous SGA infant is an important predictor of long-term maternal cardiovascular morbidity during a follow-up period of more than a decade.

Long term cardiovascular morbidity and

mortality in patients with and without a
prior occurrence of SGA

117 Misoprostol for treatment of intrauterine

fetal death at 14-28 weeks of pregnancy
Hillary Bracken1, Nguyen thi Nhu Ngoc2, Erika Banks3,
Paul Blumenthal4, Richard Derman5, Ashlesha Patel6,
Marji Gold7, Beverly Winikoff8
1
Gynuity Health Projects, New York, NY, 2Center for Research and
Consultancy in Reproductive Health (CRCRH), Ho Chi Minh City, Viet
Nam, 3Albert Einstein College of Medicine, Department of Obstetrics and
Gynecology, New York, NY, 4Stanford University, Family Planning Services
and Research, Palo Alto, CA, 5Christiana Care Hospital, Department of
Obstetrics and Gynecology, Newark, DE, 6JH Stroger Jr. Hospital of Cook
County, Department of Obstetrics and Gynecology, Chicago, IL, 7Albert
Einstein College of Medicine, Department of Family Medicine, New York,
NY, 8Gynuity Health Projects, New York, NY

OBJECTIVE: To systematically assess whether misoprostol has high

safety and effectiveness for the treatment of intrauterine fetal death at
14-28 weeks of pregnancy and to help establish the best dose of misoprostol for this purpose.
STUDY DESIGN: This double-blind trial randomized 153 women, 14-28
weeks gestation, into two groups. Women received either 100mcg
buccal misoprostol (Group 1) or 200 mcg buccal misoprostol (Group
2) every 6h for a maximum of 8 doses. The primary outcome was
successful evacuation within 48h.
RESULTS: The 200mcg dose was significantly more effective than the
100 mcg dose at evacuating the uterus within 48h (Group 1: 66.7%;
Group 2: 84.2% (RR 0.79 (95%CI: 0.65-0.95). The mean time to evacuation was significantly shorter in Group 2 (18.9h 11.9h) than
Group 1 (24.0 12.4h) (p0.03). The side effect profile was similar in
the two groups. Few women reported nausea (Group 1: 19%; Group 2:
24%), vomiting (Group 1: 10%; Group 2: 16%), chills (Group 1: 24%;
Group 2:21%) or headache (Group 1: 16%; Group 2: 21%). However,
significantly more women in the 200mcg group reported diarrhea

American Journal of Obstetrics & Gynecology Supplement to JANUARY 2013