http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437 ! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2014.924236

Invited Lectures

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HYPERIMMUNOGLOBULIN FOR PREVENTION OF CONGENITAL CYTOMEGALOVIRUS INFECTION AND DISEASE: AMERICAN PROJECTS S. Adler Department of Microbiology, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond. Reported maternal-to-fetal rates of primary cytomegalovirus (CMV) infection during pregnancy have been between 30% and 50%. The highest rate of symptomatic congenital infection and sequelae occurs in about 25% of infected infants born of mothers with a primary infection during pregnancy. Symptomatic infants demonstrate a constellation of clinical features that reflect placental dysfunction and probable viral infection of the central nervous system of the fetus. In the United States, we estimate that about 8000 affected infants are born each year. Two options may be available to prevent or treat maternal CMV infection during pregnancy, especially for women with exposure to young children in the home. The first is hygienic intervention. Two studies support the simplicity, harmlessness, and effectiveness of hygienic intervention to prevent child-to-mother transmission of CMV among high-risk pregnant women who know they are susceptible. The second is CMV immunoglobulin. A metaanalysis of 2 clinical trials showed an efficacy of 50% if immunoglobulin is given to pregnant women who have acquired a primary CMV infection during pregnancy. These results mean that seronegative pregnant women have options to prevent fetal infection. An ongoing placebo controlled randomized clinical trial of immunoglobulin to prevent CMV fetal is poorly designed and should not continue without protocol modifications.

A WOMB WITH A VIEW: FROM PHILADELPHIA TO FLORENCE S. Adzick Surgeon-in-Chief, Children’s Hospital of Philadelphia Director, Center for Fetal Diagnosis and Treatment C. Everett Koop Professor of Pediatric Surgery, Perelman School of Medicine, University of Pennsylvania Until about forty years ago, the womb shielded the fetus from observation and therapy. The rapid changes in the diagnosis and treatment of human fetal anatomical abnormalities is due to improved fetal imaging studies as well as fetal sampling techniques (e.g. amniocentesis, chorionic villus sampling), and a better understanding of fetal pathophysiology derived from laboratory animals. Fetal therapy is the logical culmination of progress in fetal diagnosis. In other words, the fetus is now a patient. The fetal surgical treatment of the most severe form of spina bifida - myelomeningocele (MMC) will be used as a paradigm to illustrate progress in and future prospects for fetal surgery. This review will focus on the rationale for in utero repair in the context of pathologic observations and animal models of MMC, outcomes from human fetal MMC repair including the recently completed Management of Myelomeningocele Study (MOMS trial), and future research directions.

PROCEDURAL PAIN AND OXIDATIVE STRESS IN THE NEWBORN G. Buonocore, M. Tei, S. Perrone, & C. V. Bellieni 1

Department of Molecular and Developmental Medicine, University of Siena, Siena Italy Despite a growing body of knowledge about the physiology of neonatal pain, the evolution of neonatal pain assessment and pain management, still persists a wide variety of opinions among health care providers on how to treat pain in newborns. The traditional view that newborns do not feel pain was supported by the belief that the pain transmission requires complete nerve myelination and a mature cerebral cortex to interpret the pain signal [1]. Although the newborn’s peripheral nerves are unmyelinated, complete myelination is not a prerequisite to pain transmission. Neonatal pain is physiologically disruptive and developmentally unexpected, occurring at a time when nature had designed a protective environment. Painful stimulation elicits specific pain behaviours, activation of the somatosensory cortex, and neuroendocrine and physiological stress responses, thus altering immediate and long-term clinical outcomes in newborns. Repeated invasive procedures occur routinely without analgesia in neonates who require intensive care. The untreated pain in these neonates may result in increased morbidity, exaggerated responses to pain in later life, and altered psychosocial development. Even routine painful procedures can be harmful for the newborn. The pain produced by a simple heel prick can provoke a series of consequences, such as a dramatic increase in intracranial pressure and in free radical release [2,3]. Poor evidences exist about procedural pain and oxidative stress (OS) in the neonatal age. Slater at al. examined the relationship between a tissue-damaging procedure (tape removal during discontinuation of an indwelling central arterial or venous catheter) and OS. He found a significant positive correlation between pain, assessed through premature infant pain profile (PIPP), and malondialdehyde [4]. Asmeron et al. detected significant increases in biomarkers of ATP degradation in neonates who received sucrose as analgesic tool and negative correlation between pain scores and biomarkers of OS in a group of neonates who received sucrose [5]. Bellieni et al. observed a significant increase between advanced oxidation protein products (AOPP) and total hydroperoxide (TH) blood concentrations in babies who showed the highest pain intensity by using ABC scale [3]. In a recent study we investigated the relationship between the grade of pain induced by a routine heel prick (HP) and OS in a large cohort healthy term newborns. The ABC scale (from 0 to 6) was used to score the pain. Babies were randomly subdivided in two groups according to the analgesic procedure performed with or without sensorial saturation (SS). The group with SS received a multisensorial stimulation and 0.5 ml of oral 10% glucose before and during HP. The group without SS received exclusively 0.5 ml of oral 10% glucose. AOPP and TH were measured at the beginning (sample A) and at the end (sample B) of the HP. The sample A/sample B ratio for AOPP and TH was calculated to evaluate the increase in OS biomarkers before and after HP. A significant correlation was found between pain scores and both AOPP and TH ratio. After HP, AOPP blood levels significantly

2 increased. Newborns treated with SS showed lower AOPP ratio levels than those without. No gender differences were found before and after HP for AOPP levels, while females treated with SS showed a significantly higher AOPP ratio. Conversely, lipid peroxidation was found to be higher in males at the end of the heel prick, even at the highest grade of pain. A linear correlation between the ABC pain score and OS markers was observed in males. A clear gender-related pain response, in term of an increased predisposition of females to painful stimuli and an innate susceptibility of males to OS was highlighted by the study. Moreover SS, an effective and easy analgesic tool, showed to reduce pain but also OS in newborns with a reduction in short term effects of neonatal nociception. Further investigations are needed to verify whether the increase in OS, induced by painful procedures in the first days of life, induces significant adverse clinical outcomes.

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References 1. Molliver ME, Kostovic I, Van Der Loos H. The development of synapses in cerebral cortex of the human fetus. Brain Res. 1973;50:403–407. 2. Bellieni CV, Burroni A, Perrone S, Cordelli DM, Nenci A, Lunghi A, Buonocore G. Intracranial pressure during procedural pain. Biol Neonate. 2003;84(3):202–205. 3. Bellieni CV, Iantorno L, Perrone S, Rodriguez A, Longini M, Capitani S, Buonocore G. Even routine painful procedures can be harmful for the newborn. Pain. 2009;147(1–3):128–131. 4. Slater L, Asmerom Y, Boskovic DS, Bahjri K, Plank MS, Angeles KR, Phillips R, Deming D, Ashwal S, Hougland K, Fayard E, Angeles DM. Procedural pain and oxidative stress in premature neonates. J Pain. 2012;13(6):590–597. 5. Asmerom Y1, Slater L, Boskovic DS, Bahjri K, Holden MS, Phillips R, Deming D, Ashwal S, Fayard E, Angeles DM. Oral sucrose for heel lance increases adenosine triphosphate use and oxidative stress in preterm neonates. J Pediatr. 2013;163(1):29–35.

MORBIDLY ADHERENT PLACENTA G. Calı` UOS Medicina Perinatale ed Assistenza alla Nascita ARNAS Civico Palermo, Italy The three forms of morbidly adherent placenta (MAP): placenta accreta, increta and percreta, present a significant obstetric challenge, at times resulting in life-threatening bleeding1 and/or peripartum hysterectomy2. The increas- ing rate of Cesarean section (CS) deliveries correlates with the rising incidence of MAP3. It occurs in 9.3% of women with placenta previa and in 0.04% of women without placenta previa4, the risk being 5% in placenta previa cases with no previous uterine surgery, 24% in those with a previous CS and 67% in those with four previous CSs. In addition to previous CS, a maternal age over 35years, multiparity, previous curettage and pla- centa previa are risk factors associated with MAP. This condition is often diagnosed during CS, upon placental removal, with unfavorable maternal outcome: attempts to remove the placenta can cause severe uterine bleeding. An accurate prenatal diagnosis is required to reduce the risk of maternal/fetal morbidity and mortality8. Ultrasonography is used routinely for diagnosis of MAP, although diagnostic criteria and accuracy are still subject to debate9,10. Magnetic resonance imaging (MRI) can be helpful when the placenta is difficult to visualize on ultrasound due to the patient’s body habitus or to a posterior location of the placenta.

ABNORMAL FETAL GROWTH I. Cetin University of Milano, Italy Intrauterine growth restriction (IUGR) occurs when fetal growth rate falls below the genetic potential. This condition affects a significant number of pregnancies (7–10% depending on the population),

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although its severity ranges from intrauterine demise to occasional recognition at delivery with birthweights below the 10th centile. Most IUGR are born from otherwise healthy mothers, although preeclampsia is often associated with this condition. A malfunctioning or ‘‘insufficient’’ placenta has been recognized as the ‘‘cause’’ of IUGR, leading to altered placental transport of nutrients, mainly amino acids and lipids, but also micronutrients such as iron and folate. However, the reason why placental development fails to be appropriate in these pregnancies is still not known. Maternal nutritional status, diet and exposure to environmental factors are increasingly acknowledged as potentially affecting fetal growth both by altering nutrient availability to the fetus, as well as by modulating placental gene expression, thus modifying placental function. This talk will review the most recent findings concerning maternal placental and fetal characteristics of IUGR as well as maternal early markers of the pathology. A comprehensive understanding of factors associated with IUGR will help in providing important tools for preventing and understanding adverse outcomes.

PHYSIOLOGY BEHIND PATTERNS IN PRETERM FETUSES E. Chandraharan Clinical Director of Obstetrics and Gynaecology and Delivery Suite Lead at St. George’s Hospital NHS Trust Sympathetic nervous system is responsible for ‘flight or flight’ response and is essential for fetal survival. Therefore, this component of the autonomic nervous system develops earlier in fetal life resulting in a higher baseline fetal heart rate as compared to a term fetus. In addition, absence of significant parasympathetic response and the resultant ‘fight’ between the sympathetic and parasympathetic components of the autonomic nervous system leads to an apparent reduction in fetal heart rate baseline variability on the CTG Trace. Absence or reduced amount of Wharton’s Jelly in the umbilical cord may result in recurrent variable decelerations due to compression of the vessels within the umbilical cord. Therefore, a CTG Trace in a preterm fetus may show a higher baseline heart rate, apparent reduction in baseline fetal heart rate variability, presence of shallow variable decelerations which may indicate normal physiology rather than ongoing hypoxia. In addition, accelerations prior to 34 weeks of gestation are likely to be of smaller amplitude. Clinicians need to understand the normal physiological physiological maturation of the autonomic and somatic nervous systems whilst interpreting a CTG trace prior to 34 weeks of gestation.

PLANNED HOME BIRTH: A CHALLENGE TO PERINATAL MEDICINE Frank A. Chervenak, M.D.1, Amos Gru¨nebaum, M.D., Laurence B. McCullough, Ph.D., Robert L. Brent, M.D., Ph.D., Malcolm I. Levine, M.D., & Birgit Arabin, M.D., 1 Professor and Chairman Weill Medical College of Cornell University/NewYork Presbyterian Hospital

This presentation addresses the recrudescence and new support for planned home birth in the United States and the other developed countries in the context of professional responsibility. Advocates of planned home birth have emphasized patient safety, patient satisfaction, cost effectiveness, and respect for women’s rights. We provide a critical evaluation of each of these claims and identify professionally appropriate responses of obstetricians to planned home birth. Planned home birth has unnecessary, preventable, irremediable and therefore unacceptable increased risk of harm for pregnant, fetal, and neonatal patients. We show that the persistently high rates of emergency transport undermines patient safety and satisfaction, the raison d’etre of planned home birth, and that a

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comprehensive analysis undermines claims about the cost-effectiveness of planned home birth. We then argue that obstetricians should understand, identify and correct the root causes of the recrudescence of planned home birth; respond to expressions of interest in planned home birth by women with evidence-based recommendations against it; refuse to participate in planned home birth; but still to provide excellent and compassionate emergency obstetric care to women transported from planned home birth. We explain why obstetricians should not participate in or refer to randomized clinical trials of planned home vs. planned hospital birth. We call on professional organizations of obstetricians and midwifes not to support planned home birth when there are safe and compassionate hospital-based alternatives and to advocate for professional responsibility in obtaining a safe home-birth-like experience in the hospital.

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NIPD FOR MONOGENIC DISORDERS L. Chitty Professor of Genetics and Fetal Medicine at GOSH - London, United Kingdom Until recently, prenatal diagnosis of genetic disorders has been dependent on the use of invasive procedures such as amniocentesis at 15 weeks gestation or chorionic villus sampling (CVS) from 11 weeks gestation. However, these carry a small but significant risk of miscarriage of around 1%. Newly developed non-invasive prenatal diagnosis (NIPD) tests based on analysis of cell free fetal DNA are allowing couples at risk of some single gene disorders to have prenatal diagnosis using a maternal blood test from nine weeks in pregnancy. The first successful NIPD tests for single gene disorders to be used clinically have been for autosomal dominant conditions that are paternally inherited or arise as a result of a de novo mutation. NIPD is also used for sex determination in pregnancies at high risk of sexlinked disorders in order to target invasive diagnostic testing appropriately. NIPD for recessively inherited single gene disorders is more complex as high background level of maternal mutant alleles must be taken into account. In the United Kingdom (UK), NIPD for autosomal dominant conditions such as achondroplasia, thanatophoric dysplasia, Torsion dystonia and Apert sydnrome have been available clinically on a research basis for several years. Many of these tests are now in routine clinical service. The process by which these tests gained approval for use in the UK National Health Service will be described, data relating to patients experience of NIPD will be presented and issues relating to implementation of a prenatal diagnostic service based on NIPD will be discussed.

NIPT: BEYOND THE COMMON TRISOMIES R. K. W. Choy Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong Non-invasive prenatal testing (NIPT) for common aneuploidy using cell-free DNA in maternal plasma has revolutionized prenatal screening and diagnosis. Current NIPT approaches involve whole-genome sequencing, targeted sequencing and assessment of single nucleotide polymorphism (SNP) differences between mother and fetus. Here we report secondary or additional findings (atypical abnormalities) arising from introduction of non-invasive prenatal testing (NIPT) for aneuploidy in our clinical service. We observed an increased screenpositive rate of NIPT when genome coverage was extended beyond the three common autosomal aneuploidies. Sex chromosome aneuploidies (SCA) contributed to a significant portion of additional findings, the remaining atypical abnormalities were due to confined placental mosaicism (CPM) or other numerical autosomal aneuploidies or structural chromosomal deletion/duplication. Our data indicate the importance of maternal and placental karyotyping or

arrayCGH in post NIPT era. It also highlighted the importance of prenatal counseling and to investigate the health system and human costs associated with the increased screen-positive rate if NIPT goes beyond the common trisomies.

PROBIOTICS IN PERINATAL MEDICINE K. Costeloe Professor of Paediatrics, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK The presence of a diverse population of commensal bacteria is essential for normal barrier and immunological function at mucosal surfaces. Disturbance of this population or, at birth, failure to acquire diverse bowel flora, has been implicated in the pathogenesis of a range of perinatal problems including preterm labour and, in the newborn, sepsis and necrotising enterocolitis. The hypotheses that manipulation of the vaginal flora might prevent some cases of preterm labour and that administration of probiotic bacteria to the newborn infant will improve intestinal mucosal function and prevent complications of prematurity are attractive and likely to be safe. There is evidence that systemic or local administration of probiotics or yogurt may modify the vaginal flora but inadequate data reliably to assess any effect on preterm birth or neonatal outcomes. A number of trials have suggested that pre- and post-natal administration of probiotic to infants of atopic women reduces childhood atopy but data describing other long term effects of perinatal administration are lacking. Trials of probiotic administration to preterm infants are more numerous and the most recent meta-analyses, which include more than 20 trials, suggest that they are safe and result in significant reductions of necrotising enterocolitis (NEC) and death. Despite this routine use of probiotics for preterm babies is very variable. This is because of outstanding questions about the choice of probiotic product and questions about how generalisable the published trials are to populations of babies in different settings with variable patterns of infant feeding and antibiotic use and different background rates of NEC and sepsis.

SUSTAINED LUNG INFLATION IN THE DELIVERY ROOM IN PRETERM INFANTS (SLI STUDY) C. Dani Dipartimento di Neuroscienze, Psicologia, Area del farmaco e Salute del Bambino - Universita` di Firenze Some studies have suggested that the early sustained lung inflation (SLI) procedure is effective in decreasing the need of mechanical ventilation (MV) and in improving respiratory outcome in preterm infants. We carried out a randomized controlled trial to evaluate confirm or refute these results. Infants born at 25 + 0–28 + 6 weeks’ gestation received the SLI maneuver (25 cm H2O for 15 seconds) followed by nasal continuous positive airway pressure (NCPAP) or NCPAP alone in the delivery room. The primary outcome was the need of MV in the first 72 hours of life, while secondary outcomes included the need and duration of any respiratory supports and survival without bronchopulmonary dysplasia (BPD). We found that the need of MV in the first 72 hours of life was significantly lower in the SLI group than in the control group (unadjusted odds ratio 0.57; 95% confidence limit [Cl], 0.38 to 0.99; p ¼ 0.043) after adjustment for gestational age and center. Moreover, the occurrence and duration of respiratory support and survival without BPD did not differ between the groups. We concluded that SLI procedure followed by early NCPAP in the delivery room was effective in decreasing significantly the need of MV in the first 72 hours of life in preterm infants in comparison with NCPAP alone, but did not decrease the need of respiratory supports and the occurrence of BPD.

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MINIMALLY INVASIVE SURFACTANT THERAPY IN PRETERM INFANTS ON CPAP Peter A. Dargaville

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Department of Paediatrics, Royal Hobart Hospital and University of Tasmania, Hobart, Australia It is now well accepted that applying continuous positive airway pressure (CPAP) at the beginning of the life of an extremely preterm infant is a reasonable alternative to intubation and ventilation. Metaanalysis of large controlled trials comparing these two approaches suggests a benefit of CPAP, with a small reduction in the risk of the composite outcome of death or bronchopulmonary dysplasia (BPD). Starting life on CPAP, without prior intubation, means that exogenous surfactant is not administered, and there is concern that for some preterm infants this leads to a progression in respiratory distress and ultimately to CPAP failure (intubation572 h). Both cohort and population-based studies indicate that CPAP failure because of worsening RDS is a relatively common occurrence, and is associated with adverse outcomes compared with infants successfully managed on CPAP in the first days of life. In an effort to circumvent this problem, techniques of minimally-invasive surfactant therapy have recently been investigated, aiming to administer surfactant to a spontaneously breathing infant, allowing them to remain on CPAP in the critical first days of life, and hopefully beyond. These techniques have included administration of exogenous surfactant i) into the pharynx, ii) by laryngeal mask, iii) by brief tracheal catheterisation, and iv) by aerosolisation. Of these, the methods involving brief tracheal catheterisation have been most extensively studied. In recent clinical trials (AMV trial, Take Care study and NINSAPP trial), instillation of surfactant after catheterisation of the trachea with a flexible feeding tube has been found to reduce the need for subsequent intubation and ventilation, and lower the incidence of short-term adverse respiratory outcomes. This approach is now part of routine clinical practice in some centres. Our research group has developed an alternative method of brief tracheal catheterisation in which surfactant is delivered via a semi-rigid vascular catheter inserted through the vocal cords under direct vision (the Hobart method). In studies to date this technique has been relatively easy to perform, and resulted in rapid improvement in lung function, and reduced need for subsequent ventilation and duration of oxygen therapy. We have now commenced a large scale multicentre international clinical trial comparing surfactant therapy via the Hobart method with continuation of CPAP in preterm infants 25–28 weeks gestation (the OPTIMIST-A trial). The result of this and other studies will help to define the place of minimally-invasive surfactant therapy in preterm infants.

BREATFEEDING DURING PREGNANCY R. Davanzo & G. Paviotti Division of Neonatology and NICU, Institute for Maternal and Child Health – IRCCS Burlo Garofolo, Trieste, Italy Breastfeeding should be strongly promoted by health authorities and health professionals, as it facilitates mother-infant bonding and improves maternal and infant health. Nevertheless, cultural taboos and not evidence based advices from health professionals often discourage breastfeeding, without careful scrutiny. As this is particularly trues for breastfeeding during pregnancy, the Italian Society of Perinatal Medicine Working Group on Breastfeeding (SIMP-GLAM) has reviewed the literature to determine the medical compatibility of coexistance of breastfeeding and pregnancy. Based on current knowledge, SIMP supports breastfeeding during pregnancy in the first two trimesters, and possibly also in the third trimester, recommending an adequate diet and supplementation for mothers.

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Obviously, individual advice could differ and health professionals may want to discourage breastfeeding in selected situations: suboptimal maternal nutritional status, severe IUGR, history of recurrent miscarriage and threat of premature delivery. In conclusion, currently available data do not support routine discouragement of breastfeeding during pregnancy, at least in developed countries.

PRETERM LABOR – TREATMENT OPTIONS V. Dimitrova State University Hospital ‘‘Maichin Dom’’, Department of Obstetrics and Gynecology, Medical University, Sofia Introduction: Preterm birth (PTB) occurring before 37 completed weeks of gestation (w.g.) is a leading cause of neonatal mortality and morbidity and long-term neurologic impairment. Its rate does not decrease over time. This may be related to increased maternal age, rising use of assisted reproductive technologies and rates of multiple gestations, and more frequent iatrogenic early deliveries. Half of the PTBs are preceded by preterm labor (PTL), 25% - by PPROM and 25% are iatrogenic (due to maternal and/or fetal complications necessitating delivery). The causes of PTL are not well understood and its pathophysiology is thought to be due to a combination of factors including over distention and stretching of myometrium, decidual hemorrhage, activation of the fetal placental hypothalamicpituitary-adrenal axis, intrauterine inflammation or infection28. PTL probably represents a syndrome rather than a specific diagnosis. The fetoplacental unit could trigger labor prematurely if the intrauterine environment becomes hostile and threatens the well-being of the fetus, as is the case with intraamniotic infection (30% of PTBs). The diagnosis of PTL is based on clinical symptoms – regular, painful uterine contractions accompanied by cervical dilatation or effacement. In 30% of cases with PTL contractions resolve spontaneously and in only 10% contractions result in PTD. Management of Preterm Labor: The primary focus of treatment for preterm labor is tocolysis – the inhibition of myometrial contractions using different pharmacological agents. Pharmacologic delay of preterm birth allows time for the antenatal administration of corticosteroids to reduce the risk of neonatal respiratory distress syndrome (RDS). The risks of intraventricular hemorrhage (IVH) and necrotizing enterocolitis (NEC) are reduced too. Tocolysis makes it possible to give the patient magnesium sulphate for neuroprotection of the fetus/newborn. Finally, delaying delivery allows transfer to a specialized neonatal center23. However, for some women in preterm labour tocolysis may not be appropriate (too advanced labor, intrauterine infection, placental abruption). Mechanism of Action and Side Effects of Tocolytics: The following agents have been evaluated as tocolytics: b2-mimetics (b2-adrenergic receptor agonists), magnesium sulfate, calcium channel blockers, prostaglandin synthetase inhibitors, oxytocin-receptor antagonists. Except for the oxytocin-receptor antagonists that have been specifically developed to arrest PTL, all the other drugs have been used off-label for that purpose33. All these agents have been widely studied, but conflicting data have led to inconclusive results concerning their overall efficacy and safety1,13,17,20,26. Since no single drug has a clear therapeutic advantage, it is their side effects that will often determine which one to be administered in a particular case. Magnesium Sulfate: suppresses the transmission of nervous impulses to uterine smooth muscle and lowers the levels of intracellular calcium thus preventing the activation of the myosin–actin contractile unit. It can cause flushing/diaphoresis, loss of deep tendon reflexes, cardiac arrest in the mother and hypotonia, respiratory depression and lethargy in the fetus/newborn. Recently its effectiveness as a tocolytic has been questioned3,5,9,14,15,25. b2-Mimetics reduce the intracellular calcium levels and decrease the sensitivity of the myosin–actin contractile unit to calcium. They may cause cardiac arrhythmias, pulmonary edema, myocardial ischemia, hypotension, hyperglycemia, hypokaliemia, tachycardia in the mother

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as well as fetal tachycardia, hyperglycemia and myocardial ischaemia. They are contraindicated in cases with cardiac arrythmias and poorly controlled diabetes. Prostaglandin-synthetase inhibitors (nsaids) block the inflammatory process that triggers labor. They cause esophageal reflux, nausea and gastritis and are contraindicated in cases with severe renal/ hepatic impairment, platelet dysfunction/bleeding disorders and gastrointestinal or ulcerative disease of the mother. Fetal/neonatal side effects include decreased renal function, oligohydramnios, IVH, hyperbilirubinemia, NEC. Premature closure of the fetal ductus arteriosus may occur if NAIDS are administered after 32 w.g. Calcium-entry blockers (nifedipine) cause dizziness, flushing and hypotension in the mother. They should be avoided in cases with preload dependent cardiac disease or hypotension. Concomitant use of magnesium sulfate should be avoided too (risk of pulmonary edema). No serious fetal side effects have been reported. Atosiban is a competitive oxytocin receptor antagonist. It inhibits the oxytocin-mediated release of inositol trisphosphate from the myometrial cell membrane, thus reducing the release of intracellular calcium from the sarcoplasmic reticulum. It also reduces the influx of calcium ions from the extracellular space and suppresses oxytocinmediated release of PGE and PGF from the decidua33. No serious maternal side effects have been reported. However, fetal death has been more frequent with gestational age 524 weeks29. Comparison studies evaluating the effectiveness of different tocolytic drugs are conflicting and most of these agents have demonstrated only limited benefit5,9,15,23. So, there is no clear first-line agent and treatment should be based upon maternal condition, potential drug adverse effects, and gestational age. Physician’s experience and local practices and protocols have to be considered too. The general consensus in the literature is in favor of calcium channel blockers (nifedipine) for initial tocolysis due to the low incidence of adverse effects, oral route of administration, efficacy in improving neonatal outcomes, and potential for use at any gestational age. Indomethacin is an available alternative for pregnancies 532 w.g. supposed no contraindications exist26. It is not recommended tocolytics to be administered for more than 48 hours, both because of side effects and because they are ineffective10,16,27. Concurrent use of two or more tocolytic drugs is not recommended either. It is not more effective than the use of a single drug, and the risk of side effects is increased. However, the use of sequential therapy may be beneficial. In women with PPROM tocolysis has not been shown to be effective and is best avoided21. Antenatal corticosteroids They are administered between 24 (26)– 34 w.g. in women who are at risk for preterm birth owing to preterm labor, PPROM, or have medical conditions that necessitate preterm delivery2,6,23. Prior to 35 w.g. corticosteroids activate the fetal hypothalamic-pituitary-adrenal axis and enhance fetal functional maturity, specifically lung maturity. IM administration of betamethasone 12 mg every 24 hours for two doses or dexamethasone 6 mg every 12 hours for four doses is recommended. A single course of corticosteroids reduces neonatal morbidity and mortality (including RDS, NEC, IVH). New data from randomized trials show that a single repeat course (2 doses) in women whose prior course was at least 7 days previously and who remain at risk of preterm delivery before 34 weeks significantly reduces neonatal morbidity7. Antenatal magnesium sulfate for fetal neuroprotection It has been demonstrated that magnesium sulfate reduces the severity and risk of cerebral palsy in surviving infants if administered when birth is likely to occur before 32 w.g. The neuroprotective effect results from a reduction in vascular instability and prevention of hypoxic and amino acid damage4,8,11,32. The ACOG supports the administration of magnesium sulfate prior to anticipated preterm birth to reduce the risk of cerebral palsy22. The recommended dose of magnesium sulfate is an IV bolus of 4 g to 6 g followed by 2 g to 3 g per hour. STRATEGIES THAT HAVE NOT BEEN PROVEN TO BE EFFECTIVE IN PRETERM LABOR Maintenance tocolysis (tocolysis with any drug used outside the 2-day window to allow antenatal steroids) has not been proven to be of benefit to prolong pregnancy10,16,27,30. The same refers to repeated

acute tocolysis. Antibiotics for prolongation of pregnancy have not been effective in patients with intact membranes12,19,31. Antibiotics are appropriate during preterm labor as prophylaxis against group B streptococcus (GBS) sepsis. Among women with PPROM, antibiotics may reduce the risk of preterm birth within 48 hours of administration, which provides time for corticosteroid administration18. There is little evidence of benefit for other outcomes. Bed rest and hydration have not been proven to have any impact on prolonging pregnancy and should not be routinely recommended to women with preterm labor14. Predictors of preterm delivery (fetal fibronectin and ultrasound cervical length) are useful only for their negative predictive value and should not be used exclusively to direct management in the setting of acute symptoms23.

Literature Beall M. H., Edgar B.W., Paul R.H., Smith-Wallace T. A comparison of ritodrine, terbutaline, and magnesium sulfate for the suppression of preterm labor. Am. J. Obstet. Gynecol., 1985, 153 (8): 854–859. Billart P.L., Bilart R.A. Scientific basis and therapeutic regimens for use of antenatal corticosteroids. Am. J. Obstet. Gynecol., 1995, 173: 254–262. Burkett G., Gilles J., Jackues E. To the Editor. Magnesium sulphate tocolysis: time to quit. Obstet. Gynecol., 2007, 109(3): 778. Conde-Agudelo A, Romero R. Antenatal magnesium sulfate for the prevention of cerebral palsy in preterm infants less than 34 weeks’ gestation: a systematic review and meta-analysis. Am. J. Obstet. Gynecol., 2009;200:595–609. Cox S.M., Sherman M.L., Leveno K.J. Randomized investigation of magnesium sulfate for prevention of preterm birth. Am. J. Obstet. Gynecol., 1990, 163(3): 767–772. Crowley P. Prophylactic corticosteroids for preterm birth. Cochrane Database of Systematic Reviews 2006, DOI: 10.14651858.CD000065.pub2 Crowther C.A., McKinlay C.J.D., Middleton P., Harding J.E. Repeat doses of prenatal corticosteroids for women at risk of preterm birth for improving neonatal health outcomes. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD003935. DOI: 10.1002/14651858.CD003935.pub3 Crowther C.A., Hiller J.E., Doyle L.W., Haslam R.R. Effect of magnesium sulfate given for neuroprotection before preterm birth: a randomized controlled trial. Australasian Collaborative Trial of Magnesium Sulphate (ACTOMg SO4) Collaborative Group. JAMA 2003; 290: 2669–76. Crowther C.A., Hiller J.E., Doyle L.W. Magnesium sulphate for preventing preterm birth in threatened preterm labour. Cochrane Database of Systematic Reviews 2002, Issue 4. Art. No.: CD001060. DOI: 10.1002/14651858.CD001060 Dodd J.M., Crowther C.A., Middleton P. Oral betamimetics for maintenance therapy after threatened preterm labour. Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD003927. DOI: 10.1002/14651858.CD003927.pub3 Doyle L.W., Crowther C.A., Middleton P., Marret S., Rouse D. Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD004661. DOI: 10.1002/ 14651858.CD004661.pub3. Flenady V., Hawley G., Stock O.M., Kenyon S., Badawi N. Prophylactic antibiotics for inhibiting preterm labour with intact membranes. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD000246. DOI: 10.1002/14651858.CD000246.pub2 Glock J.L, Morales W.J. Efficacy and safety of nifedipine versus magnesium sulfate in the management of preterm labor: A randomized study. Am. J. Obstet. Gynecol., 1993, 169(4): 960–964. Goldenberg R.L. The Management of Preterm Labor. Obstet. Gynecol., 2002, 100 (5): 1020–1037. Gyetvai K., Hannah M. E., Hodnett E. D. Tocolytics for Preterm Labor: A Systematic Review. Obstet. Gynecol., 1999,94(5): 869–877. Han S., Crowther C.A., Moore V. Magnesium maintenance therapy for preventing preterm birth after threatened preterm labour. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD000940. DOI: 10.1002/14651858.CD000940.pub3

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6 Higby K., Xenakis E. M.-J., Pauerstein C. J. Do tocolytic agents stop preterm labor? A critical and comprehensive review of efficacy and safety. Am. J. Obstet. Gynecol., 1993, 168 (4): 1247–1259. Kenyon S., Boulvain M., Neilson J. Antibiotics for preterm rupture of membranes. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD001058. DOI: 10.1002/14651858. CD001058.pub3 King J., Flenady V. Prophylactic antibiotics for inhibiting preterm labor with intact membranes (Cochrane review). In: The Cochrane Library, Issue 1, 2003. Lyell D.J., Pullen K., Campbell L. et al. Magnesium sulfate compared with nifedipine for acute tocolysis of pretermlLabor: A Randomized Controlled Trial. Obstet. Gynecol., 2007, 10 (1): 61–67. Mackeen A., Seibel-Seamon J., Muhammad J., Baxter J.K., Berghella V. Tocolytics for preterm premature rupture of membranes. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD007062. DOI: 10.1002/14651858.CD007062.pub3 Magnesium sulfate before anticipated preterm birth for neuroprotection. ACOG – Committee Opinion No 455, March 2010 (Reaffirmed 2013). Management of preterm labor. ACOG practice bulletin no. 127. Obstet Gynecol. 2012 Jun;119(6):1308–17. Marret S., Marpeau L., Zupan-Simunek V., Eurin D., Leveque C., Hellot M.F., et al. Magnesium sulphate given before very-preterm birth to protect infant brain: the randomised controlled PREMAG trial. PREMAG trial group. BJOG 2007;114:310–8. Mercer B.M., Merlino A.A. Magnesium sulfate for preterm labor and preterm birth. Obstet. Gynecol., 2009, 114(3): 650–668. Morales W.J., Madhav H. Efficacy and safety of indomethacin compared with magnesium sulfate in the management of preterm labor: A randomized study. Am. J. Obstet. Gynecol., 1993, 169(1): 97–102. Naik Gaunekar N., Raman P., Bain E., Crowther C.A. Maintenance therapy with calcium channel blockers for preventing preterm birth after threatened preterm labour. Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD004071. DOI: 10.1002/ 14651858.CD004071.pub3 Norwitz E.R., Robinson J. N. The control of labor. N. Engl. J. Med., 1999; 341:660–666. Papatsonis D.N.M., Flenady V., Cole S., Liley H. Oxytocin receptor antagonists for inhibiting preterm labor. Cochrane Database of Systematic Reviews 2005, Art. No.: CD005938. DOI: 10.1002/ 14651858.CD004452.pub2 Papatsonis D.N.M., Flenady V., Liley H.G. Maintenance therapy with oxytocin antagonists for inhibiting preterm birth after threatened preterm labour. Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD005938. DOI: 10.1002/14651858. CD005938.pub3 Romero R., Sibai B., Caritis S., Paul R., Depp R., Rosen M., Klebanoff M., Sabo V., Evans J., Thom E. Antibiotic treatment of preterm labor with intact membranes: a multicenter, randomized, double-blinded, placebo-controlled trial. Am J Obstet Gynecol., 1993, 169(4):764–74. Rouse D.J, Hirtz D.G., Thom E., Varner M.W., Spong C.Y., Mercer B.M., et al. A randomized, controlled trial of magnesium sulfate for the prevention of cerebral palsy. Eunice Kennedy Shriver NICHD Maternal-Fetal Medicine Units Network. N. Engl. J.Med., 2008;359:895–905. Tsatsaris V., Carbonne B., Cabrol D. Atosiban for preterm labour. Drugs. 2004;64(4):375–82.

METABOLOMICS IN PERINATAL MEDICINE V. Fanos Neonatal Intensive Care Unit, Puericulture Institute and Neonatal Section, AOU and University of Cagliari, Italy The newest ‘omics’ science is metabolomics, the latest offspring of genomics, considered the most innovative of the ‘omics’ sciences. Metabolomics, also called the ‘new clinical biochemistry’, is an approach based on the systematic study of the complete set of metabolites in a biological sample. The metabolome is considered the most predictive phenotype and is capable of considering epigenetic differences. It is so close to the phenotype that it can be considered the phenotype itself.

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In the last three years about 5000 papers have been listed in PubMed on this topic, but few data are available in the newborn. The aim of this review, after a description of background and technical procedures, is to analyse the clinical applications of metabolomics in neonatology, covering the following points: gestational age, postnatal age, type of delivery, zygosity, perinatal asphyxia, intrauterine growth restriction, prenatal inflammation and brain injury, respiratory, cardiovascular renal, metabolic diseases; sepsis, necrotizing enterocolitis and antibiotic treatment; nutritional studies on maternal milk and formula, pharma- metabolomics, longterm diseases. Pros and cons of metabolomics are also discussed. All this comes about with the non-invasive collection of a few drops of urine (exceptionally important for the neonate, especially those of low birth weight). Only time and large-scale studies to validate initial results will place metabolomics within neonatology. In any case, it is important for perinatologists to learn and understand this new technology to offer their patients the utmost in diagnostic and therapeutic opportunities.

SAFETY AND EFFICACY OF PROPRANOLOL IN RETINOPATHY OF PREMATURITY. L. Filippi Medical Surgical Fetal-Neonatal Department, ‘‘A. Meyer’’ University Children’s Hospital, Florence, Italy Recently, the non-selective b1/b2 adrenoreceptor (b-AR) antagonist propranolol has been demonstrated to be able to promote the regression of infantile hemangiomas, and the efficacy of this treatment has been explained on the basis that the blockade of the b2-AR inhibits the production of VEGF. These findings led us to the hypothesis that inhibition of VEGF through blockade of the b2-AR could also be effective in treating newborns with Retinopathy of Prematurity (ROP), the major cause of blindness and visual impairment in children in both developing and industrialized countries. In recent research studies performed in C57Bl/6J mice with oxygeninduced retinopathy (OIR), a worldwide used model for ROP, we have demonstrated that norepinephrine accumulation and the b-adrenoreceptor (b-AR) activation induces a HIF-1a-driven modulation of VEGF and IGF-1 and participate in mechanisms contributing to the shift from the avascular to the proliferative phase. In fact, we recently demonstrated in mice with OIR that treatment with propranolol downregulates retinal levels of angiogenic factors such as VEGF, reduces retinal hemorrhages and tufts, and decreases the bloodretinal barrier breakdown caused by hypoxia. In subsequent studies, we also showed that the b2-AR blockade with the specific inhibitor ICI 118 551 or the b2-AR desensitization after prolonged isoproterenol administration, reduce the VEGF upregulation and retinal neovascularization. Assuming that also in human preterm newborns with ROP, VEGF overexpression and retinal neovascularization in response to hypoxia might involve b-AR activation, two independent prospective pilot trials have demonstrated that oral propranolol administered in preterm newborns suffering from a precocious phase of ROP is effective in counteracting the progression of the disease, even though not sufficiently safe. The actual objective is to explore and develop topical delivery systems able to ensure high retinal concentrations of propranolol. In this regard, we recently described how propranolol application as eye drops crosses the cornea and reaches the retina of mice with OIR, drastically reducing their retinal neovascularization. In a more recent study we demonstrated that topical administration of 0.1% propranolol ocular drops in rabbits is safe and produces retinal concentration similar to those found after oral administration, but with plasma concentration significantly lower, thus avoiding the risk of associated complications and side effects. This finding opened the perspective for a possible treatment of ROP with propranolol eye drops.

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HYPERIMMUNOGLOBULIN FOR PREVENTION OF CONGENITAL CYTOMEGALOVIRUS INFECTION AND DISEASE: EUROPEAN PROJECT K. Friese

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Department of Obstetrics and Gynecology, University of Munich for the BT094 Study Group Primary Cytomegalovirus (CMV) infection during pregnancy leads to fetal CMV infection in approximately half of the cases and is a common cause of sensorineural hearing loss and mental retardation. Due to a lack of an effective and safe treatment option mothers often elect to terminate the pregnancy after confirmation of primary CMV infection. Therefore, there is a high medical need to prevent congenital CMV infections. Passive immunization with human cytomegalovirus immunoglobulin offers currently a safe but yet not registered option for this indication: ‘Off-label use’ of CMV hyperimmunoglobulin in the prevention and treatment of congenital CMV infection is widespread in Europe. In the first study on the feasibility of passive immunization against congenital infection, published by Nigro et al. (2005), women who seroconverted in early pregnancy received monthly hyperimmunoglobulin until delivery. In this non-randomized study the treatment of pregnant women with CMV-specific hyperimmunoglobulin (Cytotect, Biotest) significantly reduced the rate of intrauterine transmission. Thereafter, additional studies have been performed showing the benefit of CMC hyperimmunoglobulin in this indication. Most recently the double-blind, randomized, placebo-controlled CHIP trial of CMV hyper-immunoglobulin in the prevention of congenital CMV infection was published by Revello et al. (2014). The results of both studies indicate that passive immunization reduces the rate of fetal infection during pregnancy. Currently a large clinical trial with Cytogam (CSL Behring) is ongoing in 14 sites at US academic medical centers and another multicentre clinical trial with Cytotect (Biotest) is ongoing in Europe which will bring more evidence in this indication. The last mentioned clinical trial was initiated by Biotest in 2008 to investigate whether the treatment of pregnant mothers with primary CMV infection with a CMV hyperimmunoglobulin significantly reduces the risk of infection of the infant. This randomized, open, controlled, prospective, multicentre and multinational study assess the efficacy and safety of Cytotect (BT094) in the prevention of CMV infection in infants born to women who had experienced CMV seroconversion during pregnancy. The design of the protocol for this pivotal Phase 3 study was agreed with the EMA in 2007 and in contrast to the other studies screens patients for CMV conversion on a regular basis in order to treat pregnant women as early as possible. Up to now more than 15 000 women were screened, to randomize a total of 9500 women into the treatment group (BT094) or the control group (standard of care).

IPEX AND IPEX-LIKE DISEASES E. Gambineri Researcher/Assistant Professor, Department of ‘‘NEUROFARBA": Section of Child’s Health University of Florence, Department of Haematology-Oncology: BMT Unit Department of Fetal and Neonatal Medicine: Rare Diseases, ‘‘Anna Meyer’’ Children’s Hospital Various forms of primary immunodeficiencies are characterized by autoimmunity and/or dysregulated inflammatory responses. IPEX (Immune-dysregulation, Polyendocrinopathy, Enteropathy, X-linked) syndrome is a rare autoimmune genetic disorder caused by mutation of FOXP3 gene, which is located on X-chromosome and encodes a putative DNA-binding protein, key regulator of immune tolerance. FOXP3 regulates the transcription of multiple genes involved in T-cell responses and is critical for the development regulatory T cells (Treg) and maintenance of peripheral immune tolerance. In humans, Treg cells form a subset of CD4 T cells that either develop in the thymus

(nTreg) or are differentiated in the periphery from naive T cells in the presence of TGF-b following T cell receptor stimulation (iTreg). IPEX is one of the few existing examples of a genetically determined autoimmune disease. It is characterized by severe enteropathy, earlyonset endocrinopathy, dermatitis, elevated IgE and variable autoimmune phenomena. Patients develop symptoms early in infancy and most die prematurely either due to severe diarrhoea, unresponsive to immunosuppression, or severe infections. Nevertheless, similarly to other genetic disorders of the immune system, the disease course is variable and somehow unpredictable, despite the type of FOXP3 mutations. Moreover, patients affected by a phenotype resembling IPEX, without FOXP3 mutations, have been also described and defined as ‘‘IPEX-like’’. Some disorders have a well define genetic defects in molecules that are linked to FOXP3 function (i.e. CD25 deficiency, STAT5 deficiency). However, emerging disease entities without a well-defined molecular diagnosis are also described. Inherited disorders characterized by immune dysregulation have dramatically expanded our understanding of immune tolerance mechanisms in humans. Recognition and diagnosis of these disorders in the clinic allows timely initiation of life-saving therapies that may prevent death or irreversible damage to vital organs.

CONGENITAL AND NEONATAL INFECTIONS WITH VARICELLA-ZOSTER VIRUS (VZV) AND HERPES SIMPLEX VIRUS (HSV) Anne A. Gershon, MD, Yvonne and John Driscoll Professor of Pediatrics, Columbia University P&S_New York Brief case report: A month old full term baby, delivered vaginally, developed a vesicular rash on her scalp that became generalized the next day. She had no fever or other symptoms other than a brief fever to 101 F. There was no known exposure to anyone in the family with varicella or zoster. The baby had not been away from the family apartment. There had been no visitors. The baby had contact with her brother who attended school; he had received 1 dose of varicella vaccine in the past. The brother was entirely well as were both parents. The mother denied any past history of HSV infection. The mother had experienced varicella as a child. Other than the rash, the baby’s physical examination was unremarkable. The baby’s CBC was normal as was the CSF. PCR on the CSF was negative for HSV and VZV. The differential diagnosis was VZV or HSV. Because there was no evidence of encephalitis, the baby was started on Acyclovir (ACV), 30 mg/kg/day IV. VZV was identified by PCR in skin lesions. The baby’s rash was clearing and after a week of treatment, ACV was discontinued. The final diagnosis was varicella, although the source of the virus was never identified. (patient of Dr. C. G., NYC) This case highlights that in some infants VZV and HSV infections may resemble each other. It is important to establish the etiology of the illness because the treatment and prognosis of each is different. HSV infections with an encephalitic component require higher doses of ACV and in the presence of a CSF positive for HSV 1 or 2, six months of oral ACV (300 mg/kg/day po) to prevent developmental delay. Babies with HSV should be investigated for dissemination to the liver and lungs and eyes. Their prognosis is somewhat guarded, especially with involvement of the CNS or viral dissemination. Babies with varicella should be treated with IV or oral ACV for 5–7 days. Their prognosis is excellent with early treatment. Both VZV and HSV may rarely cause a congenital syndrome that presents with a zosteriform rash, developmental problems, and often a hypoplastic limb. A host of other abnormalities may accompany these manifestations, including developmental delay. Unlike babies with congenital rubella, they do not necessarily excrete VZV or HSV, complicating the diagnosis. Mothers of babies with the congenital varicella syndrome usually give a history of varicella in the 8th to 26 th week of pregnancy (average 13 weeks). Vaccination of varicellasusceptible woman who are not pregnant probably has a significant

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role in preventing congenital varicella syndrome. This syndrome is not responsive to ACV, although ACV can be given if there is active viral infection, usually manifested by a vesicular zostreriform rash. Finally both VZV and HSV may cause a severe disseminated form of illness in the first few days of life that occurs when the mother is acutely infected with one of these viruses at delivery. Treatment with ACV is given but the prognosis for both infections is guarded. Babies whose mothers have active varicella at delivery should receive passive immunization. The cornerstone of diagnosis for these infections is PCR. HSV may be diagnosed by viral culture, but this method is not very useful to diagnose varicella. With the widespread use of varicella vaccine in the US, the congenital varicella syndrome has become very rare. HSV infections however, continue to be a clinical problem in the absence of a vaccine against HSV. Early diagnosis with ACV therapy is essential to the survival and health of the baby with HSV.

ELECTROPHYSIOLOGICAL BRAIN MONITORING Lena Hellstro¨m-Westas, MD, PhD, Department of Women’s and Children’s Health, Uppsala University, Sweden The amplitude integrated EEG (aEEG) is a time-compressed EEG trend, created with the aim of providing continuous bed-side information of brain activity in intensive-care treated patients. The method is increasingly used in neonatal units around the world. Several reports, the first published already during the 1980’s, have demonstrated the high predictive value of the early aEEG in term asphyxiated infants. The strikingly similar results of these studies have shown that outcome can be correctly predicted already at 6 hours postnatal age in around 90% of term asphyxiated infants. However, with the introduction of hypothermia treatment, new studies have now shown that the PPV of an early abnormal aEEG for predicting poor outcome has decreased. There have also been reports that the value of the aEEG for assessment of infants eligible for cooling is limited. These findings were expected and are not surprising. When a new intervention is introduced, aiming at improving an outcome, the new treatment will also change the predictive value of methods that evaluate the condition of the infant before the intervention. An early abnormal aEEG trace still indicates that the infant has a high-risk for adverse outcome, while a normal aEEG trace is associated with good outcome. An abnormal aEEG trace after 36–48 hours is still associated with adverse outcome, while an early normalizing aEEG trace and sleep-wake cycling are associated with good outcome. So, the aEEG/EEG is very helpful for assessment also of hypothermia-treated asphyxiated infants and should, as previously, always be evaluated in relation to the infant’s clinical condition. Furthermore, the value of gaining continuous information about an infant’s brain function and the possibility to detect subclinical seizures should not be underestimated. Several studies have now shown that a single- or two-channel aEEG/EEG can detect 80–90% of seizures present in a conventional EEG, if the raw-EEG is inspected. It was recently shown that the use of aEEG/EEG in term infants with HIE was associated with earlier diagnosis of seizures, and with fewer infants with seizure diagnosis without electrographic confirmation. However, the use of aEEG/EEG was not associated with fewer recorded conventional EEGs or with an increased number of administered antiepileptic drugs or imaging investigations.

PLACENTA ACCRETA: A NEW CAESAREAN SECTION RELATED EPIDEMY AND ITS MANAGEMENT C. Hubinont, MD, PhD, E. Dardenne, P. Steenhaut, MD, M.D. Debie`ve, PhD, & P. Bernard, MD, Department of Obstetrics, Saint Luc university Hospital, Universite´ de louvain, Brussels, Belgium

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Introduction: Placenta accreta shows a dramatic rising incidence over the last 20 years. Its antenatal diagnosis and perinatal management is essential in order to decrease the associated high maternal morbidity. Patients and methods: we report a retrospective series of 19 patients managed in our department for abnormal placentation between 2002 and 2012. The study group includes 6 cases (31,60 %) of placentas accretas, 2 cases (10,50 %) of incretas et 11 cases (57,90 %) of placenta percreta, 5 of them with vesical involvement. The most frequent risks factors are the presence of placenta praevia (11/19) and previous uterine scar (12/19). Management and morbidity of placenta accreta and increta/percreta were compared. In the presence of increta/percreta, 9/13 patients were managed conservatively, 3/13 had placental extirpation and in one case only, primary combined caesarean –hysterectomy was offered. Results: placental extirpation of placentas increta/percreta is associated with less maternal complications (intravascular disseminated coagulation, endometritis) than in the group treated conservatively. But conservative approach allows to avoid hysterectomy in 3/9 cases. Conclusions: with the increased incidence of abnormal placentation, antenatal diagnosis should be offered to patients with placenta praevia and uterine scars. Conservative management could be an option in patients asking for fertility preservation but it should be carried out in strict follow up protocols in tertiary centres with intensive care and embolization facilities. Keywords: Placenta accreta, increta, percreta, hysterectomy, postpartum haemorrhage, conservative management

FERTILITY-PRESERVING TREATMENT AND PREGNANCY OUTCOMES IN CANCER SURVIVORS A. Kalugina, O. Bystrova, E. Lapina, N. Tapilskaya, A. Lisyanskaya & G. Manikhas Reproductive medicine AVA-PETER clinic, Saint-Petersburg Saint-Petersburg City Oncology Clinic The advancements in cancer therapies have led to dramatic improvements in long term survival, there has been rising interest in methods to expand fertility preservation options for cancer patients. Fertility-preserving treatment in cancer patients is one of the trends of assisted reproductive techniques (ART) and their use is on the rise throughout the world. Preserving fertility in cancer patients is possible by cryopreservation methods. Cryoreservation has been successfully used for oocytes, embryos, sperm, ovarian and testicular tissue and has made it possible to avoid the potential mutagenic effects of cancer treatment on reproductive cells and tissue. Following 5 years after cancer treatment, patients may use their frozen material to recover fertility. Furthermore recent data from many retrospective studies have shown that singletons born after frozen-thawed embryo transfer have a better perinatal outcome compared with singletons born after fresh ART cycles (IVF and ICSI) regarding low birthweight (LBW) and preterm birth (PTB). Around 30 healthy babies are known to be born after transplantation of cryopreserved ovarian tissue in the world. But details of perinatal outcomes have been published only for 13 of them. These all singleton deliveries occurred after 37 weeks of gestation, and only one woman experienced HELLP syndrome after delivery. One twin pregnancy ended in delivery of two boys at 33 weeks, following rupture of the amniotic membrane. However, undergone cancer treatment has secondary effects on pregnancy and increase the risk of adverse pregnancy outcomes. Many studies have shown that radiotherapy to the pelvic area increases the risk of LBW in the offsprings and PTB in women who have survived cancer. Furthermore, the risk of miscarriage among women exposed to abdominal irradiation is also increased. A solution for pregnancy failure patients is surrogacy program with good results in terms of pregnancy outcomes. Thus cryopreservation methods are conventional procedures with predictable and well documented outcomes in terms of

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pregnancy and child-birth rates. Main risks of delivering prematurely and producing LBW offsprings are associated with cancer survivors undergone abdominal radiotherapy. AVA-PETER clinic is one of the leading research oncofertility centers in Russia. Within our fertility preserving program we set up special cryobank of reproductive cells and tissue of cancer patients (163 biosamples in total). By now, we have 7 livebirths from male cancer survivors with better perinatal outcomes. Also, in 15 out of 21 grafting procedures (hetero – and orthotopic implanting of cryopreserved ovarian tissue) the endocrine function has been restored and one surrogate pregnancy ongoing for a patient after breast cancer treatment. We will continue these important research in the future. We should note that we would be unable to attain such results without close interaction and collaboration with perinatologists, oncologists, fertility specialists and management of relevant medical facilities.

NCPAP VS. NIPPV VS. HEATED HUMIDIFIED HIGH-FLOW NASAL CANNULA (HHHFNC) FOR THE TREATMENT OF PREMATURE INFANTS WITH RDS Prof. Amir Kugelman Department of Neonatology and Pediatric Pulmonary Unit, Bnai Zion Medical Center, The B&R Rappaport Faculty of Medicine, Technion, Haifa, Israel The aim of the management of premature infants with respiratory distress syndrome (RDS) is to provide interventions that will maximize survival whilst minimizing potential adverse effects,1 mainly bronchopulmonary dysplasia (BPD). At delivery, the term stabilization is preferred to resuscitation for the vast majority of very preterm infants. Only a minority of babies should require delivery room intubation. Recent large trials that reflect current practice (including greater utilization of maternal steroids and routine post delivery stabilization on NCPAP) demonstrate less risk of BPD or death when using early stabilization on NCPAP with selective surfactant administration to infants requiring intubation.2 The comprehensive strategy to prevent BPD in the NICU is based on ventilatory and non-ventilatory measures.3 The ventilatory route allows an individualized endotracheal intubation approach. Recent studies concluded that early nasal CPAP (NCPAP) is a safe alternative to immediate intubation in extremely low birth weight (ELBW) infants.4,5 Endotracheal intubation and ventilation can result in significant damage to premature lungs and are independently associated with cerebral palsy. Furthermore, despite new modes of ventilation and surfactant, BPD remains a significant morbidity and its incidence was correlated with the use and length of endotracheal mechanical ventilation. BPD in itself is associated with adverse neurodevelopmental outcome. Thus, we need to avoid endotracheal ventilation, if possible. NCPAP is recommended as the early primary treatment of active RDS (to avoid intubation or as part of the INSURE [INtubation SURfactant Extubation] approach), or later, post extubation at RDS resolution, in order to allow shortening of the duration of endotracheal ventilation and to treat apnea of prematurity.1 New studies4,5 report comparable rates of BPD in ELBW infants treated initially with NCPAP as compared to endotracheal ventilation with surfactant administration. Can we enhance NCPAP and get better outcome for NRS by using nasal intermittent positive pressure ventilation (NIPPV)? NIPPV was defined as a method of augmenting NCPAP by delivering ventilator breaths via nasal prongs. The rationale behind the use of NIPPV is the administration of ‘‘sigh’’ to the infant, thus opening microatelectasis and recruiting more ventilation units. It was shown that synchronized NIPPV (SNIPPV) compared with NCPAP may improve the patency

9 of the upper airway, could activate the respiratory drive, improves thoraco-abdominal synchrony, stabilizes the chest wall, improves lung mechanics and decreases the work of breathing in premature infants. When NIPPV was compared to NCPAP for the different indications of NRS, it was shown to enhance the potential of NRS.3 A recent meta-analysis demonstrated a relative risk reduction for intubation in the first 72 hours in the NIPPV group compared with NCPAP (RR 0.60, 95% CI 0.43, 0.83).6 The NIPPV trial7 was a large international multicenter randomized trial powered to study the important outcome of BPD, recruiting 1009 extremely low birth weight babies, and it showed no difference between babies randomized to NIPPV compared with CPAP. Yet, the results of this study should be considered with caution because of several limitations. For example: There was no uniform experience and equipment used for NIPPV among participating centers; approximately 50% of the infants were supported with biphasic CPAP that is a limited form of NIPPV (maximal peak inspiratory pressure of 9–10 cm H2O in that study). SNIPPV vs. NCPAP for later use, post extubation at RDS resolution, as a ‘‘bridge’’ to spontaneous unsupported breathing was shown to be more effective than NCPAP. A pooled meta-analysis showed that SNIPPV was more effective than NCPAP in preventing failure of extubation [RR 0.21 (0.10, 0.45)] and the number needed to treat was only 3 infants to prevent one extubation failure.8 SNIPPV vs. NCPAP, post extubation, also tended to decrease the rate of BPD.3 SNIPPV may be more effective than NCPAP also for apnea of prematurity.3 A meta-analysis, regarding apnea of prematurity, suggests that SNIPPV is more efficacious with apnea that is frequent or severe. However, the studies performed addressed short-term outcomes and as such could not address properly the incidence of requirement for reintubation. Thus, more studies are needed before recommending SNIPPV as standard of care for apnea of prematurity. To summarize, the available evidence supports the preference of early or later use of NIPPV/SNIPPV compared to NCPAP because of minimizing the use and the length of endotracheal ventilation.3 There are data to suggest that this approach may also reduce the rate of BPD, however this was not shown yet.3 The results of a large international RCT comparing both primary, and post-extubation use of NIPPV with NCPAP, with a composite primary outcome of death or BPD at 36 weeks’ corrected age indicate no additional benefit, or risk, conferred by NIPPV in comparison to NCPAP.7 Whether NIPPV/SNIPPV is more beneficial than NCPAP within the INSURE approach needs to be shown. Recently, heated, humidified high-flow nasal cannula (HHHFNC) is frequently used as a mode of NRS. High flows result in washout of anatomical and physiological dead space and contribute to improved fractions of alveolar gases with respect to carbon dioxide as well as oxygen and decrease the work of breathing and the energy cost of gas conditioning. HHHFNC probably creates positive end expiratory pressure (PEEP) that may contribute to its beneficial effect. However, the PEEP that is not monitored, had raised concerns regarding the safety of HHHFNC in terms of air leak. Recent prospective studies support the notion that HHHFNC is as effective as NCPAP for early stages of RDS,9 post extubation,10,11 and for apnea of prematurity.12 There is one study that found HHHFNC to be as effective as NIPPV for the initial treatments of RDS in infants 41000 g.13 Yet, more studies, especially in the initial treatment of RDS and in ELBW infants, are needed before adopting HHHFNC as an alternative mode of NRS in these conditions. The noninvasive ventilator strategy needs to be confirmed by large prospective randomized controlled trials (with long-term follow up) in order to assure it is applicable to most ELBW infants. Furthermore, the strategy needs to be tailored to individualized infants according to the infant’s maturation; antenatal steroid treatment and severity of RDS; general condition; and to certain practical NICU conditions such as experience, personnel and timing during the day.

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HOW TO MANAGE FETAL AND NEONATAL PAIN AND SUFFERING PAIN CONTROL DURING INVASIVE PROCEDURE IN NEWBORN Paola Lago

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U.O. Terapia Intensiva e Patologia Neonatale Universita` di Padova Approximately 25 years ago, the myth that nervous system immaturity precluded neonates from perception of pain and its negative effects was rejected. Preterm infants have the nociceptive circuitry required to perceive pain, however, this system is functionally immature. Therefore, they have reduced localization and specification to noxious stimuli, and become easily sensitized to repeated noxious stimuli. An imbalance of excitatory versus inhibitory processes leads to increased nociceptive signalling in the central nervous system. Otherwise descending modulation of nociceptive activity in the dorsal horn of the spinal cord that develops later, beyond the term equivalent age, and makes them particularly vulnerable to uncontrolled pain and stress. Scientific research in recent years has confirmed that neonates, especially when preterm, are more sensitive to nociceptive stimuli than older children. Neonates are capable of mounting robust physiological, behavioural, hormonal and metabolic responses to such stimuli, responses that can have adverse short- and long-term effects. (1–2) The on-going research on neurodevelopmental nociception strongly suggests that early pain experience contributes to poor neurodevelopmental outcome, altered pain thresholds, pain or stressrelated behaviour and physiological responses in later life. (3) Several lines of evidence suggest that early and/or repeated exposure to painful stimuli during a period fundamental to nervous system development, as part of their life-saving care in the neonatal intensive care unit (NICU), leads to persistent behavioural changes and abnormal brain development (e.g. a smaller volume of the sensory areas of the brain in ex-preterm infants). (4–6) In fact procedural pain induces both oxidative stress and inflammatory reactions and therefore may arrest the development of pre-myelinating cells. (7) These finding are supported by evidence from animal testing that have demonstrated both inflammatory pain and increase apoptosis due to repeated injections in the brains of neonatal rats. (8) Prolonged activation of hypothalamus-pituitary-adrenal (HPA) axis in physiologically immature neonates can lead to long-term changes in hormonal (e.g. growth, glucocorticoids), physiological (e.g. metabolic, immune) and behavioural (anxiety, depression) systems. These long-term changes to stress response appear to be related to the fact that regions rich of glucocorticoids receptors (e.g. hippocampus, prefrontal cortex) are particularly vulnerable to the effects of on-going stress (glucocorticoids regulate the transcription of genes throughout the body and the brain). (9) Therefore it appears that repeated exposure to neonatal procedural pain/stress is associated with long-term alterations to neuronal structure and function in term of cognitive, motor and behavioural abilities. Clinicians are faced with the difficult task of discriminating and appropriately managing pain in infants. Although unmanaged pain may have substantive effects on the developing brain and stress systems of premature neonates, pain management remains a challenge and the use of pain control interventions for neonates undergoing painful procedures is still limited, according to published data. Many studies have already documented the huge amount of painful and stressful procedure performed during the intensive care unit stay of preterm and term neonates. The number of tissuedamaging procedures performed per day was also reported in different surveys conducted in the US, UK, Australia, Canadian, Dutch. (10–14) Most recently a two-weeks survey of invasive procedures in 13 NICUs in the region of Paris-France, reported an average of 16 procedures per day of hospitalization (IR 9-24), including skin breaking and non-tissue damaging procedures, 12 of

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which painful, in 430 neonates enrolled in the study. During the study period, neonates experienced almost 61 000 first-attempt procedures (more than 11 000 supplemental attempts- about 1/5 of the procedures requested 4 or more attempts to be completed); of these procedures 70% were classified as painful (44 different type of procedures) and almost 30% as stressful (16 different type of stressful procedures: nursing, bath, oral aspiration, blood pressure measure, nasal prongs insertion, EEG, ECG, ultrasound, etc.). Each neonate admitted in NICU experienced a median of 115 procedures (IR 48-216) during the study period. The maximum number of procedures counted per neonate was high, with a total of 613, 364 of that painful in fourteen days, and up to 62 procedures per day. The most frequent procedures were counted 153 tracheal aspirations and 95 heel pricks in a single neonate in 14 days of monitoring. It was also highlighted that the lower the gestational age was, the higher the number of invasive procedures. In relation to this exaggerated number of invasive procedures approximately only 20% of the painful procedures and 6.6% of the stressful ones were performed with a specific pain/stress reducing intervention using pharmacological and non-pharmacological methods, depending on the type of procedure (used in 10% of tracheal aspirations and 70% of venepuncture). (15) While we acknowledge from these evidence that our little patients are more frequently and chronically exposed to tissue damaging procedures than any other hospital population, and that they are more vulnerable both in the short and long term, it is proven that pain killed interventions are not widely applied in intensive care unit, although numerous guidelines for procedural pain in neonate are available nationally and internationally. In 2000 the American Academy of Pediatrics (AAP) published a statement paper on prevention and management of pain and stress in newborn, with the objectives to increase awareness that neonates do experience pain, provide a physiological basis for neonatal pain/ stress assessment and management by health care professionals, make recommendations for reduced exposure to pain and minimize associated adverse effects and recommend effective and safe interventions that relive pain and stress. This statement was updated in 2006. (16–17) In 2001 Anand KJ and his international group of expert published a consensus statement for the prevention and management of pain in newborn, in which reported pharmacological and environmental support strategies for each invasive procedure. (18) In Italy the Pain Study Group of the Italian Society of Neonatology, developed in 2004 and 2008 (published in English in 2009) recommendation and guidelines for pain control and prevention during invasive procedure in newborn, reporting for the first time the strength of existing evidence and the grade of recommendation (based on SIGN classification) that is crucial to the quality of pain management. (19–20) These guidelines should help clinicians to choose the most effective and safe pain control measures based on current knowledge, to improving the health care professional’s awareness of the need to adequately manage procedural pain in neonates. Adequate pain prevention and management should be an essential part of standard health care at the NICU, and recognizing and assessing sources of pain should be routine in the day-to-day practice of physicians and nurses taking care of the newborn. Before these official Italian guidelines had been circulated, a national survey was undertaken in 2004 to assess pain control and prevention practices at NICUs. (21) This survey had made it clear that procedural pain was still undertreated and underscored. We then hypothesized that practical clinical guidelines adaptable to each hospital’s practices would facilitate the uptake of the best available evidence on neonatal pain management practices. Five years later, we investigated the issue again at Italian NICUs to see if there had been any improvement in their routine pain control and prevention. (22) We found that most Italian NICUs (87%) were aware of the national guidelines, and that their use was facilitated by larger volumes of activity (number of admissions, number of nurses) and by the presence of a local champion to promote pain control practices. A significant improvement in analgesic practices was seen for almost all invasive procedures between the 2004 and 2010 surveys,

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with more NICUs using pharmacological and non-pharmacological pain control methods, but these practices were still routinely implemented by a minority of the units. Pain monitoring - which is essential to appropriate, customized pain treatment – had also significantly improved at Italian NICUs, but was still far from becoming a routine practice at most units. (23) A number of environmental (nonpharmacologic) interventions (NPI) are today used for the management of routine acute pain in the NICUs (e.g. sucrose, swaddling, facilitated tucking, non-nutritive sucking, kangaroo care, breast feeding). Currently, sucrose is the most widely used NP intervention for the treatment of minor procedures in neonates, with the higher grade of recommendation (A). (24) However, while it is well established that oral sucrose reduces behavioral and physiological responses, it does not appear neither to dampen the electroencephalogram response to pain nor prevent hyperalgesia for multiple heel pricks or skin breaking procedures. (25–-26) The role of parents and the sensitive and responsive caregiver appears to improve some effects of neonatal pain-related stress on brain, stress and behavioral outcome, improving white matter maturation. (27) For the major invasive procedure the analgesic intervention are mainly pharmacological (PI). Premedication before tracheal intubation (TI) was routinely used by only 34.3% of Italian NICUs, although 69.7% used some form of PI. Although written guidelines were available at 57.6% of the Italian centers, most of them practiced ‘‘awake intubation’’ with no prior analgesia or sedation, probably causing pain, discomfort, physiological derangements and possibly even airway injury. This situation contrasts with a recent UK survey that found sedation provided at 93% of all interviewed units, while 76% adopted a written pain control policy for elective tracheal intubation. (28) Comfort measures (particularly swaddling and positioning) were used by 58.5% of the Italian centers, but only 26.3% used it routinely. The survey identified more than 10 different drug combinations are being used before elective tracheal intubation of the newborn, though fentanyl and midazolam (alone or in association) were the most often mentioned - in 59.6% and 24.2% of cases, respectively. Only 2.0% of NICUs reported using morphine, unlike the UK where it is used at most centers (80%), usually combined with Suxamethonium chloride. Although the optimal premedication for neonatal TI has not been established, associating morphine with Suxamethonium chloride might not be the best solution in preterm infants, not only because these opioids have quite a slow onset of action and may not reach the peak concentration needed to achieve its full effect in time for the procedure concerned (leaving the newborn paralyzed but without proper analgesia), but also because of its hemodynamic impact and the resulting prolonged sedation, which are not always desirable. (29) An opioid with a rapid onset and short or ultra-short duration of action (fentanyl or remifentanil) may be preferable. In contrast with UK practice, where 78% of NICUs administered paralytic agents, only 16% of Italian centers did so (mostly succinylcholine, mivacurium or vecuronium), and this was routine in only 4.0%, despite the evidence that their use can speed up the intubation procedure, reducing the related traumatism and the incidence and duration of hypoxemia. (30) Propofol or thiopental, as hypnotic agents, can be used for newborn intubations, achieving an effective sedation. (31–32) Propofol has proved effective in inducing a good sedation during TI, but its safety needs to be confirmed before suggesting its routine use in the newborn. (33) The use of sedo-analgesia for mechanical ventilation is quite common at Italian NICUs, with 87.5% reportedly using some form of sedation - usually fentanyl in continuous infusion (78.4%), or morphine (10.2%, associated with midazolam in 1). Overall, 26.3% of our NICUs considered the use of drugs (fentanyl or midazolam) even for non-invasive ventilation, though only 4.0% used them routinely; this is a scenario for which no guidelines are available. The majority of the Italian centers routinely provided comfort (swaddlingpositioning) (65.6%) and NPI (pacifier plus sweeteners) (40%) to reduce the stress and discomfort caused by the nasal cannula. Few NICUs (23.7%) were in the habit of administering medication

11 (opioids or benzodiazepines) before tracheal aspiration procedures. According to the Cochrane Collaboration 2008, analgesia and sedation during MV should be individualized on the basis of clinical pictures and pain scores (34). Due to concerns regarding short-term possible long-term effects of pharmacological agents on developmental brain, current recommendations are that opiates and sedatives be used sparingly in the NICU for non-surgical pain management of ventilated preterm neonates, in an individualized way based on pain and sedation monitoring. Failure to implement pain assessment in routine practice naturally prevents any modulation of pain therapy during MV, adjusting to the clinical situation and pain indicators. During mechanical ventilation, 60.9% of the Italian NICUs use pain scales instead of the 21.7% in 2004 (p ¼ 0.0003). The number of NICUs routinely using validated scales to monitor newborns’ pain was still low, however (9% and 21%, respectively, for INT and MV). In 2010, 49% of NICUs with surgical facilities adopted postoperative pain monitoring methods, but only 17% used pain scales routinely. More recently an epidemiological observational study on bedside pain assessment practices, collected data for all neonates in participating NICUs of 16 European countries until infants left the unit or for 28 days. From overall 58,5% of ventilated neonates and 35,2% of non –ventilated received bedside pain assessment. Wide variations in the methods used and rates of pain assessment exist among countries. (35) Various strategies have been proposed for promoting the evidence-based best practices in neonatology and it seems that health professionals’ behavior can change with appropriate action, resulting in better patient care. Variability in the application of evidence-based practices is operator- and setting-dependent: improving continuing professional education and on-the-job training schemes, and overcoming organizational barriers (e.g. ensuring the prompt availability of sucrose in single dosages, and of automatic lances) might improve their use and compliance with best practices. Providing health-care professionals with feedback on their performance (auditing) may also help. In a study at two Canadian neonatal units, nurse-physician collaboration and nurses’ work assignments were stronger predictors of the actual adoption of evidence-based care than the availability of guidelines. (36) These findings have implications for neonatal care practices and professional education programs, which should consider further national/ international quality assurance initiatives, at least for topics on which there is enough evidence to support evidence-based clinical practices, in an effort to close the gap between best practices and existing practices for dealing with newborn babies’ pain. Once a best practice for treating procedural pain has been established and recognized, coordination and implementation programs will be needed, using local champions and project teams to pursue more consistent changes in practice. (37) In conclusion exposure to repeated neonatal pain-related stress is associated with altered brain development, function, neurodevelopmental outcome and pain perception later in life. Therefore it is of the utmost importance that pain-related stress in preterm infants is accurately identified and appropriately managed. Effective management of pain therefore remains an important indicator of the quality of care provided to neonates, not only from an ethical, but also from a short and long-term outcome perspective. There is an urgent need to improve compliance with best practices, through a process of auditing and benchmarking at local and national/international levels. The availability of written guidelines helps to standardize analgesic practices in the newborn based on best evidences, but their local implementation is of paramount importance. The presence of a local champion whose duty will be to facilitate the adoption of pain control measures is vital to close the gap between policy and clinical practice. Alliances between management, professionals, and medical staff might achieve better results by improving attitudes towards change, assuring a safe and effective pain control as standard clinical practice at our NICUs. Continuous training and quality improvement schemes would improve the operators’ skills and

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make them more confident in using an integrated approach to pain control. Monitoring pain is indispensable for individualized pain control and prevention, and an integrated approach to pain control using non-pharmacological and pharmacological interventions seems more effective. Finally, major gaps in knowledge as which management interventions may be brain protective and to what degree, should be address in the future research.

occurs in up to one in five pregnancies, with a high percentage of stillbirths (four- to six-fold with respect to controls) Disease activity, presence of anti-phospholipid antibodies, kidney involvement have an important prognostic value for both maternal and fetal outcome. Active disease, anti-phospholipid antibodies, renal involvement and renal insufficiency are bad prognostic factors for the outcome of pregnancy and need to be assessed at counselling.

THE EARLY IUGR: WHEN TO DELIVER

THE VOICE OF THE PARENTS

C. Lees

Silke Mader

Department of Fetal Medicine, Rosie Hospital, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge

Plenary Hall 5th June 2014 from 9:00–9:30

Timing of delivery in early onset IUGR remains a major challenge in perinatal medicine as neonatal and childhood morbidity must be balanced with the risk of hypoxia and intra uterine death. Data from randomized and observational studies is sparse however a consensus is emerging that given gestational age is the main determinant of perinatal morbidity and mortality, prolonging gestation is the most important strategy. To safely prolong gestation implies that a robust monitoring strategy must be in place: opinion is split on the role of biophysical profile, Doppler and fetal heart rate monitoring. This talk will review the current evidence and disclosable information from the TRUFFLE study in respect of the diagnosis of IUGR, monitoring and timing delivery.

FETAL LIFE AND PSYCHOSOMATIC DISORDERS DURING ADULTHOOD Daniel Lysek Swiss Institute of Micropsychoanalysis The micropsychoanalytical setting provides many clues indicating that the structure of the unconscious originates in intra-uterine life. Therefore it integrates the inherited background including drives, relational movements and experiences. Furthermore, micropsychoanalysis also gives evidence that many bodily symptoms occurring during adulthood are psychosomatic. Micropsychoanalytical sessions allow linking certain psychosomatic symptoms with fetal experiences stored in the unconscious. With an example, the Author will show, for the first time, which intrauterine experiences can cause psychosomatic disorders.

CONNECTIVE TISSUE DISEASES AND PREGNANCY OUTCOMES Marta Mosca, Chiara Tani & Francesca Strigini Department of Clinical and Experimental Medicine, University of Pisa, Italy The term connective tissue diseases refers to an heterogeneous group of systemic autoimmune diseases including rheumatoid arthritis, ankylosing spondylitis, reactive arthritis, connective tissue diseases, polymyalgia rheumatic. These conditions affect primarily young women in their childbearing age. From the maternal point of view, risks are related with the possibility of flares of disease activity as well as of deterioration of pre-existing organ damage. The risks of flares appears related with disease activity in the months preceding conception. In addition connective tissue diseases carry a higher incidence of obstetric complications with respect to the general population. Approximately 25% pregnancies in patients with systemic lupus erythematosus (SLE) end in preterm (537 weeks). Pregnancy loss

Summary: In 1997, Silke Mader was admitted to the hospital with acute HELLP syndrome. With undetected pre-eclampsia at the age of 25, she gave birth to twins at 25 weeks of gestation. Lying three days in a coma she barely survived, as did her son. Her daughter lost the struggle of life after a few days, weighing 290 grams. Appropriate treatment and care as well as social support were lacking from the very start of her pregnancy until after the traumatic experience of preterm birth. Faced with the non-existence of support of any kind, the absence of public awareness and lacking information and education for expecting parents, she joined the local parent group in Munich soon afterwards. A few years later, she became chairwoman of the national parent organisation where together with other engaged parents, she raised national awareness, developed information material for parents in Germany and achieved the establishment of laws and guidelines for the benefit of preterm infants and their families. As the situation throughout Europe was distressingly similar, Silke Mader decided in 2008 together with another parent and a neonatologist to found the European Foundation for the Care of Newborn Infants (EFCNI) and subsequently became the chairwoman of the newly established foundation. In the six years since its establishment, EFCNI has grown into a renowned organization, representing the interests of preterm and newborn infants and their families. It gathers together parents and healthcare experts from different disciplines with the common goal of improving long-term health of preterm and newborn children by ensuring the best possible prevention, treatment, care and support. The level of information, care and support pregnant women and expecting parents receive across Europe still differs widely. Unfortunately, some care practices continue to fall far short of promoting and protecting the right to a healthy start in life. These disparities were demonstrated for the first time by the EFCNI EU Benchmarking Report 2009/10, a comparison of policies and practices regarding newborn health and support to families across Europe. Having shown these differences, EFCNI teamed up with health experts to formulate recommendations and principles for preconceptional, maternal and newborn and continuing care in Caring for Tomorrow - the EFCNI White Paper, 2011. Alongside, a Call to Action for Newborn Health was initiated by EFCNI and national parent organisations. One point of the call to action specifically asks for the provision of research funding to prevent preterm birth and reduce the number of chronic illnesses that occur as a consequence of preterm birth. EFCNI collaborates with scientific and professional societies and is involved in many research programmes and studies. It also acts as parent representative in the boards of different societies. In 2011, EFCNI started with EU-wide campaigns ‘‘ene, mene, mini.’’ and ‘‘SOCKS FOR LIFE’’ for improving neonatal health. The new project ‘‘European Standards of Care for Newborn Health’’ started in 2013. In collaboration with and supported by over 50 health professional societies, parent organisations and third parties, EFCNI will develop best practice standards for preterm birth and newborn health together with various experts from all over Europe. This is a further milestone, to ensure a better and more

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harmonised treatment in Europe and to enable the best start in life for all infants. Empowering parents, education and training for experts and increasing awareness in public and all decision makers can make a change – it’s time to act – now! Multiple choice questions:

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How many babies are born preterm worldwide? A 5% B 8% C 11% D 20% Which of the following country has the highest preterm birth rate in Europe? A Portugal B Germany C Sweden D Polen What is the leading cause of neonatal death? A HIV B Preterm birth C Diarrhea D Sepsis

PREDICTION AND PREVENTION OF PRETERM DELIVERY IN TWINS George Makrydimas, MD, Department of Obstetrics and Gynaecology, University Hospital of Ioannina- Greece The risk of prematurity is much higher in twins compared to the sigletons. It is estimated that 29% of dichorionic pregnancies develope a maternal or fetal condition leading to birth before 36 weeks, whereas 34% of the monochorionic twins are born before 34 weeks. In a recent meta-analysis, the pooled rates of birth before 37, 34 and 32 weeks for twins were 41%, 13% and 7%, respectively. During the last 15 years, significant progress has been achieved in both the prediction and prevention of preterm birth in singleton pregnancies. This process has been slower in twins, apparently reflecting the diverse pathophysiology of preterm birth in multiple pregnancy. In contrast to singleton pregnancies, where the risk for preterm birth increases exponentially when the cervix is 515 mm, the cut-off for high risk in twin pregnancies is 25 mm, apparently because a longer cervix is needed to counteract the increased uterine activity during pregnancy. Cervical length 25 mm at 22–24 weeks was reported in 100% of women delivering before 28 weeks, 80% of those delivering before 30 weeks and approximately 50% of those delivering before 28 weeks. CL525 mm is associated with 10% and CL515 mm is associated with 30% risk for birth before 33 weeks. In asymptomatic women, a positive fetal fibronectin test appears to be associated with 35% risk for birth before 32 weeks and 40% risk for birth 534 weeks, whereas a negative test decreases the risk to 6% and 17%, respectively. Several treatments have been used to prevent preterm delivery in twin pregnancies. The administration of progesterone, in general, does not reduce the rate of preterm delivery in twins. However, there is some evidence that vaginal natural progesterone treatment may be effective in women with a twin pregnancy and a short cervix. Of course further studies are needed to prove the efficacy of such treatment. Cervical cerclage in twins appears to increase the rate of preterm delivery and adverse pregnancy outcome while the data regarding the use of the cervical pessary in twins do tot support some beveficial effect.

INTRAPARTUM SONOGRAPHY AND CAESAREAN SECTION Antonio Malvasi1, Andrea Tinelli2 & Gian Carlo Di Renzo3 1

Department of Obstetrics and Gynecology, Santa Maria Hospital, Bari, Italy, 2Department of Obstetrics and Gynecology, Vito Fazzi Hospital, Lecce, Italy, and 3Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy Brief Introduction: Modern ultrasonography revolutionized the traditional midwife, and obstetric semiotics. Even if the main interest has been on ultrasound fetal malformations and fetal growth, in the recent years a new impetus was given by the modern conception of ultrasonography, applied to the delivery event. In fact, although the birth is of common interest, few technologies have been implemented for the labor monitoring. This issue contrasts with everyday reality where dystocia affects about 40% of the worldwide deliveries but it is still manually diagnosed, as in ‘700 century. Materials & Methods: We reviewed literature showing the ultrasonography application, as a clinical support of objectivity and by showing the phases of labour, with fetal head descend and rotation in occiput anterior, posterior, and transverse presentations, and the possible malpresentation. Clinical Cases or Summary Results: Intrapartum ultrasonography is a relatively new technique to monitor labor: it adds to what is felt by the fingers as the eye can see objectively the commitment, the descent, and the rotation of the fetal head in the birth canal. This makes it possible to follow the labor in a more objective view by midwives and enables early detection of labor dystocia, allowing timely intervention and reducing maternal and fetal complications. Conclusions: An objective instrumental evaluation of labor does not increase the number of cesarean section, even reducing operative deliveries based on a presumptive diagnosis of dystocia, provides a documentation of labor developments, and enables operators to lower exposure to possible litigation in case of complications that bring charges of malpractice. This is already documented by a growing number of scientific articles that increase the literature on. Keywords: intrapartum ultrasonography, cesarean section, labor, dystocia

PREGNANCY AND LONELINESS: PSYCHOBIOLOGICAL IMPLICATIONS B. Marzi & U. Honemeyer 1

Istituto Italiano di Micropsicoanalisi

Absence of prenatal and post natal bonding due to narcistic nucleus in the mother can have consequences which are visible in baby’s behaviour, and in his attachment to the mother. The fetal sensual and motoric equipment and it’s successful development within the maternal organism on the one hand, and the harmonic psycho-physic transformation and maturation of the woman into a mother on the other hand, are linked in dialectic inter-dependence

GIANT SACROCOCCYGEAL TERATOMA CYSTIC COMPONENT NEEDLE ASPIRATION IMMEDIATELY BEFORE CESAREAN SECTION DELIVERY A. Mikhailov, T. Kashtanova, A. Novikova, A. Romanovsky, A. Shlykova & A. Halikov Maternity Clinic #17, NW State Medical University, International Clinic ‘‘Medem’’, St.-Petersburg, Russia

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Sacrococcygeal teratoma (SCT) is one of the most common fetal tumors with incidence 1:20000 – 1:40000 live births. Perinatal mortality in cases of SCT is more than 50 %. Perinatal demise usually associated with fetal heart failure and fetal edema, tumor dystocia and its wall rupture with lethal bleeding during labor. Several prenatal interventions such as teratoma cystic component ultrasound guided needle aspiration (USGNA), amnioreduction, amnioinfusion and open fetal surgery are proposed in order to improve pregnancy outcome at SCT. SCT was found in 13 6/7 weeks of gestation during the 1st trimester scan. Subsequent observation by dynamic ultrasound and MRI examinations from 18 to 32 gestational weeks revealed the intensive SCT volume increase from 20 to 1442 ml. The SCT/fetal weight ratio increased from 0.07 to 0.88. But because of normal feto-placental hemodynamics, absence of signs of heart failure and preterm birth conservative approach for pregnancy management was chosen. In 32 weeks and 4 days patient was admitted because of preterm rupture of membranes. US estimated fetal weight was 2310 gr, teratoma volume – 2220 ml and SCT/fetal weight ratio – 0.96. Considering size of teratoma to prevent a high risk of its rupture during caesarian section delivery USGNA of cystic component was successful performed and 1350 ml of fluid evacuated. Preterm girl 2310 g/42 cm with Apgar score 7/7 was delivered by low segment caesarian section without any technical difficulties. Teratoma was presented as cutaneous sac 16  9  4 cm filled by poor liquid content and tumor masses. Teratoma was totally and successfully resected on 5th day after delivery and now child is doing well. Needle aspiration in cases of huge SCT could decrease the risk for fetus due to teratoma blood vessels traumatization during delivery and provide the opportunity to avoid huge uterine wall scars after corporal caesarian section. Possibility of vaginal delivery after successful teratoma USGNA in term fetuses needs to be evaluated in further investigations.

pessary or no-pessary. The primary outcome was a composite for poor perinatal outcome containing stillbirth, periventricular leukomalacia, severe respiratory distress syndrome, broncho-pulmonal dysplasia, intraventricular haemorrhage, necrotizing enterocolitis, proven sepsis and neonatal death. A prespecified subgroup analysis was performed for women with a cervical length below the 25th percentile measured at 16–22 weeks of gestation. Due to the nature of intervention the study was not blinded. The study showed a strong benefit of the pessary in this subgroup. These results have lead to new trial initiatives. We are currently aware of 6 randomised studies that are planned and that will evaluate the pessary. I will present the design of these studies.

CERVICAL PESSARY IN THE REDUCTION OF PRETERM BIRTH

PREIMPLANTATION GENETIC DIAGNOSIS OF BETA THALASSEMIA

B. Mol

G. Monni, V. Usai, G. Perra, C. Cugusi, I. Podda & F. Mulas

Professor of Obstetrics and Gynecology, The Robinson Institute j School of Paediatrics and Reproductive Health University of Adelaide

Microcitemico Hospital – Cagliari – Italy, Department of Obstetrics and Gynaecology, Prenatal & Preimplantation Genetic Diagnosis Fetal Therapy

Reduction of preterm birth is a major goal in obstetric care. In a systematic review of randomized controlled trials and cohort studies on the effectiveness of the cervical pessary to prevent preterm birth, we searched the electronic databases of MEDLINE and Embase from inception until April 2012 to identify studies investigating treatment with a cervical pessary to prevent preterm birth. We constructed twoby-two tables for delivery before 28, 34, and 37 weeks of gestation and calculated relative risks (RRs) with 95% confidence intervals. The systematic review included six cohort studies and four randomized controlled trials studying the effectiveness of a cervical pessary to prevent preterm birth. The cohort studies indicated potential effectiveness of the pessary, while the randomized studies showed conflicting results. The PECEP trial demonstrated a significant reduction of pretermdelivery of gestation by treatment with a pessary, but this effect was not confirmed by Hui et al. [1, 2]. A possible explanation for the difference between these studies might be the fact that the preterm delivery rate was much higher in the control group from the PECEP trial (8% before 28 weeks, 27% before 34 weeks and 59% before 37 weeks) than in the study by Hui et al. (6% before 28 weeks, 6% before 34 weeks, and 18% before 37 weeks). A study by Blencowe et al. for worldwide estimates of preterm birth rates demonstrated similar results for China and Spain (7.1 versus 7.4, resp.) [3]. We recently published a nationwide, multicentre, open-label, randomised controlled trial (NTR1858) in 40 hospitals in the Netherlands. Women with a multiple pregnancy between 12 and 20 weeks of gestation were randomly allocated in a 1:1 ratio, using a webbased application with a computer-generated list, to a cervical

In this study we report our experience in Preimplantation Genetic Diagnosis (PGD) on beta thalassemia in Sardinia and we discuss the medical, ethical and social aspects related to this procedure. The Preimplantation Genetic Diagnosis (PGD) has been first performed in 1992 for Cystic Fibrosis by Alan Handyside in London in order to avoid the profoundly traumatic psychological experience which voluntary termination of pregnancy (TOP) implies. It is a prenatal genetic diagnosis procedure which is performed in a very early stage of embryo development (Fig.) and used in conjunction with in vitro fertilization techniques (IVF). Cells from the embryo at the blastomer or blastocyst stadium are then sampled and tested for certain genetic conditions before being transferred in the uterus. The embryos with genetic disorders can be discarded, get frozen or not transferred. The most important indications for PGD are severe monogenic diseases and chromosomal disorders. DNA Polymerase chain reaction (PCR) with primers, restriction enzymes and heteroduplex analysis by fluorescence in situ hybridization (FISH) are the methods of analysis employed most often. As our Sardinian experience in prenatal genetic diagnosis demonstrates, couples that have had voluntary TOP for affected embryos or fetuses in 100% of cases would not repeat traditional CVS (Chorionic Villous Sampling) or Amniocentesis and consequent TOP in case of abnormal fetuses and therefore prefer choosing PGD. In Sardinia, in Greece, in Cyprus and in other Mediterranean countries, where there are well operating programs of beta thalassemia control, PGD is very efficient and well accepted by couples.

References M. Goya, L. Pratcorona, C. Merced et al., ‘‘Cervical pessary in pregnant women with a short cervix (PECEP): an open label randomised controlled trial,’’ Lancet, vol. 379, no. 9828, pp. 1800–1806, 2012. S. Y. Hui, C. M. Chor, T. K. Lau, T. T. Lao, and T. Y. Leung, ‘‘Cerclage pessary for preventing preterm birth in women with a singleton pregnancy and a short cervix at 20 to 24 weeks: a randomized controlled trial,’’American Journal of Perinatology, 2012. In press. H. Blencowe, S. Cousens, M. Z. Oestergaard et al., ‘‘National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications,’’ Lancet, vol. 379, no. 9832, pp. 2162–2172, 2012. Liem S, Schuit E, Hegeman M, Bais J, de Boer K, Bloemenkamp K, Brons J, Duvekot H, Bijvank BN, Franssen M, Gaugler I, de Graaf I, Oudijk M, Papatsonis D, Pernet P, Porath M, Scheepers L, Sikkema M, Sporken J, Visser H, van Wijngaarden W, Woiski M, van Pampus M, Mol BW, Bekedam D. Cervical pessaries for prevention of preterm birth in women with a multiple pregnancy (ProTWIN): a multicentre, open-label randomised controlled trial. Lancet. 2013;382:1341–9.

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Sciences, University of Birmingham Birmingham Women’s Hospital Edgbaston Birmingham B15 2TG

Fig. Biopsy on a single cell embryo at 6–8 stage. Certainly, several issues are related to PGD, for example, the efficient organization of the team, the financial expenses of IVF and the biopsy of blastomeres, legal and juridical problems, the 25% of pregnancy rate success following IVF, possible diagnostic errors and failures and malformations of the PGD neonates. In several cases, pregnancies achieved following PGD must be controlled by prenatal invasive diagnosis by CVS or Amniocentesis to confirm the PGD result. In this paper we examine the result on PGD in our centre before the PMA Italian Law of February 2004 when PGD was prohibited in Italy and the results following the new PMA Law modifications applied after January 2013 to present time for the beta thalassemia disease.

References Cao A, Cossu P, Monni G, Rosatelli C. Chorionic villus sampling and acceptance rate of prenatal diagnosis. Prenat Diagn 1987;7:531. Handyside AH, Lesko JG, Tarı`n JJ, Winston RM, Hughes MR. Birth of a normal girl after in vitro fertilization and preimplantation diagnostic testing for cystic fibrosis. N Engl J Med. 1992 Sep 24;327(13):905–9. Palomba ML, Monni G Lai R, Cau G, Olla G, Cao A (1994): Psychological implications and acceptability of preimplantation diagnosis Hum Reprod. 9(2):360–2. Monni G, Cau G, Usai V, Perra G, Lai R, Ibba G, Faa` V, Incani F, Rosatelli MC (2004): Preimplantation Genetic Diagnosis for betaThalassaemia: the Sardinian Experience Prenat Diagn.;24(12): 949–954. Monni G, Zoppi MA, Axiana C, Ibba RM. Changes in the approach for invasive. prenatal diagnosis in 35 127 cases at a single center from 1977 to 2004. Fetal Diagn Ther. 2006;21(4):348–54. Hens K, Dondorp W, Handyside AH, Harper J, Newson AJ, Pennings G, Rehmann-Sutter C, de Wert G. (2013): Dynamics and ethics of comprehensive preimplantation genetic testing: a review of the challenges. Hum Reprod Update. 2013 Jul-Aug;19(4):366–75. doi: 10.1093/humupd/ dmt009. Epub 2013 Mar 6. Monni G (2013): Is preimplantation genetic diagnosis ethical? UNESCO Chair in Bioethics 9th World Conference: Bioethics, Medical Ethics and Health Law, Book of Abstracts pg. 117 (2013).

THE PLUTO STUDY (2 YEARS ON): DOES PRENATAL INTERVENTION IMPROVE THE LONG TERM OUTCOME IN BABIES WITH CONGENITAL BLADDER NECK OBSTRUCTION? R. Katie Morris NIHR Clinical Lecturer in Maternal Fetal Medicine Birmingham Centre for Women and Children’s Health, School of Clinical and Experimental Medicine College of Medical and Dental

Background: Fetal lower urinary tract obstruction (LUTO) is associated with high levels of perinatal and long term childhood mortality and morbidity. Prenatal vesicoamniotic shunting (VAS) has been reported in cohort studies as improving perinatal outcome. The PLUTO study aimed to determine the effectiveness, cost-effectiveness and patient acceptability of VAS for LUTO. Methods: The PLUTO study comprised an international, multicentre randomised trial incorporating a prospective registry, decisionanalytic health economic model and pre-planned Bayesian analysis using elicited opinions. Patient acceptability was evaluated by interview in a qualitative study. Participants were women whose pregnancies were complicated by isolated LUTO with a male fetus and allocation was to either intervention (placement of VAS) or conservative management. The setting was Fetal Medicine Centres in United Kingdom and Netherlands. Randomisation was via computer, clinicians and participants were not blinded due to the invasive nature of the intervention. Pregnancies were assessed and the diagnosis made prospectively using prenatal ultrasound. The primary outcome measure was survival of the baby to 28 days. Secondary outcome measures were survival and renal function at 1 year of age, costs of care, and cost per additional life year and per disability free at end of one life year. Bayesian methods were used to estimate the posterior probability distribution of effectiveness of VAS at 28 days. Results: The trial stopped early with 31 women randomised due to difficulties in recruitment. Recruitment was hampered by logistical and regulatory difficulties, a lower incidence of LUTO and lower antenatal diagnosis rate (estimated to be 3.34 (2.95–3.72) per 10 000 total births and 47% respectively in an associated epidemiological study), and high termination of pregnancy rates. Based on intention-to-treat analysis, survival at 28 days was higher if allocated VAS (50%) than conservative management (27%) [RR 1.88 (95% CI 0.71–4.96), p ¼ 0.27)]. Analysis based on treatment received showed a larger effect [RR: 3.20 (95%CI: 1.06–9.62) p ¼ 0.03]. At 12 months survival was 44% in the VAS arm and 20% in the conservative arm [RR 2.19 (0.69–6.94), p ¼ 0.25)]. Neither difference was statistically significant. Relative risk estimates for survival at one and two years were similar to those seen at 28 days. Using Bayesian analysis combining the trial data and the elicited priors gave a 86% probability that VAS increased survival at 28 days and a 25% probability that it had a large clinically important effect (a relative increase in the proportion surviving of 55% or more). Only two babies (both in the VAS group) survived to 2 years with normal renal function. VAS was more expensive due to additional surgery and intensive care. VAS cost £15 500 per survivor at 1 year, and £43 900 per disability free life year. The acceptability study identified visualisation of the fetus during ultrasound scanning, perceiving a personal benefit, and altruism as positive influences on recruitment. Fear of the VAS procedure and the perceived severity of LUTO influenced non-participation. The need for more detailed information about the condition and its implications during pregnancy and following delivery was a further important finding of this research. There were 45 women entered onto the registry of which the majority, 78%, had conservative management. Those women who entered the study registry and had conservative management were more likely to have a normal liquor volume at diagnosis (45th centile) than those receiving VAS (p ¼ 0.07) or those randomised (p ¼ 0.05). They also had a higher proportion with gestational age at diagnosis 424 weeks compared with those randomised (p ¼ 0.003). These variables were strongly associated with improved survival to 28 days in a mutivariable logistic regression analysis. Conclusion: The PLUTO RCT found that overall survival appeared higher in those fetuses receiving VAS, but there remained uncertainty in the direction and magnitude of the effect such that it is not possible to conclusively prove benefit. Overall prognosis in both arms at 24 months is poor, with only two babies surviving to 2 years of age with no renal impairment.

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THE LARGEST STUDY ON NIPT THUS FAR: THE NEXT STUDY T. Musci

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Ariosa Diagnostics 5945 Optical Court Non-invasive prenatal testing (NIPT) with cell-free DNA (cfDNA) is highly accurate for fetal trisomy evaluation in high-risk pregnancies. Routine pregnancy population NIPT performance has not been evaluated in a large prospective study. The objective was to compare NIPT with directed cfDNA analysis to first trimester combined screening (FTS) for trisomy 21 risk assessment in a general pregnancy population – a prospective multi-center blinded cohort study compared Harmonyä Prenatal Test, a directed cfDNA test, with FTS using first trimester PAPP-A, hCG and nuchal translucency measurement. Women with a singleton fetus presenting in the first trimester for routine prenatal screening for fetal aneuploidy were eligible. Participants had both FTS and Harmony. FTS results were provided as part of routine care. Participants and care providers were blinded to Harmony results, calculated as probability scores. Pregnancies were followed for newborn outcomes. Invasive test results or neonatal phenotype, with karyotype confirmation in cases of suspected aneuploidy, were used for trisomy 21 identification. Harmony, FTS results and outcomes were reported to an independent data coordinating center. Primary outcome was comparison of the area under the ROC curve for trisomy 21 test performance of the Harmony and FTS. 18 955 women were enrolled across 38 centers in USA, Canada and Europe from March 2012 to April 2013. The mean maternal age was 30.6 (18–52) years. The mean gestational age was 12.4 (10–14.3) weeks. Follow-up is complete. Study results will be presented. Implications for use of NIPT for trisomy 21 risk assessment in the general pregnancy population will be discussed.

CAESAREAN SECTION SURGICAL TECHNIQUES (CORONIS): A FRACTIONAL, FACTORIAL, UNMASKED, RANDOMISED CONTROLLED TRIAL. S. Naz Masood, The CORONIS Collaborative Group Objectives: Variations exist in the surgical techniques used for caesarean section and many have not been rigorously assessed in randomised controlled trials. We aimed to assess whether any surgical techniques were associated with improved outcomes for women and babies. Methods: CORONIS was a pragmatic international 2  2  2  2  2 non-regular fractional, factorial, unmasked, randomised controlled trial that examined five elements of the caesarean section technique in intervention pairs. CORONIS was undertaken at 19 sites in Argentina, Chile, Ghana, India, Kenya, Pakistan, and Sudan. Each site was assigned to three of the five intervention pairs: blunt versus sharp abdominal entry; exteriorisation of the uterus for repair versus intra-abdominal repair; single-layer versus doublelayer closure of the uterus; closure versus non-closure of the peritoneum (pelvic and parietal); and chromic catgut versus polyglactin-910 for uterine repair. Pregnant women were eligible if they were to undergo their first or second caesarean section through a planned transverse abdominal incision. Women were randomly assigned by a secure web-based number allocation system to one intervention from each of the three assigned pairs. All investigators, surgeons, and participants were unmasked to treatment allocation. The primary outcome was the composite of death, maternal infectious morbidity, further operative procedures, or blood transfusion (41 unit) up to the 6-week follow-up visit. Women were analysed in the groups into which they were allocated. The CORONIS Trial is registered with Current Controlled Trials: ISRCTN31089967. Results: Between May 20, 2007, and Dec 31, 2010, 15 935 women were recruited. There were no statistically significant differences

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within any of the intervention pairs for the primary outcome: blunt versus sharp entry risk ratio 1.03 (95% CI 0.91–1.17), exterior versus intra-abdominal repair 0.96 (0.84–1.08), single-layer versus double-layer closure 0.96 (0.85–1.08), closure versus non-closure 1.06 (0.94–1.20), and chromic catgut versus polyglactin-910 0.90 (0.78–1.04). 144 serious adverse events were reported, of which 26 were possibly related to the intervention. Most of the reported serious adverse events were known complications of surgery or complications of the reasons for the caesarean section. Conclusions: These findings suggest that any of these surgical techniques is acceptable. However, longer-term follow-up is needed to assess whether the absence of evidence of short-term effects will translate into an absence of long-term effects.

VIRAL INFECTIONS IN PREGNANCY: OVERVIEW AND PERSPECTIVES G. Nigro Pediatric Unit, San Salvatore Hospital, University of L’Aquila, Italy Maternal-fetal infections (MFI) are more frequent than commonly believed, favoured by the estrogen-enhanced immunodepression occurring in pregnancy, and the consequences involve all medical and surgical fields even after many years from birth. Main viral infections in pregnancy include: rubella, herpes simplex virus 1-2, HIV, varicella, hepatitis C, parvovirus B19, and cytomegalovirus (CMV). The most frequent is due to CMV, which can be transmitted to fetus after both primary and recurrent infection in the mother. Serodiagnosis by detection of specific IgM and IgG antibodies is the first approach, while avidity of specific IgG antibodies can differentiate recent or past infections. Diagnosis of active infection is based on detection of the causal agent by PCR, culture, or antigens. In fact, prenatal and postnatal diagnosis are based on detection of the viral genome from body fluids. The most frequently immediate manifestations of MFI are preterm delivery and IUGR. Fetal or neonatal manifestations may be extremely severe but are non-specific, except for migrational disorders caused by CMV. Intrauterine transmission and fetal/neonatal symptomatology are inversely correlated: the transmission raises by gestational age contrary to fetal damages, which are more severe in the first half of pregnancy. Although diagnostic tools have been much improved, little was done for treating or preventing the severe damages caused by MFI. Urgent targets of the investigators should be: (1) Antenatal screening: is it necessary, useful or unnecessary? (2) Screening in pregnancy: should this be done only in seronegative women or also in some seropositive women (i.e. CMV); (3) Diagnostic procedures: need to obtain standardization of the technique and reproducibility of results; (4) Role of immunoglobulin and cellmediated levels in maternal-fetal transmission; (5) Value of the viral load in the amniotic fluid for prenatal diagnosis; (6) Improvement of the clinical, laboratory and ultrasound monitoring in pregnant women with viral infections; (7) Therapeutic approaches towards viral infection in pregnancy: immunoglobulins, antiviral drugs; (8) Pediatric follow-up: which children, how and how long? (9) Therapy of congenital viral infections: only symptomatic infections? Which kinds of symptoms and signs should be considered to define a symptomatic infant?

FETAL AND NEONATAL ALLOIMMUNE THROMBOCYTOPENIA D. Oepkes Department of Obstetrics Leiden University Medical Centre, Leiden, The Netherlands Introduction.Fetal and neonatal alloimmune thrombocytopenia (FNAIT) may lead to intracranial hemorrhage in the fetus or neonate, often with death or major neurological damage as consequence. The incidence ranges from 1:350 to 1:1000. A generally accepted

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definition of severe FNAIT is a platelet count 550  109/l. The most severe complication is intracranial hemorrhage (ICH), leading to perinatal mortality in 1–7% and surviving children with often severe neurological sequelae including mental retardation, cerebral palsy, cortical blindness and seizures in 7–26% of affected pregnancies. In the absence of any screening programs, the disease is only detected after birth of an affected child. Preventive measures can than only be taken in the next pregnancy. Only around 10% of HPA 1a negative pregnant women (2.1% of the population in Caucasians) actually produce HPA-antibodies despite carrying a HPA-1a positive fetus. The best estimate of the incidence of ICH comes from a systematic review of all prospective screening studies in unselected populations, encompassing a total of 176.084 pregnancies. In 7/71 (10%) of the pregnancies with severe FNAIT (platelet counts 550  109/l), severe adverse outcome occurred with ICH, leading to death (n ¼ 2) or permanent neurological sequellae in most others. All except one of these bleedings occurred before birth. Even these prospectively derived data are an underestimation, since in all these studies, some form of preventive measure was taken in screen-positive pregnancies. Our best estimate is therefore that the incidence of clinically significant ICH due to FNAIT ranges between 3–10 per 100.000 pregnancies. Given the often life-long handicaps in survivors, a screening and intervention program would in most Western countries almost certainly be cost-effective. With the current lack of screening programs, we can only focus on how best to manage pregnancies with known FNAIT, thus those pregnant women with a previously affected child. Commonly used antenatal treatments include serial fetal platelet transfusions or transplacental medical treatment using immunoglobulins and/or corticosteroids. Other options which may be used in conjunction to fetal therapy are near term induction of labour, near-term caesarean section, and delivery in a tertiary care centre with a prepared team and matched platelets available for urgent transfusion. These modalities will be discussed in the presentation.

ABNORMAL PLACENTATION IN THE SCARRED UTERUS: RISK FOR OBSTETRICIANS J. M. Palacios-Jaraquemada CEMIC University Hospital and School fo Medicine, University of Buenos Aires, Argentina An unexpected finding of placenta accreta-percreta during cesarean can offer different possibilities to be solved. In general, options depend on medical experience, surgical skills and hospital resources. For this reason, there is not an ideal treatment for all of them, but preventing massive and uncontrollable bleeding is our primary aim. Unpredicted diagnosis of abnormal placentation after cesarean incision is a not common event due to advances and quality in ultrasound studies; but the threat is possible, real and it occurs in developed and underdeveloped countries. Because most cases of abnormal placentation are lower and anterior, the presence of engorged vessels over the uterine segment in patients with previous cesarean implies a high risk of abnormal placentation. In these cases, the obstetrician could ask for help, or choose to perform a hysterotomy outside the invaded area (usually in the uterine fundus). Crossing the placenta, delivering the baby and performing a fast hysterectomy are very dangerous options without the possibility to turn back if bleeding is uncontrollable. We will provide a simple guide to analyze advantages and disadvantages of different approaches when abnormal placentation is unexpected.

SURFACTANT REPLACEMENT THERAPY IN DEVELOPING COUNTRIES R. Pejaver KIMS, Bangalore, India K R Hospital, Bangalore, India

Abstract: More than 90% of the global births happen in developing countries. More than a quarter of these babies are premature or low birth weight babies. The neonatal morbidity and mortality is quite high in these countries. In India the total annual births are 28 million. Nearly 30% are low birth weight and premature. The neonatal mortality is 31per thousand live births. More than 20% of these deaths are due to prematurity and low birth weight. Even if 10% of the premature babies have significant respiratory distress syndrome (RDS), in absolute numbers we are looking at nearly a million babies annually. It is true that suboptimal antenatal care, unsafe deliveries, perinatal asphyxia, sepsis and inadequate infant nutrition needs to be remedied. But, at the same time there are regions where the neonatal mortality is in single digit and health care standard has advanced considerably, literacy and per capita income is higher. National NRP program, national rural health mission, government health insurance has resulted in improvement. Surfactant is needed in developing countries. In India annually only around 50 000 doses are used. Surfactant is used only in major cities and only in few tier two cities. Healthcare is a mix of government and private sector. Level three NICU are not there in most of the government facilities. Health insurance and risk pooling system is still being established. Hence the affordability is limited. Newborn care practices and care seeking behavior needs to be changed. Facilities to intubate, CPAP, supportive ventilation, monitoring facilities, follow-up care may not be available in all parts of the country. It has to be very well understood that in developing countries prerequisites of surfactant administration are -good antenatal care, antenatal corticosteroid, safe delivery, good infrastructure, neonatal care of reasonable standards and proper follow-up. At the same time any strategy should consider factors like, limited availability of resources, non uniform affordability, prevention of sepsis, avoiding ventilation and early discharge from hospital Single dose surfactant is practiced a lot and if given early has been found to be effective. Combining surfactant administration with non invasive ventilation like nasal CPAP as early as possible after birth will be the strategy for countries with limited resources. INSURE technique could also be used more extensively. If minimally or non invasive techniques of surfactant instillation comes to routine practice, it will be a boon. The price of surfactant could be reduced for developing countries. It could be by government subsidy or by manufacturing locally. Health insurance for all including the newborn will improve affordability.

INHALED STEROIDS FOR PREVENTION OF BRONCHOPULMONARY DYSPLASIA (BPD): WHAT IS THE EVIDENCE? C. F. Poets, D. Bassler, V. Carnielli, H. Halliday, M. Hallman, P. H. Jarreau, R. Plavka, M. Schwab & E. Shinwell & J. van den Anker 1

Dept. of Neonatology, University Hospital, Tuebingen, Germany Survival of Extremely Low Birth Weight (ELBW) infants has improved in recent decades but BPD remains a major health care problem, contributing not only to the mortality of preterm infants but being also associated with impaired neurosensory development in survivors. For many years, dexamethasone was the main drug used to prevent BPD. Reports on adverse effects of dexamethasone on growth and neurodevelopmental outcomes, however, turned the enthusiastic use of systemic postnatal steroids into almost complete avoidance, with a subsequent increase in the incidence of BPD. An alternative would be topical application, i.e. via inhalation, but despite a widespread use of this therapy, its effectiveness has never been convincingly shown. With financial support from the 7th Framework Programme of the European Union, we thus launched NEuroSIS, a European

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18 multicentre study to investigate whether early prophylactic inhalation of Budesonide (Budiair, Chiesis) reduces the absolute risk of BPD or death in preterm infants born 528 weeks gestational age (GA) by 10%. Our primary objective was to determine whether inhalation of Budesonide within 12 hours of life improves survival without BPD at 36 weeks GA in infants born between 23 and 27 weeks GA. Secondary objectives were whether prophylactic inhalation of Budesonide affects neurodevelopment at a corrected age of 18–22 months, to determine whether inhalation of corticosteroids is associated with adverse treatment effects, alters mortality or BPD incidence at 36 weeks GA, and the duration of positive pressure respiratory support or supplemental oxygen. Data on the pharmacokinetics and pharmacogenetics of inhaled corticosteroids were also collected and a substudy on the genetic susceptibility to BPD performed. The study was designed as a randomised placebo-controlled trial, enrolling a total of 850 infants of 23–27 weeks GA in 40 centres across 8 countries (Belgium, Czech Republic, Estonia, France, Germany, Israel, Italy, The Netherlands). Infants were randomised during the first 12 hours of life to Budesonide or placebo to prevent BPD. Study drugs was administered via a metered dose inhaler (MDI; Aerochamber Mini) and continued until infants were either off supplementary oxygen and positive pressure support or had reached a GA of 32 0/7 weeks regardless of ventilatory status. The primary outcome of survival without BPD was determined at 36 weeks GA and BPD defined according to the physiological definition. Study patients were followed and neurodevelopmental outcomes assessed at a corrected age of 18–22 months. Recruitment was closed in July 2013 and the database in March 2014, but results will only become available in October 2014. It is hoped that results of this trial will ultimately provide guidance to clinicians whether inhaled steroids are an effective measure to reduce BPD in this vulnerable patient population.

MRI OF CONNECTIVITY AND FUNCTION OF THE FETAL BRAIN D. Prayer Division of Neuroradiology and Musculoskeletal Radiology Medical University Vienna MRI for morphologoical assessment of the fetal brain has become widely used as an adjunct to prenatal ultrasound. Postnatally, the visualization of brain connectivity plays a role in the characterization of brain malformations, presurgical assessment of various lesions, and white matter disease. Prenatally the challenge to receive usable data lies in duration of the acquisition time of the diffusion tensor sequence that can hardly exceed 1 minute to minimize the probability of a disturbance by fetal movements. This sequence is overlain then by a morphological sequence, such as a T2-w sequence, and anatomical landmarks are defined that are passed by the respective white matter tracts. Based on this approach the corticospinal tracts, the frontopontine tracts, and the corpus callosum can readily be demonstrated from a gestational age of 18 weeks onwards. In the third trimester association fibers can be also demonstrated. The practical application of prenatal tractography lies in the demonstration of missing or aberrant white matter tracts in cases of malformations, and in the visualization of connectivity in acquired conditions, such as, for instance, infarctions where brain plasticity may lead to the fact that white matter tracts originate in unusual cortical regions. Functional MRI, based on the enhanced oxygene consumption of active brain regions, is performed using a BOLD (Blood oxygen labelled) sequence. There spontaneous brain (the so-called resting state activity) can be shown. In healthy foetuses networks could be visualized in the frontal, occipital, temporal and parietal region. In brain malformations these networks can be disturbed. Whether these informations will be usable for prognostic purposes is currently under investigation.

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CONTROVERSIES IN NEONATAL SEIZURE MANAGEMENT E. Saliba, MD, PhD, Head Pediatric Reanimation and Neonatology Service, University Hospital Center of Tours, and research director at INSERM The estimated incidence of seizures is 1 to 3.5 per 1000 births in term newborns and even higher in preterm infants. Seizures in the newborn frequently signal significant brain pathology, such as hypoxic-ischemic injury, stroke, intracranial infection, hypoglycemia, inborn error of metabolism, or brain malformation. Neonates with seizures are at a high risk for mortality, and survivors have a high incidence of adverse neurodevelopmental outcome including motor or cognitive disability. There are currently no evidence-based guidelines for evaluation and management of neonatal seizures. The clinical diagnosis of neonatal seizures can be challenging. Neonates may display behaviors that suggest seizures but do not have an electrographic correlate. Conversely, electrographic seizure activity on electroencephalography (EEG) in neonates may be associated with minimal or no behavior change, so called ‘‘electro-clinical dissociation.’’ There is little consensus on whether clinical events without EEG correlate should be treated or how aggressively to treat ‘‘electrographic-only’’ seizures. ‘‘Electrographic-only’’ seizures without observable behavioral change are common in neonates. ‘‘Electrographic-only’’ events occur most commonly after antiepileptic drug administration, or in infants with exceedingly frequent discharge or status epilepticus. Lack of behavioral change with ictal EEG discharge may suggest functional disconnection of the epileptic focus, a situation that may reflect a more severe brain insult. Despite the lack of clinical correlate, most experts agree that these seizures have similar pathophysiology and sequelae to electroclinical events. One important question when dealing with neonatal seizures is: do neonatal seizures cause brain injury? One of the strongest predictors of outcome is underlying etiology, with poorer outcomes being seen in severe asphyxia, massive intraventricular hemorrhage, or underlying malformations of cortical development. Although there has been debate as to whether seizures, per se, cause further brain injury, there is now some compelling evidence, predominantly from animal studies, that they do. In term human infants with hypoxicischemic encephalopathy, it has been shown that an increased severity of seizures correlated with a greater degree of brain injury. How aggressively should neonatal seizures be treated? Although no study has definitely proven that aggressive therapy of seizures improves outcome, preliminary work has shown that seizures may exacerbate underlying brain injury in hypoxic-ischemic encephalopathy, or brain inflammation. As such, the therapeutic goal should probably be elimination or marked reduction of both electroclinical and electrographic-only seizures in these infants. Another important question is about the choice of antiepileptic drug therapy (AED). The first priority when beginning to treat the neonate with seizures is to ensure that there is adequate oxygenation and cardiac function. Once these basic things are addressed, there needs to be rapid assurance that the infant is not hypoglycemic, hypocalcemic, hypomagnesemic, or hyponatremic. Correction of these metabolic derangements will either control the seizures or ‘‘allow’’ the seizure medications to be effective. Phenobarbital has long been a mainstay of seizure treatment in the neonate. Administration intravenously can be accomplished quickly once intravenous access is obtained, serum concentrations can be determined rapidly, and further doses can be administered to achieve a desired value. Phenobarbital typically is given as a loading dose of 15 to 20 mg/kg. If seizures recur after loading, or if there is a perceived chronic seizure-provoking etiology, maintenance dosing is initially 3 to 4 mg/kg per day divided into two daily doses. Phenobarbital is metabolized in the liver, so maintenance dosing often needs to be increased to the range of 5 to 8 mg/kg per day because infants mature and recover from acute liver dysfunction after asphyxia. Hypothermia also decreases

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phenobarbital metabolism. Phenytoin is as effective for initial seizure control as phenobarbital. Because the transition to enteral administration is often challenging owing to difficulty sustaining therapeutic serum concentrations, many infants are treated initially with phenobarbital. Another disadvantage of phenytoin compared with phenobarbital is the much higher protein binding. There may be drug-drug interactions with other highly protein-bound medications. On the other hand, a loading dose of phenytoin is less likely than phenobarbital to cause sedation. Phenytoin typically is given as a loading dose of 15 to 20 mg/kg followed by maintenance doses ranging from 5 to 8 mg/kg per day divided into two daily doses. Phenytoin is poorly soluble. Fosphenytoin is more soluble at neutral pH, is less irritating to soft tissue, and can be administered faster than phenytoin without as great a risk of bradycardia. The loading dose for fosphenytoin is essentially the same as for phenytoin. Phenytoin’s antiepileptic mechanism is sodium channel blockade: it reduces repetitive neuronal firing. When adding a second antiseizure medication to a child’s treatment regimen, it is reasonable to use a drug with a different mechanism of action than that of the initial drug. For this reason, phenobarbital and phenytoin, with their respective inhibition-enhancing and excitation-suppressing mechanisms, have long been used in combination when neonatal seizures prove refractory to initial monotherapy. The three commonly used parenteral benzodiazepines are midazolam, diazepam, and lorazepam. All are effective antiseizure medications, although controlled trials in neonates are lacking. Lorazepam has the longest duration of action among these three medications. Midazolam and diazepam have a slightly faster onset of action because of greater lipid solubility, but they redistribute out of the brain more quickly than lorazepam. In the acute seizure setting, when the need for maintenance antiseizure medication therapy is uncertain, stopping the seizure with a benzodiazepine then assessing the situation may be the best balance between efficacy, safety, and prevention of longer-duration, drug-induced sedation. Several factors may explain the poor efficacy of GABAergic agents such as phenobarbital and benzodiazepines for neonatal seizures. Inhibitory mechanisms are relatively underdeveloped in the immature brain. In the rat, GABA receptors and the enzyme that synthesizes GABA are lower at birth and increase steadily until the third to fourth postnatal week. Furthermore, in early life, GABA may be excitatory rather than inhibitory. Finally, glutamate receptors are differentially expressed in the immature brain, resulting in lower seizure threshold. Another concern in using AED is that many of them, including phenobarbital, phenytoin, and diazepam have been shown to lead to apoptotic neurodegeneration in the developing rat brain. The impact of therapeutic doses of these agents to neurodevelopmental outcome in newborns with seizures is not known. Many other seizure medications often prescribed for older children have been reported as being used in neonates, typically in small case series. Among all these medications, levetiracetam has been adopted with some enthusiasm, despite the lack of controlled trials in neonates. It has no drug-drug interactions, and it is not metabolized in the liver. It is also available as an oral solution, making conversion from parenteral to oral/enteral maintenance dosing fairly easy. Its exact mechanism of action remains uncertain, but it does not act via direct modulation of inhibitory or excitatory neurotransmission. Numerous case series indicate its efficacy and absence of serious side effects. There is no standard dosing regimen for neonates, but described approaches range from an initial loading dose between 10 and 50 mg/kg and daily maintenance doses in a similar range (divided into twice-daily dosing). When should antiepileptic drugs be stopped? Although there is some consensus regarding the initiation of antiepileptic drug therapy in newborns, there is little agreement about when to stop medication. In deciding on duration of therapy, the natural history of seizures due to various etiologies can guide therapy. In cases due to moderate hypoxic-ischemic encephalopathy, antiepileptic drug therapy should be discontinued prior to discharge. In contrast, infants with seizures due to severe hypoxic-ischemic brain injury, intraparenchymal hemorrhage, or ischemic stroke will often need longer treatment.

Conclusion: Seizures in neonates are common and often suggest a serious underlying brain injury. There is increasing evidence to suggest that the seizures themselves can exacerbate injury, making it imperative that we develop better means to detect and treat seizures so that sick infants can receive prompt and effective therapy.

BRONCHOPULMONARY DYSPLASIA AND RESPIRATORY SUPPORT Manuel Sanchez Luna, MD, PhD Neonatology Division Hospital General Universitario ‘‘Gregorio Maran˜o´n’’ Complutense University Madrid, Spain During the last years there has been a revolutionary approach to the respiratory support of the newborn, and more specific to the immature newborn infant, not only to have a more rationale concept of prevention of airway and lung damage due to the effect of invasive mechanical ventilation, but also to decrease as much as possible long-term disease, as Bronchopulmonary Dysplasia. An immature and growing lung sometimes has to begin breathing, having an inadequate anatomy and also an insufficient surfactant and antioxidant content. This means that some kind of respiratory support is needed immediately or shortly after delivery. But respiratory support can damage the fragile and immature lung favoring in many cases the developing of Bronchopulmonary Dysplasia. In this way, the current approach means a less invasive respiratory support, and when it is possible a rapid extubation if invasive support is needed. Also, more and more premature infants are born after antenatal steroids and a less severe RDS is expected. So mainly efforts should be directed to support the initial establishment of respiration after delivery helping for the FRC to be created and giving time for the immature lung to adapt after delivery. New concepts are to be discussed as the use of prophylactic nasal CPAP or noninvasive ventilation. Also some new approaches of invasive ventilation in a protective manner are possible in order to find the most physiological and less aggressive ventilation to the patient. The new concepts on noninvasive and less invasive respiratory support will be discussed.

OPTIMAL PREDICTION AND PREVENTION OF PRETERM BIRTH IN TWINS E. Shennan Professor of Obstetrics at St Thomas London Twin pregnancies have increased dramatically over the last thirty years. The reasons for this are twofold: increased use of assisted reproductive techniques and older mothers. There are many complications associated with twin pregnancies; particularly preterm labour. Around 60% of twins are born at less than 37weeks gestation compared with 10% of singletons. Prematurity puts the neonate at risk of various morbidities including Respiratory Distress Syndrome (RDS), sepsis, patent ductus arterious, cerebral palsy, cognitive defects and is associated with intrauterine death. These gestation specific risks are comparable between twins and singletons, confounded by twins having inherently more antenatal complications. A great deal of research has been undertaken into the prevention and management of pre-term birth in singleton pregnancies; particularly high risk populations such as those with risk factors including a short cervical length in early pregnancy and a history of preterm birth. There is less evidence in twins, and it is often at variance with singleton pregnancies. Multiple gestation presents a great challenge in obstetric care and currently there are no guidelines regarding management of preterm risk in this high risk population. This talk will review the evidence regarding prediction of preterm birth in twins, particularly related to biochemical (fetal fibronectin) and cervical length measurements. Prediction will be shown to be good, but the challenge remains what interventions to prevent

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preterm delivery and improve outcome. At least research and interventions can now be evaluated in the correct targeted populations.

OVERVIEW OF ATTEMPTS TO PREVENT BRONCHOPULMONARY DYSPLASIA (BPD) Eric S. Shinwell

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Department of Neonatology, Ziv Medical Center, Tsfat, Bar-Ilan University, Israel The continuing prominence of BPD as a major morbidity of prematurity reflects the difficulties inherent in trying to prevent a complex condition of multifactorial origin. Contributing factors include prematurity itself, together with mechanical ventilation, oxygen, patent ductus arteriosus (PDA), infections, genetic predisposition, male sex and postnatal nutritional failure. This session will review recent advances, both pharmacologic and non-pharmacologic interventions that aim to prevent BPD. Three talks will describe new ventilator approaches and this specific talk will focus on other interventions. Interventions that will be discussed will include therapies such as caffeine, steroids (systemic or inhaled), nitric oxide and vitamin A. The controversial role of pharmacologic or surgical closure of the hemodynamically-significant PDA will be reviewed. Early aggressive nutrition for promotion of lung healing will also be discussed. Experimental approaches that have not yet reached the clinical arena will also be addressed.

VIDEO-FILM PRESENTATION: PLANNED SECTION/ HYSTERECTOMY FOR PLACENTA PERCRETA T. Somville Department of Obstetrics and Prenatal Medicine University Hospital Hamburg (UKE) Germany In the last years the incidence of abnormal placentation has increased (from 1/4027 to 1/533). Risk factors are (Re-) Caesarean Section, myomectomy, recurrent miscarriages and Multiparity. Placenta praevia with a history of caesarean section is potentially a life-threatening condition. Maternal Mortality up to 7% has been reported (ACOG Committee Opinion Nr 529.July 2012). This Video-film presents in the case of a 40 J GVI PV (History of 5 Cesarean Sections) the prenatal diagnosis, preoperative planning and therapy by Section/Hysterectomy. After prenatal diagnosis with US and MRT and induction of lung maturity the operation was planned at 33 + 1 WG. The ureters were stented pre-operatively. After longitudinal laparotomy and fundal uterotomy a premature neonate was extracted in good condition (2099Gr, Apgar 8/9/10,pH UA 7,36). With the placenta left in situ a hysterectomy was performed. There was a need for transfusion of 6 Ery-packs and 4 FFP. The postpartum period was without any complications. The presentation shows the possibility to reduce the high maternal mortality and morbidity of this condition by careful prenatal diagnosis and an elective multidisciplinary approach (Obstetrics, Urology, (Vascular) Surgeons, Anaesthetic-Intensive care and Neonatologists)

XXIV European Congress on Perinatal Medicine Florence, June 4–6, 2014

RESPIRATORY DISTRESS SYNDROME: IS IT AN INFLAMMATORY DISEASE? Christian P. Speer University Children’s Hospital, Wu¨rzburg, Germany

Surfactant substitution has been a major breakthrough in the treatment of neonatal respiratory distress syndrome (RDS), primarily caused by a lack of pulmonary surfactant; it has significantly reduced mortality and acute pulmonary morbidity in preterm infants. Some very immature infants, however, have a poor response to surfactant replacement or an early relapse. This brief article is based on the hypothesis that neonatal RDS has a complex and multifactorial pathogenesis characterized by an injurious inflammatory sequence in the immature lung. Fetal exposure to chorioamnionitis has been shown to initiate an inflammatory reaction beginning in utero. A ‘‘low grade’’ inflammatory stimulus in utero may ‘‘prime’’ the fetal lung for accelerated maturation of the surfactant system, especially in conjunction with prenatal steroids, and may protect the preterm infant from developing moderate to severe RDS. Depending on the severity of inflammatory injury to the alveolar-capillary unit, however, serum proteins will leak into the airways and induce surfactant inactivation. Following this intrauterine ‘‘first hit’’, the immature infant may develop severe RDS and have a poor response to surfactant substitution. Secondary insults such as traumatic stabilization techniques, oxygen toxicity, initiation of mechanical ventilation and others injure the immature lung immediately after birth and perpetuate and may aggravate the inflammatory process. Observational studies in preterm infants and animal experiments support this concept. Whenever surfactant inactivation is suspected, higher or repetitive doses of natural surfactant may help to overcome surfactant inactivation and to restore lung function. (Neonatology 2011;99:316–319)

NEONATAL HEALTH AS AN EXAMPLE OF HEALTH CARE INEQUALITY M. Stanojevic Department of Obstetrics and Gynecology Medical School University of Zagreb, Neonatal Unit, Clinical Hospital ‘‘Sveti Duh’’ Zagreb, Croatia If one would be asked what the greatest problem facing mankind is, what would be the answer? Inequality is certainly one of the greatest problems of mankind. Among them the health issues of the mothers and newborns could be considered as the greatest inequality. The most vulnerable population with the highest mortality rate among humans are neonates. Nearly 8000 newborns dye ever day which means that around three million of them dye every year. Most of neonatal deaths (98%) occur in low- and middle income countries. Decline in neonatal death rates are one third slower than in other groups of children, which means that more should be done globally to improve neonatal health. The most common causes of neonatal deaths are preterm birth complications, newborn infections and birth asphyxia. They account for over 80% of all global neonatal deaths. A newborn baby who is born preterm or has a potentially lifethreatening problem is in an emergency situation requiring immediate diagnosis and management. Delay in identification of the problem or in providing the correct management may be fatal. Reducing neonatal mortality is both an ethical obligation and a prerequisite to achieving Millennium Development Goal 4, the target of which is a reduction in child mortality by two-thirds between 1990 and 2015. A 2008 report found only a quarter of relevant countries on track to reach this target. Three-quarters of neonatal deaths occur in the first week, and just under half in the first 24 h. In South Asia and East and Southern Africa, only about 35% of births take place in institutions. Between 41% and 72% of neonatal deaths could be averted if 16 simple, cost-effective interventions were delivered with universal coverage. Among these are adequate nutrition, improved hygiene, antenatal care, skilled birth attendance, emergency obstetric and newborn care, and postnatal visits for mothers and infants. Although these simple and cheap measures can save lives, most of them are still inaccessible in middle- and low-income countries. Inequalities can be reduced through targeted and transformative policies and actions, including the promotion of inclusive and

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intergenerational growth and decent work while simultaneously addressing the priority needs and rights of poor, vulnerable and marginalized people, among whom the neonates from low-income countries are the most susceptible population.

MG SO4 FROM TOCOLYSIS TO FETAL AND NEONATAL BRAIN PROTECTION R. Vladareanu & S. Constantinescu 1

EVALUATING THE FETUS AT RISK FOR CARDIOPULMONARY COMPROMISE. Ma´ximo Vento1,2, Javier Escobar2, Miguel A. Asensi3, Juan Sastre3, Kari Teramo4, Vedran Stefanovic4 & Sture Andersson5 Division of Neonatology, 2Neonatal Research Group; University and Polytechnic Hospital La Fe; Health Research Institute La Fe; Valencia, Spain, 3Department of Physiology; Faculty of Pharmacy; University of Valencia;Spain, 4 Department of Obstetrics and Gynaecology, Helsinki University Central Hospital, Helsinki, Finland, and 5 Department of Neonatology, Helsinki University Central Hospital, Helsinki, Finland.

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Human fetus develops in an atmosphere, which is relatively hypoxic as compared to the extra-uterine milieu. However, fetal physiologic adaptation comprising the presence of fetal hemoglobin, increased cardiac output, and reduced metabolic rate, assures an adequate tissue oxygen supply, metabolism and growth. Fetal reactions to acute or chronic hypoxia are different and are modified by the preceding fetal condition. Acute fetal hypoxia episodes occur unexpectedly, are usually caused by serious complications affecting the pregnant woman and/or the fetus, and are in most of the situations not preventable. Conversely, an adequate obstetric care during labor and delivery may prevent poor fetal outcome under most circumstances in many cases of acute fetal hypoxia. There is, however, a substantial difference in the pathophysiology of chronic fetal hypoxia caused by placental insufficiency, which differs from chronic fetal hypoxia secondary to diabetic pregnancies that is detected in the last weeks of gestation. Interestingly, methods employed for antenatal fetal surveillance are not equally efficient in preventing fetal complications in both situations. Electronic fetal heart rate testing and Doppler flow assessment methods have been successful in detecting chronic fetal hypoxia caused by placental insufficiency. Contrarily, these methods have not been capable to prevent complications secondary to chronic fetal hypoxia in diabetic pregnancies. Therefore, research to find new strategies and early and reliable biomarkers is necessary to assess fetal well-being and to decide when to deliver the fetus especially in metabolic complicated gestations such as diabetic insulin dependent pregnancies. Our Finnish colleagues have in depth studied the validity of erythropoietin (EPO) as a reliable biomarker to detect chronic fetal hypoxia. Interestingly, there is a significant correlation between high levels of EPO and in utero but also postnatal fetal complications. In addition, our group has developed mass spectrometry validated methodologies to detect biomarkers of oxidative and nitrosative stress which we have shown to significantly correlate with amniotic fluid EPO levels and clinical outcomes in insulin dependent diabetic pregnancies and/or gestations from women suffering from type 1 diabetes.

References Vento M, Teramo K. Evaluating the fetus at risk of cardiopulmonary compromise. Semin Fetal Neonatal Med. 2013;18:324–9. Teramo KA, Widness JA. Increased fetal plasma and amniotic fluid erythropoietin concentrations: markers of intrauterine hypoxia. Neonatology 2009;95:105–16. Escobar J, Teramo K, Stefanovic V, Andersson S, Asensi MA, Arduini A, et al. Amniotic fluid oxidative and nitrosative stress biomarkers correlate with fetal chronic hypoxia in diabetic pregnancies. Neonatology 2013;103:193e8.

Professor of Obstetrics and Gynecology at the Carol Davila University of Medicine and Pharmacy in Bucharest Advances in perinatal and neonatal medicine have significantly improved survival rates of preterm infants. This improvement has been associated with substantial risk of neurodevelopmental impairments and with increased number of infants with special health care needs. Cerebral palsy is the most well known and potentially most disabling motor abnormality associated with prematurity. There has been limited progress in understanding the causes of cerebral palsy and in developing primary prevention strategies. Several studies have summarized the experimental evidence that supports possible neuroprotective effects of magnesium. Five randomized controlled trials of antenatal magnesium sulfate found a trend of reduced risk of cerebral palsy in preterm infants. Three meta-analyses using the data from these five trials found that magnesium sulfate given to women at risk of premature birth significantly reduced the risk of cerebral palsy without increasing the risk of perinatal or infant death.

PRETERM DELIVERY AND RISK FACTORS IN REPRODUCTIVE LIFE C. Voltolini, S. Vannuccini, C. Orlandini, Al. Cannoni, I. Moncini, M. Torricelli, F. Maria Severi & F. Petraglia Obstetrics and Gynecology, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy Preterm delivery (PTD) is a clinical syndrome, which arises from different pathological processes that activate prematurely (before 37 weeks of gestation) one or more components of the mechanisms leading to parturition. Although the pathogenesis of PTD is multifactorial, an excessive inflammatory reaction of fetal-placental unit, an alteration of immune system mechanisms and a deregulation of endocrine system represent the final pathway underlying PTD. There are many maternal or fetal factors that have been associated with the risk of PTD, classified as i) periconceptional factors such as familiar history, ethnic origins, environmental factors (low socioeconomic status, employment, low body mass index (BMI) and obesity, smoke, alcool), systemic maternal diseases, ii) obstetric factors like previous PTD, interval between pregnancy and previous uterine surgery, and iii) pregnancy-associated factors such as stress and hormonal factors, uterine overdistension, decidual hemorrhage, cervical insufficiency, infection and bacterial vaginosis, IVF (in vitro fertilization) pregnancy. Recently new periconceptional risk factors have been associated to PTD, such as epigenetics and gynecological diseases. Epigenetic DNA changes in intrauterine environment associated to maternal life style (diet, smoking, assumption of drugs), that can modify epigenoma in feto-placental unit, have shown to provoke greater susceptibility during adult life to develop obstetric complications such as PTD. In the last years, an increasing interest has been given to gynecological diseases, such as endometriosis, polycystic ovarian syndrome (PCOS) and uterine fibroids since they have shown similar pathogenetic pathways with PTD: in particular alteration of sex hormones and hormonal receptors, deregulation of the immune system and exaggeration of inflammatory processes represent common central mechanisms. On the basis of these considerations, much attention should be focused on pregnant women affected by endometriosis, PCOS or fibroids as they may represent potential periconceptional risk factors for PTD on which preventive strategies should be activated in order to reduce the incidence of this common obstetric syndrome.

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THE DIAGNOSIS OF FETAL CARDIAC ABNORMALITIES: THE FINE METHOD L. Yeo1,2 & R. Romero1,3,4 1

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Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD and Detroit, MI, 2Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, 3Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, and 4Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA. Congenital heart disease (CHD) is the most prevalent organ-specific birth defect, and is also the leading cause of infant mortality from congenital malformations. More than half of affected infants are born to mothers without known risk factors. Therefore, screening of all pregnancies is required to detect CHD prenatally. Moreover, the prenatal diagnosis of specific cardiac defects is associated with an improved preoperative condition, survival after surgery, and neurological outcome. However, the prenatal diagnosis of CHD remains difficult; the sensitivity of two-dimensional ultrasound has ranged from 15–39%, and some have reported no improvement over a 10-year period, despite improvements in ultrasound technology. Adequate examination of the fetal heart is time consuming, and requires expertise and skill to perform. Therefore, examinations commonly do not include all the standard recommended cardiac

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views, such as the left and right ventricular outflow tracts. Fourdimensional sonography with spatiotemporal image correlation (STIC) facilitates examination of the fetal heart, and may be used to evaluate CHD. STIC technology allows acquisition of a volume dataset from the fetal heart, which contains the necessary information about cardiac anatomy, and displays a cine loop of a complete single cardiac cycle in motion. However, extracting and displaying the recommended diagnostic planes from a STIC volume dataset that can be dissected in many ways (i.e. planes) is operator-dependent, time consuming, and requires an in-depth knowledge of cardiac anatomy. Thus, this process is difficult and impractical. We have recently developed a novel method and invention, Fetal Intelligent Navigation Echocardiography (FINE), to automatically generate nine standard fetal echocardiography views by applying intelligent navigation technology to STIC volume datasets. This method considerably simplifies examination of the fetal heart and reduces operator dependency. In cases of CHD, the FINE method is able to demonstrate abnormal fetal cardiac anatomy. FINE is fundamentally different from other techniques to obtain cardiac views and consists of several inventions, including: (1) automatic labeling of fetal anatomical structures and fetal echocardiography views; (2) STICLoopä (a cine loop tool developed to assess the appropriateness of STIC volume datasets before implementation of FINE); and 3) VIS-AssistanceÕ (Virtual Intelligent Sonographer Assistance), a tool that allows automatic sonographic navigation and exploration of the surrounding structures in each of the nine cardiac diagnostic planes.

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Posters ABNORMAL PLACENTATION ID 144

PLACENTAL PHENOTYPE DIFFERENCES BETWEEN XMO AND XPO IN TURNER SYNDROME S. J. Lim1,3, A. Ojarikre2 & S. Chuva de Sousa Lopes3

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College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom, 2National Institute for Medical Research, London, United Kingdom, and 3Leiden University Medical Center, Leiden, The Netherlands Brief Introduction: Turner Syndrome in human arises from the loss of genetic material from one of the sex chromosomes, resulting in the 45, XO genotype, with the remaining X chromosome being maternallyinherited (Xm) or paternally-inherited (Xp). As the gene dosage and expressions of the Xp and Xm chromosomes may not be equivalent epigenetically, this study aims to investigate the different influences of Xm and Xp on placental phenotype, using a mouse model. Materials & Methods: 14 placentas from pre-term MF1 mice (3XX, 3XY, 5XmO, 3XpO) at 18.5 days post-coitum were isolated, formalin-fixed,

paraffin-embedded and sectioned. To examine the morphological differences between the four placenta types, sections were stained histologically (H&E, PAS, Heidenhain’s Azan) and immunohistochemically (for CDX2, CK19, fibronectin, laminin, pecam-1). Student’s t-test was used to statistically analyse the different comparison parameters such as the size of the placenta and its constituent layers; as well as the estimates of cell density, and CDX2-positive and glycogen cell numbers in the junctional zone (Jz). Clinical Cases or Summary Results: Wild-type (XX, XY) placentas are quite similar to each other. XpO placentas are significantly different from the other three genotypes, especially in the Jz, being thicker especially at the lateral end of the placenta (p = 0.038). Moreover, the numbers of CDX2-positive (p = 0.0092) and glycogen cells (p = 0.017) are increased. XmO placentas exhibit large morphological variations as some were phenotypically similar to wild-type placentas, while others were phenotypically similar to XpO placentas. Some XmO placentas (N = 3) also have a 15 upward tilt at the lateral end, not observed in the other genotypes. Conclusions: We conclude that Xm and Xp affect placental development differently. Xp, which is normally silenced in the extraembryonic tissues of the murine placenta, if activated in the absence of a second sex chromosome, will result in a placenta that is morphologically quite different from normal. Conversely, XmO placentas look phenotypically more normal, although they also exhibit some defects, thus suggesting that Xm alone is insufficient to form a normal placenta. Our findings are consistent with literature stating that XpO foetuses are less viable than XmO foetuses, since we found that XpO placentas exhibit the largest degree of phenotypical abnormality, while XmO placentas share mixed characteristics between the wildtype and XpO placentas. Thus, XmO placentas may function better than XpO placentas to result in a viable pregnancy. This is also consistent with literature which documented that most of the human 45, XO foetuses that survive to birth have Xm. Keywords: Placental phenotype; Turner Syndrome; X-inactivation; X monosomy; Trophoblast development Presenter: Shujing Jane Li

ID 206

GROWTH FACTORS AND APOPTOSIS IN HUMAN EMBRYO TUBAL AND INTRAUTERINE IMPLANTATION A. Miskova1, M. Pilmane2, & D. Rezeberga3 1

ObGyn Dept., Riga Stradins University, Riga Maternity Hospital, Riga, Latvia, 2Morphology Dept., Anatomy and Anthropology Institute, Riga Stradins University, Riga, Latvia, and 3ObGyn Dept., Riga Stradins University, Riga Maternity Hospital, Riga, Latvia Brief Introduction: Normally developed embryo at blastocyst stage and receptive endometrium are necessary for successful implantation. This process is dependent on molecular interaction between mother and embryo cells. Probably implantation site and further embryo development are dependent on mother to embryo molecular interactions. The importance of growth factors in ectopic pregnancy pathogenesis and clinical use are not well understood. Materials & Methods: Human oviduct parts were obtained from 17 patients, who had underwent salpingoectomy for tubal pregnancy

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with informed consent. We used immunhistochemical method for determination of TGF beta 1, IGF-1, IGF-1R, bFGF, FGFR1, NGF, NGFRp75, PGP9.5, MMP 9, MMP 2, HGF, human defensin beta 2 and caspase 6. The TUNEL method was applied for determination of apoptotic cells. The distribution of these factors was detected semi quantitatively: 0/- occasional positive structure in visual field, + few positive structures in visual field, ++ moderate number of positive structures in visual field, +++ numerous positive structures in visual field.The data were analysed by nonparametric rank analysis with SPSS Statistic 17 software. A Mann-Whitney U test was used as appropriate for evaluation of significant differences. A p value 50.05 was considered to be statistically significant. Clinical Cases or Summary Results: Statistically significant difference was established between bFGF and FGFR1, IGF-1 and IGF-1R, NGF and NGFRp75 and TGF beta 1 appearance in tubal and uterine tissue. FGFR1 dominated bFGF in both tubal (p = 0.008) and uterine (p = 0.011) pregnancy tissue. IGF-1R was particularly absent in tissue in a case of tubal pregnancy in comparison with uterine pregnancy (p = 0.026). IGF-1R statistically feasibly appeared more in endometrial tissue in comparison with IGF-1R appearance in tubal tissue in any case of tubal pregnancy (p = 0.017). TGF beta 1 was absent in tubal tissue, but in endometrial tissue this factor was abundant (p = 0.049). NGF dominated NGFRp75 in both tubal (p = 0.001) and uterine (p = 0.011) pregnancy cases.We discovered total apoptosis in gravid endometrium and chorionic villi using TUNEL method. Tubal epithelium and connective tissue demonstrated a widely distributed apoptosis. The distribution of one of programmed cell death agents – caspase 6 was similar to TUNEL positive cells distribution. There were no statistically significant differences in apoptotic cell distribution between tubal and uterine tissue. Difference in human defensin beta 2, MMP 9, MMP 2, PGP 9.5 and HGF positive cells distribution between tubal and endometrial tissue was not statistically significant. Conclusions: There is the deficit on IGF-1R in the blastocyst implantation site in a case of tubal pregnancy. The deficit of IGF-1R in fallopian tube might be a result compensatory adaptation mechanism lead to control the pathologic process. In both spontaneous and tubal blastocyst implantation sites FGFR1 is more abundant than bFGF. Probably this is due to pregnancy caused tissue remodelling. FGFR1, bFGF, NGF, NGFRp75 PGP 9.5, HGF, human defensin beta 2, MMP 9 and MMP 2 are widely appeared in oviduct tissue in a case of tubal pregnancy and take part in tubal pregnancy morphopathogenesis. Keywords: implantation, tubal pregnancy, growth factors Presenter: Miskova Anna

ID 239

PLACENTA PRAEVIA ACCRETA: AN ARISING EMERGENCY.

A THREE-YEAR EXPERIENCE IN A TERTIARY-REFERRAL CENTER: PRENATAL DIAGNOSIS, DELIVERY MANAGEMENT AND PERINATAL OUTCOMES S. Politi1 & G. Ettore2 1

Maternal-Fetal Dept., Treviglio-Caravggio Hospital, Treviglio (Bg), Italy, and 2Maternal-Fetal Dept., A.R.N.A.S. ‘‘Garibaldi-Nesima’’ Hospital, Catania (Ct), Italy. Brief Introduction: Placenta Praevia occurs when the placenta partially or completely overlaps the internal cervical os. Placenta Accreta is a pathological adherence and invasion of uterine wall by chorionic villi. This is a potentially life-threatening obstetric condition due to the risk of massive maternal hemorrhage. The most important risk factor for Placenta Praevia Accreta (PPA) is the presence in the istmus of a uterine scar of a previous cesarean section. The reported increased incidence of PPA seems to be corresponding to the increasing cesarean delivery rate in Western Countries. Therefore, the improved number of patients with a potential PPA deeply changes the diagnostic and therapeutic approach, in order to improve the maternal and fetal outcomes of this obstetric emergency. Materials & Methods: This is a prospective longitudinal study carried out between 2010 and 2012 at the Department of Maternal-Fetal Medicine, Obstetrics and Gynaecology Unit, of ‘‘Garibaldi-Nesima’’ Hospital in Catania. During this period, we diagnosed and managed overall 10 cases of PPA; we also recorded 2 cases of PA major not complicated by accretism and 2 cases of Cesarean Scar Pregnancy (CSP) in the first trimester. Patient at high risk has undergone antenatal assessment by Ultra-Sound (US) examination with transvaginal and trans-abdominal Scans. Magnetic Resonance Images(MRI) were also recorded. The primary outcome was to evaluate the reliability of US criteria for ante-partum diagnosis of PPA. The secondary outcome was to evaluate management and outcomes in these patients. Clinical Cases or Summary Results: The absence or irregularity of retroplacental ‘‘clear space’’ and the presence of abnormal ‘‘placental lacunae’’ with hypervascularity were the most sensitive US criteria for diagnosis of PPA; the most specific criteria resulted the thinning and disruption of ‘‘bladder line’’ and the ‘‘clear space’’, with a PPV of 100% each one; the highest NPV resulted for bladder line. All patient with PPA undergone planned preterm CD and required hysterectomy, 60% needed blood transfusion and 40% needed intensive unite care. Bladder lesions occurred in both cases of PP ‘‘percreta’’. Neither maternal nor perinatal deaths were reporteded during the study period. Conclusions: Our study highlights the importance of an early detection and multidisciplinary approach in case of suspicious PPA.

Pt

Absence of Clear Space

Bladder Line Irregularity

Vascular Lacunae

Myometrial thickness 51mm

Bladder exophytic masses

MR Images

3 4 5 6 7 8 9 10 11 12 13 14

+ + + + +  + + + +  

+ + +  +   +    

+ + +  + +  + + +  +

+    +   +  +  +

+ +   +   +    

+ + +  +  + +  + + 

Ultrasounds Criteria observed in our study for each patient. Pt 1 and 2 are excluded (those affected by CSP). Pt 13 and 14 affected by PP major without accretism

25

DOI: 10.3109/14767058.2014.924236

In expertise hand, US examination is a sensitive and specific tool for antenatal diagnosis of PPA. For this reason, we also stress the need to plan delivery in a tertiary-referral center with appropriate setting, skillful staff and adequate resources. Keywords: placenta praevia, accretism, cesarean section, ultrasounds, hysterectomy. Presenter: S. Politi

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ID 335

COMPARATIVE STUDY ON RETINOPATHY OF PREMATURITY BY COLOR DOPPLER FLOW IMAGING DIAGNOSIS L. Bao1 & S. Tang2 1

Neonatal Diagnosis and Treatment Center, Children’s Hospital of Chongqing Medical University, Chongqing, China, 2 Neonatal Diagnosis and Treatment Center, Children’s Hospital of Chongqing Medical University, Chongqing, China Brief Introduction: To investigate the clinical value of color Doppler flow imaging (CDFI) in the diagnosis and clinical follow-up of retinopathy of prematurity (ROP). Materials & Methods: From January 2013 to December 2013, 196 eyes of 98 premature infants (gestational age  37 weeks, or birth weight  2 000 g) underwent ROP screening by RetCam digital retinal camera and indirect ophthalmoscopy in the fourth to sixth postnatal week. At the same time, they were also examined by 8–14 MHz CDFI. Clinical Cases or Summary Results: Determined by RetCam digital retinal camera and indirect ophthalmoscopy, ROP was found in 82 eyes, including 16 eyes at stage I, 38 eyes at stage II, 12 eyes at stage III, 16 eyes at scarring stage and no eye at stage IV and V. Compared with ophthalmologic examination, the specificity of CDFI for ROP diagnosis was 85.5%, and the sensitivity was 76. 7%. Detected by CDFI, typical changes were not found in the infants with ROP at stage I. In the infants with ROP at stage II and III, abundant blood flow signals were found in the central retinal artery (CRA). Increased amounts of the small vessels and irregular circuitousness were also observed. There was no obvious change in the systolic velocity (VS) of CRA. The diastolic velocity (Vd) was decreased and the resistance index (RI) was increased. A strong zonal echo protruded into the vitreum. Small blood flow signals which came from CRA by tracing toward their distal end were found in the same position using CDFI. Conclusions: Detected by CDFI, the sonographic features of infants with ROP at stage I are not typical, but those of infants with ROP at stage II and III are specific. CDFI is valuable in clinical ROP screening of high risk group. Keywords: premature infant, retinopathy of prematurity, color Doppler ultrasonography Presenter: L.Bao

ID 617

IMPACT OF MATERNAL FEEDING PRACTICES AND DC SIGN RECEPTOR POLYMORPHISMS ON VERTICAL TRANSMISSION OF HIV S. Singh*1,2, S. Khare1, S. Prasad3, U. Sharma1, A. Hempenstall2, & A. Rai1

1

National Centre for Disease Control, 22-Sham Nath Marg, Delhi, India, 2The Peter Medawar Building for Pathogen Research, University of Oxford, and 3Department of Obstetrics and Gynecology, Maulana Azad Medical College, Delhi, India Brief Introduction: Mother to child HIV transmission remains a considerable public health dilemma in India and is confounded by infant feeding practices. Although breastfeeding presents a considerable risk of HIV transmission, non-breastfed infants are exposed to higher risk of death in resource-limited settings. Bile sale stimulated lipase (BSSL) present in breast milk aids in digestion of milk triglycerides. It provides immune protection in breastfed infants against HIV by disrupting interaction of the virus with dendritic cell receptors (DC-SIGN) which otherwise would facilitate HIV transmission. In this study, we investigate the impact of infant feeding patterns on maternal-child HIV transmission and DC SIGN polymorphisms in infant immune protection. Materials & Methods: Mothers were recruited from six states across North India and asked to indicate their infant’s feeding practice. Early Infant Diagnosis was performed on their children between six and 18 weeks. In this study we analyzed genetic polymorphisms from blood samples from HIV-positive and negative infants (n = 118) born to HIV infected mothers (n = 118). Six polymorphisms in the promoter region of DC-SIGN at positions 116, 139, 190, 336, 871 and 939 were analyzed using DNA sequencing in infant samples Clinical Cases or Summary Results: In the HIV-infected infant group 30.8% (n = 20) HIV infected infants were non-breast fed, 60% (n = 39) were breast-fed, and 9.2% (n = 6) were mixed-fed. The HIV uninfected infant group consisted of 60.4% (n = 32) infants who were breast-fed, whereas 39.6% (n = 21) were non-breast fed. Genetic analysis of DC-SIGN promoter polymorphisms in these infants showed polymorphism -871GG and -939GG were significantly associated with susceptibility to HIV respectively (p value50.001). Conclusions: DC-SIGN promoter polymorphisms may be crucial in the protection against HIV through its interactions with BSSL in infants of HIV positive mothers. DC-SIGN has a significant role in perinatal transmission of HIV and may be considered as a promising new drug target. More studies are required to determine if these immune protective polymorphisms are present in other ethnicities. Keywords: DC SIGN, breastfeeding, HIV Presenter: Supriya Singh

ID 822

PLACENTAL ABRUPTION, RISK FACTORS AND INFUENCE IN MATERNAL AND PERIPARTAL OUTCOME S. Latifi-Hoxha, Sh. Lulaj, M. Hoxha, H. Arifi, V. Ademi-Ibishi, M. Morina Obsytetrics and Gynecology Clinic, University Clinical Center of Kosova, Kosova Brief Introduction: Placental abruption is one of the leading causes of perinatal deaths. Abruptio placentae increase the maternal and peripartal morbidity and mortality. It is one of the recognized causes of maternal fatality in developing countries Materials & Methods: The purpose of this study was to examine the incidence, risk factors for placental abruption and its influence in maternal and peripartal outcome. The study is designed as retrospective case control study and in the study are included all cases of pregnancies with placental abruption delivered at the Obstetrics&Gynecology Clinic in Prishtina, University Clinical Center Kosova, during the period January through to December 2009. Maternal data were collected from maternal evidence in delivery yard and maternal charts. All the infants’ data

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26 from the pregnancies with placental abruption including live and stillbirths were collected and analyzed. The live born infants were followed for APGAR score at five minute. The study also aimed to determine the maternal risk factors for placental abruption and its implication in peripartal outcomes. Clinical Cases or Summary Results: The total number of cases with placental abruption collected during this period was 93, while the total number of births during the same period was 10956, and giving the incidence of 93/10956 (0.8%) for placental abruption. The total number of newborns was 11211, among these 227 were stillbirths. In live newborns the incidence of placental abruption was 0.6%. In stillbirths placental abruption was 9.2%. The incidence of placental abruption was 15% in the group of newborns with Apgar Score 0–3 at five minute. Placental abruption incidence was lower in the group of newborns with Apgar score 4–7 at minute five, in all 18 out of 1353 newborns and giving incidence (1.3%) Relative risk for placental abruption between term and preterm newborns was higher in preterm’s RR 0.9,95% CI 0.9235 to 0.9529 p50.0001. Placental abruption had influence in perinatal asphyxia in 15.5% of cases and in stillbirths 9.5%.Incidence of placental abruption in parous 4 was1.8%. Risk scale for placental abruption between parity was higher in 3 parity OR 2.3 95% CI 1.261to 4.3933 p = 0.007. Higher incidence, 1.6% of placental abruption between maternal group, ages were found in group age 30–40. Risk scale between group ages was higher from30–40 years, OR 3.01 95%CI 1.9634 to 4.6302 50.0001. Maternal outcome in cases with placental abruption were: profuse hemorrhage 8.6%, hemorrhagic shock 5.37%, Couvelaire Syndrome 5.37% and acute renal insufficiency 1.7%. Conclusions: Placental abruption has a profound impact on both maternal and peripartal complications including profuse hemorrhage, hemorrhagic shock, Couvelaire Syndrome and birth asphyxia, therefore, placental abruption with these clinical characteristics should be closely monitored and prompt delivery should be carried out at tertiary care centers with adequate maternal-neonatal intensive care facilities.

J Matern Fetal Neonatal Med, Early Online: 1–437

28–33 + 6 weeks, 10.4% between 34–35 + 6 weeks (n = 35), 16% between 36–37 + 6 weeks (n = 54) and 32% after 38 weeks (n = 108). Among 257 IUFD defined as unexplained by the Wigglesworth classification, we identified 78 fetuses affected by IUGR when using the population curves of fetal weight at birth (30.4%), while we diagnosed 119 cases (46.3%) when applying the customized curves. Histological examination of the placenta was performed in 52% of all the cases (n = 270). The histological comparison between group a (n = 104) and group c (n = 586) identified a statistically significant difference (p50.05) for acute placental abruption, obstructive lesions (multiple and massive infarcts, massive deposition of fibrin and edema of the villi), hypoxic injury (only syncytial knots). The comparison between group b (n = 33) and group c identified a statistically significant difference for placental abruption, infarcts and edema of the villi. Furthermore, in group b we found a significant increased incidence of hypoxic lesions (increased syncytial knots and villous branching abnormalities) Conclusions: In most cases of IUFD the main cause of fetal distress lies in the placenta. The fetal-neonatal outcome is related to placental lesions including hypoxic modifications. In particular, the histologic pattern of chronic hypoxia is typically associated with cases of lateonset intrauterine growth retardation. Keywords: Placenta; fetal demise; intrauterine growth retardation; customized curves Presenter: M. P. Rambaldi

ID 604

Keywords: placental abruption, risk factors, peripartal outcome

EARLY DIAGNOSIS OF PLACENTA ACCRETA: AN ULTRASOUND CLINICAL CHALLENGE

Presenter: Syheda Latifi Hoxha

L. Giorgi, S. Giorgini, & G. Spinelli

ID 856

Obstetric and Gaenecology Department, Nuovo Ospedale di Prato

HISTOLOGIC PLACENTAL FINDINGS ASSOCIATED WITH LATE ONSET INTRAUTERINE GROWTH RETARDATION M. P. Rambaldi1, C. Serena1, E. Baroni1, S. Simeone1, L. Marchi1, F. Facchinetti2, F. Castiglione3, G. Mello1, & F. Mecacci1 1

High Risk Pregnancy Unit, Careggi University Hospital, Florence, Italy, 2Obstetric Dept., Modena University Hospital, Modena, Italy, and 3Pathological Anatomy Dept., Careggi University Hospital, Florence, Italy Brief Introduction: The aim of the study is to analyze the main placental histological findings in cases of intrauterine fetal deaths (IUFD) occurred in near-term pregnancies complicated by IUGR diagnosed on the basis of customized growth curves. Materials & Methods: We performed a multicenter retrospective study on 517 cases of IUFD occurred in singleton pregnancies after 20 weeks and 586 controls. The diagnosis of IUGR was based on birth weight below the 10 centile referred to standard and customized curves. We performed a comparison of the main placental lesions among 3 groups: a) all the IUFD occurred in term of pregnancy b) IUFD in pregnancies complicated by customized IUGR C) control group of 586 placentas from normal pregnancies. Clinical Cases or Summary Results: 517 cases of IUFD 34.6% (n = 179) occurred in the second trimester of pregnancy and 65.4% (n = 338) after 28 weeks. Of the late IUFD, 41.6% (n = 141) took place between

Brief Introduction: Placenta accreta is an abnormal adherence of placenta to the uterine wall. Incidence of placental attachment disorders has increased intensifying cesarean section (CS), and other additional uterine surgical procedures (USP). Antenatal diagnosis of placenta accreta is a challenge, but its suspicious is useful to plan location, staff and mode of delivery, aiding improved outcomes. Materials & Methods: We focus on screening of placenta attachment disorders at first trimester, evaluating women at high risk of placenta accreta due to previous history of almost one CS and/or USP. Our clinical study, still on progress, plans to perform in this selected group an early (within 12 + 6 weeks) transvaginal ultrasound (TU) to individuate precociously patients with placenta lower implantation. Cases with placenta overlapping the section scare and or joining the internal os should be highlighted. All these patients undergo to TU in the second trimester, and if the low implantation persists, also in the third trimester, with Color Doppler and magnetic resonance to study placenta lying towards internal os, placenta features, placentalmyometrial interface, and placental vascolarisation. Clinical Cases or Summary Results: Performing this study we are able to individuate case at high risk of haemorrhage/isterctomy with surgical aspiration in case of early pregnancy loss, and to highlight women with placenta accreta in case of evolutive pregnancy to plan a safe delivery. Conclusions: In conclusion a TU in the first trimester and eventually further instrumental studies in high risk women for placental attachment disorders may allow a conservative management both at early trimester gestation in case of spontaneous or provocated abortion, and at term gestation, to plan time, staff and mode of delivery. Keywords: Presenter: L Giorgi

27

DOI: 10.3109/14767058.2014.924236

ID 008

ID 137

MATERNAL PLACENTAL VASCULOPATHY AND INFECTION

ASSESSMENT OF THE ACTUAL CARE ON POSTPARTUM HEMORRHAGE USING VIDEO IMAGES OF THE THIRD STAGE.

E. Zare

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Iran Brief Introduction: Objective: Our aim was to find out whether patients delivered preterm because of preterm labor or preterm premature rupture of membranes can be categorized according to clinical characteristics and placental pathologic findings. Materials & Methods: Study design: We performed a case-control study of 105 patients who were delivered preterm, 42 because of preterm labor and 63 because of premature rupture of membranes, and 100 patients who were delivered at term after uncomplicated pregnancies. Clinical Cases or Summary Results: Results: Maternal placental vascular lesions were present in 14 (34.1%) patients with preterm labor, 19 (35.1%) patients with premature rupture of membranes, and 9 (11.8%) control patients (od ds ratios 3.8 and 4.0, 95% confidence intervals 1.3 to 11.1 and 1.5 to 10.8, p = 0.0065 and 0.0022, respectively). Infection of the products of conception was found in 16 patients (38%) with preterm labor, 23 patients (36.5%) with premature rupture of membranes, and 19 control patients (18%) (odds ratios 2.7 and 2.6, 95% confidence intervals 1.1 to 6.6 and 1.2 to 5.6, p = 0.017 and 0.01, respectively). Patients with maternal placental vasculopathy had significantly different characteristics compared with those of infected patients. Conclusions: Conclusions: It is possible to identify two subgroups of patients among those who are delivered preterm because of preterm labor or premature rupture of membranes, one with infection of the products of conception and another with maternal placental vasculopathy. Keywords: Presenter: E. Zare

M. Woiski1, S. Visser1, H. van Vugt1, F. Lotgering1, R. Grol2, J. Middeldorp3, M. Marcus4, B. Mol5, A. de Wit6, M. Porath7, M. Oudijk8, A. Dijkman9, C. Meir10, R. Rijnders11, J. Heres12, J. Molkenboer13, P. Pernet14, D. Moonen-Delarue15, A. Huisjes16 Departement of obstetrics and gynaecology: 1Radboud University Medical Centre Nijmegen, 2IQ Healthcare, Radboud University Medical Centre, 3Leiden University Medical Centre, 4 Department of Anesthesiology Maastricht University Medical Centre, 5Academical Medical Centre Amsterdam, 6Hospital Boxmeer, 7Maxima Medical Centre Veldhoven, 8Academical Hospital Utrecht, 9Reinier de Graaf Delft, 10Groene Hart, Gouda, 11Jeroen Bosch, Den Bosch, 12Lucas Andreas Hospital, Amsterdam, 13Spaarne Hospital, Haarlem, 14Kennemer Gasthuis Haarlem ,15Laurentius Hospital, Roermond, 16Gelre Hospital, Apeldoorn, 17Diaconessen Hospital Utrecht, and 19 Maastricht University Medical Centre Brief Introduction: Incidence of postpartum hemorrhage (PPH) still rises, despite of the development of evidence based guidelines and obstetric emergency skills courses, suggesting an incomplete implementation. Insight into actual care is essential for successful implementation. We assessed the actual PPH care by measuring adherence to valid guideline-based quality indicators (QI). Materials & Methods: In an observational multi center study, measurement of actual PPH care, by valid QI was performed in 16 Dutch hospitals. Data was extracted from medical records and complemented with prospective video observations of the third stage of over 320 high risk patients (HRP) for PPH. Outcome measures were adherence to the QI regarding process, structure and outcome of PPH care.

Adherence to the performance indicators for prevention of PPH Performance indicators for prevention of PPH Indicator The professional should in case of a high risk patient on PPH: (N = 383) 1. identify a high-risk patient on PPH during pregnancy at the out-clinic, determine policy for parturition and document this (n = 193) * a. identify a high-risk patient on PPH during pregnancy at the out-clinic (n = 277) b. determine policy for parturition and document this (n = 193) *

Adherence N

(%)

Adherence incl.cam (%)

62

32.1

NA1

205 68

74.0 35.2

NA NA

96

31.0

NA

365 101

95.3 33.0

NA NA

315

83.6

87.5

70 328 NA 79

18.3 85.6 NA 20.6

35.0 88.5 98.4 38.9 TC2

Not applicable; high risk occurred during labour (n = 106) *missings because of a mistake in the CRF wich was adapted after a while (n = 84) 2. identify a high-risk patient on PPH during pregnancy at the outclinic and during labor, determine or adapt policy for parturition and document this. (N = 310)* * missings because of a mistake in the CRF wich was adapted after a while (n = 73) 1. identify a high-risk patient on PPH at the outclinic and during labor 2. determine or adapt policy for parturition at the outclinic and during labor and document this. (N = 306)** **77 missings because of a mistake in the CRF wich was adapted after a while. 3. ensure IV access during labour Not applicable; high risk occurred at time or after birth (n = 6) 4. provide an active management of the third stage of labour 1. 5/10 U oxytocin IM or slowly IV 2. quick cord clamping 3. controlled cord traction. 5. objectify blood loss

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J Matern Fetal Neonatal Med, Early Online: 1–437

Adherence to the performance indicators for management of PPH Adherence N

(%)

Adherence incl.cam (%)

68 9 63 12 13 140 21 60 23 13 35 67 54 102 16 22 80

45.0 5.9 41.4 7.9 8.6 92.1 15.0 42.8 16.4 9.2 23.0 44.1 35.5 67.1 10.5 14.5 52.6

57.9 13.8 47.4 15.8 9.9 94.1 37.1 46.2 19.6 12.6 25.0

65

42.8

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Performance indicators for management of PPH Indicator The professional should in case of 4500 ml of bloodloss. . . N = 152 1. inform the gynecologist (in training) 2. continuously monitor pulse and saturation and BP (5–10 min) a. continuously monitor pulse and saturation b. monitor BP (5–10 minutes) 3. ensure an IV access (18 gauge) and commence volume replacement (1 liter of saline) a. IV acces – 18 gauge (n = 140) – commence volume replacement (n = 140) – 1 liter (n = 140) – saline (cristaloiden) (n = 140) 4. take blood samples: FBC and cross match screen Hemoglobine Hematocrite Cross match screen 5. treat uterus atony: continuous uterus massage and bladder catheterization. a. continuous uterus massage b. bladder catheterization Uterus atony was not included in this calculation (this wil be done in the subanalizes) 6. treat uterus atony by the use of uterotonic medication in steps according to local protocol. 7. if retained placenta: empty the uterus by performing controlled cord traction followed by placenta removal in the theater controlled cord traction placenta removal in the theater

37.5(HB + HT) 67.8 27.0 32.9 57.9 53.3 TC TC TC

Performance indicators for management of PPH 41000 ml or signs of shock Indicator The professional should in case of 41000 ml of bloodloss. . . N = 64 (5941000 cc + 5 met shock) 8. call for the gynaecologist on ward (n = 49), (if the clinician is not a gynaecologist (n = 15)) 9. allocate one members of the team to record events, fluids, drugs 10. monitor additional vital functions appriopriately by monitoring urine production by means of a urimeter a. urineproduction (CAD) b. CAD and urimeter 11. administer 10–15 liters/minutes of oxygen by facemask regardless of her saturation a. Administer oxygen – 10–15 liter (n = 21) – 510 liter (n = 21) – onbekend (n = 21) 12. provide a second IV access (18 gauge) second IV access – 18 gauge (n = 29) – no information abouth the (gauge) (n = 29) 13. replace volume by using pressure bags 14. replacement of fluid must be warmed fluid (in case of large volumes) 15. urgently order units of blood and fresh frozen plasma, units of blood fresh frozen plasma 16. check and correct clothing status a. check clothing status b. correct clothing status 17. treat PPH as a atony till proven otherwise a. continuous uterus massage b. bladder catheterization c. use of uterotonic medication in steps (41 uterotonic medication and/or IV prostaglandines) – no uterotonic medication – 1 uterotonic medication – 2 or more uterotonic medication 18. use prostaglandins IV as last resort if other uterotonic treatment fail

21

42.8

TC2

NA1 1

NA 1.5

4.7 28.1

31 1 6 21 6 3 12 3 29 3 26 10 3 4 22 4 0 4 0 4 16 45 17

48.4 1.5 9.4 32.8 28.6 14.3 57.1 5.0 48.3 10.3 89.7 15.6 4.7 6.3 34.4 6.3

6.3 25.0 70.3 26.6

– 28.1 9.4 39.0 24.0 12.0 64.0 TC 54.7 – – 21.9 10.9 6.3 34.4 6.3 0 1.0 0 40.6 53.1 81.3 73.4

23 27 14 13

35.9 42.1 21.8 20.3

– – – 21.9

2 3

10.0 15.0

TC TC

1.0

Performance indicators for management of PPH 42000 ml or signs of shock Indicator The professional should in case of 42000 ml of bloodloss. . . N = 20 19. call for a second gynaecologist and 20. timely inform radiologist (if applicable)

29

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DOI: 10.3109/14767058.2014.924236

Clinical Cases or Summary Results: The actual care was assessed in 16 hospitals, whereas video recordings in 12. Staff refused video recordings in 4 hospitals. 99% of included patients were HRP. The overall adherence to the QI was below 50%. Regarding the prevention of PPH, identification of HRP, policy determination and documentation scored 31% adherence. Active management of the third stage (oxytocin, quick cord clamping, controlled cord traction) scored 39%, whereas oxytocin was given in 89% of the cases. For women with4500 ml blood loss, low scores were seen for monitoring vital parameters (14%) and taking blood samples (25%). In managing atony, uterus massage was performed in 33%, bladder catheterization in 58% and uterotonics given in 53%. For women with 41000 ml blood loss, measurement showed very low adherence in oxygen supply (9%) and ordering blood units (11%). The gynecologist was summoned in 43% of the cases. Conclusions: This study showed poor adherence to the quality indicators even when caregivers were aware of video registration. This clearly indicates an implementation problem of the PPH guideline and skills courses in The Netherlands. The additional video observations proved valuable as it gives a precise and accurate illustration of the factors that affect the quality of PPH care. Keywords: Post partum haemorrhage, quality indicators, video recordings Presenter: HCJ Scheepers

ID 547

DOES PCOS AFFECTS UMBILICAL ARTERY DOPPLER PARAMETERS IN PREGNANCY? B. Usluog˘ulları1, A. Ko¨s¸ u¨s¸ 2, N. Ko¨s¸ u¨s¸ 3, D. Hızlı4, & _ Kaygusuz5 I. 1

Cengiz Gokcek State Hospital Department of Obstetrics and ¨ zal University Gynecology, Gaziantep, Turkey, 2Turgut O Faculty of Medicine, Department of Obstetrics and ¨ zal University Gynecology, Ankara, Turkey, and 3Turgut O Faculty of Medicine, Department of O Brief Introduction: PCOS that affects an estimated%5–10 of reproductive women is complex endocrine disorder. Patients with PCOS may have deleterious consequences for process of fertilization and pregnancy. We evaluated in this article that whether PCOS effect on umbilical artery velocities in women with PCOS during pregnancy. Materials & Methods: 63 primigravid women who were suffering from PCOS and 148 primigravid healthy women who were regularly menstruating, non-hirsute, normoovulatory were screened during the mid-second trimesters. Clinical Cases or Summary Results: UA S/D ratio, PI and RI values were detected in significant increases in the PCOS group (p50.001 and p = 0.013, p = 0.048) Conclusions: Our study showed that in the mid-second trimester of pregnancy, PI and RI values, systolic/diastolic ratio of the umbilical Table I. Demographic and ultrasonographic data of umblical artery velocimetry in cases (PCOS group) and controls (control group) PCOS (n = 63)

Control (n = 148)

p Value

Mean age 31.4 ± 4.7 30.6 ± 3.8 0.660 Gravidity 2 (1–2) 2 (1–3) 0.774 Parity 0.0 (0–1) 0.5 (0–2) 0.155 Gestational age(week) 21 (20–22) 21 (20–23) 0.549 Peak sistolic flow 33.75 (24–45) 31.70 (16–49) 0.021 End diastolic flow 10.80 (6.4–13) 10.05 (3.4–28.1) 0.957 S/D 3.52 (2.60–4.83) 3.10 (0.28–5.07) 50.001 PI 1.18 (0.70–1.54) 1.11 (0.26–2.84) 0.013 RI 0.70 (0.18–0.79) 0.68 (0.22–0.80) 0.048

artery Doppler was significantly increased in pregnant patients with PCOS than in controls. PCOS could affect umbilical artery blood flow leading to abnormal placentation. Keywords: Presenter: A. Ko¨s¸ u¨s¸

ID 497

MATERNAL MORBIDITY AND MORTALITY ASSOCIATED WITH CONSERVATIVE MANAGEMENT FOR PLACENTA ACCRETA DIAGNOSED DURING PREGNANCY F. de Marcillac1, A. Gaudineau2, N. Sananes3, G. Fritz4, B. Viville5, E. Boudier6, I. Nisand7, & B. Langer8 1

Department of Gynecology-Obstetric, University hospital of Strasbourg, Strasbourg, France, 2Department of GynecologyObstetric, University hospital of Strasbourg, Strasbourg, France, 3Department of Gynecology-Obstetric, University hospital of Strasbourg, Strasbourg, France, 4Department of Gynecology-Obstetric, University hospital of Strasbourg, Strasbourg, France, 5Department of Gynecology-Obstetric, University hospital of Strasbourg, Strasbourg, France, 6 Department of Gynecology-Obstetric, University hospital of Strasbourg, Strasbourg, France, 7Department of GynecologyObstetric, University hospital of Strasbourg, Strasbourg, France, and 8Department of Gynecology-Obstetric, University hospital of Strasbourg, Strasbourg, France Brief Introduction: Placenta accreta, a life-threatening condition, occurs in 0.02 to 0.2% of all childbirths. In 90% of cases those arrise in patients with placenta previa and past history of cesarean. Cesarean hysterectomy is considered the gold standard treatment but is associated to high risk of maternal morbidity (hemmorrhage, cystotomies, admission in intensive care unit...)However conservative treatment leaving the placenta and closing the hysterotomy may be a viable option with a risk of secondary hysterectomy of 20–25%. The objectives of the present study were to evaluate the success of conservative treatment defined by uterine preservation and shortand long-term maternal morbidity and mortality. Materials & Methods: This retrospective study included all patients presenting a placenta accreta antenatally diagnosed between 2003 and 2013 in our level III maternity unit in Strasbourg, France. Clinical Cases or Summary Results: All 10 patients (0.03% of all childbirths) presenting with a placenta accreta were managed conservatively. Average gestational age at childbirth was 36.4 weeks (±1.2). Conservative treatment was successful in 80% of patients: only two patients underwent hysterectomy due to immediate post-partum hemorrhage (one of them was complicated by ureter injury). Of the three patients who underwent immediate blood transfusion only one had a hemorrhagic shock complicated by disseminated intravascular coagulation requiring monitoring in an intensive care unit for three days. Only one patient needed immediate uterin arteries embolization because of active bleeding right after the conservative management (two patients underwent prophylactic embolization according to our protocol). No other severe medical conditions were reported and averaged hospitalisation lasted for 7.2 days (±2.9). During monitoring, only one patient underwent embolization of uterin arteries due to secondary hemorrhage. Two cases of sepsis required hospitalisation for IV antibiotics. No other severe medical conditions and no case of maternal mortality were noted. Spontaneous abortion of the placenta occured in 5, 6 months (±2.1). Conclusions: In comparison to previous reports, maternal morbidity and mortality seem relatively low with conservative treatment. It

30 could be an alternative option in young patients, providing that childbirth and monitoring are performed in a tertiary care department close to a technical platform of interventional radiology due to high risk of hemorrhage.

MARKERS IN PREGNANCIES WITH PLACENTAL ABRUPTION

Keywords: Placenta accreta, conservative treatment, immediate post partum hemorrhage

A. Incebiyik1, M. Vural2, A. Camuzcuoglu1, H. Camuzcuoglu1, N. G. Hilali1, A. Taskin3, H. Aydin4, & Nurten Aksoy3

Presenter: F.de Marcillac

1

ID 645

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

J Matern Fetal Neonatal Med, Early Online: 1–437

PERIPARTUM HYSTERECTOMY. EVALUATION OF THE PARAMETERS THAT INFLUENCE THE OUTCOME N. Papantoniou, V. Pergialiotis, S. Mesogitis, A. Rodolakis, & G. Daskalakis 1st Department of Obstetrics and Gynecology, Athens University, Athens, Greece Brief Introduction: Peripartum hysterectomy is an extremely demanding procedure that frequently results to increased rates of both maternal and neonatal morbidity and mortality. Our aim was to present the experience of a university tertiary hospital and evaluate the rates of intraoperative and postoperative morbidity and to assess the impact of various predisposing factors. Materials & Methods: We retrospectively assessed all cases offered peripartum hysterectomy at our department for a period of 5 and half years (Jan 2008 – June 2013). Data retrieved from the patients personal records were indication for the procedure, perioperative transfusion of blood, plasma, colloids and crystalloids, hospital stay, and short term morbidity. Clinical Cases or Summary Results: A total of 22,437 deliveries were scanned during the study period and we identified among them 63 cases of peripartum hysterectomy (2.8 cases per 1.000 deliveries). The indications for peripartum hysterectomy included 10 cases of uterine atony (15.9%), 21 cases of placenta accreta (33.3%), 30 cases of placenta previa (47.6%) and 2 second trimester cervical gestations (3.2%). Significantly higher rates of perioperative whole blood (p50.001) and plasma transfusion (p50.001), administration of colloids (p50.001) and crystalloids (p = 0.009), were observed among emergent deliveries, when compared to planned cases. Similarly intraoperative duration was significantly prolonged among emergent deliveries (p50.001). No differences were observed among groups stratified per reason of PH, with the exception of intraoperative duration (p = 0.017) and neonatal birth weight (p = 0.050). Prophylactic ureteric catheterization significantly lowered morbidity (p50.001). However this wasn’t the case with hypogastric artery ligation (p = 0.434). Conclusions: Our study indicates that cases offered peripartum hysterectomy in well-organized medical facilities may have low perioperative morbidity. To our experience, cases offered emergent procedures had significantly higher rates of mild and moderate morbidity, compared to planned cases. Keywords: peripartum hysterectomy, cesarean section, abnormal placentation, uterine atony Presenter: G. Daskalakis

ID 563

SERUM PROLIDASE ENZYME ACTIVITY AND OXIDATIVE STRESS

Harran University, Faculty of Medicine, Depatment of Gynecology and Obstetrics, Sanliurfa/Turkey, 2Marmara University, Faculty of Medicine, Depatment of Gynecology and Obstetrics, Istanbul/Turkey, and 3Harran University, Faculty of Medicine, Depatment of Bi Brief Introduction: Placental abruption is defined as the separation of the placenta from the uterus before labor. Placental abruption is a major cause in both maternal and fetal morbidity and mortality. It is the result of the rupture spiral arteries in the decidua basalis and the incidence of placental abruption varies between 0.4% -2%. Even placental abruption is an acute disorder, underlying pathology is believed to be a chronic vasculopathy. Major component of vascular architecture is collagen and a correlation is present between collagen turnover and prolidase enzyme activity. Therefore in this study we aimed to study serum oxidative stress and prolidase enzyme activity in pregnants with placental abruption. Materials & Methods: Seventy-two cesarean section cases were included into study between April 2013 and February 2014. Groups were designed according to the having diagnosis of placental abruption or not (n = 36 for each). Women with a confirmed or suspected clinical diagnosis of placental abruption were eligible for recruitment as potential cases. Placental abruption cases, or women suspected to have experienced an abruption by the delivering physician, were regarded as true cases if they satisfied at least one of the following 3 specific clinical criteria: (i) patients presenting with classical signs of painful vaginal bleeding accompanied by at least one of the following: nonreassuring fetal status, severe abdominal pain, tetanic uterine contractions, or uterine hypertonicity; (ii) the freshly delivered placenta showing evidence of clinically significant retroplacental bleeding or clot(s); or (iii) placental abruption diagnosed on prenatal ultrasound. Pregnant having risk factor for placental abruption were excluded from study. Venous blood sample were collected from all patients just before the surgery. Additionally placental tissue sample were collected during surgery in order to evaluate prolidase enzyme activity. Clinical Cases or Summary Results: Oxidative stress parameters like total oxidant status and oxidative stress index were found to be elevated in the placental abruption group (p50.001). Placental tissue prolidase enzyme activity was significantly higher in the study group (p50.001). Additionally a positive correlation between prolidase enzyme activity and oxidative stress parameters was detected. Conclusions: Our findings were proved that increased prolidase enzyme activity and oxidative stress levels were closely related. So that, increased collagen turnover may be an important etio-pathogenetic factor in placental abruption. Keywords: Placental abruption, prolidase enzyme activity, Oxidative stress Presenter: A Incebiyik

ID 112

EFFECTS OF PREGNANCY WITH MALE FETUS ON ONSET OF PLACENTAL ABRUPTION K. Odaira, M. Ogawa, J. Konno, F. Tsuchiyama, M. Mitani, Y. Makino, & H. Matsui Department of Obstetrics and Gynecology, Tokyo Women’s Medical University, Tokyo, Japan

31

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

DOI: 10.3109/14767058.2014.924236

Brief Introduction: To clarify the differences in onset of placental abruption between placenta with and without the Y chromosome, i.e., placenta with male fetus and placenta with female fetus. Materials & Methods: A multicenter retrospective cohort study was conducted. We reviewed the chart records from the database of the Japan Perinatal Registry Network during the period from January to December 2009. In this database, 570 pregnant women from 76,113 births after 22 gestational weeks were diagnosed with placental abruption. Of them, 348 women were included as subjects in this study. Risk factors and perinatal and neonatal outcomes of pregnant women with a male fetus were compared to those of pregnant women with a female fetus. Clinical Cases or Summary Results: The fetal sex ratio was 1.22: 191 male cases and 157 female cases. There were no significant differences in maternal age, parity, maternal ambulance transfer to tertiary care hospital after onset of abruption, delivery gestational weeks, delivery route, birth weight, and administration of tocolytic agent before delivery. In terms of risk factors, pregnant women with a male fetus had a significantly lower incidence (30/191, 15.7%) of pregnancy-induced hypertension as compared with female fetuses (44/157, 28.0%, p = 0.0052) (relative risk: 0.48 [95% confidence intervals: 0.29–0.80]). The incidence of other risk factors, including trauma, smoking habit, and previous abruption, were much lower in the case of male fetuses as compared with female fetuses, but not significantly. There were no significant differences in perinatal or neonatal and infantile outcomes between the two groups. Conclusions: Placental abruption occurred in pregnancies with a male fetus even in the absence of reported risk factors for placental abruption. Keywords: Placental abruption, Y chromosome

p0.005 and p50.05, respectively). Moreover, in IUGR group there were a negative correlation between aIMT and adiponectin/leptin ratio (A/L ratio) (p50.05) and between fetal adiponectin and IL-6 than SGA and AGA group (p50.05). Conclusions: In IUGR fetuses a higher fetal aIMT associated with decreased blood adiponectin levels and increased adipocytokines concentrations might relate to a greater risk of endothelial damage and insulin resistance. These conditions could predispose to vascular and metabolic disorders in adult life. Keywords: Presenter: Silvia Visentin

ID 766

RISK FACTORS AND PREGNANCY OUTCOMES IN VELAMENTOUS CORD INSERTION BIRTHS. M. Naveiro Fuentes1, J. Go´ngora Rodrı´guez2, S. Ruiz Dura´n3, M.T. Maroto Martı´n4, A. Alkourdi Martı´nez5, & A. Puertas Prieto6 1

Obstetrics Dept., Virgen de las Nieves University Hospital, Granada, Spain, 2Obstetrics Dept., Virgen de las Nieves University Hospital, Granada, Spain, 3Obstetrics Dept., Virgen de las Nieves University Hospital, Granada, Spain, and 4 Obstetrics Dept., V

Presenter: K.Odaira

ID 882

ADIPOCYTOKINES, ENDOTHELIAL DYSFUNCTION AND INTRAUTERINE GROWTH RESTRICTION S. Visentin, A. Galzignato, A. Friziero, S. Lazzarin, & E. Cosmi Deparmet of Woman and Child Health, University of Padua, Padua, Italy Brief Introduction: Intrauterine growth restriction (IUGR) is considered a risk factor for the future development of cardiovascular events and insulin resistance in adulthood. Adipocytokines are involved in the control of metabolism and have been associated with IUGR condition. The aim of this study was to investigate the relationships among immune system and endothelial dysfunction in IUGR mother and child couple. Materials & Methods: One hundred and seventy pregnant patients giving birth consecutively were included in the study. Adiponectin, leptin, Tumor Necrosis Factor a (TNFa) and Interleukin-6 (IL-6) in maternal and cord blood of IUGR, small for gestational age (SGA) and appropriate for gestational age (AGA) mother and child couple at delivery were assessed. Fetal aorta intima media thickness (aIMT) was evaluated in the same fetal groups. Clinical data (age, BMI, parity, and pregnancy outcomes) were collected. Serum adiponectin and leptin levels were measured by radioimmunoassay. Human TNFa and IL-6 were measured by an immunoassay and CRP by immunonephelometric assays. Data was analyzed by R (version 2.15.2). Clinical Cases or Summary Results: maternal adiponectin concentration presented the same distribution among the three groups (p0.137), leptin, TNFa, IL-6 and CRP serum levels were higher in IUGR mothers than SGA and AGA patients (p0.04, p0.008, p0.06 and p0.04, respectively). adiponectin levels were significantly reduced in IUGR fetuses than SGA and AGA ones, leptin (p50.05), TNFa and IL-6 levels conversely were higher in the former group, such as aIMT (p0.05,

Brief Introduction: Velamentous cord insertion (VCI) is a rare condition associated with adverse pregnancy outcomes. The aim of this study was to determine the frequency of VCI, to identify risk factors associated with VCI and to evaluate the association between adverse pregnancy outcomes and VCI. Materials & Methods: Observational case control study. The total population of women delivered in our Centre during the study period between January 2009 and July 2012 was reviewed. The case group consisted of all pregnancies affected by VCI (n = 128). Control group were pregnancies without VCI and birth in the same period of time (n = 13999). Variables were recorded for risk factors (maternal age, parity, miscarriages, fetal sex, singleton or twin pregnancy, placenta previa, assisted reproductive technology, hypertension and gestational diabetes) and perinatal outcomes (gestational age, fetal weight, Apgar score, fetal pH and admission to a neonatal unit). To identify risk factors and variables associated with adverse perinatal outcomes a specific logistic regression model was constructed for each dependent variable, and the crude (cOR) and adjusted odds ratios (aOR) were calculated together with their 95% confidence interval. Clinical Cases or Summary Results: The frequency of VCI among all women was 0.91% (IC 95% 0.75–1.1). Independ risk factors for VCI were placenta previa and twin pregnancy (aOR: 5.1 and aOR: 2.5 respectively). VCI was associated with a 2.7- and 2- fold increased risk of admission to a neonatal unit and low birth weight. Women with VCI more commonly underwent cesarean section (p50.001) than women with normal cord insertion. Conclusions: VCI has a low incidence. Placenta previa and twin pregnancy are independent risk factors for VCI. VCI is a risk condition increasing the risk of cesarean section, impaired fetal growth and admission to a neonatal unit. Keywords: Presenter: A. Puertas Prieto

ID 661

PREVENTION OF REPRODUCTIVE LOSSES IN WOMEN WITH

32

THROMBOPHILIA AND MULTIPLE PREGNANCY AFTER IVF V. Bitsadze, N. Makatsariya, R. Abramian, & Z. Gadaeva

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

I.M. Sechenov First Moscow State Medical University Department of obstetrics and gynecology, Russian Federation Brief Introduction: Our aim was to evaluate efficiency of anticoagulant, antioxidant and vitamins, folic acid, group B vitamins in the preparation course for IVF, in the IVF protocols, during multiple pregnancy and postpartum period. Materials & Methods: There was carried out the comparative analysis in two groups. The group I: 100 women with the physiological multiple pregnancy; the group II: 100 women with the pathological course of pregnancy after IVF. The criteria for thrombophilia were: factor V Leiden mutation, prothrombin G20210A mutation, deficiency of antithrombin III, protein C, 3 homozygous thrombophilic polymorphisms or 5 heterozygous polymorphisms, moderate and severe hyperhomocysteinemia and antiphospholipid antibodies. Clinical Cases or Summary Results: In the group I (control) thrombophilia was diagnosed 14 women (5 heterozygous polymorphisms without other forms of a thrombophilia). In the group II in 96% of women the thrombophilia was revealed: factor V Leiden mutation in 16%, prothrombin G20210A mutation in 12%, hyperhomocysteinemia in 34%, APS in 11%, homozygous polymorphisms – 11%, heterozygotic polymorphisms in 64%. The combined forms of thrombophilia (APS/hyperhomocysteinemia and genetic thrombophilia) in 15%. In women with multiple pregnancy after IVF (96 of 100 in the II group) pregnancy was complicated with threatened abortions in I and II trimesters (17.5%); moderate preeclampsia developed in 17% of women; placental abruption with antenatal death of both fetuses in 50 women; placental abruption with antenatal death of one fetus – in 10 women; chorionic abruption in early terms of pregnancy was observed in 10 women; premature birth on term of 29–32 weeks occurred in 30 women; thrombosis (thrombosis of a jugular vein, ileofemoral thrombosis) – in 4 women (4%) during the I trimester of pregnancy. In the postpartum period ileofemoral thrombosis was diagnosed in 4 women with factor V Leiden mutation. In the group I (control) 200 alive children, from them 96 were born prematurely. In 76 women was performed cesarean section. In the group II were born 140 alive children. Fetal losses were associated with antenatal fetal death in 24 women (28 children), early abortions in 8 women (16 children), early neonatal death – 8 women (16 children). Results of research showed the pathogenetic role of an initial thrombophilia in development of complications in multiple pregnancy after IVF. In addition, hormonal therapy during IVF is the risk factor for development of pregnancy complications. Conclusions: This research allows to assume the necessity of use of anticoagulant, antioxidant, folic acid, group B vitamins in both (in preparation for IVF, during IVF and pregnancy, and in the postpartum period. Keywords: Presenter: V. Bitsadze

ID 164

EFFECT OF BREASTFEEDING ON INFANT CYTOMEGALOVIRUS VIRAL LOAD Huaiyan-Wang1, Lin- Zang1, & Ye-Shi2 1

Neonatal Dept Changzhou Maternal and Child Health Hospital, Changzhou, Jiangsu, China and 2Laboratory, Changzhou Maternal and Child Health Hospital, Changzhou, Jiangsu, China, 213003)

J Matern Fetal Neonatal Med, Early Online: 1–437

Brief Introduction: Follow-up monitoring was carried out on infants infected with cytomegalovirus to find out effect of breastfeeding on changes of cytomegalovirus viral load Materials & Methods: Urine of the neonates born in the hospital was collected for cytomegalovirus screening, and the positive infant patients were divided into artificial feeding group and breastfeeding group, with 6 months of follow-up. During the 1st, the 3rd and the 6th month after their birth, their urine and their mother’s breast milk were collected. The method of real-time fluorescent quantitative PCR was adopted to test the viral load change of CMV-DNA in the urine and breast milk. Meanwhile, head B-ultrasound test, otoacoustic emission hearing screening, liver function test, blood routine analysis and so on were carried out. Clinical Cases or Summary Results: For infants from both artificial feeding group and breastfeeding group, during the 1st, the 3rd and the 6th month after birth, no significant changes to the DNA viral load of urine cytomegalovirus have been found. And meanwhile, there is no clinical significance in the head B-ultrasound, otoacoustic emission hearing screening, liver function test, blood routine analysis, etc. Conclusions: For CMV-infected neonates, even if cytomegalovirus in breast milk is tested to be positive, breastfeeding can continue without causing secondary symptoms of infection. Keywords: cytomegalovirus, breast milk, infant, viral load Presenter: Huaiyan-Wang

ID 062

CLINICAL PERFORMANCE CHARACTERISTICS OF ELECSYSÕ FREE-BHCG AND PAPP-A FOR FIRST TRIMESTER TRISOMY 21 RISK ASSESSMENT IN GESTATIONAL WEEKS 8 + 0 TO 14 + 0 N. Tørring1, C. Aulesa2, B. Eiben3, P. Luppa4, J. U. Ortiz5, M. Ferri6, U. Sancken7, A. Vereecken8, U. Wiedemann9, J. Zitzler10, & K.H. Nicolaides11 1

Department of Clinical Biochemistry, Aarhus University Hospital, Skejby, Aarhus, Denmark, 2Clinical Laboratories Unit, Valle de Hebron Hospital Complex, Barcelona, Spain, 3 Department of laboratory medicine, Amedes Institut fu¨r Labormedizin und Medizinische Genetik Rhein/ Ruhr, Essen, Germany, 4Department of Clinical Chemistry and Pathobiochemistry, Klinikum Rechts der Isar, Technical University Munich, Germany, 5Frauenklinik und Poliklinik, Technische Universita¨t Mu¨nchen, Munich, Germany, 6Hospital Universitari Dr. Josep Trueta. Laboratori Clı´nic ICS Girona, Spain, 7Department of Biochemical Genetics, Bioscentia, Ingelheim, Germany: 8Algemeen Medisch Laboratorium, Antwerp, Belgium, 9Labormedizinisches Zentrum Dr. Risch, Liebefeld, Switzerland, 10Roche Diagnostics, Clinical Operations Professional Diagnostics, Penzberg, Germany, and 11 Harris Birthright Research Centre for Fetal Medicine, Kings College Hospital, London, UK Brief Introduction: Screening for fetal trisomy 21 (T21) in the first trimester includes analysis of the serological markers pregnancyassociated plasma protein A (PAPP-A) and free beta choriogonadotropin (free bhCG). With the launch of these assays on the cobas e and Elecsys platforms, we investigated their clinical and analytical performance.

33

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

DOI: 10.3109/14767058.2014.924236

Materials & Methods: Patients and Methods We conducted a multicenter study in 5397 pregnancies including 108 cases with verified fetal T21 at 8 to 14 weeks of gestation. A technical validation of the Roche ElecsysÕ free bhCG and PAPP-A assays were performed, including method comparisons with the Brahms KryptorÕ , PerkinElmer AutoDELFIAÕ and Siemens IMMULITEÕ assays. Furthermore a clinical validation including generation of assay specific medians from gestational age 8 + 0 to 14 + 0 weeks, and clinical test performance of risk assessment was performed. Clinical Cases or Summary Results: The imprecision of the Elecsys free bhCG and PAPP-A assays was between 1.0% and 2.8%. The assays showed correlation to Kryptor (free bhCG 0.981; PAPP-A 0.987), AutoDELFIA (free bhCG 0.995; PAPP-A 0.979) and IMMULITE assays (free bhCG 0.983; PAPP-A 0.983). With a cut off at 1:300 the overall sensitivity of the screening including nuchal translucency reached 94% for a 3% false positive rate. In gestational weeks 8 and 9 the sensitivity was 95% for a 2% false positive rate, and in gestational weeks 10 to 14 the sensitivity was 94% for a 3% false positive rate. Conclusions: The technical and clinical validation of the Roche Elecsys free bhCG and PAPP-A assays for first trimester screening approve with the standards set by the Fetal Medicine Foundation. Keywords: PAPP-A; Free beta hCG; Trisomy 21, Screening Presenter: Niels Tørring

ID 182

NORMAL DELIVERY OF A LIVE FETUS COEXISTING WITH A COMPLETE HYDATIDIFORM MOLE Jong In Kim, M.D., PhD, Jun Chul, . Park, M.D., PhD Department of Obstetrics and Gynecology, School of Medicine, Keimyung University, Daegu, Korea Brief Introduction: Gestational trophoblastic diseases are neoplasias originating from the placenta. The pregnancy with a complete hydatidiform mole(CHMF) and a normal fetus is extremely rare, with an estimated incidence of one in 22,000–100,000 pregnancies. The condition is a dilemma with respect to the diagnosis and management of associated maternal (preeclampsia, hyperthyrodism, and a risk of malignancy) and fetal (spontaneous abortion, neonatal thyrotoxicosis, preterm delivery, intrauterine fetal death, bleeding) complications. Materials & Methods: A 33-year-old woman was referred to our hospital with a diagnosis of hydatidiform mole and live fetus. The pregnancy was unremarkable except for the complaints of nausea, vomiting and intermittent abdominal pain. The hCG levels were significantly increased and genetic amniocentesis at 18 weeks’ of gestation showed normal diploid fetal karyotype. Successive ultrasound examinations demonstrated a normally growing live fetus alongside a normal placenta and an additional intrauterine echogenic mass with features of hydatidiform mole. Ongoing prgnancy, the features of hydatidiform mole was slightly decreased. Clinical Cases or Summary Results: A cesarean section performed at 37 weeks’ gestation due to abrupt onset of pregnancy induced hypertension and vaginal bleeding and resulted in the delivery of live normal male infant (2680gm of body weight). Gross placenta showed an normal configuration with abruption(20%) and abnormal placenta(H-mole), Microscopic examination of the abnormal placentas confirmed complete hydatidiform mole. In the case of a normal fetal karyotype and the absence of serious signs of maternal pathology, waiting until fetal viability is achieved can justifiably be proposed, however there is still a risk of prenatal complications such as intrauterine death. Continuation of a pregnancy with complete hydatidiform mole (CHMF) is an acceptable option. Conclusions: We report a case of normal delivery of a live fetus coexisting with a complete hydatidiform mole Keywords: a live fetus, complete hydatidiform mole Presenter: Jong In Kim, M.D., PhD

ID 748

RETROSPECTIVE ANALYSIS OF PLACENTA ACCRETA: INCIDENCE, RISK FACTORS, SURGICAL MANAGEMENT AND MATERNAL OUTCOMES S. D’Eusanio, E. Tidu, B. Landi, S.R. Giannubilo, V. Bezzeccheri, & A. Ciavattini Dipartimento Materno Infantile, Azienda Ospedaliero Universitaria, Ospedali Riuniti di Ancona, Ancona, Italia Brief Introduction: Placenta accreta significantly contributes to maternal morbidity and mortality. The incidence of placenta accreta has increased and seems to parallel the increasing cesarean delivery rate. The aim of the study was to estimate the incidence of placenta accreta, to evaluate risk factors, surgical treatment options, and outcomes of patients with placenta accreta. Materials & Methods: We retrospectively reviewed the medical records of placenta accreta patients who were diagnosed and hospitalized between Jenuary and December 2013 at the Dipartimento Materno Infantile, Azienda Ospedaliero Universitaria, Ospedali Riuniti di Ancona. Maternal demographic features, risk factors, type of surgical intervention and maternal outcomes were evaluated. Clinical outcome measures were surgical complications, intensive care unit admission and packed red blood cells transfused.

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

34

J Matern Fetal Neonatal Med, Early Online: 1–437

Clinical Cases or Summary Results: Of the 2522 deliveries during 1-year, there were 8 cases of placenta accreta. The incidence of placenta accreta was 1/315 deliveries over a 1-year period. Eight (100%) patients had placenta previa and five (62.5%) patients had at least one previous cesarean delivery. Five women with placenta accreta had other previous uterine surgery. The mean age and parity of the women was 37 years and 2 respectively. Four (50%) were suspected to have placenta accreta antenatally. Planned cesarean hysterectomy was performed in 3 (37.5%) patients. Three (37.5%) patients were managed conservatively. In two cases we attempt to remove the placenta with severe haemorrhage and need of performing emergent hysterectomy and requirement of majorvolum blood transfusion (6 packed red blood cell) compared to those underwent planned cesarean hysterectomy (3 packed red blood cell). Five patients (62.5%) were admitted to the intensive care unit. Abdominal organ injury occurred in two patients. Conclusions: Placenta accreta is highly associated with the existence of placenta previa, especially in cases with previous cesarean delivery. Women with placenta accreta who have no attempt to remove any of their placenta, with the aim of conserving their uterus, or prior to hysterectomy, have reduced levels of haemorrhage and a reduced need for blood transfusion. Keywords: placenta accreta, placenta previa, maternal outcomes, surgical management

Materials & Methods: The diagnosis of placenta previa was set initially by ultrasound. The degree of invasion into the myometrium placenta was evaluated by Doppler blood flow studies in the placenta. If placenta accreta was suspected the MRI of the uterus in the timing from 32 - 36 weeks of pregnancy was performed. Clinical Cases or Summary Results: Comparing the results of conventional surgical treatment and combined operations with the use of UAE in patients with placenta accreta (sub CONTa and UAEa) there was revealed a statistically significant difference in the absolute and relative volumes of blood loss (Table 2, Figure 1, 2). In addition, as can be seen from the data presented in Table 2 and Figure 3, the women from the main group needed significantly lower volumes transfusion. It should be noted that in the control group donor was used to compensate the blood loss, and in the main group were used only erythrocytes which were recived by Cell Saver. The combined use of UAE allowed to avoid complitly cases of hysterectomy in patients of the main group. In the control group all interventions in cases of placenta accreta lead to hysterectomy (Table 2). Conclusions: 1. The use of temporary UAE in operative abdominal delivery in women with placenta accreta significantly reduces blood loss, need for blood transfusion and women disability. 2. This study did not reveal any benefits of combined technique over the conventional abdominal operative delivery in patients with placenta praevia with no signs placenta accreta.

Presenter: Beatrice Landi

Keywords: placenta previa, accreta, uterina arteriesembolization Presenter: Philipp Ovsyannikov

ID 024

EFFECTS OF ENDOVASCULAR EMBOLIZATION OF UTERINE ARTERIES ACCOMPLISHED BEFORE SURGICAL DELIVERY IN WOMEN WITH PLACENTA PREVIA AND PLACENTA ACCRETA 1

2

F. Ovsyannikov , D. Ivanov , & A. Bautin

3

1

Perinatal Dept., Almazov Federal Heart, Blood and Endocrinology Centre, S-Petersburg, Russia and 2Delivery Dept., State maternity hospital N9, Saint-Petersburg, Russia Brief Introduction: A retrospective controlled study included 51 patient with a complete placenta previa. The purpose of the study was: To compare the effectiveness of the traditional surgical treatment combined with the use of endovascular techniques in surgical abdominal delivery in women with placenta previa and accreta. To estimate the effects of endovascular embolization of uterine arteries accomplished before surgical delivery in women with placenta previa and placenta accreta.

ID 142

PLACENTAL ABRUPTION: RISK FACTORS, MANAGEMENT AND MATERNAL-FETAL PROGNOSIS. COHORT STUDY OVER 10 YEARS T. Boisrame´1, N. Sanane`s1, B. Langer1 1

Gynecology-obstetrics Dept, University Hospital of Strasbourg, Strasbourg, France Brief Introduction: Placental abruption (PA) is the cause of both significant maternal and perinatal morbidity and mortality. Recent advances in its management have enabled its prognosis to be improved. Our aim is to describe maternal and fetal risk factors, diagnosis, management and prognosis of PA. Materials & Methods: This was a retrospective cohort study between January 2003 and December 2012 within the 3 maternity units of a French university hospital. We conducted univariate analyses to compare PA and control groups. Multivariate models were constructed in order to study PA risk factors and perinatal morbidity and mortality. Clinical Cases or Summary Results: We included 55 926 deliveries after 24 weeks’ gestation including 247 cases of PA (0.4%). Independent risk factors for PA were major multiparity (OR 1.6; 95% CI [1.1–2.4]), gestational hypertension (OR 7.4; 95% CI [5.1–10.8]), preeclampsia (OR 2.9; 95% CI [1.9–4.6]) and preterm premature rupture of membranes (OR 9.5; 95% CI [6.9–13.1]). The classic clinical triad associating metrorrhagia, uterine hypertonia and abdominopelvic pains was present in only 9.7% of cases. Caesarean section rate was 90.3% with 51.8% being performed under general anesthesia. There was no case of maternal death, but maternal morbidity was considerable, with 7.7% of coagulation disorders and 16.6% of transfusion. After adjustment for the gestational age, we found an increased risk for pH  7.0 (OR 14.9; 95% CI [9.2–23.9]) and neonatal resuscitation (OR 4.6; 95% CI [3.1–6.8]). Perinatal mortality was 15.8%, including 78% of fetal deaths. Conclusions: Appropriate multidisciplinary management can limit maternal morbidity and mortality, but perinatal mortality, which occurs essentially in utero, remains high. Keywords: placental abruption; third-trimester hemorrhages; maternal morbidity; perinatal mortality; preeclampsia Presenter: Thomas Boisrame´

35

DOI: 10.3109/14767058.2014.924236

ID 402

PREECLAMPSIA-RELATED INCREASED EXPRESSION OF LEPTIN AND HYPOXIA-INDUCED FACTOR-1A IN THE THIRD TRIMESTER PLACENTAL BED Y. J. Lee1, S. Y. Kang1, G. Y. Yoon1, S. E. Han1, SCh Kim1 1

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Department of obstetrics and gynecology, Pusan national university hospital, Busan, Korea Brief Introduction: To investigate the differential expression of leptin, hypoxia-induced factor (HIF)-1a and leptin receptors in the third trimester placental bed of normotensive controls and preeclampsia (PE) patients. Materials & Methods: Placental bed tissues were collected from 18 PE patients (9 mild and 9 severe) and 20 gestational-matched controls. Placental bed expressions of leptin, HIF-1a and leptin receptors were evaluated by RT-PCR, real-time PCR, western blot and immunohistochemistry. Clinical Cases or Summary Results: There was no statistical difference between the normotensive controls and PE groups with respect to their age and parity, gravidity and body mass index (BMI). Expressions of leptin and HIF-1a were significantly higher in the severe PE group than the mild PE and the normotensive group. However, no significant difference was found in the expressions of leptin receptor isoforms between the three groups. Conclusions: This result suggests that altered expression of leptin and HIF-1a in the placental bed may contribute the pathogenesis and severity of PE. Keywords: Preeclampsia; placental bed, hypoxia-induced factor-1a, leptin, leptin receptor. Presenter: SCh Kim1

ID 935

DYSSEGMENTAL DYSPLASIA OF SILVERMAN-HANDMARKER TYPE: A CASE REPORT AND LITERATURE REVIEW. S. Meddeb1, J. Mathlouthi2, J. Rhim1, S. Mili1, H. Saidi1, & H. Khairi1 1

Department of gynaecology obstetrics university hospital Farhat Hached Sousse Tunisia, and 2Department of neonatal medecine university hospital Farhat Hached Sousse Tunisia Brief Introduction: Dyssegmental dysplasia, Silverman-Handmarker type (DD-SH) is a rare autosomal recessive lethal disorder, originally considered as a Kniest-like skeletal dysplasia with campomelia. It is linked to functional null mutations of the heparin sulphate perlecan gene (HSPG2) located on chromosome 1p36.1–35. Materials & Methods: case report Clinical Cases or Summary Results: We report the first case of DD-SH diagnosed in our pathology department. The foetal ultrasound findings, the radiological characteristics, the foeto pathological examination and the results of the mutation analysis of the perlecan gene 2 were reviewed. We report a case of DDSH in a foetus that presented at 22 weeks of gestation with severe micromelic dwarfism and narrow thorax. After termination of pregnancy, radiographs showed short limbs with Kniest-like large metaphyses, bowing of long bones and pleomorphic vertebral bodies with irregular segmentation. Ossification of pelvic

bones was absent. External examination showed a facial dysmorphy, thick neck, pterygia and micromelia with angulations of limbs, chest narrowing and an abducted hallux in the right foot. There was no anomaly in visceral examination. Histologically, the resting cartilage showed scattered, large puddle-like spaces. The physeal growth zones were disorganized. Conclusions: DD-SH can be diagnosed prenatally using foetal ultrasound as early as 13weeks of gestation in order to terminate the pregnancy earlier. Foetopathological examination with skeletal radiographics are mandatory in order to establish a precise diagnosis allowing a suitable genetic. Keywords: Dyssegmental dysplasia, Silverman-Handmarker dysplasia, dyssegmental dwarfism, mutation of the perlecan gene. Presenter: S. Meddeb

ID 074

PLACENTA PEAEVIA: MORBIDITY, MORTALITY AND STRUCTURE OF DEATH J. Ivanov1 & G. Bushinoska-Ivanova2 1

Gynecology and Obstetrics Department, Clinical Hospital Acibadem-Sistina Skopje, Macedonia, and 2University Clinic of Gynecology and Obstetrics Mother Theresa, Skopje, Macedonia Brief Introduction: Objective: The aim of this study is a retrospective analysis of premature neonatal death of newborns born to mothers with placenta preavia. Materials & Methods: Material and methods: There were analyzed the total number of births in specific period, the incidence of birth of newborns from mothers with Placenta Preavia, mortality of this group of newborns, the gestational age of deceased newborns, the time of death of these newborns, the structure of death according to diagnosis. During the past 3 years (2009- 2011) at Special Hospital for Gynecology and Obstetrics, there were 9496 newborns. 9415 were born alive (99.14%), 81 died (0.85%). Out all newborns, 20 or 0.21%, were born from mothers with placenta preavia. Clinical Cases or Summary Results: Results: The mortality in this group of newborns with placenta praevia is 17.39%. The gestational age of all deceased newborns is less than 33 weeks. During the first 12 hours the percentage of deaths is 50%, from 13–24 hours 25%, from 25–48 12.5% and after 48 hours 12.5%. According to patho-histological analysis that were done on 100% of the deceased newborns, 38.1% from this risk group of newborns died from hyalinomembrane disease as the main cause of death, 14% from intercranial hemorrhage. 42% had as a main cause of death hyalinomembrane disease and intercranial hemorrhage, and 6% fall in the group of rare other causes. Conclusions: The high percentage of death of these newborns is determined by maturity and adaptability of these newborns. Keywords: Placenta parevia, morbidity, mortality Presenter: Jordancho Ivano

ID 966

TITLE: PERINATAL OUTCOME OF TWIN PREGNANCIES ACCORDING TO CHORIONICITY: AN OBSERVATIONAL STUDY FROM TERTIARY CARE HOSPITAL

36 S. Masheer, H. Maheen, S. Munim

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Department of Obstetrics and Gynecology, The Aga Khan University Hospital, Karachi, Pakistan Brief Introduction: Objective: To assess the perinatal outcome in twin pregnancies according to chorionicity. Materials & Methods: Methods: This was a retrospective cohort study of twin pregnancies from January 2001 to December 2012. Maternal and perinatal outcomes of monochorionic (MC) and dichorionic (DC) twins were compared by using chi-square and t-test. Perinatal complications were compared by adjusted odds ratio using logistic regression at 5% level of significance. Clinical Cases or Summary Results: Results: Among 377 twin pregnancies, 102 (27.1%)were MC and 275 (72.95%) were DC. In MC twins, the rate of miscarriage was three fold higher than DC (14.7% vs 4.5%)p-value 50.001) Mean birth weight in DC was 217.54 grams higher than the MC (p value 50.001). Similarly, MC twins were 2.01 times [CI (1.12–3.94), p value = 0.021] more likely to be delivered preterm. Likewise, neonatal intensive care admission for MC was 2.36 times [CI (1.08–5.16), p value = 0.031], congenital anomalies were 4.17 times [CI (1.79–9.69) p value = 0.001] and the odds of neonatal death was 3.5 times than DC twins [OR 3.49 (1.51–8.10) p value = 0.003] Conclusions: Conclusions: Monochorionic twins were more at risk for adverse outcomes than dichorionic twins. Determining chorionicity at early pregnancy will help the Obstetricians to plan the care of these patients. This will help not only in caring these women but also helps in realistic counseling regarding local perinatal outcome and emerging psychosocial issues Keywords: Twins, chorionicity and perinatal outcome Presenter: Shama Munim

ID 513

ABNORMALLY INVASIVE PLACENTA (AIP). IS THIS A DIAGNOSE IN THE THIRD TRIMESTER ONLY? M. Tavares de Sousa, W. Diehl, G. Ortmeyer, K. Hecher Dept. of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Germany Brief Introduction: Acute abdominal pain with hemoperitoneum is a challenge in the diagnosis and management during pregnancy. Obstetric as well as non-obstetric causes must be considered. Materials & Methods: We report two pregnancy in the second trimester (24 0/7 and 20 0/3 gestational ages) presenting both with acute abdominal pain. Abdominal ultrasound showed a large amount of intraperitoneal fluid and a suspicious of uterine rupture for both. The clinical situation deteriorated within minutes with clinical signs of a hypovolemic shock. Clinical Cases or Summary Results: The abdomen was explored. A placenta percreta, actually perforating the uterus caused the hemoperitoneum. For the pregnancy at 24 0/7 we decided to perform a caesarean section. A premature boy of 640 g was delivered through a lower segment incision. Consecutively, a total hysterectomy was carried out without further problems; total blood loss was 3500 ml. For the pregnancy at 20 0/3 we had to perform a caesarean section aswell. Here, we considered a conservative approach without hysterectomy; total blood loss was 3800 ml. The postoperative course was completely uneventful for both. The pathologist’s report confirmed the diagnosis of placenta percreta. Conclusions: Hemoperitoneum and uterine rupture due to placenta percreta is challenging in the diagnosis. Although an uncommon occurence, abnormal placentation and subsequent uterine rupture should be taken into consideration also in women in the second

J Matern Fetal Neonatal Med, Early Online: 1–437

trimester with or without previous uterine surgery because aggressive surgical management reduces maternal morbidity and mortality. Keywords: placenta percreta; abnormal placentation Presenter: M. Tavares de Sousa

ID 042

RETAINED PLACENTAL TISSUE AFTER CESAREAN SECTION M. Orelj Popic, S. Milosevic, Lj. Mladenovic Segedi, G. Stajic, D. Vukicevic 1

Clinic for gynecology and obstetrics, Novi Sad, Serbia

Brief Introduction: Retained placental tissue after cesarean section is rare, but incrising phenomenon that can lead to significant complications in the postpartum period - excessive secondary postpartum hemorrhage, endometritis etc. Risk factors for residual tissue after cesarean section are: premature birth, lower gestational age of the pregnancy, multiple pregnancies and pregnancies from IVF. Management of this condition consists of uterine curettage, supstitution of blood products, and antiinflamative drugs usage. Materials & Methods: A prospective and retrospective study. Data on the number of audit curettage were continuously collected from October 2011 until October 2013, and for more details- we have reviewed archived data. The study includes all patients who were hospitalized at the Department of Conservative Gynecology, Clinic for Gynecology and Obstetrics in Novi Sad for curettage, after cesarean section, and the clinical and/or ultrasonographic findings of suspected impacted placental tissue. Clinical Cases or Summary Results: The curettage was performed in 26 patients, mean age 30.9 (19–38) years, which is 0.55% of the total number of births by caesarean section at the Clinic during this period. Patients were admitted in hospital in average of 19.3 (9–50) days after delivery with symptoms of bleeding (69%), abdominal pain (23%) and fever (27%). The ultrasonographic findings in 77% of cases showed existence of echogenic field in cavity of uterus, in 25% of patients in uterine cavity was both hyper - and hypoechogenic material, while in only 8% there was hypoechogenic content in uterus. In 5 patients multiple instrumental revisions were indicated and performed. Histopathologic analysis in 22 patients (85%) confirmed the presence of chorionic villi - residual trophoblast. Mean duration of hospitalization was 4.3 hospital days. In all cases uterotonics and antibiotics were administrated (parenteral use in 46% of cases). In 15% of patients transfusion of blood derivates was necessary. Conclusions: The incidence of curettage due to impacted placental tissue after delivery by Caesarean section is constantly increasing. Secondary postpartum hemorrhage is the main symptom of this condition, and sonographic findings of a hyperechogenic mass in the cavity of the uterus is correlated with positive pathological findings. Concerning patient morbidity, length of hospital staying and potential complications, it is necessary to further investigate the risk factors of described pathologic condition. Keywords: Presenter: Durda Vukicevic

ID 451

PROSTHETIC VALVE THROMBOSIS IN PREGNANCY – A CASE REPORT M. Palma, S. Couto, C. Leite Servic¸o de Ginecologia e Obstetrı´cia, Hospital Garcia de Orta, Almada, Portugal

37

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DOI: 10.3109/14767058.2014.924236

Brief Introduction: Effective anticoagulation is critical in patients with mechanical prosthetic heart valve (MPHV), but poses dilemma in cases such as pregnancy. Pregnant women with a mechanical heart valve are at a higher risk of thromboembolic complications. The optimal anticoagulation strategy remains unclear Materials & Methods: Case Report Clinical Cases or Summary Results: We report the case of a 24- year-old pregnant woman at eight weeks’ gestation, with a prosthetic valve under low doses of therapeutic regimen of enoxaparin (60 mg/day), brought to the emergency department with ischemic cerebral infarction. The echocardiogram performed at hospital admission revealed a severe mitral prosthesis thrombosis. Intravenous heparin was started. The patient switched to warfarin ate´ 16 weeks of gestation. Four weeks later, the patient revealed a new ischemic cerebral infarction, and restarted perfusion of intravenous heparin. She was closely followed up and taken care of by a multidisciplinary approach. At 25 weeks was diagnosed intrauterine growth restriction, and at 29 weeks the evidence of placental infarction was detected. The labour induction was decided due to the IUGR and placental lesions, although the patient suffered from a sudden onset of headache and slightly lowered consciousness. An urgent cesarean section under general anesthesia was performed, giving birth to a female baby weighing 990gr. Computed tomography of the brain showed intracerebral hemorrhage in the parietal lobe with uncal herniation, due to a hemorrhagic transformation of a new ischemic cerebral infarction. She underwent a percutaneous mechanical thrombectomy and an urgent craniotomy and removal of the hematoma. Currently, her left hemiparesis and sensory aphasia persisted, and was transferred to another service for further rehabilitation. Although, we need to be aware to the possibility of a new intracerebral hemorrhage or a new cerebral infarction. The morphological and histological findings of placenta indicate abnormal placentation and evidence of chronic hypoxia. The newborn was discharged home on the first month of life, with 2110 g. Conclusions: This case of early pregnancy MPHV thrombosis emphasized the importance of adequate initial coagulation. The options for anticoagulation during pregnancy and for management in the event of valve thrombosis are unclear, however a discussion of the various risks and benefits with the patient is necessary, as well as a multidisciplinary team approach is essential

velamentous cord insertion located in the intergemelar membrane of the second twin. Materials & Methods: Retrospective descriptive study of all diagnosed cases of vasa previa at the University Hospital of Vigo, Spain, between January 2007 and January 2014. We follow this diagnostic scheme (Cajal’s Method). First, placental ingegrity is evaluated detecting the presence of placental lobes and its relationship with the low uterine segment. Secondly, we find the insertion of the umbilical cord. The morphology of the placental fetal side - hypertrophic or not (convex or concave respectively)- will help the diagnosis. Convex placenta would be associated with marginal or velamentous cord insertions. Finally, we studied paths of free fetal vessels and its connection with inner cervical os. We introduce a 3D scan to know anatomical relationships. VP was confirmed in placental study after cesarean section. Clinical Cases or Summary Results: We diagnosed 20 cases of VP in our center in the last 6 years, 11 single pregnancies and 9 twin pregnancies. Our incidence is 1/1130 births. The average maternal age was 36.5 years. 40% of the patients were multiparous, 20% of these had a previous cesarean and 45% (9 cases) were in vitro fertilization pregnancies. The average gestational age at the time of ultrasound diagnosis of VP was 25 weeks. 55% (11 cases) were classified as type I (velamentous insertion), 5%(1 case) as type II (bilobed placenta) and 15%(3 cases) as type III (velamentous cord insertion of second twin). The marginal or low insertion placenta was diagnosed in 30% of the cases and bilobed placenta was found at 15%. 25% (5 cases) of patients had at least one episode of vaginal bleeding during pregnancy. The elective cesarean occurred in 65% of cases, being urgent in 35%. The average gestational age at the time of the cesarean section was 34 weeks. Apgar score at 5 min was 49 in all cases. All newborns were healthy. Conclusions: It is advisable the routine evaluation of the placental cord insertion in the second trimester ultrasound examination. This method helped us diagnose all cases of VP in our Hospital. Keywords: Vasa previa, prenatal diagnosis, velamentous inserting cord, Cajal method’s. Presenter: G. Cordeiro Vidal

Keywords: Presenter: Maria Joa˜o Palma

ID 393

‘‘ IS IT TIME TO LOOK FOR VASA PREVIA? CAJAL METHOD’S FOR PRENATAL DIAGNOSIS’’ G. Cordeiro Vidal, Z. Valladares Bajo, E. Cervin˜o Go´mez, & C.N. Lo´pez Ramo´n y Cajal 1

G. Cordeiro Vidal, Obstetrics and Gynecology Department, Universitary Hospital of Vigo, Spain, and 2Z. Valladares Bajo, Obstetrics and Gynecology Department, Universitary Hospital of Vigo, Spain, and 3E.Cervin˜o Go´mez, Obstetrics and Gynecology Department Brief Introduction: Vasa previa (VP) describes a situation where fetal vessels cross or run membranes around the lower uterine segment in close proximity to the inner cervical os. The estimated incidence is 1/2000–6000 deliveries. An accurate prenatal diagnosis before the rupture of membranes or before the initial stages of labor would avoid fetal exsanguination and demise ought to laceration of umbilical vessels. We could describe different VP types. Type I due to free fetal vessel in a velamentous cord insertion in single or bilobed placenta. Type II where fetal vessels are running between lobes of a placenta with one or more accesory lobes. And type III, associated with a

ID 965

PROGNOSTIC VALUE OF OBSTETRIC DOPPLER ULTRASOUND IN FETUSES WITH FETAL GROWTH RESTRICTION: AN OBSERVATIONAL STUDY IN A TERTIARY CARE HOSPITAL Z. Islam, D. Dileep, S. Munim Department of Obstetrics and Gynecology The Aga Khan University Hospital Karachi, Pakistan Brief Introduction: Objective: To determine the prognostic value of umbilical artery Doppler (UAD) with fetal growth restriction (FGR) and their perinatal outcomes. Materials & Methods: Methods: This was a retrospective cohort study of fetuses with growth 5th centile from 2001–2012. Pregnancy outcomes were compared according to UAD findings for 253 cases. Doppler findings were categorized as; Normal End Diastolic Flow (NEDF), Reduced End Diastolic Flow (REDF) and Absent/Reverse End Diastolic Flow (AREDF). Mean and proportion were calculated and odds of perinatal complications were compared by using logistic regression for REDF and AREDF with NEDF at 5% level of significance. Clinical Cases or Summary Results: Results: The perinatal morality rate was 3.2%. Neonates with abnormal Doppler were at increased risk of

38 cesarean delivery, low birth weights and low Apgar scores. Amongst the perinatal morbidity, neonatal intensive care unit (NICU) admission was 4.2 and 15.3 times in neonates with REDF and AREDF and similarly the perinatal mortality of AREDF was 12.5 times higher as compared to NEDF. Other morbidities were also much higher in abnormal Doppler groups. Conclusions: Conclusion: There is a prognostic value of UAD in predicting the outcomes for FGR fetuses and therefore recommend its use in the conservative management of such pregnancies to reduce perinatal mortality and morbidity. Keywords: Umbilical artery, fetal growth restriction, perinatal outcome, Doppler velocimetry, absent or reverse end diastolic flow Presenter: Shama Munim/Zaheena Islam

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ID 496

NEED FOR BLOOD TRANSFUSIONS IN NEWBORNS FROM PLACENTA PREVIA PREGNANCIES D.J. Cecez1, S. Rakic1,2, S. Jankovic Raznatovic1,2, L. Hajnal Avramovic1, L.J. Stankovic1, A. Curkovic1, T. Mitrovic1, & M. Rascanin1 1

Department of Obstetrics and Gynecology ‘‘Narodni front’’, Belgrade, Serbia, and 2Belgrade University Medical School, Belgrade, Serbia Brief Introduction: INTRODUCTION. Placenta Previa is a leading cause of antepartum hemorrhage in the last trimester of pregnancy. The lower implanted the placenta, the earlier the antepartum hemorrhage is to occur. Placenta previa centralis (PPC), the most severe form of abnormal placenta implantation, is completely embedded into uterine isthmus and entirely covers the internal ostium of the uterus. Maternal hemorrhage during the pregnancy and delivery leads to anemia and a need for transfusion in newborns. GOAL. To investigate weather PPC is a risk factor for transfusions in newborns in the first three days of their life. Materials & Methods: MATERIALS AND METHODS. The frequency of need for transfusion in 33 newborns born from pregnancies with PPC was analyzed. Control group (CG) consisted of 40 newborns born in our clinic from pregnancies with normally implanted placenta, of the same gestational age, and delivered by cesarean section for other than placenta previa indications. Anemia is defined by the value of venous blood Hematocrit (Htc)540% and Hemoglobin (Hb)5140g/l in the first 72 hours of infant’s life. The data were analyzed using analytical (2 test) and descriptive statistical tests. Clinical Cases or Summary Results: RESULTS. Anemia at birth was found in 12 newborns (36.4%) from pregnancies with PPC and in none of the newborns from CG (2 = 17.047; p50.001). Transfusions were given to 11 newborns (33%) while no blood transfusions were given to newborns from the CG (2 = 15.699; p50.001). Conclusions: CONCLUSION. In newborns from PPC pregnancies, there is a high frequency of need for transfusions during the first three days of their life. Hence, PPC is a high risk factor for transfusion in newborn. Keywords: newborn, placenta previa, transfusion Presenter: S. Rakic

ID 200

CERVICAL PREGNANCY WITH MASSIVE HEMORRHAGE AFTER METHOTREXATE TREATMENT

J Matern Fetal Neonatal Med, Early Online: 1–437

K. Watanabe1, Y. Kuwabara2, S. Kondo3, R. Matsui4, A. Iida5, M. Kato6, H. Kaseki7, M. Yonezawa8, N. Ohuchi9, K. mine10, M. Satomi11, & T. Takeshita12 obstetrics & gynecology Dept., nippon medical school, bukyo-ku tokyo, Japan Brief Introduction: Cervical pregnancy is a rare condition of ectopic locations. It can be resulted massive hemorrhage requiring hysterectomy. However, it can be diagnosed by transvaginal ultrasonography in the early stage recently, no universally protocol is accepted to preserve fertility. We report 2 cases with successfully conservative approach. Materials & Methods: Case report Clinical Cases or Summary Results: Case 1 was an early cervical pregnancy at 7 weeks with 236,731 IU/mL of serum hCG were managed with intrachorionic injection of methotrexate. A combination of uterine artery embolism was performed before dilatation and curettage of uterine contents when 1600 mL of massive hemorrhage was induced 28 days later of methotrexate treatment. Neo-metro balloon tamponade set in uterine cervix prevents bleeding during transferring the patient to interventional radiology room and additional hemorrhage was in small amount. Case 2 was an early cervical pregnancy at 7 weeks with 26,751 IU/mL of serum hCG with intramuscular injection of methotrexate. In the same way, a combination of uterine artery embolism was performed before dilatation and curettage of uterine contents when 100 mL of hemorrhage was induced 29 days later of methotrexate treatment. Intravaginal gaze tamponade prevents bleeding during transferring the patient to interventional radiology room, and additional hemorrhage was 4380ml. Conclusions: Control of active bleeding with neo-metro balloon tamponade can possibly be useful in case of uncontrolled bleeding, because It is difficult to recognize as a case of cervical pregnancy leading to severe hemorrhage. Keywords: cervical pregnancy Presenter: K. watanabe

ID 050

SUCCESSFUL USE OF BT-CATH BALLOON TAMPONADE IN THE MANAGEMENT OF POSTPARTUM HEMORRHAGE DUE TO PLACENTA PREVIA D. Uygur, T. Altun Ensari, A. S. Ozgu-Erdinc, H. Dede, S. Erkaya, & A. N. Danisman

39

DOI: 10.3109/14767058.2014.924236

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Department of Perinatology, Zekai Tahir Burak Women Health Care, Education and Research Hospital, Ankara, Turkey Brief Introduction: We aimed to report our experience and success rate with the BT-Cath balloon in case of uncontrollable hemorrhage due to placenta previa. Materials & Methods: In this retrospective study, we evaluated the patients treated with the BT-Cath balloon in the event of postpartum hemorrhage (PPH) due to placenta previa despite the optimal management with medical treatment. Clinical Cases or Summary Results: Between 2011 and 2013, 237 women were delivered as placenta previa (0.45%). We evaluated the 53 women who had uterine tamponade with BT-Cath balloon. In 45 cases (84.9%) hemostasis was achieved and in 6 cases (11.3%) hysterectomy was required. The mean duration of balloon tamponade was 9.8 ± 6.4 hours. In the analysis of the balloon volume and treatment success, the area under ROC curve was 0.803 (%95CI: 0.633–0.973) (p value: 0.007) and the optimal cut-off point was 220 ml with a sensitivity of 87.5% and specificity of 71.1%. Conclusions: Intrauterine balloon tamponade is easy to apply, require less experienced skill and effective choice of management in case of PPH due to placenta previa in which medical treatment is unsuccessful. We suggest inflation of the balloon with the minimal amount of volume, shorter period of intrauterine placement and early start of deflation of the balloon. Keywords: Placenta Previa, BT-Cath Baloon Catheter, Postpartum Hemorrhage Presenter: A.S. Ozgu-Erdinc

babies (%63.5) had TFT abnormality (p = 0.049). Weight, height and head circumference in 6, 9, 12 and 18 months of corrected age was recorded. Mean head circumference in 18 months of age in normal TFT group was 46.3cm ± 1.6 compared to babies with abnormal TFT whose mean head circumference was 45cm ± 2.4 at the same age, difference was statistically significant (p = 0.047). There were no statistically significant difference between groups for antropometric values in 6, 9, 12 moths and neurodevelopmental evaluation. Conclusions: TFT abnormalities are frequent in prematu¨re babies and it is one of the most common causes of preventable mental retardation. In neonates, even transient hypothyroidism is associated with poor neurodevelopmental outcome, hence it must be treated urgently. As also detected in our study, maternal hypothyroidism is associated with increased neonatal hypothyroidism and these babies must be managed closely in postnatal period. Although not statistically significant, SGA babies were found to have increased rate of hypothyroidism. Further investigation with larger number of patients is necessary. Keywords: premature, thyroid functions tests Presenter: N Ko¨ksal

ID 951

AN UNUSUAL CASE OF RETAINED MEMBRANES A. Pramanick & M. Mathur

ID 390

RESULTS OF THYROID FUNCTION TESTS IN PREMATURE INFANTS N. Ko¨ksal1, P. Dog˘an1, H. O¨zkan1, C. Canbolat1, E. Eren2, _ Varal1, & O. Bag˘cı1 I. 1

Neonatology Dept. Uludag˘ University, Faculty of Medicine, Bursa, Turkey, and 2Pediatric Endocrinology Dept, Uludag˘ University, Faculty of Medicine, Bursa, Turkey Brief Introduction: Thyroid hormones are critical for normal growth and neurodevelopment. Abnormalities of thyroid functions tests (TFT) are frequently seen in premature infants, physiological hypothyroxinemia being the most common (%70). Clinical findings are usually subtle or absent. Clinical and subclinical hypothyroidism is common (%0.3–2.5) in woman who are in conceptional age or pregnant. Maternal hypothyroidism is known to have an adverse impact on the developing fetus. In this study we aim to identify the rate of abnormalities of TFT, its association with morbidities and impact on long term neurodevelopment. Materials & Methods: In this retrospective study, rate of abnormalities of TFT, its association with morbidities and neurodevelopment is investigated in 139 premature babies admitted to neonatal intensive care unit in Uludag˘ Universitiy Medical Faculty between January 2009 and January 2012. Clinical Cases or Summary Results: Fifty six of 139 premature infants (%40.3) male and 85 (%59.7) were female. Mean gestational weeks and birth weights of infants were 31.3 ± 2.9 weeks 1667 gr ± 707 gr. Fourty one patients (%24) had TFT abnormality, %53.6 had transient TSH elevation, %22 had primary hypothyroidism, %22 had nonthyroidal disease and %2.4 had transient hypothyroxinemia. Demografic properties were similar between patients who had TFT abnormalities and who had not. Fourty seven percent of SGA babies and, %26 of AGA babies had TFT abnormalities, difference was not statistically significant. Most common TFT abnormality was found to be transient TSH elevation in SGA and AGA babies. Mothers of 8 patients had maternal hypothyroidism. Five of these

KK Hospital, Singapore Brief Introduction: Circumvallate placenta is seen in 0.2% of pregnancies. It is a form of extrachorial placenta which is associated with premature delivery, oligohydramnios, non-reassuring fetal status on cardiotocogram, placental abruption and intrauterine fetal death. The odds ratio of placental abruption in patients complicated by circumvallate placenta was 13.1.

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40 On antenatal ultrasound, irregular edge, uplifted margin, placental sheet or shelf at the margin of the placenta is suggestive of circumvallate placenta. There are no reports of higher incidence of retained placenta with placenta circumvaletta. We present a case of circumvallate placenta where the placenta and membranes were retained and had to be removed manually. Materials & Methods: case report Clinical Cases or Summary Results: A 39 year old Chinese lady, G5P2, who has had two elective termination of pregnancies followed by two uneventful full term normal deliveries. She did not have any prior uterine or gynecological surgeries. Antenatally she booked at 8 weeks and trisomy screen was low risk. All her antenatal scans were within normal limits. She presented at 40 weeks of gestation with contractions and requested induction of labour. Labour was induced with cervical prostaglandins, augmented with intravenous oxytocin and progressed to normal delivery of a 3240g healthy baby girl. Following delivery, there were no signs of placental separation. She was started on oxytocin infusion and saline was infused through the umbilical cord. Placenta could not be delivered after these measures and with a diagnosis of retained placenta she underwent manual removal under regional anaesthesia. Following removal of the placenta it was noted to be circumvallate with a small fetal surface. The membranes had detached at the edge of the fetal surface and had to be removed separately. Second degree perineal tear was repaired and since her family was complete she also opted for post partum tubal ligation. Post natally, she had acute retention of urine and was on IDC for a day following which she was able to PU. Uterus remained well contracted and she had an uneventful recovery. Pathological examination of the placenta confirmed circumvallate placenta with hyper coiling of umbilical cord. Conclusions: Circumvallate placenta is associated with suboptimal pregnancy outcomes. Accuracy of sonography of the placenta for revealing circumvallation appears to be limited. Coexistence of circumvallate and retained placenta may lead to detachment of the membranes from the placenta and it is important to carefully remove the membranes and check for completeness. Keywords: retained circumvallte membranes placenta Presenter: A. Pramanick

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complicated by morbidly adherent placenta.The study evaluates the potential risk factors, and the maternal outcome.This study covered 14076 deliveries for a period of 2 years 2011–2012 Clinical Cases or Summary Results: Study covered 14076 deliveries from which (0.7%) morbidly adherent placenta were diagnosed. Placenta accrete account for 85% of the cases of morbidly adherent placenta. The risk factors were previous C/S19% comparing with 2.5% in group (ii), previous curettage 7.5% in group (i) 2.5% in group (ii), previous myomectomy 2.5%, high gravidity (mean 6 in group (i) and 4 in group (ii) and placenta previa15% in group (i) 1.5% in group (ii). The majority of the cases of placental attachment (96%) were diagnosed at cesarean section or by histopathological examination, 3% of the cases diagnosed by ultrasound and 1% by MRI. In study group operation time were prolonged, hysterectomy were did in 5 cases, 40% requires blood transfusion and 3 patients died Conclusions: Morbidly adherent placenta is associated with serious maternal outcome. Increasing incidence of placenta accrete due to increasing rate of cesarean section. Early and preoperative diagnosis should be done to allow multidisciplinary planning for minimize potential maternal complication Keywords: Morbidly adherent placenta, risk factors, previous cesarean section, maternal outcome Presenter: Karima Tayb Hwissa

ID 197

UPPER SEGMENT CAESAREAN SECTION, BILATERAL UTERINE ARTERY LIGATION, WITH KHALIL, S TRACTION STITCH FOR BAKRI BALLOON TAMPONADE TO CONTROL POSTPARTUM HEMORRHAGE FROM MORBID ADHERENT PLACENTA PREVIA M. Khalil

ID 104

MORBIDLY ADHERENT PLACENTA: RISK FACTORS AND MATERNAL OUTCOME K. Hwissa Obstetric Department, Zawia Hospital, Zawia, Libya Brief Introduction: Morbidly adherent placenta is associated with serious maternal outcome.The incidence of placenta acreta has increased due to increasing cesarean delivery rate. Placenta accreta is the most common accounting for approximately 75% of all cases, increta account for serious one is percreta which penetrates through the entire uterus.Risk factors for morbidly adherent placenta are previous cesarean delivery and placenta previa. Besides advanced maternal age and multiparity. Apreoperative diagnosis is difficult, and it is usually established at cesarean delivery or on histological examination after obstetric hysterectomy for postpartum hemorrhage. Diagnosis of placenta attachment is usually established by ultrasonography and Magnetic resonance imaging (MRI). Materials & Methods: Retrospective analysis of all pregnancies complicated by morbidly adherent placenta. For comparison purposes we defined 2 groups: group (i) 100 cases with morbidly adherent placenta and group (ii) 100 cases of pregnancy not

Consultant, Department of Obstetrics and Gynecology, Security Forces Hospital, Riyadh, Kingdom of Saudi Arabia, and Assistant Professor, Faculty of Medicine, Menoufiya University, Egypt Brief Introduction:; With the considerable rise in the rate of caesarean section in recent years, the incidence of placenta praevia and placenta accreta has risen substantially. The average blood loss in cases of placenta accrete is 3–51. It is not easy to control this bleeding even by many different surgical procedures.The objective of the study is to evaluate the effectiveness of bilateral uterine artery ligation, and a new technique to maintain the Bakri balloon over the placental bed withen the lower uterine segment by traction stitch through anterior abdominal wall to control postpartum hemorrhage from morbidly adherent placenta previa. Materials & Methods: A randomized study of 50 cases with postpartum hemorrhage from morbidly adherent placenta previa during upper segment (transverse or longitudinal) caesarean section, were treated with bilateral uterine artery ligation, and placement of intrauterine Bakri balloon. Cases were divided into 2 groups, group A (25 cases) had Bakri balloon fixed by nylon loop traction stitch to the anterior abdominal wall. Group B (25 cases) the balloon placed inside the uterine cavity without traction stitch. In all case the balloon has to stay in for 24 hours. Clinical Cases or Summary Results: In-group A, the balloon remained in situ in all cases by the effect of traction stitch without displacement to the vagina with subsequent control of bleeding in 92% (one had

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DOI: 10.3109/14767058.2014.924236

hysterectomy, and one had reinflation of the balloon for total 36 hour) However in-group B, the balloon displaced to the vagina in 9 cases (36%) with continuation of bleeding in 24% (6 cases) and further surgical procedures to control bleeding in 20%. Conclusions: bilateral uterine artery ligation, with an intrauterine Bakri balloon as tamponade and Khalil,s traction stitch is more successful than balloon without traction stitch in treating postpartum hemorrhage from morbidly adherent placenta previa. Keywords: morbidly adherent placenta previa., khalil,s traction stitch Presenter: Mohamed Ibrahim Khalil

ID 589

ARE PRENATAL SCREENING TEST PARAMETERS AFFECTED BY EITHER PLACENTAL LOCATION OR FETAL GENDER? M. Yıldırım1, A. Ko¨s¸ u¨s¸ 2, N. Ko¨s¸ u¨s¸ 3, & M. Duran4 1

Atatu¨rk Education and Researche Hospital, Ankara, Turkey, ¨ zal University Faculty of Medicine, Ankara, Turkey, Turgut O

2

3

¨ zal University Faculty of Medicine, Ankara, Turgut O Turkey, and 4¸Sevket Yılmaz Education and Researche Hospital, Bursa, Turkey Brief Introduction: Screening tests for fetal chromosomal abnormalities and structural congenital malformations are offered to expectant mothers as a crucial part of antenatal care. The relationship between fetal gender and prenatal screening tests has been a focus of interest for many scientists. Moreover there are plenty of researches studying the effect of placental location on the pregnancy and its outcome. The aim of this study is to investigate the relationship between first or second trimester screening test parameters and placental location and fetal gender as well. Materials & Methods: This analysis was carried out as a retrospective study at Obstetrics and Gynecology Clinic of Turgut O¨zal University Hospital. The study population comprised of 300 pregnant women with singleton pregnancies. Fetal nuchal translucency (NT) measurement and maternal serum free beta human chorionic gonadotropin (b-HCG) and pregnancy-associated plasma protein-A (PAPP-A) values in the first trimester and maternal serum alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG) and unconjugated estriol (uE3) levels in the second trimester were determined. Placental position was categorized as anterior and posterior based on their location in the uterine cavity. Then aforementioned variables were compared to fetal gender and placental location in order to demonstrate the relationship between them.

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Table 1. Distribution of first and second trimester screening test parameters according to placental location. Anterior (n = 165)

Posterior (n = 135)

PAPP-A (mm/mL) 2.22 (0.47–11.70) 2.09 (0.67–15.70) b-hCG (ng/mL) 33.40 (8.40–110) 43.95 (10.10–116) NT (mm) 1.30 (0.6–2.5) 1.25 (0.6–2.7) AFP (m/mL) 33.20 (3.05–255) 33.25 (13.60–74) hCG (mm/mL) 25957 (6059–70245) 22065 (5552–87258) uE3 (ng/mL) 2.53 (0.32–9.80) 2.92 (0.40–6.81)

p 0.908 0.056 0.085 0.042 0.886 0.258

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PAPP-A:Pregnancy-associated plasma protein-A, NT: Fetal nuchal translucency, b-HCG : maternal serum free beta human chorionic gonadotropin, AFP: maternal serum alpha-fetoprotein, hCG: human chorionic gonadotropin in the second trimester, and uE3:unconjugated estriol

Table 2. Distribution of first and second trimester screening test parameters according to fetal gender Male (n = 129)

Female (n = 171)

PAPP-A (mm/mL) 2.03 (0.47–15.70) 2.19 (0.67–11.70) b-hCG (ng/mL) 34.25 (10.10–116) 35.50 (8.40–110) NT (mm) 1.3 (0.60–2.70) 1.35 (0.60–2.50) AFP (m/mL) 35 (3.05–74) 32.95 (13.60–255) hCG (mm/mL) 20666 (5552–87258) 23404 (6059–70245) uE3 (ng/mL) 3.33 (0.32–9.80) 2.90 (0.40–6.81)

p 0.628 0.867 0.048 0.856 0.233 0.071

PAPP-A:Pregnancy-associated plasma protein-A, NT: Fetal nuchal translucency, b-HCG : maternal serum free beta human chorionic gonadotropin, AFP: maternal serum alpha-fetoprotein, hCG: human chorionic gonadotropin in the second trimester, and uE3:unconjugated estriol

Clinical Cases or Summary Results: In this current study, median age was 31 (20–43) years, gravity was 2 (1–6), parity was 1(1–5), and median gestational age was 21 (19–23) weeks. Of the 300 pregnant women 171 (57%) had female fetuses and 129 (43%) had male fetuses. One hundred five women (55%) had anterior and 135 women (45%) had posterior placental position. AFp values were found to be significantly higher in the posterior placenta group comparing to anterior ones (p = 0.042), and first trimester hCG values were higher in the posterior placenta group with a borderline level of statistical significance (p = 0.056). PAPP-A and NT values were identified as higher in anterior placenta group, but this finding turned out to be statistically insignificant (p = 0.908 and p = 0.085 respectively). Although high-level second trimester hCG values were observed in the anterior placenta group, and uE3 values were predominantly high in the posterior placenta group however these results failed to demonstrate the statistical differences between study groups (p = 0.886 and 0.256 respectively) When comparing groups based on fetal gender, NT values were found higher among female fetuses (p = 0.048) (Table 2). Even though PAPP-A and first trimester hCG values were found as higher among female fetuses, these results couldn’t reach the statistically significant levels (p = 0.628 and p = 0.867 respectively). While AFP and uE3 values were high in the male fetus group and second trimester hCG values were high in the female fetus group, all findings were not found to be significantly difference. (p = 0.856, p = 0.071 and p = 0.233 respectively). Conclusions: First and second trimester screening test parameters can be affected by fetal gender and placental location, but further studies are needed to confirm this argument. Keywords: Presenter: A. Ko¨s¸ u¨s¸

ID 910

PLACENTA ACCRETA AT 16 WEEKS ASSOCIATED WITH POLYFIBROMATOSIS AND CONSECUTIVE HYSTERECTOMY – A CASE REPORT A. Filipescu1, A. Boiangiu1, C. Vladu1, & R. Vladareanu 1

Obstetric and Gynecology Department, University Hospital ELIAS, Bucharest, Romania Brief Introduction: Placenta accreta is a potentially life-threatening obstetrical condition that requires a multidisciplinary approach. Placenta accreta is defined as a abnormal adherence of the placenta to the uterine wall with abnormal attachment of the placental villi through the endometrium, directly into the myometrium, due to a defective or an absent decidua basalis. Materials & Methods: Clinical Cases or Summary Results: We report a case of a patient with 16 weeks amenorrhea, polyfibromatosis and a previous cesarean section 10 years ago. At admission she was having mild vaginal bleeding and abdominal pain. She was diagnosed with incomplete abortion, polyfibromatosis and underwent dilation and curettage. Due to a massive and persistent bleeding, an ultrasound examination was required. There were identified retained adherent placenta remains and an emergency total hysterectomy was performed. The histopathological exam revealed a polyfibromatous uterus and placenta accreta adherent to isthmic fibroid tumors. Conclusions: Abnormal placentation in early pregnancy is a rare condition with few cases reported. The incidence of placenta accreta is rapidly rising worldwide correlating with the increasing cesarian rate. Keywords: abnormal placentation; placenta accreta; polyfibromatosis; emergency hysterectomy. Presenter: A. Filipescu

ID 795

CONGENITAL MALFORMATIONS, DEFORMATIONS AND CHROMOSOMAL ABNORMALITIES – NINETEEN YEARS’ EXPERIENCE J.M. Raimundo1, R. Luz1, R. Mendonc¸a1, R. Leal1, H. Machado1, A. Cunha1, S. Mineiro2, M. Mouraz3, B. Maria1, V. Gabriel1, & I. Matos1 1

Gynecology and Obstetrics Department, Centro Hospitalar de Setu´bal, E.P.E. Portugal, 2Gynecology and Obstetrics Department, Hospital Espı´rito Santo, EPE – E´vora, Portugal, and 3Gynecology and Obstetrics Department, Hospital de Cascais, Cascais, Portugal Brief Introduction: Congenital anomalies (CA) are also known as birth defects, congenital disorders or congenital malformations. CA can be defined as structural or functional anomalies, including metabolic disorders, which are present at the time of birth. Major congenital malformations occur in approximately 3 to 4 percent of live births, although minor anomalies are more frequent. Birth defects can be isolated or present in a characteristic combination or pattern.

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DOI: 10.3109/14767058.2014.924236

Although approximately 50% of all congenital anomalies cannot be linked to a specific cause, there are some known causes or risk factors: socioeconomic factors, genetic factors, infections, maternal nutritional status, environmental factors. Materials & Methods: The aim of this study was to evaluate the most frequent congenital malformations, in a single center, and assess the associated risk factors. We performed a retrospective analysis of all the congenital malformations in children born at Centro Hospital de Setubal, EPE, between 1st January 1992 and 31th December 2011. The congenital malformations were grouped according to ICD-10, chapter XVII. The aim of this study was to evaluate the most frequent congenital malformations, in a single center, and assess the associated risk factors. Clinical Cases or Summary Results: There were 36100 births with 308 congenital malformations. Classification of CA by organ systems: circulatory system 22.73% (70/308); musculoskeletal system 21.43% (66/308); genetic syndrome 17.21% (53/308); nervous system 12.01% (37/308); chromosomal abnormalities 9.74% (30/308); urinary system 6.17 (19/308); digestive system 4.55% (14/308); genital organs 3.9% (12/308); other 2.27% (7/308). Conclusions: The incidence of congenital malformations was 8.0% which was identical to that described in developed countries. Circulatory system abnormalities were the most common causes of CA. Keywords: Congenital malformations Presenter: Jose´ Miguel Raimundo

ID 173

GENITAL WARTS IN PREGNANT WOMEN M. Orelj Popic´, S. Milosˇevic´, Lj. Mladenovic´ Segedi, & G. Stajic´, Ð. Vukic´evic´ Clinic for Gynecology and Obstetrics, Clinical Center of Vojvodina, Novi Sad, Serbia Brief Introduction: Genital warts (GW) are the most common sexually transmitted viral disease. Pregnancy is a condition suitable for the expression of GW due to mild suppression of cellular and humoral immunity, increased vascularization and persistent mucorrhea. Treatment of GW in pregnancy is indicated for extensive changes with a tendency to spread. GW are an indication for Cesarean delivery when reducing the elasticity and obstructing the birth canal, or when their vulnerability can lead to increased blood loss during delivery. Materials & Methods: A retrospective study included 225 patients diagnosed with genital warts during pregnancy between April 2003rd and April 2012th at Department of Gynecology and Obstetrics in Novi Sad. Electrocoagulation was used as a therapeutic method in 92 patients with GW during pregnancy, while 181 patients with GW were delivered. Clinical Cases or Summary Results: 57% of patients were younger than 25 years, while 79% of them were primiparas. 90% of patients gave birth at term. Half of the patients were engendered by Caesarean section, in which GW were not always the only indication for termination delivery by operation. Number of patients with GW in the observed ten-year interval was from 21 to 46 in 10 000 births. In 74% of patients GW were multi- region, localized mostly at vulva and perineum. Conclusions: GW with higher rates occur in primipara younger than 25 years (p50.05). Preterm delivery has occured in 10% of patients with GW. The most common localization of GW in pregnancy are vulva and perineum. Keywords: genital warts, pregnancy, electrocoagulation, delivery Presenter: Orelj Popic´ Mileva

ID 542

MAY CIRCULATING M30 - 65 LEVELS BE A USEFUL MARKER IN DIAGNOSIS AND FOLLOW UP OF PATIENTS WITH COMPLETE HYDATIFORM MOLE? A. Incebiyik1, M. Vural2, H. Camuzcuoglu1, A. Taskin3, A. Camuzcuog˘lu1, N. G. Hilali1, & N. Aksoy3 1

Harran University, Faculty of Medicine, Depatment of Gynecology and Obstetrics, Sanliurfa/Turkey, 2Marmara University, Faculty of Medicine, Depatment of Gynecology and Obstetrics, Istanbul/Turkey, and 3Harran University, Faculty of Medicine, Depatment of Bi Brief Introduction: Complete hydatidiform mole which is a type of gestational trophoblastic disease is defined as an abnormal placentation that prone to malignant tranformasyon. Although the etiology is not fully understood, it was suggested that oxidative stress and apoptotic activity to be more common patients with complete hydatidiform mole. Our purpose of this study, to investigate prognostic value of maternal serum oxidative stress and M30 – M65 level which is accepted to denote apoptotic activity in complete hydatiform mole (CHM) patients. Materials & Methods: This study is conducted in the Departments of Obstetrics and Gynecology and Bichemistry of our institution between April 2013 and March 2014. Sixty-eight women in first trimester pregnancy are included into study. Study group (n = 34) was consisted of women who had high serum b-hCG level and confirmed hystopathological diagnosis of complete hydatidiform mole, whereas control group (n = 34) was consisted normal women in the first trimester. Venous blood sample was collected from all women in both groups to study maternal serum oxidative stress and M30 – M65 level. Additionally second blood sample was obtained in the study group on 8th day of dilatation and curettage to compare M30 – M65 level change. Clinical Cases or Summary Results: Serum oxidative stress and M30 – M65 levels were significantly higher in the complete hydatidiform mole patients (p50.001). In complete hydatidiform mole patients a positive and significant correlation was detected between b-hCG level and M30 – M65 levels (r = 0.618, p50.001 and r = 0.794, p50.001, respectively). Moreover, M65 level is found to be as efficient as b-hCG to detect complete hydatidiform mole patients (b regression coefficient: 810.21; standart error: 172.88 and p50.001). Conclusions: In the follow-up of complete hydatidiform mole patients after dilatation and curettage, serum M30 – M65 level can be an alternative laboratory parameter to b-hCG. Keywords: complete hydatidiform mole, b-hCG, M30, M65 Presenter: A Incebiyik

ID 495

OCCURRENCE OF HYSTERECTOMY IN PLACENTA PREVIA CENTRALIS PREGNANCIES D.J. Cecez1, S. Jankovic-Raznatovic1,2, Z. Mikovic1,2, L. Avramovic Hajnal1, S. Rakic1,2, A. Curkovic´1, L. J. Stankovic´1, & T. Mitrovic1 1 Department of Obstetrics and Gynecology ‘‘Narodni front’’, Belgrade, Serbia, 2Belgrade University Medical School, Belgrade, Serbia

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Brief Introduction: INTRODUCTION. Placenta previa centralis (PPC) is the most severe form of placenta previa in which the placenta is completely implanted in the uterine isthmus and entirely covers the internal os of the uterus. Good vascularity, thin endometrium, weak decidual reaction and brittleness of the lower segment of uterus allow for easy penetration and ingrowth of chorionic villi into myometrium. This may cause heavy haemorrhage accompanied by uterine atony and development of hemorrhagic shock. Hysterectomy may be required as the last resort for treating this life-threatening condition. GOAL. To investigate frequency of hysterectomies in PPC pregnancies in comparison to pregnancies with normally implanted placenta. Materials & Methods: MATERIALS AND METHODS. Occurrence of hysterectomies in 69 pregnancies terminated with cesarean section was analyzed. 31 of pregnancies were with PPC. Control group (CG) consisted of 38 pregnancies with normally implanted placenta. Maternal age, gestational age, frequency of twin pregnancies and frequency of emergency and elective cesarean sections (CS) were also analyzed. Clinical Cases or Summary Results: RESULTS. There was no statistically significant difference between the two groups in: maternal age (t = 0.183, p = 0.855), gestational age (t = 0.065, p = 0.948), twin pregnancies (p = 0.531), term pregnancies (37gw), preterm pregnancies (537gw) (2 = 0.003, p = 0.958), emergency and elective CS (2 = 0.076, p = 0.783). In the group with PPC pregnancies, hysterectomy was performed in 5 patients while none was performed in CG. Fischer’s test showed statistically significant difference in occurrence of hysterectomies between the two groups (p = 0.015). Conclusions: CONCLUSION. There is a significant occurrence of hysterectomy in the group with PPC pregnancies as comparing to CG. Thus, PPC is a significant risk factor for hysterectomy. Keywords: placenta previa centralis, hysterectomy Presenter: S. Jankovic-Raznatovic

ID 152

COLLI HYGROMA, CYSTIS HYGROMA –TURNER SYNDROM

Conclusions: PRENATAL DIAGNOSIS THAT INCLUDES prenatal screening, biochemical, cytogenetic, Ultrasound screening anomalies and timely information THEREGULAR CONSULTATIVE check is ecessary challenge in developing congenital malformations. In this case COLLI hygroma, Turner SYNDROM.

M. Sasic

Keywords:

Railway Health Care Institute, Belgrade, Serbia

Presenter: Marijana Sasic

Brief Introduction: JJ 29 years old, first pregnancy, not bolovala.Ne suffering from chronic diseases. Family history of regular, my husband also. P.M.18.05.2011 Materials & Methods: 23.06.2011.  The first ultrasound findings were normal, GM 17.4 mm, 36.8 mm CRL, visible fruitEHO 29/07/2011.  With NG11/12 findings: Cystic fragments in the cervical spine area, NT 7.9 mm 08/05/2011.  BHS: another test 1: 125, increased risk for fetal anomalies, PRO CVS 09/08/2011.  CVS Facta est 08/15/2011.  CVS Result: The normal female karyotype, 46 XX. 20.08. And 29 08.2011.  3D/4D Ultrasound Facta est: Generalized Subcutaneous EDEM, abnormal face and profile, with EXTENDED LINFNIM Jugular Sacks and CERVICAL SPIN: COLLhygroma. Clinical Cases or Summary Results: 31.08.2011. GAK NATIONAL FRONT, PATHOLOGY PREGNANCY, THE COMMISSION FOR FETAL ANOMALIES concludes that due to anomaliesabortion. Abortion INDUCTUS CUM INSTILATIO FACTA EST. 02.09.2011.  PATIENTS aborted PLODNEJASNOG HALF DEAD. 01.10.2011.  HP FINDINGS. Histopathological findings confirm: COLLI hygroma. 31.08.2011.  National GAK frond, Pathology of pregnancy, fetal anomalies COMMISSIONconcludes that due to anomalies abortion. Abortion INDUCTUS CUM INSTILATIO FACTA EST. 02.09.2011.  PATIENTS aborted dead fetus of unknown origin. 01.10.2011.  HP findings, histopathologic findings confirm: COLLI hygroma.

ID 934

COMPLET HYDATIFORM MOLE ASSOCIATED TO NORMAL PREGNANCY: CASE REPORT AND REVIEW OF THE LITERATURE S. Meddeb1, S. Mili1, J. Mathlouthi2, Ms Rhim1, H. Saidi1, & H. Khairi1 1

Department of gynaecology obstetrics university hospital Farhat Hached Sousse Tunisia, and 2Department of neonatal medecine university hospital Farhat Hached Sousse Tunisia Brief Introduction: The association between a pregnancy with normal development and a hydatiform mole in a multiple pregnancy is rare, about 1/20000 pregnancy. The number of living children at the end of these pregnancies is evaluated to 16–28%. Materials & Methods: Studies estimate differently the risk of progression to trophoblastic tumor. The risk currently used is

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DOI: 10.3109/14767058.2014.924236

equivalent to the unique complete moles, about 20%. The clinical presentation is highly variable and often, the diagnosis suspicion is made by ultrasound. Pregnancy in such situations is subject to a high morbidity: thyroid storm, pre-eclampsia, prematurity, and a considerable bleeding risk during delivery the management of patients with such pregnancies is not yet codified and the medical termination of pregnancy is not yet consensual. Clinical Cases or Summary Results: From this case, authors will discuss the different clinical call symptoms, biological and ultrasound signs together with differential diagnosis, the prognostic factors to predict the fetal future and the possibilities of evolution to gestational trophoblastic tumor, and thus guide the therapeutic approach to the medical termination of pregnancy or the preservation of pregnancy involving the couple in the decision. Conclusions: From this case, authors will discuss the different clinical call symptoms, biological and ultrasound signs together with differential diagnosis, the prognostic factors to predict the fetal future and the possibilities of evolution to gestational trophoblastic tumor, and thus guide the therapeutic approach to the medical termination of pregnancy or the preservation of pregnancy involving the couple in the decision. Keywords: pregnancy hydatiform mole Presenter: S. Meddeb

1

UMF Carol Davila Bucharest, Department Obstetrics Gynecology, Clinical Emergency Hospital Sf Pantelimon, Bucharest, Romania, and 2Department Obstetrics Gynecology, Clinical Emergency Hospital Sf Pantelimon, Bucharest, Romania Brief Introduction: The objective of our study was to see if an isolated echografic finding of mild decreased AFI in early third trimester in low risk patients is associated with adverse perinatal or maternal outcome Materials & Methods: This was a retrospective study between 2008– 2012 on pregnancies with ultrasound exam between 28 weeks and 32 weeks. We have two cohorts of patients: with AFI 8–11 (border line –low AFI) and AFI 12–19 (normal AFI) were compared for perinatal outcome. We excluded pregnancies with fetal structural anomalies, maternal hypertension, diabetes, cardiac disease, renal disease, prior preterm birth, premature rupture of membranes, uterine anomalies. Clinical Cases or Summary Results: We have 332 pregnancies that meet our criteria for analysis. Patients with border line low AFI were more likely to develop early and late premature preterm birth, delivery SGA neonate, and a higher NICU admission, and develop preeclampsia Conclusions: A mild decreased AFI in the early third trimester may be an early sign of abnormal placentation with the following high incidence of hypertensive disease and SGA noenate. Also premature birth contribute to increased morbidity Keywords: abnormal placentation, decreased amniotic fluid index

ID 009

Presenter: C. Ionescu

CESAREN SECTION IN MATERNITY HOSPITALS IN SHIRAZ, IRAN E. Zare

CESAREAN SECTION

Iran

ID 261 Brief Introduction: Objective(s): To assess the cesarean rate and related factors in maternity hospitals in shiraz.iran Materials & Methods: Material & Methods: This was a cross-sectional study using data from 824 pregnant women via a two step random sampling. A standardized form was completed for each mother, collecting past and present obstetric history and demographic characteristics. Clinical Cases or Summary Results: Results: 66.5% of mothers delivered by cesarean section & 33.5% vaginaly. 72% of cesareans were elective. Of these 22% were done because of maternal request and 71% of mothers who requested cesarean had no logic reason for their request. Also 65% of doctors suggested cesarean for their patients without any true medical indications. The majority of cesarean sections were performed in private hospitals (84% in private vs. 47% in public hospitals (p50.0001). Conclusions: Conclusion: The results show significant variability among hospitals when opting for cesarean section. Also, the results indicate that, cesarean section is widely performed for non-medical reasons Keywords: Presenter: E. Zare

ID 879

PERINATAL OUTCOME IN PREGNANCIES WITH MILD DECREASED AMNIOTIC FLUID INDEX IN EARLY THIRD TRIMESTER C. Ionescu1, D. Gheorghiu2, I. Pacu1, H. Ha1, C. A. Coroleuca2, & M. Banacu2

PREGNANCY OUTCOME AFTER INDUCTION OF LABOR IN WOMEN WITH PREVIOUS CESAREAN SECTION E. Ashwal, L. Hiersch, N. Melamed, A. Wiznitzer, M. Hod, Y. Yogev Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Brief Introduction: As conflicting data exist concerning the safety of induction of labor (IoL) in women with previous single lower segment cesarean section (CS), we aimed to assess pregnancy outcome following IoL in such patient population. Materials & Methods: All singleton pregnancies with previous single CS which underwent IoL during 2008–2012 were included (study group). Their pregnancy outcome was compared to those pregnancies with previous single CS that admitted with spontaneous onset of labor (control group). Clinical Cases or Summary Results: Overall, 1,898 pregnancies were eligible, of them, 259 underwent IoL, and 1,639 were admitted with spontaneous onset of labor. Parity, gestational age at delivery and birthweight were similar. Women in the study group were more likely to undergo CS mainly due to labor dystocia (8.1% vs. 3.7%, p50.01). The rate of CS due to non-reassuring fetal heart rate was similar. No difference was found in the rate of uterine rupture/dehiscence. Short-term neonatal outcome was similar between the groups. On multivariable logistic regression analysis, IoL was not independently associated with uterine rupture (OR 1.33, 95% C.I 0.46–3.84, p = 0.59) Conclusions: Our data suggest that IoL in women with one previous low segment CS neither increases the risk of uterine rupture, nor adversely affects immediate neonatal outcome.

46 Keywords: Induction of labor; cesarean section; uterine rupture; pregnancy outcome

uterin rupture frequencies and bring up a method protection that decreases cesarien ratios.

Presenter: Eran Ashwal

Keywords: Rat, uterus, cesarean, scar, rupture, wound healing, adipose tissue derived mesenchymal stem cells.

ID 420

THE EFFECT OF ADIPOSE TISSUE-DERIVED MESENCHYMAL STEM CELLS ON REGENERATION OF UTERINE SCARS R. A. Bender1, A. Yucel1, V. Noyan1, A. Gurpinar2, P. Atasoy3, & F. M. Comu4 1

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Obstetrics and Gynecology Department, University Hospital of Kirikkale, Kirikkale, Turkey, 2Biology Department, University of Hacettepe, Ankara, Turkey, 3Pathology Department, University Hospital of Kirikkale, Kirikkale, Turkey, and 4 Physiology Department, Brief Introduction: An approach to induce healing of uterine scars and introduce similar histomorphology to normal tissue will reduce the risk for uterine rupture in pregnancy. These stem cells, differentiate into normal mesenchymal cells of uterus, when used at the healing period of wound, ultimately leading to wound healing. In this study, by introducing uterine incision in rats, our aim is toevaluate the primarily suturated wound healing in terms of tissue tensile strength and hystopathology and to identify the positive impacts of adipose tissue derived mesenchymal stem cells on wound healing. Materials & Methods: We used 19 female Wistar Albino rats, at the same age and weighted between 250- 300 grams in the study. Randomly selected 3 rats were used for producing adipose tissue derived mesenchymal stem cells. The rest 16 rats were randomly divided into two groups as study group and control group, each group involving 8 rats.In the control group, left uterin horn was incised and only primarily suturated. In the study group, left uterin horn was incised, primarily suturated and subsequently adipose tissue derived mesenchymal stem cells were put into the incision area. Clinical Cases or Summary Results: As expected, weights of the incised horns were significantly lower comparing to the intact horns in control group (p = 0.012); in the study group, weights were significantly high (p = 0.012). Evaluating the tissue tensile strength, incised horns had significantly reduced tensile strength in comparison with not incised horns (p = 0.012); but in the study group, no difference was observed between the incised and not incised horns (p = 0.123). When we compared the not incised horns of the study and control group, there was no significant difference in terms of weight and tissue tensile strength (p = 0.06, p = 0.07, respectively). In addition, we found no significant weight difference between the incised horns of study and control group (p = 0.07); in terms of strength, study group had higher value (p = 0.04). Considering the pathologic results, hystopathologic scoring values were not significantly different between the study and the control group. Investigating the incised horns, control group had significantly higher amount of edema and mononuclear cell infiltration and there was no other significant difference. In the study group, comparison of the histomorphologic results of the incised and not incised horns, amount of hemorrhage, dehiscence and angiogenesis revealed a significant induction in the incised horns (p = 0.049, p = 0.049, p = 0.048, respectively). In the control group, incised horns had only significantly more monouclear cell infiltration than not incised horns. Conclusions: In conclusion, adipose tissue derived mesenchymal stem cells, induces the tissue tensile strength and make angiogenesis more effective during the wound healing. When used right after the suturation, these cells may prevent the uterine rupture in the subsequent pregnancy. Prospective studies about the use of adipose tissue derived mesenchymal stem cells for wound healing, may lower

Presenter: Rukiye Ada Bender

ID 293

REDUCING CAESAREAN SECTION RATE: HOW TO OPTIMISE INTERVENTIONS? A. Pin˜as1, E. Ofori-Asare1, & E. Chandraharan1 1

St George’s Healthcare NHS Trust, London, UK

Brief Introduction: Caesarean section rate has been increasing over the last 40 years and the rate of c.sections in most developed countries now exceed 20%. In the UK, the rate of caesarean sections has increased from 9% in 1980 to 25% in 2011–12 and in London, the average caesarean section rate has been reported to be 28%. Such dramatic increase in caesarean sections not only increase healthcare costs but also may increase maternal and fetal morbidity and mortality, including morbidly adherent placenta. Materials & Methods: The objective of our study is to assess the caesarean section rate at a large, tertiary referral centre in London according to the Robson’s 10 Group Classification to determine areas for optimum interventions so as to reduce the rate of caesarean sections. Records of births were obtained from the Maternal Data System (Euroking) at St George’s Hospital, London for the last 5 years (2008–12). Indications for caesarean sections were classified according to Robson’s 10 group classification system and a direct comparison was made in between the different groups over the 5-year period. Clinical Cases or Summary Results: St George’s Maternity Unit had 25735 deliveries over the 5 year period analysed, with an overall Caesarean section rate that has been progressively decreasing from 25% in 2009 to 22% in 2011. Most births occurred in Groups 1 and 3 (single cephalic, 437 weeks, both nullipara and multipara). The rate of Caesarean section in Group 1 (nullipara single cephalic, 437 weeks, spontaneous labour) ranged from 14.3 (2009) to 9.5% (2011) and the rate in Group 3 was especially low (52%). The CS rate in group 5 (previous CS, single, cephalic, 437 seeks) was constant (60%) throughout the five years. Consequently, this group was the major contributor to the overall CS rate around 6% (range 5.5–6.8%). The rate in Groups 6 and 7 (all nullipara and multipara, breech) was around 90% for nulliparas and 80% for multiparas, reflecting the current tendency to opt for a Caesarean section in breech presentation. The CS rate in Group 8 (all multiple pregnancies) has been progressively decreasing to 58% over the 5-year period. Conclusions: Despite our increasing complexity, our rate of emergency caesarean sections for nulliparous and multiparous women who are admitted with spontaneous onset of labour is one of the lowest in London, reflecting excellent intrapartum management, including physiology base CTG training, use of fetal ECG (ST-Analyser) and hands-on training in operative vaginal delivery. The two groups that contributed most to the overall number of CS at St George’s Maternity Unit were Groups 2 and 5 (induction of labour and previous c.sections). Therefore, these are the primary target groups that need urgent intervention to reduce the CS rate. Systematic analysis of caesarean section rate using the Robson’s classification system appears to help identify areas for optimising interventions. Keywords: Caesarean section, Robson’s criteria Presenter: Ana Pin˜as

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DOI: 10.3109/14767058.2014.924236

ID 337

ID 287

THE RELEVANCE OF THE SKINTO-SKIN CONTACT FATHER AND BABY AFTER THE CAESAREA

THE DECLINING RATE OF VBAC IN A IRISH TERTIARY REFERRAL CENTRE

V. Cortesao Travesset1, S. Capdevila Bet2, M. C. Roig Garcia3, E. Borra`s Bentanachs4, & N. Martinez Coso5

M. Farren, A. Mullally, N. Daly, A. Mc Keating, M. Turner, & N. Farah

1

UCD Centre for Human Reproduction, Coombe Women and Infant’s University Hospital, Dublin, Ireland.

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Hospital Arnau De Vilanova, Lleida, Spain

Brief Introduction: WHO recommends setting the skin to skin contact between infants and mothers already that reported positive results and benefits in short term like the maintenance of temperature, reforges successfully breastfeeding establishment, the decline often crying and favoring the link between mother and son. However, the increase of the interventionism in the labour birth and the practice of caesarean sections can disturb this interaction between mother and son, leading to certain harmful effects on the new born. In recent times, it has stimulated a more active participation by fathers, in the whole process of the birth. In this context, fathers have the possibility to acquire a notable role in the skin to skin contact with babies in caesarian cases, increasingly common in today. Materials & Methods: Proceeded to a literature review, through databases considered to be of particular relevance in health sciences, such as PubMed, CINAHL and Scielo. As a search strategy, we used the key words: ‘‘skin-to-skin’’ AND ‘‘Father * ’’ AND ‘‘Caesarean’’. It was conceded literature published in the last ten years, and were considered original articles under a methodology developed both qualitative and quantitative. It excluded all scientific production covering situations of neonatal intensive care or studies on new born phase in pre-term. Clinical Cases or Summary Results: In response to the proposed objective, recovered a total of 4 articles. All of them noted to the benefits that provides the skin-to-skin contact for new-borns with their respective fathers. In one of these articles, we obtained a experimental study with 29 randomly selected parents, and was distributed in a group of fathers that kept the skin-to-skin contact with their children, while in the other group, only stood to the side of the crib. We recorded the crying of such infants and described their behaviours based on the Neonatal Behavioural Assessment Scale (NBAS). The results demonstrated the positive impact that has the skin-to-skin contact for the child, because it diminishes the crying and favours the dream, thereby reducing the state of wakefulness of new-borns. In addition, it should be noted that in other articles recovered, it was demonstrated that the skin-to-skin contact between father and child, immediately after the caesarean section, promotes the vocal interaction between both, reinforcing an early appearance of the bond father-infant. Finally, a recent study analysed the perception of 14 fathers about their personal experiences, through in-depth interviews. The results showed that parents perceive the need to be involved in the skin-to-skin contact, and stresses the importance of health professionals in promoting this practice. Conclusions: Results were demonstrated positive and beneficial to promote the practice of skin-to-skin contact with the father after the practice of caesarean section. In addition, it should be noted that none of the reviewed articles not found harmful results about the skin-to-skin contact between fathers and their children. Despite all this, there are few scientific publications about the skin-to-skin contact between fathers and their infants that we deem it appropriate to encourage the development of more research on this subject of study. Keywords: ‘‘skin-to-skin’’, ‘‘father’’, ‘‘caesarean’’ Presenter: V. Cortesao Travesset

Brief Introduction: The promotion of VBAC has been of interest since the 1950’s when trial of labour was deemed safe. Concern regarding the morbidity associated with repeat LSCS led to the drive to promote Trial of Labour and Vaginal Birth after Caesarean. In the last decade the trend has been that of a decline in the VBAC rate. In the UK, the rates quoted nationally for the year 2001 ranged from 6% to 64%. In the US the rates have remained at approx 10%. In Ireland, to date there are no published figures. Materials & Methods: Our data was sourced from computer-stored records. The records compared the difference in VBAC rate among Para 1 in 2011 and 2005. Included were all Para 1 who had one previous LSCS. The outcome (Elective LSCS, Emergency LSCS or VABC) was determined and expressed as a percentage. Clinical Cases or Summary Results: Results reveal a declining VBAC rate. The overall rate fell from 33.1% VBAC rate in 2005 to 23% in 2011. In 2011, 56% had an elective LSCS. Of those who laboured, 52% (n = 166) had a VBAC, 47.6% (n = 151) had an Emergency LSCS. This was in comparison to 2005 where 42% had an Elective LSCS. Of those who laboured, 56.2% (n = 189) had a VBAC, 43.75% (n = 147) had Emergency LSCS. Conclusions: It is clear our VBAC rate is falling. However, it is the group that opt for repeat elective section that require the most focus. For those that opt for trial of labour the chance of VBAC is high. Keywords: Vaginal Birth after Cesarean, Trial of Labour Presenter: Dr. Maria Farren

ID 103

COMPARISON STUDY BETWEEN PREVIOUS ONE AND MULTIPLE CESAREAN SECTION IN ORDER TO ESTIMATE FETAL AND MATERNAL MORBIDITY IN HIGH ORDER CESAREAN SECTION K. Hwissa Obstetric and Gynecology Department, Zawia Teaching Hospital, Zawia, Libya Brief Introduction: Cesarean section considered as safe surgical procedure.Worldwide incidence of cesarean births has increased markedly. The increasing rate of cesarean section poses a threat in the developing world where family size has not dipped to the low levels seen recently in industrialized countries. Large family size is desired and sterility is not acceptable so the prevalence of multiple previous cesarean sections is high. About one third of cesarean section are repeat procedures which associated with increased maternal and neonatal morbidity Materials & Methods: To assess the maternal and neonatal risk associated with high-order cesarean sections, a prospective study was carried out in Zawia hospital maternity wards. There the patient interviewed in the labor word and a performed case sheet filled with

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specific data. The outcome of 458 case, 218 women undergoing cesarean section for the 3rd time or more was compared with 240 women sectioned for the 2nd time previous one cesarean section(p1c/s), the outcome measures were antenatal complication, maternal operative and postoperative morbidity and neonatal prematurity, Apgar scores, and the need for intensive care Clinical Cases or Summary Results: The antenatal complication is more in group of (P2c/s), placenta previa 9(3.7%) versus 3(1.3%), and abruption 8(3.3%) versus 1(o.4%). Intra operative complications found in 17.7% of the cases, 14.2% of the patients with p1c/s comparing with 20.8% with p2c/s. Intra peritoneal adhesions more in women with (P2c/s) (10.8%) comparing with P1c/s(8.7%), the need for blood transfusion in(5.0%) with p2c/s compared with P1c/s (4.1%). The mean duration of operation for patients with P1c/s 41.5 minutes and with 4p2c/s 47.8 minutes. Neonatal morbidity rate (20.9%). there was an increased number of Preterm baby in study group Conclusions: High order repeat cesarean section carry risk of intra operative and post operative complication in particularly, placenta previa and acreta and risk of blood transfusion. And also neonatal morbidity is increased

Patients with spontaneous and augmentation of labour had more chance for VB and there is statistically significant relationship between onset of labour and mode of delivery (P4000gm is 22%. No significant association found in the outcome of labour with regard to age. Short women5150 cm were found to have a tenfold risk of having CS as compared to tall women. Risk of maternal infection and infants born with Apgar score57 were more among women who had failed TOL (p50.012). Neither maternal mortality nor scar rupture has been recorded in this study. Conclusions: Maternal age has no influence on the outcome of labour after CS, while previous indication of CS, maternal height and birth weight have a greater effect once the uterus has been scarred. TOL has been accepted as a way to lower the overall CS rates, therefore, women ought to be encouraged to give birth to the next child vaginally with more attention to individualized risk assessment.

Keywords: Cesarean section rate, multiple cesarean section, maternal morbidity, fetal morbidity

ID 918

Presenter: karima Tayeb Hwissa

ID 643

VAGINAL BIRTH AFTER CESAREAN SECTION,(TRIAL OF SCAR) AT MISURATA TEACHING HOSPITAL, LIBYA A. Elbareg1, I. Elarbah1, & F. Essadi1 1

Misurata Teaching Hospital, Libya

Brief Introduction: Backgrounds &objectives: Vaginal birth after one previous cesarean section (VBAC) represents one of the most challenging issues in obstetric practice. Cesarean section (CS) rates rose markedly at our hospital to 33 percent in 2013 from 14 percent 15 years back. Pregnant women with previous section may be offered either planned vaginal birth after CS (VBAC) or elective repeat cesarean section (ERCS). In our community, large family usually practiced, therefore, trial of scar is a key step toward reducing the high rate of repeat CS. The aim of this study is to analyze the outcome in patients who were allowed to undergo trial of previous scar (TOL) in relation to their: age, height, birth weight (BW) and indication of previous scar. Materials & Methods: Prospective controlled study for two years (January 2012 through December 2013). 150 selected patients with one previous CS who had undergone spontaneous, augmentation or induction of labor at department of obstetrics & gynaecology, Misurata Teaching Hospital. Inclusive criteria were: maternal age (20–45) years, indication of previous CS, onset of labour, history of vaginal birth (VB) before CS, BW, apgar score, and indication of repeated CS. Patients excluded: twin’s gestation, malpresentation, previous myomectomy scar, medical problems during pregnancy and more than one previous CS. During labour, CPD excluded, continuous CTG, also ultrasound estimation of fetal weight was performed for every patient. Data analysed using chi-square test and P-value considered to be significant if 50.05. Clinical Cases or Summary Results: All 150 patients attempted TOL: 92(61.33%) had successful VB and 58(38.66%) had CS. 30(20%) patients had their previous CS for recurrent cause: 13(43.33%) delivered vaginally and 17(56.66%) had failed T.O.L. 120(80%) patients with non recurrent cause: 79(65.83%) had successful VB and 41(34.16%) had failed T.O.L. The relation between recurrent and non recurrent causes are statistically significant (p50.05).

Keywords: Vaginal birth, cesarean section, trial of scar Presenter: Aisha Elbareg

IS THE NEONATAL MORBIDITY OF ELECTIVE CESARIAN SECTION BEFORE 39 WEEKS OF GESTATION AVOIDABLE? O. Kaabia1, S. Meddeb1, M. Bibi1, R. Fatnassi2, & H. Khairi1 1

The Gynecology and Obstetrics department of Farhat Hached University Hospital in Sousse, Tunisia, and 2 The Maternity center of Ibn El Jazzar Hospital in Kairouan Tunisia Brief Introduction: The indications of elective cesarian sections (ECS) are increasing. It is common knowledge that the ECS have a high nenatal morbidity leading to high medical expenses. The hypothesis of this work is that Before 39 weeks of gestation (WG), ECS in off labor women have a high preventable neonatal morbidity. Materials & Methods: It is a retrospective study including all the 5564 infants born at 37 through 40 weeks of gestation and 6 days of an ECS off labor. Were excluded all patients with abnormal pregnancy including twins, the cesarian section during labor and all the still borns. We compared the neonatal morbidity detween the group of infants born before and after 39 WG. Clinical Cases or Summary Results: Respiratory distress was higher in the group of children born before 39 WG (36% vs 29%) but the difference was not statistically significant (p = 0.055). There was no significant difference in terms of Apgar’s scores, of mean birth weight or of neonatal mortality. Conclusions: The neonatal adaptation to the extra-uterine environment is different in infants born after 37 WG. This information should be given to the families among to the higher risk of neonatal morbidity especially respiratory distress in case of Early term programmed ECS. Keywords: Presenter: S. Meddeb

ID 894

VAGINAL BIRTH AFTER C-SECTION AT DONOSTIA UNIVERSITARY HOSPITAL N. Marin, M. Lure, J. Navarrina, & A. Lekuona

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DOI: 10.3109/14767058.2014.924236

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Dept of Obstetrics and Gynecology. Donostia Universitary Hospital. San Sebastian, Guipuzcoa, Basque Country, Spain Brief Introduction: C-Section rates have been increasing all around the world in the last years. In our Hospital, applying evidence based protocolos we have been able to achieve a very good cesarean rate of 14.7% in 2013. This good results are influenced by our politics of trial of labour after cesarean section in allmost every women who come to our Hospital for labour. The only situations were we offer a programmed C-section after one previos cesarean are those in common for women without any scar in the uterus (such as placenta previa or breech presentation) and if the first cesarean was made with a longitudinal incision in the uterus. Materials & Methods: We made a retrospective annalisys of our database of women on labour at Donostia Universitary Hospital. From 3887 women that were in labour, 164 had a previos c-section. we annalized different characteristic of this women and compared them with the group of patients that did not have a previos c-section. We annalized: number of C-section (%), % of induction and delivery mode (c-section, espontaneous or operative delivery), influence of women age and gestational age on c-section rate Clinical Cases or Summary Results: C section rate was 26.8% in previos c-section group vs 11.2% Induction of labour was more frecuent en the previous c-section group (52% vs 48%). In the previous c-section group, been induced was a risk factor for a second c- section, with a cesarean rate of 30% and also deliverys were more frecuently operated (42% in the induction group vs 28% in the espontaneous group) This situation was similar in the group without previous c-section, with a cesarean rate of 7.57% when the labour beggins spontanously compared to 11.88% in the induction group. The % of spontanous delivery was aslo smaller in the induction group (72.7 vs 84.2%) In both groups, we observed a higher c-section rates when the babies were born before 41 weeks of gestation and in mothers younger than 40 years We had 3 cases of uterine rupture in women with previous c-sections Conclusions: Trial of labour after c-section is a good and safe option for the women that come to our hospital. We should offer this information to women, so that they feel secure and understand when we offer trial of labour after c-section We are now working very hard trying not to induce labour without serious medical reasons to decrease the risk of a c-section in our patiens. Keywords: previous cesarean section, vaginal birth Presenter: N. Marin

ID 947

SAFETY AND EFFICACY OF CARBETOCIN IN HYPERTENSIVE PREGNANT WOMEN UNDERGOING CESAREAN DELIVERY W.A. Sayed Ahmed, Z. M. Ibrahim, I. Mostafa, E. A. Kishk, & M. A. Elbahie Suez Canal University Hospitals, Ismailia – Egypt Brief Introduction: The efficacy of carbetocin in preventing postpartum hemorrhage is well established but according to the latest Cochrane review in 2012, its safety in hypertensive pregnant women is not yet well established.

The aim of the study is to evaluate the effectiveness of carbetocin in reducing the blood loss during and after cesarean delivery in hypertensive women in comparison to oxytocin. In addition, the effects of both medications on the hemodynamic profile as well as clinical parameters are also assessed. Materials & Methods: In this single blind randomized trial and after approval of the hospital ethics committee, 80 hypertensive pregnant women with singleton pregnancies undergoing elective or emergency cesarean delivery were allocated into two groups, 40 patients each. Group A received 100 mg carbetocin as slow bolus injection over one minute and group B received 10 IU of oxytocin intravenously; both after delivery of the placenta during cesarean section (CS). All types of hypertension (chronic, gestational and pre-eclampsia) were included. All women with risk factors for excessive blood loss were excluded e.g. those with placenta previa and abruption. Primary outcome measures were the amount of blood loss and the effect of the medications on the hemodynamic profiles. Secondary outcome measures were the reported side effects. Clinical Cases or Summary Results: Both groups were matched in age, parity, the number of prior CS, types of hypertension included as well as the numbers of elective and emergency CS. The estimated amount of blood loss was significantly lower in the carbetocin vs the oxytocin group (323 mls vs 673 mls; p value 40.005). Carbetocin use was associated with post-operative lower levels of mean arterial pressure blood pressure, (109 vs 114 mmHg) as well as significantly higher levels of hemoglobin and hematocrit (11.2 vs 9.5 gm/dl and 33.6 vs 26.4% respectively). No significant difference was noted in hemodynamic alterations between the two medications. Slight rise in temperature was noted in 20% of those used carbetocin while nausea, vomiting and sweating were reported more frequently in the oxytocin group. Conclusions: The use of carbetocin in hypertensive pregnant women undergoing cesarean delivery appears to be safe and provides significant control of blood loss compared to oxytocin. Tolerable side effects were noted with the use of both medications. Keywords: Hypertension during pregnancy, Carbetocin, Oxytocin, Safety, Efficacy Presenter: Waleed Ali Sayed Ahmed

ID 170

RESPIRATORY MORBIDITY OF NEONATES BORN WITH ELECTIVE CESAREAN SECTION BETWEEN 34 WEEKS AND 39 WEEKS OF GESTATION M. Mihelak1, A. Ilijasˇ Trofenik3, S. Trajkovicˇ3, & J. Koren4 1,2,3

Neonatal unit, Departement of Gynecology and Obstetrics, General hospital Celje, Celje, Slovenia, and 4Departement of Gynecology and Obstetrics, General hospital Celje, Celje, Slovenia Brief Introduction: By current guidelines, antenatal corticosteroid treatment is indicated in all obstetric patients expected to deliver between 24 and 34 weeks of pregnancy. Delivery by elective cesarean section also lacks influence of natural corticosteroids during delivery, contributing to respiratory problems among late pre-term and early term neonates, which by current guidelines do not recieve antenatal corticosteroid treatment. The aim of this study was to determine the incidence of respiratory complications in newborns between 34 weeks and 39 weeks of gestation, delivered by elective cesarean section compared to the same gestational age group of neonates with delivery started vaginally but finished either vaginally or by urgent cesarean section in our regional hospital.

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Materials & Methods: The retrospective observational populationbased study included neonates born from 1.1.2013 to 31.12.2013 between 34 weeks 0 days and 38 weeks 6 days of gestation in our regional hospital in Celje, Slovenia. We separated newborns delivered with elective cesarean section (CS) from those deliveries that started vaginally and ended either vaginally or with urgent CS. We observed whether neonates developed respiratory distress syndrome (RDS) or transient tachypnea of newborn (TTN). Clinical Cases or Summary Results: We included 387 newborns. Of 6 newborns in the late preterm group (34 to 36 week) delivered by elective cesarean section, 1 (16%) developed RDS that needed transport in a tertiary centre with intensive respiratory care and 3 (50%) developed TTN. In the control group of 76 late preterms, that started delivery vaginally, 6 (7.8%) developed RDS and 6 (7.8%) developed TTN. There were 51 elective CS in the early term group (37 to 38 weeks), and one had TTN. 154 were born in the control group, 1 (0.6%) developed RDS and 2 (1.2%) developed TTN. Conclusions: The elective CS increased the risk of TTN and RDS in late preterm and early term neonates. Antenatal corticosteroid treatment 48 hours before elective CS could contribute to reduction of respiratory problems mainly in late preterm and possibly also in early term neonates. Keywords: pregnancy, late preterm neonate, transient tachypneoa of neonates, respiratory distress syndrome, elective cesarean section Presenter: Mojca Mihelak

ID 454

INHALATION ANESTHESIA WITH SEVOFLURANE VERSUS SPINAL ANALGESIA IN PERFORMING EXTERNAL CEPHALIC VERSION C.S. Pin˜el Pe´rez, A. Castillo Martı´n, N. Pe´rez Pe´rez, J.E. Asenjo de la Fuente, N. Izquierdo Me´ndez, M.A. Herra´iz Martı´nez Hospital Clı´nico San Carlos, Madrid, Spain Brief Introduction: The background of this study is to analyze main differences in performing of external cephalic version (ECV) by using sevoflurane inhalation anesthesia versus spinal analgesia, by analyzing procedure success rate, neonatal outcomes, complications and costs. Materials & Methods: We have designed an analytic study of all the primigravid patients with fetus in a breech presentation during the third trimester ultrasonography exam, who were performed a ECV, since February 2008 to December 2013. We have distributed the study population into two groups, by anesthetic technique (group 1, sevoflurane inhalation anesthesia; group2, spinal analgesia). Sevoflurane is a halogenated anesthetic with a low partition bloodgas coefficient (0.65), nor irritating nor pungent, that provides a quick and gentle induction, likely to intravenous anesthesia. When analyzing efficiency of each intervention we have included the cost of personal, medicines, hospital stay, infrastructures, surgical material, etc. Statistical analysis was performed by using statistical software STATA 12.0. We have analyzed differences between two groups of patients with ji-squared for categorical variables and t de Student for quantitative variables. We have performed multiple and lineal regressions and chunk tests to study possible confusion factors and interactions between variables and normality tests to asses our sample is representative of global population.

Clinical Cases or Summary Results: 69 patients have been included in the study and distributed into two groups: sevoflurane (group1, 57 patients) and spinal analgesia (group 2; 12 patients). Both groups were similar in most of main features (Table 1 and 2), with exemption of gestation course and gestational age at ECV. Procedure success rate was 63.16% (50.30%-46.02%) in sevoflurane group and 16.67% (95%CI:-5.76%-39.10%) in spinal analgesia group (ji-squared p = 0.003), with success proportion difference 46.49% (95%CI:16.56%-76.42%). There were not statistical differences in procedure complications (p = 0.788). Neonatal outcomes were similar into both groups: newborn weight (p = 0.741), APGAR (0.534). Umbilical artery pH was lower in sevoflurane group (p = 0.028), but its mean was 7.242. So, different is statistically significant, but not clinically important. Vaginal delivery rate was 50.00% (95%CI:36.28%-63.72%) in sevoflurane group, and 16.67% (95%CI:-5.77%-39.11%) in spinal analgesia group (ji-squared p = 0.035). Global cost was 2675E (2483.143E-2867.857E) in sevoflurane group and 3141.667E (95%CI:2795.422E-3487.911E) in spinal analgesia group (t-test p = 0.036), with mean gain of 466.67E (95%CI:32.15E-901.18E) by using sevoflurane. Conclusions: - ECV success rate was significantly higher in sevoflurane group (63.16%). With 95% confidence, we can affirm minimal difference in success rate between the use of sevoflurane and spinal analgesia for performing ECV is 16.56%. – There were not significant or clinically important differences in complications rate or neonatal outcomes between both anesthetic techniques. – Vaginal delivery rate was 50% in sevoflurane group, significantly higher than spinal analgesia group (16.67%). – Sevoflurane utilization for performing ECV was significantly more efficient than spinal analgesia, with a mean saving of 466.67E. With 95% confidence, minimal saving is 32.15E. – However, our spinal analgesia group number of patients is quite small, so it would be necessary to design future studies with bigger population in this cohort. Keywords: external cephalic version, cesarean section, sevoflurane, spinal analgesia Presenter: C.S. Pin˜el Pe´rez

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ID 145

THE SAFETY OF THROMBOPROPHYLAXIS SOON AFTER SURGERY WITH LOW MOLECULAR WEIGHT HEPARINS IN OBESE WOMEN UNDERGOING CESAREAN SECTION Y. S. Kim, S. D. Choi, J. G. Sunwoo, & D. H. Bae

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Obstetrics and Gynecology Dept., University Cheonan Hospital of Soonchunhyang, Chunan, Korea Brief Introduction: Obesity means that body mass index (BMI) is over 30. Obese patients increase complications like as endometritis, venous thromboembolism (VTE), pulmonary embolism (PE) after cesarean section. LMWH has recently been used for thromboprophylaxis soon after cesarean delivery. However, the manufacturer’s instructions recommend its use 24 h, not soon, after surgery, in principle. But, these days many studies have been showed that thromboprophylaxis with early administration of LMWH did not increase the incidence of hemorrhagic complications compared with unfractionated heparin (UH). Materials & Methods: We performed retrospective study of pregnancies registered and managed in our hospital from January 1st, 2009 to December 31st, 2013. We administered UH in the first half of the study period (n = 50), and LMWH (nadroparin) in the latter half (n = 50) for two days postoperatively. We examined the incidence rate of hemorrhagic complications and preoperative and postoperative activated partial thromboplastin time (aPTT), and we compared these in cases using UH and LMWH. Clinical Cases or Summary Results: No clinically discernable thromboembolism occurred in either group. Hemorrhagic complications occurred in two of 50 women in the UH group and none of 50 women in the LMWH group. LMWH did not prolong the aPTT. But, UT prolonged aPTT significantly. Conclusions: Compared with thromboprophylaxis with UT, thromboprophylaxis with early administration of LMWH after cesarean section did not increase the incidence of hemorrhagic complications and prolongation of the aPTT in our study. Keywords: thromboprophylaxis, LMWH, cesarean section Presenter: Y.S. Kim

2012. Although caesarean section (CS) is often performed because of the previous caesarean birth, abnormal presentation of the foetus, multiple pregnancy and preterm labour, CS in nulliparous women with a single vertex pregnancy at 37or more weeks constitute more than one third of all caesareans. The aim of our study was to determine the socio-demographical and medical factors, which increase the odd to deliver by both elective and emergency CS. Materials & Methods: Cross-sectional retrospective study was conducted in 8 obstetric hospitals, (7 - at second level of reference and 1 at third level of reference) in the Central and South East Poland. Standard questionnaires were applied to 150 women after delivery in each hospital: Pregnancy Cards were filled in on the basis of hospital documentation; all women were also interviewed on regarding care during pregnancy. Clinical Cases or Summary Results: The analyzed population constituted of 476 nulliparous women with a single vertex pregnancy at 37 or more weeks. In 64.9% of them the onset of labour was spontaneous, in 25.6% the labour was induced and in 9.5% the CS was performed before the onset of labour. 36.7% of the analysed group delivered by CS: 23.6% of women after spontaneous onset of labour and 45.1% of women after induction of labour. Among CS in the analysed group 36.3% were elective and 63.7% were emergency CS. Among CS performed before the onset of labour 95.6% were elective, while 77.8% of women with spontaneous onset and 94.4% of women after induction of labour underwent emergency CS. The main causes of elective CS in the analysed population were chronic diseases (36.3%), cephalo-pelvic disproportion (22.7%) and macrosomia (12.1%), whereas the major causes for emergency CS - threatening intrauterine asphyxia (39.1%), obstructed labour (39.1%) and high straight head position (10.9%). The odds of delivery by elective CS was related to the maternal age above 35 years (p50.001) and the hospital of birth (p = 0.001), irrespective of adjustment for educational level of the mother, her economic situation, place of residence, BMI before pregnancy and type of the health centre where the care in pregnancy was provided. The odds of delivery by emergency CS was not related to the hospital of birth (p = 0.285) but it was related to maternal age above 35 years (p = 0.011) and the induction of labour (p50.001). Conclusions: There are differences in rates of planned - but not emergency- caesarean sections between the analysed hospitals. These differences may reflect diversity of maintained procedures concerning CS between centres. The other factors increasing the odd of delivery by CS were: older age of mother (for both elective and emergency CS) and induction of labour (for emergency CS). Keywords: cesarean section, elective CS, emergency CS Presenter: Tomasz Maciejewski

ID 824

RISK FACTORS FOR ELECTIVE AND EMERGENCY CAESAREAN SECTION AMONG FULL-TERM NULLIPAROUS WOMEN WITH A SINGLE VERTEX PREGNANCY E. Mierzejewska1, K. Szamotulska1, T. Maciejewski2, & M. Troszynski3 1

Department of Epidemiology, National Research Institute of Mother and Child, Poland, 2Department of Obstetrics and Gynaecology, National Research Institute of Mother and Child, Poland, and 3Department of Reproductive Health, National Research Institute of Brief Introduction: The rate of caesarean births is high in Poland and in the past decade has risen radically, from 23.1% in 2002 to 37.1% in

ID 523

ANALYSIS OF THE CAESAREAN SECTION RATE USING THE ROBSON TEN GROUP CLASSIFICATION AND ITS RELATIONSHIP TO THE NEONATAL OUTCOME F. Saner1, U. Gobrecht-Keller1, A. Osterwalder1, M. Scharfe2, A. Kind1, & I. Hoesli1 1

Department of Obstetrics, University Hospital Basel, Basel, Switzerland, and 2Clinical Trial Unit, University Hospital Basel, Basel, Switzerland

52

J Matern Fetal Neonatal Med, Early Online: 1–437

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Brief Introduction: Why does the caesarean section rate rise all over the world? Is there an ‘‘ideal’’ section rate in regard of the neonatal outcome? A classification system for patients undergoing a caesarean section (CS) as proclaimed by Robson et al. 2001 is helpful to understand the worldwide increase of the CS rate by allowing a comparison of national and international hospitals as much as the changes over time within one hospital (1). The aim of this study was to analyse all births and the CS rate at University Hospital Basel 2013 using the Robson ten group classification (RTGC) and to compare our RTGC results with already published RTGC data from Ireland (2). Further we intended to find out whether there is a relationship between the CS rate and the neonatal outcome for the 10 groups. Materials & Methods: All 2229 patients who delivered at the University Hospital in Basel 2013 were prospectively classified into one of 10 RTGC due to parity, gestational age, onset of labour, fetal presentation, single/multiple pregnancy and previous caesarean section.

Mode of delivery (CS vs. vaginal birth (VB)), gestational age at birth, fetal weight, and neonatal outcome from 2323 newborns, given as arterial pH and transfer to neonatological intensive care unit (NICU), were analysed for each group. Clinical Cases or Summary Results: The overall CS rate was 34.8%. Women in group 5 (previous CS, single cephalic 37 weeks) made the highest contribution to the overall CS rate. Nulliparous women with single cephalic full-term pregnancy with induction of labour or CS before labour (group 2) were the second highest contributor. They accounted for 25.8% of all births, but their contribution to the overall CS rate was 43.1.%. More than 50% of all births occurred in group 1, nulliparous, and group 3, multiparous women with single cephalic full-term pregnancy in spontaneous labour. Contribution of these two groups to the overall CS rate was only 20.9%. CS rate was highest in all groups with abnormal fetal position: group 9 (all women with single transverse or oblique lie) 6 and 7 (nulliparous and multiparous women with single breech pregnancy).

Table 1. Caesarean Section Rate

Groups 1 2 3 4 5 6 7 8 9 10

Nulliparous, single cephalic, 37 weeks, in spontaneous labour Nulliparous, single cephalic, 37 weeks, induced or CS before labour Multiparous, single cephalic, 37 weeks, in spontaneous labour Multiparous, single cephalic, 37 weeks, induced or CS before labour Previous CS, single cephalic, 37 weeks All nulliparous breeches All multiparous breeches, incl. previous CS All multiple pregnancies, incl. previous CS All abnormal lies, incl. previous CS All single cephalic 537 weeks, incl. previous CS Total

Number of CS over total number of women in each group

Relative size of groups %

CS rate in each group %

Contribution made by each group to overall CS rate %

132/624

28.0

21.2

17.0

158/312

14.0

50.6

20.4

30/505

22.7

5.9

3.9

47/172

7.7

27.3

6.1

176/262 59/65 32/37 70/97 17/17 54/138 775/2229

11.8 2.9 1.7 4.4 0.8 6.2 100

67.2 90.8 86.5 72.2 100.0 39.1 34.8

22.7 7.6 4.1 9.0 2.2 7.0 100

CS = caesarean section Table 2. Neonatal Outcome

1 2 3 4 5 6 7 8 9 10

Mean gesta-tional age [weeks]

Median arterial pH CS

Median arterial pH VB

Trans-fer to NICU CS %

Trans-fer to NICU VB %

Groups

CS rate %

Mean birth-weight [g]

Nulliparous, single cephalic, 37 weeks, in spontaneous labour Nulliparous, single cephalic, 37 weeks, induced or CS before labour Multiparous, single cephalic, 37 weeks, in spontaneous labour Multiparous, single cephalic, 37 weeks, induced or CS before labour Previous CS, single cephalic, 37 weeks All nulliparous breeches All multiparous breeches, incl. previous CS All multiple pregnancies, incl. previous CS All abnormal lies, incl. previous CS All single cephalic537 weeks, incl. previous CS Total

21.2

3340

39 + 6

7.30

7.25

0.76

0.41

50.6

3426

40 + 2

7.30

7.24

1.90

0.65

5.9

3473

39 + 5

7.29

7.28

0.00

0.21

27.3

3528

40 + 1

7.32

7.27

4.26

0.00

67.2

3402

39 + 3

7.31

7.25

0.56

0.00

90.8 86.5

2770 3037

37 + 2 37 + 5

7.31 7.31

7.23 7.19

3.45 0.00

0.00 0.00

72.2

2275

35 + 4

7.33

7.29

10.95

3.85

100.0

3298

38 + 7

7.29

39.1

2175

33 + 5

7.31

7.30

9.09

9.52

34.8

3220

39 + 1

7.31

7.26

3.44

0.95

pH = pH of arterial cord blood, CS = caesarean section, VB = vaginal birth

–-

0.00

–-

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DOI: 10.3109/14767058.2014.924236

However these three groups were the smallest, counting only for 5.4% of all deliveries (119 patients in total) and contributed 13.9% to the overall CS rate (Table 1). Transfer to the NICU occurred more often in the CS group compared to the vaginal delivery (group 1, 2, 4, 5, 6, 8). In contrast to the transfer rate there was a tendency for higher pH values after CS for all groups with a statistical significance for groups 1,2,4,5 and 8. Gestational age was higher in women with induction of labour (group 2 and 4). Fetal weight in term pregnancies was lower in twins and nulliparous with breech. After CS, newborns of group 2 and 5, with the highest contribution to the overall CS rate, had a three to five time higher transfer to the neonatology. Newborns of women in groups 1 and 3, where most deliveries occurred, had a very low rate of transfers to the NICU with a higher rate of transfer in the vaginal delivery group in multiparous but not in nulliparous women (Table 2). Conclusions: As far as we know our data analysed for the first time the relationship between the RTCG and neonatal outcome. Compared with the data from the National Maternity Hospital of Dublin, Ireland from 2011 with a CS rate of 21.4% the overall CS rate in our institution in 2013 was 34.8% due to higher CS rates in groups 1 to 4. In these groups the median arterial pH was lower in vaginally delivered newborns than after CS but the transfer rate to the neonatology was higher in the CS group. CS rates in groups 5 to 10 were similar compared with Dublin. In the groups with the highest contribution to our CS rate (group 2 and 5) the rate of transfer to the NICU was higher. As the RTGC does not consider maternal and neonatal co-morbidities as preeclampsia, gestational diabetes or fetal malformations, further analysis are necessary, before these data can be used for individually counselling pregnant women. Keywords: caesarean section rate, neonatal outcome, Robson ten group classification Presenter: F. Saner

ID 189

AMNIOINFUSION AND CAESAREAN SECTION RATE IN MECONIUM-STAINED AMNIOTIC FLUID . Ciric LjubinkovicV, O. Stanojlovic, M. Nikolic, B. Jovanovic, J. Djorovic, J. Durutovic, & N. Jovanovic Department of Obstetrics and Gynaecology- Neonatology unit, City Hospital, Belgrade, Serbia Brief Introduction: The purpose of our study was to evaluate the rate of caesarean deliveries and perinatal outcome following intrapartum transcervical amnioinfusion in labours complicated by meconiumstained amniotic fluid, in a setting with routine electronic fetal monitoring and specialized neonatal care. Materials & Methods: This prospective study was conducted in Department of Obstetrics and Gynaecology, City Hospital, Belgrade, Serbia and enrolled 100 patients admited in labour. One group of 50 women received amnioinfusion, whilst in the other group of 50 women amnioinfusion was not done. Only patients of gestation more than 37 weeks, presenting in active labour with dilatation of 2–6 cm were included. The amnioinfusion was performed with 1000 ml of normal saline solution. Clinical Cases or Summary Results: Caesarean section rate was statistically significant lower in the study group (6 vs. 28%; p value 50.005). Amnioinfusion was associated with a significant decrease in the incidence of low Apgar score at 5. min (mean AS in amnioinfusion group 8.58, mediana 9, modus 9 vs. control group 8.24; 8; 8; p value 50.005). In our study amnioinfusion was not associated with

reduction in the incidence of SAM, neonatal acidemia, respiratory distress and number of admission into NICU. There were no perinatal deaths, none of babies needed mechanical ventilation and there were no difference in incidence of neonatal infection in study and control group. Conclusions: Transcervical amnioinfusion in labour for meconiumstained amniotic fluid is a simple, safe and easy-to.perform procedure which may decrease caesarean section rate and reduce perinatal asphyxia even in setup where the use of electronic fetal heart rate monitoring is standard care. Keywords: amnioinfusion, caesarean section rate, perinatal asphyxia Presenter: Vesna Ciric Ljubinkovic

ID 834

PHARMACOLOGICAL ANTITHROMBOTIC PROPHYLAXIS AFTER ELECTIVE CAESAREAN DELIVERY IN THROMBOPHILIA UNSCREENED WOMEN: SHOULD MATERNAL AGE HAVE A ROLE IN THE DECISION-MAKING? M. Noventa1, S. Gizzo1, S. Di Gangi1, E. Ancona1, G. Giunta1, L. Righetto1, C. De Santis1, M. Rampon1, D. D’Antona1, & E. Cosmi1 Department of Woman and Child Health, University of Padua, Padua, Italy Brief Introduction: In obstetrical practice, the best prevention strategy for pregnant women aged 435 years without known thrombosis risk factors who underwent elective caesarean delivery is controversial. Materials & Methods: We performed an observational-longitudinalcohort study on pregnant women aged 435, who delivered at term by elective caesarean section after a physiological single pregnancy to evaluate the role of maternal age in the decision making process of whether or not to perform low-molecular-weight-heparin prophylaxis during the postpartum period after elective caesarean delivery in healthy women with unknown inherited thrombophilia status. During six postpartum weeks we followed two groups: GROUP-A (349 women treated for 7 days with low-molecular-weight-heparin) and GROUP-B (180 women not treated with low-molecular-weightheparin treatment). The outcomes were as follows: thromboembolic events onset during the post-partum period, non-obstetrical-linked maternal haemorrhage, blood transfusion, re-laparotomy, detection of surgical site haematoma, length of hospitalisation, and treatment suspension because of decreased platelet count. Clinical Cases or Summary Results: Except for the parity number, the two groups were homogeneous for the general features. In both groups, we reported no cases of thromboembolic events during the follow up period. Maternal haemorrhage requiring transfusion occurred in 16 women in GROUP-A and none in GROUP-B. Among the GROUP-A women, 11 demonstrated a surgical site haematoma, and 4 required re-laparotomy. No cases of treatment suspension were reported. Conclusions: Pneumatic compression stockings represent a better, low cost and safe way to prevent postpartum venous thromboembolic episodes after elective caesarean section in an unscreened population. Pharmacological prophylaxis after elective caesarean section should be performed only in case of clear and known adjunctive risk factors, independent of maternal age.

54 Keywords: Venous Thromboembolism; Heparin, Low-molecularweight heparin; Caesarean delivery; Postpartum period; Prophylactic anticoagulant treatment; Thromboembolic events.

Department of Obstetrics and Gynecology of West Kazakhstan State Medical University after Marat Ospanov, Aktobe, Kazakhstan.

Presenter: Marco Noventa

Brief Introduction: Postpartum and pregnancy hemorrhage is one of the primary causes of maternal mortality throughout the world. Although the mortality rate has significantly decreased in recent years in Kazakhstan, it remains 3–4 times higher than in developed countries. This requires further efforts towards developing optimal standards of maternal death prevention for both Kazakhstan and the world. The recent decrease of mortality rate has been resulted due to implementation of novel approaches for profuse obstetric hemorrhage such as B-Lynch suture. The latter is positively referred in observations of various authors. Materials & Methods: Data for the study were collected from 41 birth cases of women with postpartum hemorrhage for the period 2009– 2013. In all of these cases the ineffectiveness of non-surgical methods of hemostasis led to application of surgical ones. The retrospective analysis of cases was selected as a research method. The subjects were divided into two groups on the basis of surgical hemostasis approach type. Group 1 comprised of 26 subjects that were undergone the application of B-Lynch suture. Group 2 was made up of 15 cases including 5 cases of total and 10 cases of subtotal hysterectomy. An indication for laparotomy was uterine atony resistant to nonsurgical treatment and accompanied with 1000.0 ml or more blood loss. Clinical Cases or Summary Results: The analysis of hemorrhage volumes in Group 1 revealed the blood loss of 1500 ml in 57.7% of cases, from 1500 to 2000 ml in 30.8% and over 2000 ml in 11.5% of cases. The average hemorrhage volume in this group amounted 1400.0 ± 142 ml. In Group 2 the blood loss was up to 1500 ml and up to 2000 ml in 26.6% and 46.7% of cases respectively. More than 2000 ml of hemorrhage volume was observed in 26.7% of cases including two with loss of 3000.0 and 3250.0 ml. Total hemorrhage volume amounted 2000.0 ± 132 ml in average. The 2nd degree hemorrhagic shock took place in 7.7% of cases in Group 1 and in 26.7% in Group 2. While the 3rd degree hemorrhagic shock and coagulopathy signs were not registered in Group 1, subjects in Group 2 showed the former in 13.3% of cases and DIC in 26.7% of cases. Although the effectiveness of B-Lynch suture reached 92.3%, this approach failed in 7.7% of subjects and led to application of O’Leary stitch. Conclusions: Application of B-Lynch suture prevents lethal outcomes and severe complications and appears to be an effective, organ and fertility preserving, simple and fast-applicable approach of surgical hemostasis for profuse atonic hemorrhage.

ID 068

URINARY INCONTINENCE, GENITAL PROLAPSE AND VAGINAL DELIVERY: EVIDENCE FROM SECONDARY DATA A. Lanfer1, A. Gillessen1, J. Weller1, & C. Vietor1 J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

J Matern Fetal Neonatal Med, Early Online: 1–437

1

Techniker Krankenkasse, Hamburg, Germany

Brief Introduction: The fear of conditions such as postnatal urinary incontinence (UI) and genital prolapse (GP) is commonly believed to be one of the factors contributing to caesarean section on request. Using secondary data from one of the largest German statutory health insurances (Techniker Krankenkasse), we aim to investigate urinary incontinence and genital prolapse peri- and postnatally in association with delivery mode. Materials & Methods: A retrospective analysis was performed on outand in-patient claims data. All female insurants who had given birth to a living baby in 2008 were identified and matched with the data of their newborns, if possible. G-DRGs and in- and outpatient diagnoses (ICD-10) were used to differentiate between caesarean section and vaginal delivery, as well as to identify UI and GP perinatally and up to two years after birth. Probability for urinary incontinence and genital prolapse by delivery mode was estimated by means of multiple logistic regression. Clinical Cases or Summary Results: Data for 38,174 mothers could be matched with the data of their children. In this population, 30% delivered by caesarean section and the overall prevalences of UI and GP anytime during the first year after birth were 1.2% and 8.8%, respectively. UI and GP during the first year after childbirth were more often in women with vaginal delivery than in women with caesarean section. Even after controlling for weight of the child and sociodemographic covariates, the odds of UI after vaginal delivery were 2.5 times higher and GP was twice as likely compared to delivery by caesarean section. The association between delivery mode and both conditions pertained even in the second year after birth, although a significant drop in overall prevalence especially for GP of more than 65% could be observed. Taking part in insurance-covered postpartum exercise courses could not explain the drop in prevalence between the first and second year after birth. Conclusions: In population of insurants, vaginal delivery is associated with a higher rate of urinary incontinence and genital prolapse up to two years after birth. However, overall prevalence is decreasing in the second year after birth suggesting no long-term effects. Keywords: Urinary incontinence, vaginal delivery, claims data, vaginal delivery Presenter: A. Lanfer

Keywords: B-Lynch suture, maternal mortality, women with postpartum hemorrhage, total and subtotal hysterectomy. Presenter: Akylbek Tusupkaliyev

ID 904

NEONATAL OUTCOMES AFTER ELECTIVE CESAREAN DELIVERY A. Troshani1, E. Vevecka2, & E. Tushe3 1

ID 102

SURGICAL HEMOSTASIS AS AN APPROACH OF HEMORRHAGE MANAGEMENT A. Tusupkaliyev, S. Shikanova, B. Karimova, S. Bermagambetova, A. Gaiday, & S. Assembaj

Pediatrician M.D. at UHGO ‘‘Queen Geraldine’’, 2Prof near Pediatric-Pulmonary Service UHC ‘‘Mother Tereza’’, and 3Chief of Neonatal Service, Pediatric Department Brief Introduction: Because of increased rates of respiratory complications, elective cesarean delivery is discouraged before 39 weeks of gestation unless there is evidence of fetal lung maturity. We assessed associations between elective cesarean delivery at term (37 weeks of gestation or longer) but before 39 weeks of gestation and neonatal outcomes.

55

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DOI: 10.3109/14767058.2014.924236

Materials & Methods: Cohort study with prospectively collected data of all the deliveries on mothers with gestational ages between 37 and 40 weeks that were performed in our Hospital from 1 January 2011 to 1 January 2014. The primary outcome was respiratory complications, treated hypoglycemia, newborn sepsis, and admission to the neonatal intensive care unit (NICU). Clinical Cases or Summary Results: Of 7643 cesarean deliveries 35.4% were performed before 39 completed weeks of gestation (6.3% at 37 weeks and 29.1% at 38 weeks) and 49.6% at 39 weeks of gestation. As compared with births at 39 weeks, births at 37 weeks and at 38 weeks were associated with an increased risk of the primary outcome (adjusted odds ratio for births at 37 weeks, 2.1; 95% confidence interval [CI], 1.7 to 2.5; adjusted odds ratio for births at 38 weeks, 1.5; 95% CI, 1.3 to 1.7; P for trend50.001). The rates of adverse respiratory outcomes, mechanical ventilation, newborn sepsis, hypoglycemia, admission to the NICU, and hospitalization for 5 days or more were increased by a factor of 1.8 to 4.2 for births at 37 weeks and 1.3 to 2.1 for births at 38 weeks Conclusions: Elective cesarean delivery before 39 weeks of gestation is common and is associated with respiratory and other adverse neonatal outcomes. Keywords: Presenter: Ajmone Troshani

ID 536

ECHOGRAPHIC ASPECTS OF CESAREAN SCARS IN NONPREGNANT UTERUS AFTER SINGLE OR MULTIPLE CESAREAN SECTIONS C.A. Ionescu1, I. Pacu1, D. Gheorghiu2, H. Haradja1, M. Dimitriu1, M Banacu2, & Cip Coroleuca2 1

UMF Carol Davila, Clinical Emergency Hospital Sf Pantelimon, Bucharest, Romania, 2Clinical Emergency Hospital Sf Pantelimon, Bucharest, Romania Brief Introduction: The objectives of our study was to establish an association between echographic parameters of the cesarean scar in non-pregnant uterus and the number of previously performed Cesarean sections. Materials & Methods: The study group include 110 nonpregnant women with a history of low transverse Cesarean section with single or 2 layer uterine closure. The transvaginal ultrasound was performed to establish the parameters of the cesarean scar: the thickness of the tissue scar segment, the triangular shaped anechoic scar defect. Clinical Cases or Summary Results: The cesarean scar section was evidence with transvaginal ultrasound. In 98.4% of cases the scar was identified. In 24.4% of cases the completely hysterotomy scar tissue was identified. In 75.5% of cases an anechoic triangle identified as scar defect, was observed. The thickness of the tissue scar segment varies with the number of cesarean section. So the mean thickness after a single Cesarean section was 10.1 mm, after two cesarean section was 8.1 mm and after 3 cesarean section was 4.4 mm. We identified the basis of the triangle (P) and the height of the triangle (W) and we made the the index Thickness/basis and thickness/height of triangle. Conclusions: The thickness of the scar tissue segment and the index thickness/height decrease with the number of cesarean section. Also there is no diference according to single layer closure or two layer closure. Keywords: ultrasound, cesarean scar, multiple cesarean section Presenter: Cringu Ionescu

ID 101

THE ROLE OF INNOVATIVE TECHNOLOGIES IN UTERINE SCAR DEHISCENCE MANAGEMENT AFTER CESAREAN SECTION A. Tusupkaliyev1, B. Karimova1, Zh. Darybai1, & M. Kadrushev1 1

Department of Obstetrics and Gynecology of West Kazakhstan State Medical University after Marat Ospanov, Aktobe, Kazakhstan. Brief Introduction: Frequency of operative delivery in Russia and Kazakhstan composes in average 10%. Frequency of cesarean section in Aktobe was 17% - in Regional Perinatal center. The rise of gravity of cesarean section normally involves the increase of frequency of postoperative infectious complication, the rate of which varies from 13.3 up to 54.3% and in women with high infection risk they may rich 91% (I. S. Sidorova at al, 2006). Modern novel technologies have wide opportunities in treating purulent septic complications in obstetrician’s practice and allow to improve their results, that reveal new perspectives in development of organ serving direction in obstetrics during uterine scar dehiscence (V. I. Krassnopolskiy at al., 2001; N. I. Izimbergenov at al, 2009). Materials & Methods: The results of treatment of 11 women for the period 2010–2012 delivered through cesarean section, developed then uterine scar dehiscence and undergone preserving surgical treatment were analyzed. The average age of women delivered at term, urgently due to pelvic disproportion. The technique of cesarean operation, antibiotics prevention were done according to the protocols. Subfebrile and decrease of intestinal peristalsis were noted in 8 women during the first 24 hours of postoperative period. 3 women had no abnormalities from normal puerperium. According to the protocols all the puerperal were made US examination on the 3rd-4th day that allowed to identify uterine scar dehiscence at early dates, even in unclear clinical picture and this influenced on the results of treatment. Clinical Cases or Summary Results: The range of surgical intervention included relaparotomy. Due to limited inflammatory changes, young age of women and wish to preserve reproductive organ, we performed organ preserving surgical treatment: excision of necrotic tissues of the uterine wall, curettage of uterine wall, ozone sanation and draining of the abdominal cavity, restoration of the abdominal wall. All the patients undergone an antibacterial medication during the postoperative period. All the operations were successful, there were no any complications connected with uterus preservation. Tactics and indications to organ preserving operations should be determined in each case individually. Two patients in 11 months and 1.5 years after secondary suture were undergone cesarean section according to the plan in full-term pregnancy. Postoperative period was smooth, babies were discharged on the 5th and 7th days. Conclusions: Thus in present cases timely diagnosis, general satisfactory organism condition, absents of peritonitis presence of possibilities for technical fulfillment of operations, the use of modern technologies provided favorable results. Keywords: cesarian section, oaone sanation, uterine scar dehiscence Presenter: Akylbek Tusupkaliyev

56

ID 274

INFLUENCE OF MATERNAL AGE REGARDING OVERALL CESAREAN SECTIONS RATES AND CESAREAN SECTIONS DUE TO LOSS OF FETAL WELL BEING A. Garcia Deus, J.R. Cervilla, A. Perez-Mun˜uzuri, M.L. Couce Pico, & J.M. Fraga

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Neonatal Unit. Pediatric Assistance Area. Hospital Clinico Universitario (CHUS). Santiago de Compostela (SPAIN) Brief Introduction: Over 35 years of age these events are much more frequent, may diminish the fetus oxygen store and turn out in a loss of fetal well-being (LFW) during the pre-delivery or in delivery process itself. In these situations the fetus needs to be delivered in an emergency way as soon as possible. Cesarean section (CS) deliveries due to LFW have higher risk of missadaptation to extrauterine life of the newborn, which may need to be resuscitate. These types of situations prompted us to review our records examining the overall CS rate, the percentage of CS due to LFW and the cumulative CS rate by seven increasing maternal age in the last seventeen years. Materials & Methods: We have reviewed our perinatal data regarding the CS rate due to LFW, the overall CS and vaginal deliveries (DLV) overall 43.845 DLV. Rate of CS and vaginal DLV were also classified regarding seven increasing maternal age’s groups since 520 years till 445 years old in the period 1996–2012. Clinical Cases or Summary Results: The median percentage of 8.764 CS regarding the overall 43.845 DLV was 19.9. The 1.794 CS due to LFW overall DLV reached a median percentage of 20.5 (range 25.6% 17.0%). The cumulative percentage rate of CS regarding maternal age’s groups over a total of 43.845 DLV were in increasing order: 520yr (12.2%); 20yr-24yr (13.1%); 25yr-29ry (17.1%); 30yr-34yr (19.9%); 35yr-39yr (24.5%); 40yr-44yr (37.0%); and445yr (56.4%).The rate of CS by age’s group were overall 8.764 CS: 520yr (1.4%); 20yr to 24 yr (6.5%); 25yr to 29 yr (22.3%); 30yr to 34 yr (36.9%); 35yr to 39 yr (25.3%); 40yr to 44 yr (6.9%) and 445 yr (0.6%). Conclusions: The lowest rate of CS with 12.2% was observed in the youngest maternal age group 520yr, and the highest in the 445yr age’s group (56.4%). The highest rates of CS and DLV (36.9% and 37.0%) occurred in the 30yr-34yr age group. The lowest rates with 0.6% of CS and 0.2% of DLV were observed in the 445yr oldest age group. The median rate of CS overall DLV 19.9% is slightly higher than the 15% recommended as ideal by the WHO. Only 20.5% of total CS were due to LFW but to everyone is a challenge for the attendance neonatologist’s team. Keywords: Presenter: JR Cervilla

ID 479

RATES OF CESAREAN SECTION: ANALYSIS OF REGIONAL ESTIMATES M. Chiavarini, E. Trequattrini, & L. Minelli Department of Experimental Medicine, Division of Public Health, University of Perugia Brief Introduction: The World Health Organization has indicated that a Cesarean Section (CS) rate greater than 10–15% is not justified in any region of the world.

J Matern Fetal Neonatal Med, Early Online: 1–437

CS rates continue to be an issue of great concern to many midwives, obstetricians, women and society. Although Umbria has adopted the National Guidelines on Cesarean Section, containing the recommendations on CS produced by a multi-professional panel, the frequency of CS was 30.7% with significant differences between birth centers (range 18.1% - 34.5%). Materials & Methods: Data were obtained from the administrative source of regional Standard Certificate of Live Birth (Umbria) during 2012. The aim of the study was to obtain standardized collection of information, analyze the frequency of CS in a reproducible manner, distributed into 10 classes according to Robson’s classification. The classes are as follows mutually exclusive, fully inclusive, easy to build and easy to use. This classification is defined in relation to parity, duration of pregnancy, mode of labor, simple or multiple birth and presentation of neonate. Clinical Cases or Summary Results: For Umbria region, the distribution of 10 classes shows that class I (nulliparous women, childbirth at term, spontaneous labor, single fetus, cephalic presentation) and class III (multiparous women, childbirth at term, spontaneous labor, single fetus, cephalic presentation) are the most representative of population (36.0% and 21.5% respectively); class II (nulliparous women, childbirth at term, induced labor or elective cesarean section, single fetus, cephalic presentation), V (previous cesarean section, childbirth at term, single fetus, cephalic presentation) and I are the ones with higher weight percentage of the total number of CS (25.7, 20.6 and 11.4 respectively). The frequency of CS is particularly high in some Robson’s classes: class VI, class VII (podalic presentation), class VIII (multiple pregnancy) and class V (86.8%); the frequency in class I (class with no special risk factors) is 17.7%. Conclusions: Some classes are characterized by a high percentage of population compared to the total number of women who give birth and contribute minimally to the total number of cesarean sections (eg. Class I), other classes have a very small weight in terms of population but contribute significantly to the total number of cesarean sections (eg. class V). It’s necessary to act at the level of larger class (class I), predominantly low-risk, reducing the% of women with previous CS (class V) The weights of the individual classes vary between birth centers, leading to different overall rates of cesarean sections, also due to various health care delivery behaviors. Keywords: robson classification, Cesarean Section Presenter: Elisa Trequattrini

ID 147

GENERAL VERSUS SPINAL AND EPIDURAL ANAESTHESIA FOR ELECTIVE CAESEREAN SECTION: EFFECT ON NEONATAL SHORT TERM OUTCOME M.O. Ergun1, A. Memisoglu2, T. Saracoglu1, E. Malcok3, Z. Eti1, H. Bilgen2, & E. Ozek2 1 Anesthesiology and Reanimation Department, 2Neonatology Department, and 3Obstetrics and Gynecology Department, Marmara University, Istanbul, Turkey.

Brief Introduction: It has been reported that regional anaesthesia, which avoids neonatal depression associated with general anaesthesia, should be regarded the preferable method during caserean section (C/S). However there are few data about the effects of different methods of anaesthesia during C/S on neonatal short

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DOI: 10.3109/14767058.2014.924236

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term outcome. We conducted a study to investigate the impact of general, spinal and epidural anaesthesia for elective C/S on neonatal transition and short term outcome. We aimed to compare short term outcome in babies who were born after general, spinal or epidural anesthesia for elective caeseran section. Materials & Methods: 75 pregnant women undergoing elective caeseran section at term were allocated to general (GA) (n = 25), spinal (SA) (n = 25) and epidural (EA) (n = 25) anaesthesia. Umbilical venous blood pH, HCO3, BE, SPO2, heart rate, blood pressure, Apgar scores at postnatal 1, 5., 10. minutes, the need for ressuscitation and intensive care, postnatal weight loss at 24. hrs, highest bilirubin level and the need for phototherapy, time to first void, time to first breastfeeding were evaluated. Clinical Cases or Summary Results: As regards neonatal outcome, no significant differences were found in umbilical venous pH, HCO3, BE between the study groups. However, umbilical venous PCO2 was significantly higher in general anesthesia group (p50.05). Apgar scores, SPO2 and heart rate at 1.,5.,10. minutes were significantly lower in GA group compared to SA and EA groups and 6 babies required supplemental oxygen and positive pressure ventilation in GA group (p50.05). There were no differences between SA and EA groups. Type of anaesthesia did not influnce postnatal systolic, diastolic, and mean arterial blood pressure and postnatal weight loss at 24. hours, however time to first breastfeeding was significantly longer in the GA group (p50.05). There were no differences among the groups with respect to highest bilirubin levels, the need for phototherapy, and the time to first void. Conclusions: Although all types of anaesthesia seem to be safe, spinal or epidural anesthesia may be considered the preferred approach with regard to better impact on short term neonatal outcome. Keywords: caeseran section, neonatal outcome, spinal anesthesia, epidural anesthesia Presenter: Aslı Memisoglu

ID 678

NEW HIGHLY EFFECTIVE ZHUKOVSKIY BALLOON KIT DESIGNED SPECIALLY FOR CESAREAN SECTION TRANSABDOMINAL INSERTION Y. Zhukovskiy1, I. Kukarskaya2 1

GynaMed, Moscow, Russia, 2Regional Perinatal University Hospital, Tyumen, Russia Brief Introduction: Recently balloon application during CS is considered to be an effective measure for preventing main complications. But as the existent balloons’ design had not been targeted for CS, it proved to have quite high failure rate, up to 30% (Olsen R., 2013). The most common reported reasons for failure are continuing bleeding, balloon extrusion, blood not passing through the drainage tubing; the balloon therapy may have masked continuing bleeding, blood clots accumulation in the fundal region resulting in hysterectomy. Also certain difficulties usually appear during the insertion due to the balloon’s construction flaws: some of the balloons can be introduced only via the cervix (due to absence of an axial tube), and some have a double-pipe fork insertion end. Materials & Methods: We created a special Zhukovskiy Balloon kit to improve effectiveness and simplify insertion during CS. The kit consists of a catheter (an axial tube attached to the silicone balloon), a tank, a connecting tube, a clamp and a probe-plug during the whole procedure. The balloon itself is easy-expandable and fills the whole uterine cavity leaving no dead space. Filling the balloon we use

a principle of connecting vessels, without turning off the lead-in pipe. The open circuit between the balloon and the tank implies keeping constant contact of the balloon and the uterine wall during the relaxation and retraction of the uterus practically with the same interaction force. So the balloon does not overstretch the newly stitched wound. This construction allows to use individually chosen volume and minimal required pressure by placing the tank at a selectable height. Immediately after the closure of the incision the balloon is filled with sterile warm solution. It is removed via cervix within 2–3 hours after deflating, so the cavity is left dry, clean and well-ventilated. Clinical Cases or Summary Results: The given kit was used in 117 cases of CS in the group of pregnant women with high risk of hemorrhage and infection. 72 patients (61.5%) had elected CS and 45 cases of CS (38.5%) were urgent. Main risk factors were: anomaly of labor activity 28.4%; placenta previa and its premature detachment 18.2%; two and more uterine scars 17%; obesity 16%; fetal macrosomia 15%; multiply pregnancy 12.8%; polyhydramnios 7.6% and others. Summary Results: Our experience showed the high efficiency of this design for the prevention of CS complications. In more than 98% we managed to prevent the pathological blood loss in the group of high

58 risk pregnant women. Surgical methods were required in 2 cases only (morphological causes of the hemorrhage revealed). There was not any puerperal endometritis in the given patient group. Conclusions: The main Zhukovskiy Balloon Kit distinctive features are: its easy transabdominal insertion, the earliest filling of the whole uterine cavity with minimal required pressure and its immediate responding to the uterine activity by changing the volume of the balloon. Thus the given design allows to get rid of the mentioned drawbacks and to achieve higher efficiency in preventing hemorrhages and inflammatory complications of CS.

J Matern Fetal Neonatal Med, Early Online: 1–437

highest leukocytes count in study group of patients was in three pregnant women with previous cesarean section. According to our study there were not postoprative complications nor in control, neither in study group. Conclusions: Applying of a single dose of Cefazolin after umbilical cord clumping during Cesarean section is as safe as Ceftriaxon intramuscularly therapy for five postoperative days. Keywords: cesarean section, prophylaxis, cefazolin Presenter: S. Jankovic-Raznatovic

Keywords: Balloon tamponade, CESAREAN SECTION, Postpartum haemorrhage Presenter: Y. Zhukovskiy

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ID 257

CEFAZOLIN VERSUS CEFTRIAXON IN CESAREAN SECTION PROPHYLAXIS S. Jankovic-Raznatovic1,2, S. Rakic1,2, J. Stankovic1, D. Cecez1, S. Brankovic1, N. Zecevic1, A. Curkovic1, L. Tasic1,2, A. Jurisic1,2, V. Soldo1, D. Sokolovic Curkovic1, & A. Dobrosavljevic1 1

Department of Obstetrics and Gynecology ‘‘Narodni front’’, Belgrade, Serbia, and 2Belgrade University Medical School, Belgrade, Serbia Brief Introduction: Cesarean section is associated with a significant number of postoperative complications. Prophylactic antibiotic therapy reduces this rate.There is a current debate on the time, type and doses of antibiotic in cesarean delivery. We wanted to compare the efficacy of a single dose of Cefazolin to a five days Ceftriaxon therapy for preventing post-cesarean section complications. Materials & Methods: Our study included 62 term pregnancies that delivered by cesarean section at the Department of Obstetrics and Gynecology Narodni Front, Belgrade, in the period from March 2009 until December 2010. Study group was represented by 32 patients who were given 1 g of Cefazolin intravenously immediately after clamping the umbilical cord. Thirty pregnant women, were treated with Ceftriaxone 2 g intramuscularly, for 5 days after surgery and they represent the control group. In both groups of patients, the values of leukocytes (Leu) were studied before surgery as well as the second and the fifth day after surgery. The results were analyzed using Pearson’s correlation coefficients, Mann-Whitney and Freidman’s nonparametric test and Kruskal-Wallis test. Clinical Cases or Summary Results: Values of leukocytes were low before the operation while the second day after surgery the values raises and they fall on the fifth day in control and in study group. The highest value of leukocytes before surgery in the control group was in patients with placental abruption, while in one half of them were within normal range The highest value of leukocytes the second day after surgery was measured in two patients, in whom the previous delivery was by cesarean section. In the fifth day, it was in patients with prolonged labor, who was vaginaly examined for several times. We concluded that the value of leukocytes before surgery is lower than the value of the fifth postoperative day in 37.1%. This means that after five days of Ceftraxon therapy leukocytes count was lower on the fifth postoperative day compared to the leukocytes count before surgery. Time series/ tendencies values of leukocytes in the study group show that the values of leukocytes were lowest before the operation, the second day after surgery values raise and fall on the fifth day. The lowest value measured before surgery was in patients with pregnancy realized according to a program of assisted reproduction, The

ID 813

CESAREAN SECTIONS USING THE ROBSON CLASSIFICATION SYSTEM. FIVE OBSTETRIC HOSPITALS IN WARSAW – 2012 YEAR M. Troszynski1, K. Szamotulska2, & T. Maciejewski3 1

Department of Reproductive Health, Institute of Mother and Child, Warsaw, Poland, 2Department of Epidemiology, Institute of Mother and Child, Warsaw, Poland, and 3 Department of Obstetrics and Gynecology, Institute of Mother and Child, Warsaw, Poland Brief Introduction: Cesarean section rate has been increasing in Poland for the last 20 years and ranks at the last third position in European Union. The aim of the study was to analyze cesarean sections in five great Warsaw hospitals in 2012 using Robson classification. This classification allows to evaluate specific cesarean sections rates in 10 mutually exclusive and defined obstetrical situations. This classification after our opinion may be used for comparisons between obstetric departments. Materials & Methods: Data from 5 Warsaw hospitals in 2012 (14462 cases, makes 48.4% of all births in Warsaw) and were used for this elaboration. Deliveries were classified according to obstetrical history of women, type of pregnancy (single/multiple), gestational age, fetal presentation and course of labour and delivery using 10 of classification Robson’s groups. In each group, the relative size of the group, group-specific cesarean sections rate and its contribution to the overall cesarean section rate was calculated. Comparison between tertiary and secondary level hospitals was also done. Clinical Cases or Summary Results: In studied hospitals, the overall cesarean section rate was 34.6%. The highest contribution to the overall cesarean section rate have made cesarean sections in singleton, term, cephalic women: nulliparous women in spontaneous labour (group 1–7.7%) and nulliparous women with induced labour or cesarean section before the labour (group 2–7.7%), multiparous women after previous cesarean section (group 5–7.9%). The contribution of multiparous women who hadn’t had previous cesarean section (group 3 and 4) was relatively small and equaled 3.1%. The remaining contribution of other groups was 8.1%. Conclusions: Robson classification allows to identify groups of typical obstetrical situations, in which further examination of induction cesarean sections may be performed. Detailed analysis of cesarean sections should be especially carried out in singleton, term, cephalic, nulliparous women (Group 1,2 and 5 of Robson). Keywords: cesarean sections, classification, statistics and numerical data Presenter: M. Troszynski

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DOI: 10.3109/14767058.2014.924236

ID 842

EFFECTS OF DIFFERENT ANESTHESIA TECHNIQUES ON CEREBRAL OXYGENATION OF TERM BABIES M. Malcok1, H. Bilgen1, P. Corman2, E. Malcok3, Z. Unkar1, S. Kalaca4, A. Memisoglu1, K. Gucuyener5, & E. Ozek1

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1

Neonatology Dept. Marmara University Faculty Of Medicine, Istanbul, Turkey, 2Anesthesia Dept. Marmara University Faculty Of Medicine, Istanbul, Turkey, 3Obstetrics And Gynecology Dept., Marmara University Faculty Of Medicine, Istanbul, Turkey, 4Public Health Dept. Marmara University, Faculty of Medicine, istanbul, Turkey, and 5Child Neurology Dept., Gazi University Faculty Of Medicine, Ankara, Turkey Brief Introduction: The choice of anesthesia for cesarean section (C/S) depends on the etiology for C/S, emergency level and on the patient’s and the anesthesiologist’s preference. None of the anesthesia methods are ideal for C/S. The anesthesiologist has to choose a method that is safe and comfortable for the mother; which is also proven to have minimum side effects to the baby. The aim of our study is to compare the early postnatal cerebral tissue oxygenation values of babies born to mothers who underwent elective C/S under two different anesthesia techniques [spinal anesthesia (SA) and general anesthesia (GA)] by using ‘‘Near-Infrared Spectroscopy (NIRS)’’. Materials & Methods: Term babies born to mothers who underwent C/S were included in our research. Term babies were grouped into two according to the type of anesthesia given for C/S as spinal versus general anesthesia. The babies’ demographical data, umbilical blood gas values, vital signs, APGAR scores and 3rd, 5th, 10th, 13th and 15th minute cerebral tissue oxygenation (rScO2) (Invos 5100; Somanetics Corp, Troy, Michigan) and pulse oximetry measurements (Nellcor N200) were recorded. Cerebral fractional tissue oxygen extraction (FTOE) indices were calculated according to pulse oximetry values (FTOE = pulse oximetry value - rScO2/pulse oximetry value). SPSS version 18 was used to compare the results. Results: Demographical data, arterial pH, pCO2, HCO3 and lactate levels, and 1st, 5th and 10th minute APGAR scores among the two groups were found to be statistically similar. In the 3rd minute SaO2 and FTOE, in the 3rd and 13th minutes rScO2 were observed to be statistically significantly higher in the spinal anestesia group when compared to the general anesthesia group. When repeated measurements were evaluated, there was not any statistically significant difference among the two types of anesthesia methods, except heart rates which were higher in all measurements in the spinal anesthesia group. (Image 1) Clinical Cases or Summary Results: Blood gas analyses and APGAR scores were found to be similar in two study groups. Our results are parallel to the results of meta-analyses comprising researches comparing spinal and general anesthesia. When our cerebral tissue oxygenation data was plotted on the percentile charts of Pichler et al, 88.5%, 94.6%, 94.6%, 100% and 98.8% of the babies’ rScO2 values were above the 10th percentile in the 3rd, 5th, 10th, 13th and 15th minutes respectively. when the

values were evaluaed considering the thype of anesthesia, only one baby’s rScO2 values in the 3rd and 13th minutes were below the 10th percentile. Conclusions: These results lead to the conclusion that if appropriate general anesthetic agent is used, none of the techniques is superior to the other. Keywords: caesarean, NIRS, anesthesia Presenter: Eren Ozek

ID 481

PERINATAL OUTCOME OF ELECTIVE CAESAREAN DELIVERIES DUE TO FEAR OF CHILDBIRTH V. Astover1, A. Siller2, & H. Varendi1 1 Children’s Clinic, Tartu University Hospital, Tartu, Estonia, and 2Women’s Clinic, Tartu University Hospital, Tartu, Estonia

Brief Introduction: The number of women with fear of childbirth (FOC) and deliveries by elective caesarean section (ECS) increases worldwide. The aim of the study was to evaluate perinatal outcome of cases of FOC women who delivered by ECS. Materials & Methods: A retrospective review of delivery charts of Tartu University Hospital for 4 years (2010–2013) identified 100 women with FOC as reason for ECS and their 103 newborns. The FOC was registered as reason for 11.8% of ECS deliveries and 1.0% of all deliveries during this period. The official statistics of all deliveries at the same hospital in 2010–2013 was used for comparison. Clinical Cases or Summary Results: Mean maternal age at delivery was 31.2 years. Obesity (BMI430) was diagnosed in 10% of FOC mothers; 29% were primiparas. Previous caesarean delivery was registered in 50% and traumatic birth experience in 34% of cases. Anxiety or depression rate was 9%. Compared to controls, the FOC women had higher frequency of gestational diabetes (7.0% vs 3.0%, p = 0.03) and use of assisted reproduction (7% vs 3.4%, p = 0.05). Complications of delivery were low, similarly to controls. During the study period 103 neonates were born (range 38 - 42 gestational weeks (GW)). Neonatal respiratory morbidity was significantly higher in FOC group (13.6% vs 1.23%, p50.0001); with distribution: 79% if ECS performed at 38–39 GW and 21% for at 39–42 GW (p = 0.029). Anaemia due to fetomaternal hemotransfusion was relatively high (5.8% vs 0.23%, p50.0001) in FOC group and 41.2% of newborns experienced feeding problems. Conclusions: The perinatal outcome of newborns of FOC mothers was poorer than other neonates. The incidence of respiratory morbidity and fetomaternal hemotransfusion was high. ECS before 39 weeks was a risk factor for transient tachypnoea and resulted in higher need for neonatal intensive care. Better psychological, obstetric and social support and councelling should be provided for pregnant women with FOC. Keywords: perinatal outcome, elective caesarean section, fear of childbirth Presenter: V.Astover

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ID 696

USEFULNESS OF 3T MRT IN CASE OF SUSPECTED UTERINE DEFECTA CASE REPORT OF 2 PATIENTS WITH PREVIOUS CESAREAN SECTION J. Hoffmann1, P. Stumpp2, T. Kahn2, & H. Stepan1 1

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Department of Obstetrics, University of Leipzig, Germany, and 2Department of Diagnostic and Interventional Radiology, University of Leipzig, Germany Brief Introduction: A scar defect/uterine rupture in a new pregnancy is a rare but threatening secondary complication of a previous cesarean section. Scar dehiscences or covered ruptures are often low or not symptomatic and raise the risk for uterine rupture during the delivery. For that reason, 2D-sonography is used for prenatal diagnosis by measuring the lower uterine segment. Because of methodical limitations of ultrasound examinations with regard to dependency on the examiner and patient’s constitution different accessory techniques are needed for a more detailed prenatal diagnostic. These case reports of two patients demonstrates the usefulness 3T MRI in case of suspected uterine dehiscence. Materials & Methods: Transabdominal 2D sonografie (GE HealthcareÕ , Voluson E8 Expert) was used for primary diagnostics of the lower uterine segment. T2 weightend sequences in sagittal and axial orientations were performed on a 3 Tesla MRI scanner (Magnetom Trio, Siemens HealthCare) for advanced diagnostics. Clinical Cases or Summary Results: Two pregnant women presented with lower abdominal pain after previous cesarean section with 31 + 1 and 26 + 1 gestational weeks. In both cases the lower uterine segment sonographically (GE HealthcareÕ , Voluson E8 Expert) appeared very thin. In the first case a uterine dehiscence was suspected and likewise could not be safely excluded by ultrasound in the second case. We performed an additional 3T MRT examination (Magnetom Trio, SiemensÕ ) with the use of a sagittal T2-HASTE-sequence. In the first case a uterine rupture was confirmed by MRI examination and the women was delivered by caesarean section with 31 + 3 weeks of gestation. In the second case, MRI examination could definitively exclude a uterine rupture and pregnancy could be prolonged to 37 + 0 weeks of gestation. This patient was delivered by cesarean section as well. In both cases MRI findings were verified intraoperatively. Conclusions: These two cases demonstrate the use of an additional MRI examination in case of a sonografically suspected uterine dehiscence or symptomless uterine rupture after previous uterine section. Since MRI is non-invasive and applicable without contrast agents or any premedication, it can be performed safely in pregnancy. Additional MRI findings can be helpful to classify sonographic findings more accurately and to decide about the following management. MRI findings and intraoperative findings correlated well in the presented cases. Keywords: cesarean section, uterine scar, pregnancy, rupture, mri Presenter: J. Hoffmann1

ID 414

CONGENITAL UNILATERAL ABSENCE OF A PULMONARY ARTERY IN A PREGNANT WOMAN: A CASE REPORT H. Moroi, H. Tsuda, E. Yamada, Y. Mano, S. Sumigama, T. Kontani, & F. Kikkawa

J Matern Fetal Neonatal Med, Early Online: 1–437

Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, Nagoya, Japan Brief Introduction: Congenital unilateral absence of a pulmonary artery (UAPA) is an unusual anomaly. The incident rate of UAPA is unknown, but recently estimated to be one per 200,000 people. Many case reports and a few reviews can be found, but its pathogenesis and therapeutic methods are still unclear. In addition, the report of UAPA with pregnancy is extremely rare and we can find only several case reports. Materials & Methods: We report a patient who had a diagnosis of UAPA at the age of 21, became pregnant at 24 years old and delivered a premature newborn. And we surveyed all cases of pregnancy with UAPA reported between 1988 and 2011. MEDLINE was used to identify the cases. Clinical Cases or Summary Results: A 24-year-old pregnant woman was referred to our obstetrics department at 12 weeks of gestation. When she was 21 years old, she was suffering from chronic hemoptysis and then diagnosed as an isolated right UAPA, which was established with chest radiograph, pulmonary ventilation-perfusion scan and chest CT scan. She received a follow-up examination and had no event of respiratory or cardiac problem since then. Her first trimester pregnancy was uneventful. At 27 weeks of gestation, she admitted to our hospital due to threatened preterm labour and had tocolytic treatment. In spite of medical intervention, she complained frequent uterine contraction and dyspnea at 35 weeks. She had a cesarean section under general anesthesia and delivered a 2350g male infant. During her hospitalization, her UAPA was followed up with echocardiography every 2 weeks, and no evidence of pulmonary hypertension was detected. During and after the cesarean section, mild elevation of pulmonary artery pressure was observed, but it gradually decreased without treatment. Patient was discharged 8 days after operation without any symptoms. Conclusions: We can find 7 literatures which reported on 11 cases of pregnancy women with isolated UAPA. In these literatures, pulmonary hypertension was found in one patient, but pulmonary arterial pressure was well controlled in this case. There was none of the dead during the pregnancy except one who died due to ARDS and sepsis 15 days after delivery. Previously known, UAPA with pulmonary hypertension leads a high mortality rate. Fortunately, pulmonary artery pressure of our patient was almost controllable during pre and postpartum period. But if pulmonary hypertension had occurred, we would have been forced to make a difficult decision on when we should stop her pregnancy. In conclusion, we report on one case of pregnant woman with UAPA. Extensive evaluation and careful observation, which includes monitoring pulmonary artery pressure, are needed not to overlook symptoms suggesting pulmonary hypertension, especially during peripartum period. Keywords: Pregnancy, Unilateral absence of a pulmonary artery, Pulmonary hypertension Presenter: H. Moroi

ID 073

METHODS OF DELIVERY AS A REASON FOR BIRTH TRAUMA J. Ivanov1 & G. Bushinoska-Ivanova2 1

Gynecology and Obstetrics Department, Clinical Hospital Acibadem-Sistina Skopje, Macedonia, and 2University Clinic of Gynecology and Obstetrics Mother Theresa Skopje, Macedonia Brief Introduction: OBJECTIVE: The aim of this study was to prove the connection between the birth trauma and the methods of delivery.

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DOI: 10.3109/14767058.2014.924236

Materials & Methods: MATERIAL AND METHOD: 9496 newborns, term 8630 (90.88%), praeterm 866 (9.12%), who were born at Special Hospital for Gynecology and Obstetrics –Mother Theresa, Skopje, Macedonia, during the period of tree years (2009–2011), were studied retrospective. We analyzed the method of delivery: vaginal (spontaneous and with intervention) and cesarean and the type of birth trauma. 7699 (81%) of newborns were born by spontaneus vaginal method,135 (1.42%) were born vaginal with intervention and 1662 (17.5%) were born with cesareum section. Clinical Cases or Summary Results: RESULTS: The incidence of birth trauma in the whole group (9496 newborns) was 5.72% (544). In a group of newborns with spontaneous vaginal delivery 6% (462) were with birth trauma. In a group of a newborns with vaginal delivery with intervention 37% (50) were with birth trauma. In newborns with cesareum section 1.92% (32) with birth trauma. From 9496 newborns: Intracranial hemorrhage (ICH) were 0.85% (81), term 0.7% (61), praeterm 2.3% (20). Cefalhaematoma 2.54% (242), term 2.6% (225), praeterm 2% (17). F-ra claviculae 1.94% (185), term 2.1% (181), praeterm 0.5% (4). Paresis plexus brachialis 0.23% (22), term 0.23% (20), praeterm 0.23% (2). Paresis N.Facialis 0.11% (11), term 0.1% (9), praeterm 0.23% (2). F-ra Femoris 0.01% (1), term newborn. Oedema cerebri 0.02% (2), term newborn 0.01%(1), preterm 0.1%(1). Conclusions: CONCLUSIONS: Obstetric techniques of delivery, like the methods of Bracht, vacuum extraction, forceps and extraction are connected with increase of incidence of birth trauma. This is pointing us to the risk of the use of vaginal obstetrics intervention, and to avoid them when ever it is possible.

with No1 chromic cat gut. Uterine incision was sutured 2 layers. Uterus was manual compressed for 15 minutes. 5 cm. laceration of bladder was detected, urologist was consulted. Patient was transferred to intensive care unit for post-operative care. Total operation time is 5 hours, EBL 5000ml, and PRC 6 unit FFP 5 unit and LPPC 3 bags were replaced. After one day in ICU with prolong bed rest, vital signs were stabilized. The patient was moved to post-partum ward. Patient’s clinical status was gradually improved. On post-operative day5, at the time of changing position from sitting to stand, the patient was fall, turned unconscious and developed cardiac asystole. The patient passed away after 1 hour continuous cardiopulmonary resuscitation. Massive bilateral pulmonary vein thrombosis was found at autopsy. Conclusions: Conclusion: Venous thromboembolism (VTE) has been reported to be less common among Thais than Caucasians(1), although rare, is a major cause of maternal mortality and morbidity. Now, there is insufficient evidence on which to base recommendations for thromboprophylaxis during pregnancy and the early postnatal period(2). Assessment of the individual thrombotic risk in women after a cesarean section may be benefit to prevent VTE(3). Keywords: Placenta accreta, Pulmonary vein thrombosis, Cesarean section Presenter: Sudden maternal death: 5 days after cesarean section for placenta accreta.

Keywords: Delivery, Birth Trauma Presenter: Jordancho Ivanov

ID 670

ID 778

TIMING OF CESAREAN SECTION IN ABSENCE OF LABOR AND RISK OF RESPIRATORY COMPLICATIONS IN NEWBORNS

SUDDEN MATERNAL DEATH: 5 DAYS AFTER CESAREAN SECTION FOR PLACENTA ACCRETA S. Hamontri, W. Charaschaisri, & P. Puapornpong Faculty of Medicine, Srinakharinwirot University, Thailand Brief Introduction: Introduction: A case of sudden death in a young woman after cesarean section for placenta accreta is presented. Evidence of extensive pulmonary vein thrombosis is found at autopsy. Awareness of this syndrome is necessary to prevent tragic consequences. Materials & Methods: Case Report: A 38-year-old gravid 2 para1 at 34 weeks of gestation, she had no significant past medical history but she had previously undergone one uncomplicated low-transverse cesarean section delivery. During antenatal care period, amniocentesis for chromosome study was performed(46, XY). She had history of antepartum bleeding at GA 21 weeks and totalis placenta previa was detected from transabdominal sonography. But at GA 30 weeks, placenta previa was resolved and the placental location was at the anterior segment of the uterine cavity. On the admission date, the patient came to hospital because of leakage for 4hours. PPROM was proved. Breech presentation fetus was detected from ultrasonography. Emergency cesarean section was set due to previous cesarean section, PPROM and breech presentation. Clinical Cases or Summary Results: Intra-operative findings: Severe dense adhesion between urinary bladder and lower segment of uterus, dense adhesion at posterior surface of uterus with bilateral hydrosalpinx due to pelvic endometriosis were found. Low-transverse uterine incision was performed. Active male fetus was delived, BW 2190g. Placenta was located at anterior wall. Manual removal of placenta was performed. Placenta accrete was detected. The area of accrete is about 3  6 cm. Placenta accreta site was interrupt sutured

M. Pace1, G. Corona1, F. Fontanella1, M. Bonito2, C. Haas3, & R. Di Iorio1,2 1

Department of Obstetrics, Gynecology, and Urology, Sapienza University, Rome, Italy, 2Division of Obstetrics and Gynecology, San Pietro Fatebenefratelli Hospital, Rome, Italy, and 3Neonatal Intensive Care Unit, San Pietro Fatebenefratelli Hospital, Rome, Brief Introduction: Cesarean sections (CS) rate is increasing worldwide. Among them, a large number is represented by a planned CS performed in absence of labor. The absence of labor is associated with an increased risk of respiratory morbidity, but this seems to change according to gestational age. Most of international guidelines today suggest to postpone the CS in absence of labor, if possible, at 39 weeks of gestation. The aim of this study is to investigate the difference in the risk in babies delivered at term or near term by planned CS. Materials & Methods: We collected data from 4,565 singletons ended in a CS in absence of labor between 34 and 41 weeks of gestations. For each case we recorded: parity, nationality and age of the mother, neonatal gender and weight, and presence or absence of respiratory complications of the newborn (excluding pneumonia and meconium aspiration syndrome). We performed a bivariate and a multivariate analysis to calculate the Odd Ratio (OR) in order to estimate the risk to develop a respiratory complication for each week of gestation. Clinical Cases or Summary Results: A respiratory complication was presented by 3.8% of newborns. Almost half of CS was performed at 38 weeks (2,100) with 2.1% of respiratory complication, but this percentage is higher among babies born at lowest weeks of gestations (25.0%, 11.3%, 6.0%, 2.3% at respectively 34, 35, 36, and 37 weeks). If we consider 38 weeks as reference, the risk to have a complications is significant between 34 and 37 weeks, but it is not

62 at 39 even after adjusting for the other factors (OR 0.61 (0.31–1.19 IC95%)). Conclusions: Compared with newborns delivered at 38, those delivered at 39 do not have an decreased risk of respiratory complications. The risk increases with decreasing gestational age.

J Matern Fetal Neonatal Med, Early Online: 1–437

Conclusions: there is no ideal cesarean section rate, but most authors agree that beyond 25–30%, the rate is abnormal. Keywords: cesarean section, morbidity, mortality Presenter: A. Ben Haj Hassine

Keywords: timing, cesarian section, respiratory complications, labor Presenter: M. Pace

TORSION OF THE GRAVID UTERUS: A CASE REPORT

HOW TO DECREASE CESAREAN DELIVERY RATE; USE OF ROBSON 10 GROUP CLASSIFICATION SYSTEM

Fred Kirss

T. Asatiani

Tartu University Women’s Clinic, Tartu, Estonia

Department of Reproductive Health, State Medical University. Tbilisi, Georgia

ID 764

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

ID 210

Brief Introduction: Torsion of the uterus is a rare obstetric complication. Symptoms of uterine torsion vary depending on the degree and duration of torsion. Variable symtomatology and lack of a specific diagnostic sign make uterine torsion extremely difficult to recognise before laparotomy. Materials & Methods: We present a case report of a 31 –year-old woman, gravida 2, para 0, hospitalized for elective caesarean section due to placenta praevia totalis and transverse situs of fetus. Clinical Cases or Summary Results: An elective Caesarean section was performed at 36 weeks and 2 days of gestation. An infant in good condition with birth weight 2250 grams was delivered with estimated intraoperative blood loss of 500 ml. At surgery appeared, the uterus was 180 degrees levorotated. The uterus was restored to normal position. B-Lynch compression suture were placed during the Caesarean section. The patient left from the hospital with baby on fift day after surgery. Conclusions: The uterine torsion was diagnosed during the caesarean section. Keywords: Uterine torsion Presenter: Fred Kirss

ID 194

Brief Introduction: To analyze the reasons of cesarean delivery rate increase on institutional level of using Robson 10 group classification system Materials & Methods: Prospective clinical audit of women underwent cesarean delivery at Shararashidze Medical Center, Tbilisi, Georgia were conducted in 2008 and 2013. Contribution of each group of Robson classification in overall cesarean section rate was calculated. In addition CS indication in each group were analyzed. Clinical Cases or Summary Results: At Sharashidze Medical Center CS rate increased from 9.4% to 16.7%. The most common indication for CS in both time frame was a previous CS (Group 5); CS rise was most prominent in nulliparous women at term with singleton fetuses with vertex presentations (Group1), nulliparous women at term with singleton fetuses with vertex presentations, induced (Group 2); women at term with previous cesarean sections (Group 5) and all nulliparous breeches (group 6); multiparous women at term with breech presentation including previous CS (Group 7) Conclusions: Audit of CS rate in subgroups using Robson 10 group classification system is useful to help in planning strategy for specific subgroups. Avoiding unnecessary abdominal deliveries in these groups will also have a long-term effect, in that the number of repeat CS will be reduced in the future Keywords: cesarean section, Robson classification

CESAREAN SECTION: A STUDY ABOUT 5008 CASES

Presenter: T. Asatiani

A. Ben Haj Hassine, R. Arfaoui, H. Siala, S. Menjli, & R. Rachdi

DIABESITY

Department of Gynecology and Obstetrics – Military Hospital of Tunis – Tunis – Tunisia

ID 458

Brief Introduction: Caesarean section as a mode of delivery takes nowadays a more important place. Significant variations in the rate of cesarean were found by geographic region. Materials & Methods: It’s a retrospective study about 5008 cases of cesarean section done at the maternity of the military hospital of Tunis during seven years (2004–2010) Clinical Cases or Summary Results: Cesarean rate was 28%. Primiparity was 48%. Main indications were: acute fetal suffering 24%, breech presentation 18%, revious scarred uterus 34%. Maternal prognostic was good: peroperative bleeding needing transfusion 1%, postoperative complications 15% represented by urinary infection, parietal infection, anemia. Maternal mortality was 0.13% due to maternal diseases Neonatal morbidity was 3% due to prematurity and perinatal asphyxia

USING ESTIMATED FETAL WEIGHT AT LEVEL II ULTRASONOGRAPHY TO PREDICT GESTATIONAL DIABETES MELLITUS AND NEWBORN MACROSOMIA P. Liao1, A. Park2, H. Berger1, J.G. Ray3 1

Department of Obstetrics & Gynaecology, University of Toronto, Toronto Ontario, 2Institute for Clinical Evaluative Sciences Toronto Ontario, and 3Departments of Medicine, Obstetrics and Gynaecology and Health Policy Management and Evaluation, St. Michael’s H

63

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DOI: 10.3109/14767058.2014.924236

Brief Introduction: 1. Does estimated fetal weight (EFW) at 18–22 week ultrasound predict gestational diabetes mellitus (GDM) at 24–28 weeks gestation? 2. Is EFW at 18–22 weeks associated with newborn weight and LGA birthweight 90th percentile? Materials & Methods: We performed a case-control-control study at St. Michael’s Hospital, Toronto. Cases comprised women with GDM on insulin (n = 65) or diet (n = 65). Controls were women with a negative GDM screen (n = 131). We obtained standardized sonographic EFW at 18–22 weeks gestation. Multivariable linear (LIN) and logistic (LOG) regression analyses were used. Clinical Cases or Summary Results: A 1-SD (70-g) higher EFW was not associated with GDM (ORa 1.00, 95% CI 0.61 to 1.66) (LOG: adjusted for gestational age at time of EFW, infant sex, maternal age, ethnicity, parity and BMI). However, upon combining cases and controls, a 1-SD (70-g) higher EFW was associated with a 231 g (95% CI 128 to 334) higher birthweight (LIN: adjusted for gestational age at time of EFW, gestational age at delivery, infant sex, maternal age, ethnicity, parity and BMI). Similarly, a 1-SD (70-g) higher EFW was associated with LGA (ORa 4.02, 95% CI 1.76 to 9.19) (LOG: adjusted for gestational age at time of EFW, infant sex, maternal age, ethnicity, parity and BMI). Conclusions: While EFW at 18–22 weeks was not associated with GDM, it did predict newborn weight and LGA status. Keywords: Gestational diabetes mellitus, ultrasound, estimated fetal weight, birthweight, macrosomia, large for gestational age birthweight Presenter: P Liao

ID 065

RELATIONSHIP BETWEEN PREGNANCY OUTCOMES AND APPLICATION OF LESS STRINGENT IADPSG CRITERIA TO SCREEN FOR GDM. PRELIMINARY RESULTS 1

2

G. Page , A. S. Page , I. Dehaene

the two criteria of which we are now able to analyse the pregnancy outcomes. This is part of an ongoing, prospective study where we continue to monitor the incidence of GDM in our hospital as well as follow the perinatal policy and pregnancy outcomes further. Clinical Cases or Summary Results: We have complete data from 162 mother-child cases with gestational diabetes according to the strict criteria and 87 mother-child cases with gestational diabetes according to the less stringent criteria. The incidence of GDM dropped from 25.8% to 13.9%. Risk factors between the two groups weren’t neither statistically nor clinically significant different. We found no significant differences in perinatal policy. The rate of Caesarean Sections in the con-trol group is 19.13% and 20.69% in the experimental group. Instrumental deliveries were 11.9% and 9.2% respectively. Induction rates were 21.0% and 24.1%,.We can not identify a difference in maternal outcomes. Also hypertensive disorders do not appear to differ (OR = 0.593, CI 95% 0.226–1.550) Only an increase of macrosomia can be retained (OR = 2.0 (1.1 to 3.6). However, this is not ac-companied by an increase in interventional obstetrics and admission in neonatal wards (OR = 0.68). Perinatal acidosis was no different. Conclusions: The preliminary results of our ongoing study show no significant short term different clinical out-comes with the use of less stringent IADPSG criteria. However, further research of observational studies and ideally, randomised controlled trials, should confirm these preliminary results. Universal screening for GDM in all pregnant women seems to be recommended. However, cut-off levels for positive screening remains discussable. Regional estimates of the inci-dence of GDM are imperative before screening is to be implemented. Due to the current low pa-tient numbers, we admit the limited clinical significance of our findings.However, the significant more occurrence of macrosomia (although without short term clinical im-plications) in the experimental group suggests the IAPDSG recommended cutoff level of HAPO OR = 2 is the upper lower limit for screening a pregnant population. Keywords: IADPSG, gestational diabetes, Presenter: G.H. Page

3

Obstetric Dept. Jan Yperman Hospital, Ypres, Belgium Brief Introduction: The global implementation of IADPSG criteria for screening pregnant women for gestational diabe-tes mellitus (GDM) resulted in a sharp rise of the incidence of GDM. Our hospital has an incidence of 25.8%. We decided to switch to a less stringent screening method. The cut-off value for the diagnosis of GDM was made on the ba-sis of an OR = 2, instead of the currently available cut-off value based on a OR1.75 for birth weight4P90, umbilical cord blood C-peptide4P90 and percentage of body fat neonatally4P90 in the HAPO trial. We want to investigate whether this change has an effect on the incidence of GDM, the relation-ship of a positive screen with risk factors and the most common pregnancy outcomes. Materials & Methods: We made a retrospective cohort analysis of all pregnant women diagnosed with gestational diabe-tes, according to

Neonatal outcomes birthweight Apgar 1 min Apgar 5 min pH a macrosomia dysmaturity shoulder dystocia NIC and NICU

ID 148

THE ASSOCIATION OF PREPREGNANCY OVERWEIGHT/ OBESITY AND EXCESSIVE GESTATIONAL WEIGHT GAIN WITH PERINATAL COMPLICATIONS I. Szymusik1, K. Kosinska-Kaczynska1, M. Starek2, E. Bumbul2, A. Koziel2, B. Wardenska2, B. Pietrzak1, & M. Wielgos1

IADPSG (HAPO OR = 1,75)

IADPSGA (HAPO OR = 2.0)

3329 g 8.6 9.4 7.3 31 (19.3) 12 (7.40) 0 21(12.9)

3428g 8.6 9.5 7.2 28 (32.2) 8(9.19) 0 8 (9.19)

p Value

OR(CI 95%)

0.022 0.621

2.005(1.105–3.641) 1.266(0.497–3.225)

0.379

0.680(0.288–1.606)

64 1

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Poland, and 2Students’ Research Group at the 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Poland Brief Introduction: The number of overweight and obese women of reproductive age has definitely risen over the last few years. Nearly two thirds of reproductive-aged women in the United States are currently overweight or obese. The aim of the study was to determine the impact of pre-pregnancy BMI and excessive gestational weight gain (GWG) on perinatal complications and the outcome of delivery. Materials & Methods: 822 medical charts of pregnant women, divided into 6 groups on the basis of pre-pregnancy BMI and weight gain during pregnancy were analyzed: control- BMI 18.5–24.9 gained 11–16 kilograms (kg) (252women) – normal BMI, recommended GWG G1 (203) -BMI 18.5–24.9 gained 416 kg (203) – normal BMI, excessive GWG G2 (99) - overweight, recommended GWG G3 (164) - overweight, excessive GWG G4 (50) - obese, recommended GWG G5 (54) - obese, excessive GWG The rate of gestational diabetes mellitus (GDM), gestational hypertension, first trimester bleeding, macrosomia, the duration of delivery, the frequency of preinduction and induction of labor and the rate of cesarean section were analyzed and compared among groups. Statistical analysis was performed using SAS with p50.05 considered significant. Clinical Cases or Summary Results: Overweight (G2 + G3) and obese (G4 + G5) women were more likely to develop GDM (overweight – 21.76%; obese- 32.69%; control-7.93%; G1–2.98%) (p50.001). Both pre-pregnancy overweight/obesity and excessive weight gain increased the risk of hypertension (control-3.97%; G1–11.82%; G2 + 3 – 10.65%; G4 + 5 -23.08%) (p50.002). With the gain of each kg during pregnancy, the risk of first trimester bleeding increased by 5% (OR = 1.049; p50.0115). Macrosomia was more often observed in G5- 14.8% in comparison to other groups - control (1.59%), G1 (3.94%), G2 (3.03%), G3 (1.83%), G4 (2%) (p50.001). Excessive weight gain during pregnancy increased the necessity of labor preinduction, especially in the group of overweight women (p50.04). The risk of operative delivery seems to be the highest in obese patients (G4– 54%, G5–53.7% vs. controls-41.3%), although the difference did not reach significance. Conclusions: Excessive kilograms increase the rate of pregnancy complications and contribute to the greater number of perinatal medical interventions. Appropriate pre-pregnancy BMI seems to be more important to avoid pregnancy complications than normal weight gain during gestation. Keywords: BMI, gestational weight gain, obesity, pregnancy complications

J Matern Fetal Neonatal Med, Early Online: 1–437

occurs in the second trimester of pregnancy due to insulin resistance. There are different diagnostic criteria for gestational diabetes resulting in different incidence of gestational diabetes. The aim of the research was to compare perinatal outcomes of pregnant women with gestational diabetes according to the criteria established by World Health Organization (WHO) and International Association of Diabetes and Pregnancy Study Groups (IADPSG). Materials & Methods: The study included pregnant women who made oral glucose tolerance test (OGTT) with 75 grams of glucose between 24 and 34 weeks of gestation in the period since 2009. – 2011th year. Gestational diabetes is diagnosed according to WHO and IADPSG criteria. Data on pregnancy and perinatal outcome were analyzed from the medical histories of women who conducted and completed their pregnencies in the Department of Obstetrics University Hospital Center Zagreb. We analyzed age, pregnancy, parity, duration of pregnancy, pregnancy complications (hypertension/pre-eclampsia), the way of completion of pregnancy, weight and length of the newborn, Apgar score after the first and 5 minutes, newborn complications (hypoglycemia, hyperbilirubinemia, infection, etc) and puerperium complications. Clinical Cases or Summary Results: The first group (WHO/IADPSG) was the group of pregnant women with GDM according to WHO and IADPSG criteria (N 430; 16.1%). In the second group were pregnant women who had GDM according to WHO criteria (N 126; 4.7%). A third group of pregnant women were those with GDM according to IADPSG criteria (N 521; 19.5%). The fourth group of pregnant women had overt diabetes according to WHO and IADPSG criteria (N 54: 2.0%). The fifth group of pregnant women were those with overt diabetes according to the criteria IADPSG, but they had also GDM by WHO criteria (N 119; 4.5%). The sixth group of pregnant women had overt diabetes according to IADPSG criteria, who according to WHO criteria had normal oGTT (N 51; 1.9%). The seventh group was the control group of healthy pregnant women (N 1368; 51.3%). The incidence of cesarean section was higher in pregnant patients with GDM according to WHO criteria and IADPSG compared to the control group (26.7%; 25.4%; 18.6%). The highest incidence of cesarean section was in the group with overt diabetes (29.6%; 27.7% and 35.3%), while the lowest was in the control group (14.4%) (2 = 62.01; p 90 th percentile) was the largest in the group of pregnant women with GDM by IADPSG criteria (24.4%), in the group with overt diabetes (38.9%, 29.4%, 29.4%) compared to the control (17.4%) and WHO group (16.7%) (2 = 45.971; p50.001). The highest incidence of preeclampsia and gestational hypertension was in the group of obese women (0.9%; 22.9%) and lowest in the group with normal BMI (0.4%; 0.1%; 3.0%) (2 = 184.819; p50.001). Conclusions: According to IADPSG criteria for GDM it was diagnosed more often overt and gestational diabetes in relation to the WHO criteria. The largest number of caesarean sections (35.3%), hypertension/pre-eclampsia and macrosomic newborns (44500 g, 23.5%) were

Presenter: Iwona Szymusik TABLE 1. Frequency of GDM and overt diabetes according to WHO and/or IADPSG criteria.

ID 409

PERINATAL OUTCOME IN PREGNANT WOMEN WITH GESTATIONAL AND OVERT DIABETES ACCORDING TO WHO AND/OR IADPSG CRITERIA M. Pavic, M. Ivanisevic, & J. Djelmis Department of Obstetrics and Gynecology, University Hospital Center of Zagreb, Zagreb, Croatia Brief Introduction: Gestational diabetes mellitus (GDM) is diabetes that is first diagnosed during pregnancy. Gestational diabetes usually

Studied groups GDM according to both criteria WHO/ IADPSG (overlapped results) GDM according to WHO criteria GDM according to IADPSG criteria OVERT DIABETES according to both criteria WHO/IADPSG OVERT DIABETES according to IADPSG criteria while according to WHO diagnosed as GDM OVERT DIABETES according to IADPSG criteria while according to WHO normal OGTT CONTROLS (normal OGTT according to WHO and IADPSG) Total

N

%

430

16.1

126 521 54

4.7 19.5 2.0

119

4.5

51

1.9

1368

51.3

2669

100

65

DOI: 10.3109/14767058.2014.924236

found among women with overt diabetes by IADPSG, which according to WHO criteria had no GDM. Keywords: gestational diabetes, overt diabetes, WHO/IADPSG criteria, perinatal outcome Presenter: Mato Pavic

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

ID 060

SEVERE NEONATAL COMPLICATIONS OF GESTATIONAL DIABETES: DATA FROM THE FRENCH POPULATION IN 2011 C. Billionnet1, A Weill1, U. Simeoni2, P. Ricordeau1, F. Alla1, S. Jacqueminet3, A. Hartemann3, & D. Mitanchez4 Caisse Nationale de l’Assurance Maladie, Paris, France, 2Poˆle de Ne´onatologie, Assistance Publique Hoˆpitaux de Marseille & Aix-Marseille universite´, Marseille, France, and 3Service de Diabe´tologie, Hoˆpital Pitie´ Salpeˆtrie`re, Universite´ Paris VI, Paris, Franc 1

Brief Introduction: The risks incurred by newborn infants in the case of gestational diabetes (GD) are debated. We evaluated the risks of severe complications according to the type of maternal diabetes from the French birth cohort in 2011. Materials & Methods: Data were obtained from the French DRG program (PMSI) and the inter-regimens national system of information (SNIIRAM) of the French health insurance system. All childbirths and terminations of pregnancy (TOP) after 22 weeks of gestation, due to medical reasons were selected. The mother’s diabetic status was determined by an algorithm based on the consumption of antidiabetics and hospitalization diagnoses before and during pregnancy. An identifier in the PMSI was used for the chaining between maternal status and the infant’s morbidity. Clinical Cases or Summary Results: 806 579 childbirths/IMG422SA were identified in the PMSI. Mother-infant chaining was obtained for 474 614 births in public institutions. In the case of type 1 and type 2 diabetes, the risks were respectively increased for the following complications (OR adjusted on mother age [IC 95%]): perinatal death (2.2 [1.4–3.4] and 3.0 [2.2–4.1]), perinatal asphyxia (3.3 [2.2–5.1] and 2.5 [1.6–3.7]), respiratory distress syndrome (OR adjusted on mother age and gestational age: 2.6 [2.0–3.4] and 1.9 [1.5–2.5]), brachial plexus trauma and/or collarbone fractures in cases of vaginal delivery (8.5 [4.9–14.8] and 2.9 [1.5–5.9]), cardiac malformations (4.4 [3.0–6.5] and 3.2 [2.2–4.7]). On the other hand, in cases of GD, the risks were not increased for these complications compared to the population without diabetes, except for the risk of respiratory distress syndrome (1.2 [1.1–1.3]). Conclusions: These data obtained in the French population over one year show that the risks of severe complications in cases of GD are similar to those in the general population, except for the moderately increased risk of respiratory distress syndrome. Keywords: Epidemiology, maternal diabetes, perinatal death, malformations, respiratory distress Presenter: D MITANCHEZ

ID 370

GESTATIONAL WEIGHT GAIN AND OBESITY: WHICH CORELATION WITH FETAL OUTCOMES? A. Giudicepietro, A. Sirico, F. Quaglia, G.M. Maruotti, G. Saccone, M. Di Cresce, A. Migliucci, L. Sarno, A. Capone, G. Mallia Milanes, & P. Martinelli Department of Neurosciences, Reproductive and Dentistry Sciences - High-Risk Pregnancy Unit, University Federico II, Naples, Italy Brief Introduction: The prevalence of obesity in pregnancy is approximately 20–30%. This is an increasingly growing health problem. Obesity during pregnancy is considered an high-risk because there is a correlation between pre-gestational BMI and adverse maternal and fetal outcomes. The gestational hypertension, the gestational diabetes, the failure of induction of labour, the preterm birth, the intrauterine fetal death, the first caesarean section, the fetal growth restriction and macrosomia are possible disease correlated to obesity. Materials & Methods: The main objective of the study was to correlate pre-gestational weight, measured by the body mass index (BMI), and gestational weight gain with NICU admission and fetal or neonatal death. In our retrospective study, we included 35 singleton pregnancies of women with a BMI430 followed in our High-Risk pregnancy Department between 2008 and 2013. For each pregnant with single fetus were collected data about age, anthropometric measurements necessary for calculating the BMI, information about obstetric anamnesis, complications and any medications taken during pregnancy. We collected also data on maternal diseases in particular diabetes, hypertension, preeclampsia. For the neonatal outcome were collected data on: sex, weight, Apgar scores at 1 and 5 minutes and admission at NICU. We compared pregestational BMI and gestational weight gain in cases with NICU admission versus controls; we also compared pregestational BMI and gestational weight gain in women with fetal or neonatal death and controls. Statistical analysis was carried out using the Statistical Package for Social Sciences (SPSS) Statistics v. 19 (IBM Inc., Armonk, New York, USA). Clinical Cases or Summary Results: In our population 12 women had babies admitted at NICU and 4 women had neonatal death. No statistical difference was observed in mean pregestational BMI between women with or without NICU admission (37.45; SD 6.74 vs 40.17; SD 8.07; p = 0.37) and in women with or without fetal or neonatal death (35.85; SD 4.16 vs 39.93; SD 8.02; p = 0.33). A statistical difference was observed in mean gestational weight gain weight between women with or without NICU admission (14.87; SD 16.67 vs 6.02; SD 7.33; p50.05) and in women with or without fetal or neonatal death (23.00; SD 17.58 vs 6.12; SD 7.93; p50.05). Conclusions: Our results show that even if pregestational weight has been showed to be associated with adverse fetal and neonatal outcomes, gestational weight gain may be more important as risk factor for the developing of adverse outcomes in pregnancies complicated by obesity. Thus a strict medical control on maternal nutrition and weight gain should be done in pregnancies complicated by obesity. Keywords: Obesity Pregnancy Presenter: A. Giudicepietro

66

ID 128

ID 129

ARACHIDONIC AND DOCOSAHEXAENOIC ACID IN THE BLOOD OF A MOTHER AND UMBILICAL VEIN IN DIABETIC PREGNANT WOMEN

THE RELATION OF GLUCOSE AND ADIPOKINES TO BIRTH WEIGHT IN TYPE 1 DIABETIC PREGNANCY

E. Berberovic, M. Ivanisevic, M. Hovraticek, I. Delas, & J. Djelmis University Clinic for women’s diseases and delivery, University Clinical Hospital Centre Zagreb, School of Medicine University of Zagreb, Petrova 13, Zagreb, Croatia J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

J Matern Fetal Neonatal Med, Early Online: 1–437

Brief Introduction: The essential long-chain polyunsaturated fatty acid, arachidonic and docosahexaenoic acid are important for fetal growth and development. Fetal concentration of AA and DHA depends on the mother’s concentration, i.e. on their ingestion by food. Previous studies showed that type 1 diabetes is associated with low AA and DHA levels of pregnant women. The aims of the study were: 1. To determine total FAs concentration in the maternal vein serum and in the umbilical vein serum in pregnant women suffering from T1DM and Control group; 2. To determine and analyze AA and DHA concentrations and percentages (%) in relation to the total FAs concentration in the mother’s vein serum and the umbilical vein serum in pregnant women suffering from T1DM compared to the Control group. Materials & Methods: The study included 63 pregnant women, 32 suffering from T1DM and 31 from Control group. Samples of a mother’s vein blood and the umbilical vein blood were taken immediately after the birth. The total lipid extraction was carried out by the mixture of chloroform: methanol solvent: a method of increasing polarity according to Folch. Heptadecanoic acid was used as internal standard in order to determine the exact proportion of total lipids. Fatty acids from lipid extracts were converted to methyl esters by transesterification with methanolic HCl (ref: ISO standard) and their composition analyzed by GC-MS on Varian 3400 (Varian, USA) equipped with Saturn II ion trap mass spectrometer operating in the electron impact (EI) mode. Clinical Cases or Summary Results: There was statistically significant difference in the total FAs concentration in the maternal vein serum and the umbilical vein serum between the two groups (p50.001). There was a statistically significant higher concentration of total FAs in the maternal and umbilical vein serum of the diabetic group. Statistically significant difference of AA and DHA concentrations in the maternal vein serum were found between two groups (AA: p50.001; DHA: p50.001). Significantly higher concentrations of AA and DHA were found in the umbilical vein serum in T1DM (AA: p50.01; DHA: p50.05). Higher AA and DHA concentrations were found in the maternal vein serum compared to an umbilical vein serum of the diabetic group. Conclusions: Our study found no difference in AA and DHA percentages in the maternal or in the umbilical vein serum of diabetic pregnant women. Despite of T1DM, a good metabolic control leads to insignificant changes in the AA and DHA levels in diabetic pregnancy. Further studies are needed to understand the mechanism of diabetic pregnancy and its influence on biochemical abnormality and its implications for fetal development. Keywords: AA, DHA, Type 1 diabetes, pregnancy Presenter: E. Berberovic

M. Ivanisevic, E. Berberovic, M. Horvaticek, S. Kralik-Oguic, & J. Djelmis University Clinic for women’s diseases and delivery, University Clinical Hospital Centre Zagreb, School of Medicine University of Zagreb, Zagreb, Croatia Brief Introduction: Pregnancy is associated with major changes in woman’s hormonal status and metabolism. In the past several years the role of adipokines has been linked to the development of maternal insulin resistance and consequently fetal growth. The aim of this study was to establish relationships between the levels of glucose, insulin, C-peptide, leptin and adiponectin in maternal and umbilical vein serum and birth weight in Type 1 diabetic pregnancies (T1DM) and also in healthy pregnancies. Materials & Methods: The study included 120 pregnant women divided into 4 groups: 30 suffering from type 1 diabetic pregnancy (T1DM) who gave birth to eutrophic and 30 who gave birth to macrosomic infants; 30 from Control group (CTRL) who gave birth to eutrophic and 30 who gave birth to macrosomic infants. Samples of the mother’s vein blood and the umbilical vein blood were taken immediately after the birth. Serum insulin, C-peptide, leptin and adiponectin levels were quantified by ELISA. Clinical Cases or Summary Results: Fetal macrosomia is associated with higher level of leptin in the fetal serum in both groups (T1DM: p = 0.049; CTRL: p = 0.031). Fetal levels of glucose and insulin have an influence on birth weight in the Control group (glucose: p = 0.002; insulin: p = 0.015). Adiponectin levels are higher in the maternal (p = 0.001) and fetal serum (p50.001) in eutrophic newborns of healthy pregnant women compared to the macrosomic newborns. Conclusions: The fetal growth is a complex process. Our results confirmed the relation between leptin and insulin levels and birth weight. They also suggest that adiponectin may be involved in the fetal growth. Keywords: leptin, adiponectin, birth weight, Type 1 diabetes, pregnancy Presenter: M. Ivanisevic

ID 650

ARE GLUCOSE LEVELS IN EARLY PREGNANCY PREDICTIVE OF SUBSEQUENT GDM? F. Mecacci1, M.G. Dalfra`2, E. Ragazzi3, A. Soldato2, E. De Benedetti2, S. Biagioni1, C. Nardini1, L. Dal Martello4, S. Burlina2, A. Lapolla2, & G. Mello1 1

DPT di Ostetricia, Ginecologia e Scienze della Riproduzione umana, Universita` di Firenze, Italy, 2DPT di Medicina, Universita` di Padova, Italy, 3DPT di Farmacologia e Anestesia, Universita` di Padova, Italy, and 4Medicina di Laboratorio, Universita` di Padova Brief Introduction: IADPSG consensus guidelines for diagnosis of gestational diabetes (GDM) recommend a screening procedure at 24–28 gestational age (g.a) in all pregnant women. It establishes also that a fasting plasma glucose (FPG) level 92 mg/dl in the first trimester be diagnostic for GDM but this choice didn’t find universal consensus. The Italian Protocol agrees that FPG in the first trimester between 100–125 mg/dl needs to be evaluated with a

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DOI: 10.3109/14767058.2014.924236

early OGTT 75 g at 16–18 g.a, but FPG between 92–99 mg/dl don’t need particular attention. So far, recommendations on early screening are not clear. Aim of this study was to speculate if there is a relationship between the results of the screening for GDM at 24–28 g.a. and the glucose level measured in the first trimester. Materials & Methods: Retrospective study of 1773 pregnant women screened for GDM. We collected the first FPG measured in pregnancy, g.a of its measurement and the results of the OGTT 75g at 24–28 g.a. for diagnosis of GDM. IADPSG Correlation analysis and ROC curve for glycemia and gestational week were performed. Clinical Cases or Summary Results: 911 women resulted affected by GDM and 863 had normal glucose tolerance test (NGT). The groups differed in the mean FPG in the first trimester (89.6 ± 11.7 vs 84.3 ± 9.4 p50.05), which was higher in the GDM group: no differences were found in pre-pregnancy BMI (24.4 ± 5.3 vs 23.2 ± 5.1, p = ns) and timing of the first test for FPG (8.2 ± 2.8 vs 8.1 ± 1.6, p = ns). FPG at the first trimester of pregnancy (p50.0001) and its g.a. (p50.0002) were significantly correlated with GDM diagnosis. The ROC curve shown, as best performance for glucose level at 85mg/dl, a sensitivity of 66% and a specificity of 54%; for g.a. at 8 weeks a specificity of 75% and a sensitivity of 37% to predict GDM subsequent development. Sensitivity and specificity were not improved when adding obesity or family history for diabetes or age higher than 35 yrs. A glucose level 92 mg/dl shows a OR for GDM onset of 2.03 (1.63–2.52 95%CI). Furthermore, GDM women with FPG 92 mg/dl in the first trimester showed a higher frequency of overweight and insulin therapy with respect to those with FPG 592mg/dl (p50.01). A risk stratification model considering all the above variables and validated on some adverse pregnancy outcome is in course. Conclusions: Our data show a correlation between FPG detected early in the first trimester of pregnancy and subsequent GDM development. These results suggest that it is possible to select women at risk and to introduce an early prevention program in pregnancy.

Materials & Methods: Methods: 84 women diagnosed with GDM were followed up 1 week immediately after their diagnosis of GDM and subsequently every 2 weeks. All women underwent fetal USS at the time of GDM diagnosis and then at least every 4 weeks, until delivery. After 1 week of diet control, insulin was initiated with the following two criteria: (a) if glucose levels were persistently high – fasting glucose (FCG)495mg/dl and 1 hour postprandial glucose (PPCG)4130mg/dl – and fetal abdominal circumference (FAC)410th centile or (b) if FAC470th centile with simultaneous implementation of glucose targets FCG580mg/dl and/or 1h PPCG5120mg/dl. Clinical Cases or Summary Results: Results: Of the 84 GDM women, 49 (58.3%) were treated with diet only and 35 (41.7%) with diet and insulin. The number of fetuses with FAC470th centile were 23 (26.7%) at the time of the first USS and 11 (13.3%) during the last USS, indicating a 50% reduction (p = 0.021). There was no difference in the rate of caesarean sections between the diet and insulin groups. Mean gestational age of last USS was 36 weeks, with an accuracy of 96.7% when compared with neonatal birth weight (mean GA = 38 weeks). Out of 84 neonates only 2 was 490th centile and 3 were 510th centile. Conclusions: Conclusion: serial fetal USS in GDM pregnancies provides very useful information for the decision making of initiating insulin treatment in pregnancies complicated by GDM, and appears to decrease the percentage of macrosomia, without further increasing at the same time, the number of small for gestational age fetuses. Keywords: Presenter: G Daskalakis

ID 562

OBSTETRICAL OUTCOME IN THE DIABETIC PREGNANCIES

Keywords: Gestational diabetes, fasting plasma glucose

Mure¸san Daniel1,2, Stamatian Florin1,2, Florian Andreea2, & Rotar Ioana1,2

Presenter: S.Biagioni

1

ID 896

CLINICAL MANAGEMENT OF GESTATIONAL DIABETES (GDM) BASED ON ULTRASOUND MEASUREMENTS DECREASES THE RATE OF MACROSOMIA (PRELIMINARY DATA) P. Antsaklis1, N. Papantoniou1, S. Kouki2, G. Daskalakis1, E. Anastatsiou2, U. Honemeyer3, & A. Antsaklis1 1

Fetal & Maternal Medicine Unit, 1st department of Obstetrics & Gynaecology, ‘‘Alexandra’’ Maternity Hospital, University of Athens, Greece, 2Department of Endocrinology, ‘‘Alexandra’’ Maternity Hospital, Athens, Greece, and 3Department of Obstetrics & Gynecolog Brief Introduction: Aims: to evaluate in everyday clinical practice the effectiveness of a protocol regarding the management of pregnancies with GDM. The protocol is based on a combination of maternal glycemic levels and the measurements from serial fetal growth ultrasound (USS) examinations in order to decide whether we should initiate insulin treatment in women with gestational diabetes (GDM). Aim of this protocol to prevent fetal macrosomia.

University of Medicine and Pharmacy, Iuliu Hatieganu’’ Cluj Napoca, Romania, and 2St Clinic of Obstetrics and Gynecology, Cluj Napoca, Romania Brief Introduction: The introduction of insulin was a milestone allowing a pregnancy to diabetic patient previously considered infertile. Even if the progress is enormous the obstetrician that deals with diabetic patient is still facing maternal and fetal issues. Materials & Methods: The study was designed as retrospective. It was conducted in the 1‘st Clinic of Obstetrics and Gynecology Cluj Napoca, Romania in 2013. A total number of 41 patient were included in the study (thirteen patients with previously known insulindependent diabetes and twenty-eight pregnant women with gestational diabetes were included in the study). For each patient the following parameters have been followed: the age at delivery, the birth pathway, maternal BMI, glycemic cycle, Hb A1c, obstetric ultrasound parameters (position, presentation, placental height, estimated weight, fetal umbilical Doppler), parameters for vaginal delivery, neonatal parameters (length, weight, Apgar score, glycemia). Clinical Cases or Summary Results: Macrosomia has been frequently encountered. The incidence of cesarean section was higher in patient with both type of diabetes and even higher in the group with previously known insulin dependent diabetes. Two cases of intrauterine growth restriction have been detected both in the group with insulin dependent diabetes prior to pregnancy. Conclusions: The recent advances in the field of insulin therapy have lead to a reduced rate of maternal and fetal morbidity. Macrosomia and its related may increased the number of cesarean sections. Keywords: diabetes, gestational diabetes, insulin Presenter: Muresan Daniel

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ID 651

ID 059

INFLUENCE OF DIABETES ON OBSTETRICAL RESULTS IN PREGNANT WOMEN WITH DIABETES MELLITUS IN DEPENDENCE OF ITS TYPE

DIABETES IN PREGNANCY AND MACROSOMIA: A NATIONWIDE STUDY IN FRANCE

I. Kaim1, H. Huras1, D. Wra_zen´1, K. Cygenek2, K. Kus´mierskaUrban1, A Hebda-Szydło2, M. Mełecki2, M. Radon´-Pokracka1, & P. Ossowski1

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1 Obstetrics and Perinatology Dept., Collegium Medium Jagiellonian University of Krako´w, Krakow, Poland, and 2 Metabolic Diseases Dept., Collegium Medium Jagiellonian University of Krako´w, Krakow, Poland

Brief Introduction: Pregnancy complicated by diabetes presents a risk on both a newborn and a mother. The aim of this study was to compare obstetrical results in two groups of pregnant women: patients with pregestational and gestational diabetes mellitus (PGDM and GDM). Materials & Methods: The study included 147 women with pregnancies complicated by diabetes. Pregnant women were divided into two groups: the first group represented 93 (63.3%) women with GDM, including 79 women treated with only a diet and 14 women treated with a diet and an insulin; the second group represented 54 (36.7%) women with PGDM - classified by P. White: A- 1, B - 12, C- 25, D- 11, F- 2 and R- 3. In both groups the glycemic control and obstetric outcomes were compared. Additionally, the study compared three groups of women divided based on P. White classification. First group consisting of women with GDM type 1 and 2; second group consisting of women with PGDM without vascular changes (White class A, B, C) and third with vascular changes (White class D, R, F). Clinical Cases or Summary Results: In the t-student and U MannWhitney test, there was no statistical difference in both groups (GDM and PGDM) for maternal age, sex, weight of newborns and indications for cesarean section. In contrast, women with GDM were more metabolically aligned (HbA1c 5.1%) than women with PGDM (HbA1c 6.8%) p = 0.001. Additionally, duration of pregnancy in women with GDM was longer by 1,2 weeks compared to women with PGDM (38.6 vs 37.4, p50.001). Also, infants of women with GDM evaluated by Apgar score received more pointsin 5th minute of evaluation (10 vs. 9.3, p = 0.00006). Then, when divided into three groups depending on the vascular complications women with vascular changes (class D, R, F) were characterized by higher levels of HbA1c than group of women without vascular complications (class A, B, C) and group of women with GDM (6.9% vs 6.7 g g% vs 5.1 g%, p50.001). Similarly, the mean duration of pregnancy was longer in group of women with vascular changes than in group with PGDM without vascular changes and a group with GDM, respectively 38.6 weeks vs 37.5 weeks and 37.1 weeks (p50.001). In these groups according to the level of HbA1c, infants weight was higher in a group with PGDM without vascular changes than in GDM group and PGDM group with vascular changes (3813.2 ± 512.3g vs. 3.599.8 ± 512.1g vs 3250 ± 456.3g, p = 0.002). Conclusions: We are not able to obtain normoglycemia in all pregnant despite appropriate treatment. Women with gestational diabetes and pregestational diabetes without vascular changes achieved better metabolic and obstetric outcome than women with complicated pregestational diabetes. Keywords: gestational diabetes mellitus, pregestational diabetes mellitus Presenter: M. Radon´-Pokracka

C. Billionnet1, A. Weill1, U. Simeoni2, P. Ricordeau1, F. Alla1, S. Jacqueminet3, Ahartemann3, & D. Mitanchez4 Caisse Nationale de l’Assurance Maladie, Paris, France, 2Poˆle de Ne´onatologie, Assistance Publique – Hoˆpitaux de Marseille, Marseille & Aix-Marseille Universite´, Marseille, France, 3Service de Diabe´tologie, Hoˆpital Pitie´ Salpeˆtrie`re, Paris, France, and 4 Service de Ne´onatologie, Hoˆpital Armand Trousseau, Paris, France 1

Brief Introduction: The impact of maternal diabetes mellitus, whether pre-existing or purely gestational (GD), on the offspring is a matter of public health concern. We evaluated the incidence of macrosomia in relation to the type of maternal diabetes in the French birth cohort in 2011. Materials & Methods: Data were obtained from the French DRG program (PMSI) and the inter-regimens national system of information (SNIIRAM) of the French health insurance system. All childbirths and terminations of pregnancy (TOP) after 22 weeks of gestation, due to medical reasons were selected. The mother’s diabetic status was determined by an algorithm based on the consumption of antidiabetics and hospitalization diagnoses before and during pregnancy. An identifier in the PMSI was used for the chaining between maternal status and the infant’s birth weight. Macrosomia was defined as a birth weight (BW)44kg or490th percentile for gestational age. Clinical Cases or Summary Results: 806 579 childbirths/TOP were identified. Mother – infant chaining was obtained for 474 614 births in public institutions. 16.7% of the infants had a BW44 kg in type 1 diabetes (T1D), 13.4% in type 2 diabetes (T2D), 9.0% in GD, and 6.6% in the normal population. 42.5% (n = 354) of the infants had a BW490th percentile in case of T1D, 30.4% (n = 348) in T2D, 15.7% (n = 5096) in GD and 9.4% in the absence of diabetes. The OR compared with the absence of diabetes were respectively 7.0 [6.1– 8.0], 3.9 [3.4–4.4] and 1.7 [1.6–1.8]. The frequency of macrosomia increased with maternal age in the population without diabetes with a maximal rate of 11.3% after 40 years, while it remained stable for all maternal age in GD (15.2 to 16.2%). The median BW was significantly higher whatever the term of birth in cases of GD compared to the normal population. Conclusions: These data obtained from the French population over one year confirm that GD and not only T1D and T2D has a significant impact on the offspring, with a major short and long term potential impact on public health. Keywords: Epidemiology, macrosomia, LGA, maternal diabetes Presenter: D. Mitanchez

ID 898

THE ROLE OF 4-D ULTRASONOGRAPHY FOR THE IN UTERO ASSESSMENT OF FETAL NEUROBEHAVIOUR IN PREGNANCIES COMPLICATED BY GESTATIONAL DIABETES MELLITUS P. Antsaklis1, U. Honemeyer3, M. Syndos1, G. Daskalakis1, N. Papantoniou1, E. Anastasiou2, & A. Antsaklis1

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DOI: 10.3109/14767058.2014.924236 1

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First Department of Obstetrics & Gynaecology, ‘‘Alexandra’’ Maternity Hospital, University of Athens, Greece, 2Department of Endocrinology, ‘‘Alexandra’’ Maternity Hospital, Athens, Greece, and 3Department of Obstetrics & Gynecology, Wellcare Hospital, Dubai, UAE Brief Introduction: OBJECTIVE: To assess with 4-D ultrasound the differences in fetal behavior in pregnancies complicated by gestational diabetes (GDM), and to examine how glycemic control affects fetal neurobehaviour. Materials & Methods: METHODS: A 16 month prospective study, where Kurjak antenatal neurodevelopmental test (KANET) has been applied to assess fetal neurobehavior in pregnancies complicated by GDM, using 4-dimentional ultrasound. Patients had regular ultrasound examinations after 28 weeks, when gestational diabetes was diagnosed, which were scheduled according to either the level of glycemic control or the ultrasound findings (e.g. polyhydramnios, macrosomia and KANET score). Based on the KANET scores, the fetuses were considered as normal (14 points), borderline (6–13), or abnormal (0–5). Clinical Cases or Summary Results: RESULTS: We studied 119 pregnancies complicated by GDM and 110 low-risk pregnancies, which represented the control group. Comparison of KANET scores in diabetic (119 patients) and non-diabetic pregnancies (110 pregnancies) showed differences in the fetal neurobehavior. The largest incidence of fetuses with abnormal and border line KANET scores was found in the group of fetuses with poor glycemic control, or ultrasound findings indicative of poor glycemic control (e.g. polyhydramnios, macrosomia etc.). KANET test scores appeared to improve, with improvement of glycemic control. Conclusions: CONCLUSION: Evaluation of the fetal behavior in fetuses of diabetic pregnancies using KANET test has the potential to detect fetuses with abnormal behavior and this appears to relate with the level of the glycemic control, and the improvement of KANET score was related with the improvement of glycemic control. Keywords: Presenter: G. Daskalakis

Table 1. Maternal and fetal/neonatal characteristics

Age (yr) BMI (kg/m2) Weight gain in pregnancy (kg) Chronic hypertension n (%) Diabetic nephropathy n (%) HbA1c: first trimester HbA1c: second trimester HbA1c: third trimester New born weight (g) Ponderal index (100xg/cm3) Perinatal mortality n (/%) Cesarean section n (%) Fetal macrosomia n (%) Premature deliveries n (%) Neonatal malformations n (%)

Type-1 DM (n = 557) X ± SD

Type-2 DM (n = 149) X ± SD

p

29.3 ± 32 23.5 ± 3.8 13.3 ± 5.3 37 (6.5%) 40 (12.6%) 7.42 ± 1.6 6.5 ± 1.2 6.6 ± 1.3 3353.1 ± 770 2.82 ± 0.3 4 (0.7%) 466 (93.5%) 174 (31%) 109 (19.7%) 12 (2.2%)

32.8 ± 5.5 29.2 ± 6.5 10.1 ± 6.5 15 (9.8%) 0 (0%) 7.4 ± 1.4 6.3 ± 0.9 6.6 ± 1.2 3385 ± 824.3 2.79 ± 0.3 2 (1.3%) 82 (55.0%) 38 (24.7%) 31 (20.1%) 7 (4.5%)

50.003 50.001 50.003 n.s. 50.001 50.018 n.s. n.s. n.s. n.s. n.s. 50.001 50.035 n.s. n.s.

what can be the result of introduced insulin treatment during pregnancy. Keywords: Perinatal outcomes, type-1 DM, type-2 DM Presenter: Vito Starcˇevic´

ID 201

COST-EFFECTIVENESS ANALYSIS ON GESTATIONAL DIABETES MELLITUS SCREENING STRATEGIES P.Y. Chen1, E.A. Finkelstein2, E. Kruger2, M.J. Ng3, & K.H. Tan3 1

ID 418

PERINATAL OUTCOMES IN WOMEN WITH TYPE-2 VERSUS TYPE-1 DIABETES MELLITUS V. Starcˇevic´, M. Ivanisˇevic´, & J. Djelmis Department of Obstetrics & Gynaecology, School of Medicine, Zagreb, Croatia Brief Introduction: Objective was to compare perinatal outcome in pregnant women with type-2 DM vs. type-1 DM. Materials & Methods: Patients and methods. In the period (2000.– 2012.) 557 pregnant women with type-1 DM and 149 with type-2 DM were delivered. Following data were analyzed: age, body mass index (BMI), weight gain, HbA1c level in each trimester of pregnancy, complications of labor and delivery, new born weight and ponderal index, perinatal mortality and morbidity. All women with type-2DM received insulin. Clinical Cases or Summary Results: Results. 557 type-1 DM women delivered 563 newborn children (4 pregnancies with twins and 1 pregnancy with triplets). 149 type-2 DM women delivered 154 newborn children (5 pregnancies with twins). No shoulder dystocia occurred. Conclusions: Conclusion. Despite a milder glycemia disturbances and better HbA1c level in first trimester women with type-2 DM had higher perinatal mortaliy than type -1DM group, but fetal macrosomia and CS rate was siginificantly lower in type-2 DM group

Duke-NUS Graduate Medical School, Singapore, Singapore, Health Services and Systems Research Program, Duke-NUS Graduate Medical School, Singapore, Singapore, and 3 Division of O&G, KK Women’s and Children’s Hospital, Singapore, Singapore 2

Brief Introduction: To conduct an incremental cost-effectiveness analysis of three gestational diabetes mellitus screening options: (1) universal screening, (2) risk-stratification screening, or (3) no screening. Materials & Methods: The primary outcome was lifetime incremental cost per quality-adjusted life year (QALY) gained. Probabilities, costs, and utilities were derived from the literature, the Growing Up in Singapore Towards healthy Outcomes (GUSTO) birth cohort study conducted between June 2009 and September 2010, and the KK Women’s and Children’s Hospital’s internal database. The decision tree model was developed in TreeAge Pro 2013. Base case, sensitivity analyses, and a Monte Carlo simulation were performed. Clinical Cases or Summary Results: Based on GUSTO data, the prevalence of Overt Diabetes Mellitus (ODM), Gestational Diabetes Mellitus (GDM) and mild GDM (mGDM) were 0.7%, 2.0%, and 6.6% respectively. Compared to universal screening, risk-stratification screening failed to identify approximately 40% of ODM, 25% of GDM, and 60% of mGDM. Risk-stratification screening compared with no screening had an ICER of $8,700 per QALY gained in our preliminary analyses. Relative to risk-stratification screening, universal screening had an ICER of $11,300 per QALY gained. Sensitivity analyses showed that the effectiveness of early glucose management had the biggest impact on ICER. If treatment of GDM reduced the complication likelihood by 13–15%, risk-stratification

70 screening was favored, whereas universal screening was favorable when complication rates were reduced by more than 15%. The cost-effectiveness acceptability curve showed that, at a willingness to pay between $0–$8,700, no screening was selected in 50–100% of simulations. At a willingness to pay between $8,700–$11,700, risk-stratification screening was selected in 50– 65% of simulations. At a willingness to pay greater than $11,700, universal screening was selected in 50–100% of simulations. Lastly, at a willingness to pay of $65,000, which is in line with WHO guidelines for cost-effectiveness, universal screening would be selected in 100% of simulations. Conclusions: Based on the model and best available data, universal screening is a cost-effective screening method compared to riskstratification screening and no screening. Keywords: Gestational diabetes mellitus, screening strategies, costeffectiveness analysis, and health services and systems research J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Presenter: Pin Yu (Petty) Chen

J Matern Fetal Neonatal Med, Early Online: 1–437

Those women with GWG 9 Kg are more likely to have a SGA or macrosomic newborn, low 50 Apgar score or NICU admission than those with lower GWG. We were unable to found differences between higher GWG and higher cesarean section rates, preeclampsia or birth trauma. Keywords: gestational diabetes, obesity, weight variation Presenter: Tiago Ferraz

ID 067

HIGH RATES OF CAESAREAN SECTIONS AND OVERWEIGHT BABIES IN OBESE MOTHERS: CAN THEY BE EXPLAINED BY COMORBIDIETIES? A. Lanfer, A. Gillessen, J. Weller, & C. Vietor

ID 351

IMPACT OF GESTATIONAL WEIGHT GAIN IN OBESE PATIENT’S WITH GESTATIONAL DIABETES T. Ferraz1,2, J. Barros3, C. Ramalho1,2, L. Pinto3, G. Namora1, & N. Montenegro1,2 1

Dept. of Gynecology and Obstetrics of Sa˜o Joa˜o Hospital Center, Porto, 2Faculty of Medicine of University of Porto, Porto, and 3Dept. of Obstetrics and Gynecology from Santa Maria University Hospital, Lisbon Brief Introduction: To study how weight variation during pregnancy in obese patient’s with gestational diabetes influences perinatal outcomes. Materials & Methods: Two-center retrospective analysis of a cohort of 418 obese (body mass index 30Kg/m2) pregnant women with gestational diabetes (GDM) diagnosed between October 2010 and June 2013. The exposure was categorized as gestational weight gain (GWG) less than, within or greater than the American Institute of Medicine recommendations. The maternal outcome was a composite of preeclampsia, third- to fourth-degree laceration and cesarean section. The neonatal outcome was a composite of preterm delivery, macrosomia, small for gestational age (SGA), level 3 NICU admission and 50 Apgar57. Clinical Cases or Summary Results: Mean weight change in our sample was 10.2Kg (range -11.2 to 38Kg); differences were noted between centers (10.7 vs. 8.6Kg, p50.009). Obese women with GDM with GWG  9Kg have 3.62 (95% CI 1.92– 3.86) the odds of macrosomia, SGA, low Apgar score and preterm delivery, after adjusting for potential confounders, than those with GWG59Kg. In our sample, there is no significant association (OR 0.87; 95%CI 0.55–1.37) between GWG  9Kg and preeclampsia, birth trauma and cesarean section. There is an association between birthweight and GWG (p = 0.043), after adjusting for maternal age, BMI, parity and gestational age at birth. For every additional kilo gained above 9Kg, birthweight increases 14.9g (95%CI 8.2–29.8). Cesarean section rate among our sample was 43.7% and no association between GWG  9Kg was found, after controlling for macrosomia, SGA or parity. Conclusions: This is the first Portuguese study aiming to test the impact of weight change in obese women with GDM on perinatal outcomes

Techniker Krankenkasse, Hamburg, Germany Brief Introduction: The association between obesity and the metabolic syndrome is well known. The higher rate of caesarean sections and the increased number of overweight babies in mothers with obesity is often explained by comorbidities such as diabetes and hypertension. There is less focus on the question if obesity is linked to birth outcome and -mode independent of comorbidities. Using secondary data from one of the largest German health insurances (Techniker Krankenkasse), we aimed to investigate maternal obesity in relation to birth mode and neonatal outcome with focus on its interaction with diabetes and hypertension. Materials & Methods: A retrospective analysis was performed on outpatient and in-patient data. All female insurants who had given birth to a living baby in 2008 were identified and matched with the data of their newborns, if possible. G-DRGs and in- and outpatient diagnoses (ICD-10) were used to differentiate between caesarean section and vaginal delivery and low/normal and high birth weight as well as to identify obesity, diabetes (Type I/II, gestational diabetes) and hypertensive diseases (pre-existing and pregnancy-induced) from four quarters prior to birth. Adjusted odds ratios for the probability of caesarean section by obesity were calculated by means of multiple logistic regressions. Clinical Cases or Summary Results: Of all 38,174 women included in the analyses, caesarean section was reported for 30% (11385) and at birth,4% (1412), 95% (37066) and 1% (379) of the babies were underweight, normal weight and overweight respectively. During pregnancy, 7% (2703) of mothers were reported as being obese. Prevalence of hypertensive diseases and diabetes was significantly higher in these women. Women with diagnosed antenatal obesity were almost 2 times as likely to deliver via caesarean section (Odds Ratio = 1.9, p50.0001). This association remained highly statistically significant after adjusting for socio-demographic factors. It could even be observed in obese women who delivered a normal weight baby and did not suffer from diabetes or hypertension (Odds Ratio = 1.8, p50.0001). Similarly, the association between maternal obesity and giving birth to an overweight child could not be statistically explained by higher rates of diabetes in obese mothers. Conclusions: In our population of German health insurants, the high rate of caesarean sections and overweight babies in obese mothers cannot fully be explained by comorbidities. Other aspects such as assumed limited physical fitness may play a role in the decision for caesarean section that have to be considered during treatment of obese pregnant women. Keywords: Obesity, Claims data, comorbidities, caesarean section Presenter: A. Lanfer

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DOI: 10.3109/14767058.2014.924236

ID 410

ID 955

METABOLIC CONSEQUENCES OF PRIOR GESTATIONAL DIABETES

GESTATIONAL DIABETES MELLITUS AND LACTATION

J. Juras1, G. Vujic2, M. Ivanicevic3, J. Djelmis4

N. Machairiotis1, P. Korovessi2, G. Amountza2, P. Kouroutou3, & C. Machairiotis1

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Department of obstetrics and gynecology, Clinical Hospital Center Zagreb, Zagreb School of Medicine, Zagreb, Croatia Brief Introduction: In the last thirty years, almost every study on longterm consequences of gestational diabetes mellitus (GDM) on women’s health has shown that it is associated with an increased risk of glucose and fat metabolism disorder, as well as a higher incidence of cardiovascular diseases. Pathological concentrations of blood cholesterol and triglycerides are increasingly found in such women. Together with elevated blood pressure and increased waist circumference, these conditions constitute the basis of metabolic syndrome. Materials & Methods: In the period from 2007 to 2012, a study on long-term consequences of GDM on women’s and children’s health later in life was conducted at the Clinical Hospital Centre Zagreb and funded by the Croatian Ministry of Health. During that period 177 women with their children were included in the study, and divided into groups according to the time since delivery. Anthropometric measurements were taken. The WHO (1999) and IDF (International Diabetes Federation) criteria were used to make the diagnosis of glucose metabolism disorders and metabolic syndrome, respectively. A HOMA 2 calculator was used to calculate insulin resistance. Clinical Cases or Summary Results: The women in the five-years-afterdelivery group had the highest insulin resistance in addition to the highest frequency of glucose intolerance (about 22%), compared to 4.3% in the six-months-after-delivery group (p50.01). In total, approximately 18% of all women included in the study had glucose intolerance, with the highest frequency occurring in the two- and fiveyears-after-delivery groups. Overall, the study has shown 6.2% of type two diabetes mellitus with the highest frequency in the group of women examined five years after delivery. There was a statistically significant positive correlation of BMI and the frequency of metabolic syndrome with a coefficient of 0.58 (p50.001). The rate of metabolic syndrome in the group of women with BMI525kg/m2 was about 6%, while in the group of overweight women it amounted to 50%. The highest rate of 78% occurred in the group of obese women. The concentration of serum adipokines has shown a similar distribution. Adipokines such as leptin, interleukin 6 and serpin-1 (plasma concentration), whose higher concentration is considered to carry a greater risk of cardiovascular disease, were elevated, being the highest in the five-years-after-delivery group as compared to the six-month, one-year and two-years-after-delivery groups (all p50.001). The concentration of adiponectin (which is thought to have protective activity) had quite the opposite distribution. Conclusions: The survey described the risk of long-term effects such as glucose intolerance, diabetes mellitus and metabolic syndrome later in the life of women with prior GDM. Long-term monitoring of the health status of women with previous gestational diabetes is important. An interdisciplinary approach along with the patients’ own awareness are of invaluable importance. The importance of retesting can be explained to the patient already during pregnancy. A considerable reduction of long-term consequences of GDM can be achieved by changes in lifestyle. Keywords: Metabolic syndrome, gestational diabetes, diabetes, adipokines Presenter: Josip Juras

1

Obstetrics and Gynecology Dept., Thriassio Hospital, Athens Greece, 2Paediatric Dept., Thriassio Hospital, Athens Greece, and 3internal Medicine Dept., Thriassio Hospital, Athens Greece Brief Introduction: Gestational diabetes mellitus (GDM), is a clinical entity defined as carbohydrate intolerance of any degree, that has its onset or it is first recognized during pregnancy. This diagnosis is independent of the persistence of insulin resistance as well as the use of insulin after pregnancy. Lactation is considered to be not only beneficial for the child but increasing evidence suggests that it is beneficial for the mother as well. The aim of this presentation is to examine whether there is a connection between GDM and lactation. Materials & Methods: We made a complete review of the literature using Medline, Pubmed, Google Scholar and we searched for all the available articlesusing as key words the terms ‘‘gestational diabetes mellitus’’, ‘‘lactation’’. Clinical Cases or Summary Results: The U.S. Nurses’ Health Study II is a big study, in which 55,636 parous women participated. According to this study women who never lactated their infants or were not well programmed on their infant breastfeeding seemed to be prone to the development of hypertension in comparison with women who breastfed for more than 6 to 12 months per child. The NordTrondelag Health Study (HUNT2), which was conducted in 1995–1997 and in which 21,368 parous women aged 20 to 85 years participated. In this study parous women in an age scale from 20 to 50 years, who had never lactated, were compared with women who had breastfed for more than 2 years during their lives. The first group had an increased risk for the development of hypertension, obesity, and diabetes. The SEARCH for Diabetes in Youth study, reported that breastfeeding protected the neonatals from developing childhood type 2 diabetes mellitus (T2DM). Reilly et al also highlights the importance of early post partum glucose testing and it quantifies the impact on maternal health of persistent hyperglycemia after gestational diabetes mellitus. The risk of developing type 2 diabetes mellitus after Gestational Diabetes Mellitus (GDM) vary from 17 to 63% in the first 5 to 16 years postpartum and it seems to be ethnicity depended.The prospective German GDM studycontains a follow up of 19 years after labor of patients with in order to determine actual risk of developing diabetes type 2 and to identify the factors that could modify the long-term risk for the development of postpartum diabetesthis study lactation did not seem to affect diabetes development among islet autoantibody-positive women and postpartum diabetes risk was inversely associated with full breastfeeding duration with a lower 15-year risk in women who practiced full breastfeeding for at least 3 months. Conclusions: In conclusion, breastfeeding is extremely important for the maintenance of the glycemic stability and the lipidemic profile of the mother. It also helps in the avoidance of neonatal hypoglycemia and the reduction of the risk of development childhood diabetes mellitus. Lactation is a natural bond between mother and child, it enhances the maternal relationship with the child and it is a shield for the child’s health, as it offers passive immunization to the child. Additionally, lactation protects the mother’s health from the development of metabolic disorders and breast cancer. It should be a great priority for the medical practitioners as well as the whole community to provoke breastfeeding for a time period of at least six months. Breastfeeding is a nature’s gift to humanity and it should be our major concern and priority to protect it and urge women to use it. Keywords: GDM, Lactation Presenter: G. Amountza

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ID 871

ID 772

MASSIVE MONOLATERAL VETRICULOMEGALY AND CORPUS CALLOSUM AGENESIS IN A NEONATE BORN TO A MOTHER WITH UNCONTROLLED GESTATIONAL DIABETES

INCIDENCE OF GESTATIONAL DIABETES MELLITUS AND PERINATAL OUTCOMES USING THE IADPSG GUIDELINES

A. Mareri1, L. Di Luca1, V. Nardi1, M. Maresca1, L. Di Stefano3, G. Nigro1, & S. Di Fabio2 1

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

J Matern Fetal Neonatal Med, Early Online: 1–437

Pediatric Unit, Maternal-Infant Department, San Salvatore Hospital, University of L’Aquila, L’Aquila, Italy, 2Neonatal Intensive Care Unit, Maternal-Infant Department, San Salvatore Hospital, L’Aquila, Italy, and 3Obstetrics and Gynecology Unit, Maternal-In Brief Introduction: Gestational diabetes can cause profound effects on embryogenesis, organogenesis, fetal and neonatal growth, although insulin therapy can generally prevent them. We report a case of an infant born to diabetic mother who required urgent neurosurgical intervention for hydrocephalus. Mterials & Methods: Complete blood count, metabolic evaluation, screening for congenital infections, chest X-ray, neonatal cerebral ultrasonography and cerebral MRI were performed. Clinical Cases or Summary Results: A 39 week baby boy was born to uncontrolled insulin dependent diabetic mother. Weight 3.5 kg, head circumference 34.2 (50  C), Apgar score 9-/10. Two hours after delivery, he developed respiratory distress signs (oxygen saturation 80–85%) and oxygen therapy was required. Clinical examination revealed: generalized cyanosis, poor bilateral air entry, tachypnea (respiratory rate: 120/min), 70% oxygen saturation on 12 l/min O2, normal heart sounds, heart rate 160 ppm, good femoral pulses, soft abdomen and axial hypotonia. Blood glucose: 50 mg/dl. Blood gas analysis showed respiratory acidosis. He was intubated on SIMV (Fio2: 40%, PIP 28, PEEP 6, Ti 0,3, RR 40). A chest- X- Ray showed MIP and surfactant was given. Echocardiogram was normal. Cranial ultrasound showed: extensive dilatation of the right ventricle, with signs of brain parenchyma compression, moderate left ventricle dilatation with midline strongly deviated to the left, and corpus callosum agenesis. Ventricle-peritoneal shunt was performed. Examinations for cytomegalovirus, rubella, toxoplasmosis and Parvovirus B 19 were negative. A 6 month neurological follow-up showed difficulty to control his head when the baby is picked up, axial hypotonia and limbs hypertonia without evidence of hearing loss or visual impairment. Conclusions: Type I and II gestational diabetes is associated to a 2–3 fold increased risk of congenital abnormalities. Oxidative stress may lead to cell apoptosis by protein kinase C activation causing malformations. During the 4–5th post-conception days the embryo grows rapidly and develops several important organs such as the heart and the neural tube; a disturbance of the development at this time may result in congenital malformations. Our case shows that, despite current diabetes management, there are still adverse neonatal outcomes and severe congenital malformations in neonates of diabetic mothers. Keywords: Presenter: A. Mareri

P. Gironi1, C. Gerday1, C. Kirkpatrick1, & M. Cnop2 1 Department of Obstetrics and Gynaecology, Hoˆpital Erasme, Universite´ Libre de Bruxelles, Belgium, and 2Department of Endocrinology, Hoˆpital Erasme, Universite´ Libre de Bruxelles, Belgium

Brief Introduction: In 2010, the International Association of Diabetes and Pregnancy Study Group (IADPSG) introduced new diagnostic criteria for Gestational Diabetes Mellitus (GDM). IADPSG proposed as a first step to perform a fasting plasma glucose (FPG) (screening threshold: 92 mg/dl) at the beginning of pregnancy. In women with normoglycemic FPG (592 mg/dl), the second step is to perform a 75-g oral glucose tolerance test (OGTT) between 24 and 34 gestational weeks (GW) (diagnostic thresholds: 92 mg/dl and/or4180 mg/dl after 1 hour and/or 4153 mg/dl after 2 hours). The principal objective of this study was to evaluate GDM incidence following implementation of the IADPSG guidelines. Secondarily, we examined maternal and neonatal outcomes in women with and without GDM. Materials & Methods: We performed a retrospective analysis of GDM screening based on IADPSG criteria in the Erasme hospital (ULB, Brussels, Belgium) spanning the period 2012–2014. We restricted the sample to women with a singleton pregnancy who had a FPG screening before 16 GW and, if required, an OGTT between 24 and 34 GW (n = 1659). All women with GDM were treated by lifestyle modifications and, if necessary, by insulin therapy. The glucose control aimed to reach the following treatment targets: FPG 95 mg/ dl and 1 hour postprandial 140 mg/dl or 2 hours postprandial 120 mg/dl. We compared normoglycemic pregnant women (control, n = 1045) and women who had GDM diagnosed in the first (GDM1, n = 163) or second trimester (GDM2, n = 171) for the perinatal complications large-for-gestational-age (LGA, defined using Audipog reference curves), Caesarean section (CS), and neonatal hospitalization rates. Clinical Cases or Summary Results: The incidence of unknown preexisting diabetes was 1.0% (FPG 126 mg/dl) in our patient population, while the incidence of GDM1 was 9.8%. Of the 1479 women with a FPG below 92 mg/dl, 1216 underwent an OGTT. The OGTT led to the diagnosis of GDM2 in an additional 14.1% of women. The total incidence of GDM in our population was thus 24.0%, approximately 8 times higher than the incidence obtained using Carpenter and Coustan criteria in the past years (2009–2011). The LGA incidence was significantly higher in the GDM groups (18.4% in GDM1, p = 0.002; 17.0% in GDM2 p = 0.008) compared to the control group (9.9%). By contrast, CS (15.3% in GDM1, 18.1% in GDM2 versus 13.8% in controls), and neonatal hospitalization rates (8.6% in GDM1, 7.6% in GDM2 versus 8.3% in controls) were not significantly different. Conclusions: Using the IADPSG criteria, dramatically more women are diagnosed as having GDM. Our data suggest that LGA rates remain elevated in both GDM1and GDM2 groups in spite of diabetes care. On the other hand, GDM was not associated with increased rates of CS or neonatal hospitalization. Keywords: Gestational Diabetes Mellitus, IADPSG criteria, maternal and neonatal outcomes Presenter: Gironi Pamela

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DOI: 10.3109/14767058.2014.924236

ID 756

CARDIAC INVOLVEMENT IN NEWBORN OF DIABETIC MOTHER L. Dimitriu1, A. G. Dimitriu2, & M. Stamatin2

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

1 Medex Medical Center Iasi, Romania, and 2University of Medicine and Pharmacy Iasi Romania

Brief Introduction: Cardiac involvement is one of the most important clinical manifestations of newborn of diabetic mother. Infants born to mothers with diabetes have been at significantly greater risk for cardiac congenital malformations and cardiomyopathy with perinatal morbidity and even mortality. The authors present the main aspects of cardiac involvement in newborn of diabetic mothers (IDMs). Materials & Methods: Methods: Patients:89 IDMs newborns investigated in the first week of life and 53 of them re evaluated at 6–12 month, by clinical exam, ECG, cardiothoracic radiography (Rx.CT), Doppler echocardiography (Echo). Fetal echo:in 38 cases after 28 weeks of gestation. Clinical Cases or Summary Results: Results: Fetal Echo:cardiomegaly and myocardial hypertrophy of LV(11 cases), confirmed by postnatal Echo. Clinical exam:macrosomia (40%), systolic murmur (32), 3 cases with signs of heart failure, the other being asymptomatic or presenting signs for other pathology. ECG: LV hypertrophy (14) and disturbed ventricular repolarization (30 cases). Rx.CT: cardiomegaly (12). Echo: non obstructive hypertrophic cardiomyopathy (HCMP) with asymmetric IVS hypertrophy (42%), arterial pulmonary hypertension (6), LV diastolic dysfunction with normal systolic function (52%), congenital cardiac anomalies(16%): PDA, VSD, coarctation of aorta, ASD. LV myocardial hypertrophy was not significantly correlated with the type of mother’s diabetes, before pregnancy or gestational, but rather to an inadequate control of disease. Control at 6–12 months revealed: normal morphological cardiac aspect (42 cases) or significant reduction of HCMP (11), all of them showing normal diastolic and systolic LV function. Conclusions: Conclusions: Newborn of diabetic mother presents a high incidence for cardiac involvement: cardiac congenital malformations (16%) or acquired cardiac pathology: hypertrophic cardiomyopathy (42%) and disturbances of diastolic function of LV (54%), which may be symptomatic or asymptomatic. Fetal echo provides useful data for diabetic pregnant women and should be made mandatory to all these patients. Early cardiologic screening for all of these newborns with or without of cardiac suffering symptoms, especially by Doppler echocardiography that is the most sensitive, noninvasive method for initial diagnostic as well as for follow up. Keywords: Newborn, cardiomypathy

diabetic

mother,

cardiac

involvement,

Presenter: L. Dimitriu

ID 819

A LOOK AT GESTACIONAL DIABETES IN THE LAST EIGHT YEARS AT OUR DEPARTMENT 1

2

3

4

S. Mineiro , A. Codorniz , J. Raimundo , A. Ladeira , & M. Janeiro5

Brief Introduction: Gestational diabetes carries a potential risk of adverse obstetric and perinatal outcomes and a long-term chance for women to became diabetic thereafter. The incidence is expected to increase as we see more women with risk factors such as advanced maternal age and obesity. It requires a tight metabolic control of glycemia to reduce morbidity and mortality in the mother and fetus/ newborn. Materials & Methods: A retrospective and descriptive analysis performed in all pregnant women with gestational diabetes followed in our hospital between January 2006 and December 2013. We have studied predictive variables which proved to be indicative of metabolic control and neonatal outcome, such as maternal age, body mass index preconception, HbA1c value in third trimester, gestational age at delivery and child birthweight. Maternal and perinatal implications were also assessed. Clinical Cases or Summary Results: The study population included 193 pregnancies affected with gestational diabetes, in which 90 were controlled with diet, 102 required insulin and only 1 metformin. The mean maternal age was 32.4 years; 122 of pregnant women were multiparous, and 27 (22.13%) of them had history of gestational diabetes. We have found that 142/193 (73.57%)of pregnant women had a family history of diabetes, 64/193 (33.16%) were obese (body mass index 30) but mean HbA1c at the third trimester was 5.63 (171/193). We reported medical complications associated to diabetes such as gestational hypertension in 22 cases, 2 with chronic hypertension and 2 with severe preeclampsia associated. Cesarean section was performed in 89 cases (46.11%), instrumented delivery in 19 (9.85%) and natural vaginal birth in 85 (44.04%). There was a neonatal morbidity in 44 cases. Hypoglycemia complicated 12 (6.2%) and respiratory distress syndrome 6 (3.1%). We had 127 term deliveries (65.8%) and 8 (6.29%) with associated macrosomia. We reported 11 cases of maternal morbidity: 2 mothers suffered postpartum hemorrhage, 3 preeclampsia and 1 encephalopathy secondary to eclampsia. Among the gestational diabetes postpartum reclassification, about 3/109 (2.75%) were type 2 diabetic mellitus and 17/109 (15.6%) had impaired glucose tolerance. Conclusions: A large number of pregnancies ended in cesarean section. However, in vaginal deliveries we had only three cases of injury related to shoulder dystocia. Despite of higher hypertensive disorders described in literature, as well as complications related to macrosomia, we were able to achieve a low maternal and neonatal morbidity. Keywords: Gestational diabetes, high risk pregnancy, glycemia Presenter: Susana Mineiro

ID 598

IS FPG (FASTING PLASMA GLUCOSE) BETWEEN 92–99 MG/DL WITHIN 10TH WEEK OF PREGNANCY A WARNING OF ABNORMAL FETAL GROWTH? S. Biagioni1, M. P. Rambaldi1, S. Simeone1, L. Marchi1, C. Serena2, C. Nardini1, S. Ottanelli3, G. Mello1, & F. Mecacci1 1

High Risk Pregnancy Unit, Careggi University Hospital, Florence, Italy, 2Obstetric Dept, Nuovo Ospedale del Mugello, Borgo San Lorenzo, Florence, Italy, and 3Obstetric Dept, San Donato Hospital, Arezzo, Italy

1

Obstetrics and Gynecology Department, Hospital Jose´ Joaquim Fernandes, Beja, Portugal, 2Obstetrics and Gynecology Department, Hospital Espı´rito Santo, E´vora, Portugal, and 3Obstetrics and Gynecology Department, Centro Hospitalar de Setu´bal, Setu´bal, Portuga

Brief Introduction: IADPSG consensus guidelines for diagnosis of gestational diabetes (GDM) recommended that a fasting plasma glucose (FPG) level 92 mg/dl in the first trimester be diagnostic for GDM but this choice didn’t find universal consensus. The Italian Protocol established that FPG in the first trimester between 100–125

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Table 1. Maternal characteristics and neonatal outcomes. FPG  92  99 mg/dl FPG592 mg/dl (107) (363)

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Pregravidic BMI GA at birth Birth weight AGA SGA LGA Ponderal Index (PI) PI  90 centile (42.85) Macrosomia (birth weight 4000 g)

24.53 ± 6.28 39.89 ± 1.46 3393.8 ± 527.6 81/107 (75.7%) 10/107 (9.3%) 16/107 (15.0%) 2.7 ± 0.38 26/107 (24.3%) 14/107 (13.1%)

p

22.16 ± 4.00 50.01 39.81 ± 1.43 n.s 3332.1 ± 479.1 n.s 284/363 (72.8%) n.s 54/363 (14.9%) n.s 25/363 (6.9%) 50.01 2.73 ± 0.51 n.s 102/363 (28.1%) n.s 20/363 (5.5%) 50.01

mg/dl needs to be evaluated with a early OGTT 75 g at 16–18 gestational age (GA), but FPG between 92–99 mg/dl don’t need particular attention. Moreover, recently, the attention for mild glycemic dysmetabolisms is increasing, as risk factor for abnormal fetal growth, which often are less cared. We speculated on the risk of fetal overgrowth in patients with FPG in the first trimester between 92–99 mg/dl, without subsequent diagnosis of GDM at 24–28 weeks of GA. Materials & Methods: It’s an ongoing retrospective study. So far, we analyzed a sample of 470 pregnant women attended the High Risk Pregnancy Unit of Careggi University Hospital of Florence from January 2011 to December 2012, with negative diagnosis for GDM at 24–28 weeks. We compared the neonatal outcome in relation to the FPG at the first visit in the early 1st trimester: Group 1 included women with FPG between 92–99 mg/dl, Group 2 with FPG 592 mg/dl. Clinical Cases or Summary Results: Pregnant women with FPG between 92–99 mg/dl have a higher mean pre-pregnancy BMI (24.53 ± 6.28 vs 22.16 ± 4.00, p50.01). Moreover, in this group the risk of macrosomia (13.1% vs 5.5%, p50.01) and LGA (15.0% vs 6.9%, p 90th percentile with respect to Group 2 (11/16 vs 12/25, p n.s), even though not statistically significant. Conclusions: In our experience, FPG between 92–99 mg/dl, independently from the diagnosis of GDM, should be considered a risk factor for fetal overgrowth, so it deserves more attention from the clinicians. Keywords: Gestational diabetes, fasting plasma glucose, fetal growth Presenter: S. Biagioni

ID 416

PERINATAL RISK FACTORS OF THE DEVELOPMENT OF ALIMENTARY OBESITY WITH INSULIN RESISTANCE IN ADOLESCENCE

delivery, presence/absence of chronic intrauterine hypoxia, family obesity, parental smoking were estimated. Statistical analyze were made using SPSS.18.0. Clinical Cases or Summary Results: Birth weight in IR children (3.6 ± 0.4 kg) were higher than in normal-weight (3.3 ± 0.4 kg) (p = 0.01) without any significance difference between non-IR (3.5 ± 0.5 kg) (p(1–3) = 0.1), (p(1–2) = 0.3).Gestational age group 1 – 38.8 ± 2.5 weeks, group 2 - 39 ± 1, group3 – 39.7 ± 1.1 (p1–3 = 0.001), (p2–3 = 0.001), (p1–2 = 0.4). Complicated pregnancy in group 2 were detected in 58.3% (preeclampsia – 29.2%, iron deficiency anaemia (IDA) 8.3%, infections 8.3%, threatened miscarriage 12.5%) in group 1 – 64.3% (preeclampsia 28.6%; infections 7.1%, threatened miscarriage 28.6%) (p = 0.2), group 3 - (preeclampsia – 17.9%, IDA – 16.2%) (p(1– 3) = 0.0001), (p(2–3) = 0.0001); delivery by caesarean section were in 31% obese IR children with none – in group 1 (p = 0.0001) and 3 (p = 0.0001). Parent’s obesity of group 1 were noted in 87.1% of cases, group 2 – 77.8%, control 1.7% (p1–3 = 0.0001), (p2–3 = 0.001), (p1– 2 = 0.2). There were no significant differences between pregnancy and delivery account; parental smoking, birth height. Conclusions: Large birth weight, less gestational age, complications of pregnancy (preeclampsia, infections, threatened miscarriage), delivery by caesarean section; obese parents are related to perinatal risk factors for the development of obesity with insulin resistance in adolescence. Keywords: Obesity, risk factors Presenter: Anzhalika Solntsava

ID 880

THE DIFFERENCES BETWEEN PLACENTAL LIPID CONTENTS IN TYPE-1 DIABETIC AND HEALTHY PREGNANCY V. Starcevic, J. Djelmis, M. Ivanisevic, M. Herman, J. Juras, E. Berberovic, & J. Blajic Department of Obstetrics & Gynaecology, School of Medicine, Zagreb, Croatia Brief Introduction: The placenta is a complex organ which plays the central metabolic role in pregnancy. This study was designed to investigate the effect of type 1 DM on the content of lipids in deciduas free placental tissue. Materials & Methods: It was realized by comparing fatty acid contents in placentae from normal term pregnancies (group I, No. = 34) with those from pregnancies complicated with type-1 DM (group II, No. = 38). All pregnancies were terminated by cesarean section. All 72 Table. The Differences between Placental Lipid Contents in Type-1 Diabetic and Healthy Pregnancy

A. Solntsava, O. Zagrebaeva, & Y. Dzmitrovich

Control group (Mean ± SD)

Belarusian State Medical University Brief Introduction: To identify perinatal risk factors of the development of alimentary obesity with insulin resistance in adolescence. Materials & Methods: We analysed retrospectively 375 adolescents histories of development: group 1 - 88 obese children without insulin resistance (non-IR) (14.9 ± 2.06 yrs, BMI 32.5 ± 3.8 kg/m2, HOMA – 1.7 ± 0.5), group 2 – 118 obese patients with insulin resistance (IR) (14.5 ± 1.9 yrs, BMI 35.1 ± 5.8, HOMA 4.8 ± 0.3 (p = 0.0001), group 3 169 normal-weight patients (12.6 ± 2.2 yrs (p(1-c) = 0.2), (p(1-c) = 0.2); BMI 20.5 ± 1.2 kg/m2 (p(1-c) = 0.0001),) (p(2-c) = 0.001)) from the University Hospital (Minsk). We collected anamnesis clarifying gestational age, account and complications of pregnancy and

mg/g placental tissue Total lipids (NS) Total phospholipids (PL) (NS) Total triglycerides (TG) (NS) Total free fatty acids (FFA) (S) Total cholesterol-esters (CE) (S) lauric acid 12:0 Total lipids (S) Total triglycerides (TG) (S) Total free fatty acids (FFA) (S) Total cholesterol-esters (CE) (S) *p50.001

Type 1 DM (Mean ± SD)

2253.65 ± 861.19 2204.84 ± 1552.22 712.81 ± 236.76 631.03 ± 243.69 56.80 ± 29.63 50.35 ± 37.55 191.89 ± 100.75* 114.50 ± 73.06* 82.80 ± 44.28* 54.58 ± 31.39* 2.21 ± 6.32* 0.42 ± 0.91* 0.20 ± 0.45* 0.39 ± 0.91*

6.19 ± 7.54* 1.75 ± 1.95* 1.46 ± 1.85* 1.79 ± 2.28*

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J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

DOI: 10.3109/14767058.2014.924236

decidua free placental samples from term pregnancies were analyzed for fatty acid content. Thin-layer chromatography of extracted lipids was performed on silicic acid impregnated paper. Gas chromatography of the fatty acid methyl esters was carried on a SRI 8610C GAS CHROMATOGRAPH. Clinical Cases or Summary Results: The highest amount of PL in placental tissue in both groups were found. In type 1 DM were found decrease of FFA and CE. It was found higher levels of laurinic (12:0), myristinic (14:0) and lignocerinic (24:0) fatty acids in placentae of type 1 DM in total lipids. In the group of triacylglycerols/triglycerides there was statistically more lauric C 12:0 fatty acids at the pregnant women with type-1 DM, but less number of docosahexaenoic C 22:6 n-3 acid and lignoceric C 24:0 fatty acids. The total free fatty acids were were statistically less present in the type-1 DM. Higher quantity was established in lauric C 12:0 fatty acid, whereas lower quantity of the palmitic C 16:0; stearic C 18:0; oleic C 18:1 n-9; miristoleic C 14:1 n-5, linoleic C 18:2 n-6 and docosahexaenoic fatty acid C 22:6 n-3 have been foundin type-1 DM. In the group of total cholesterol-esters there was significantly more lauric C 12:0 fatty acid and significantly less palmitic C 16:0; linoleic C 18:2 n-6; lignoceric C 24:0; docosahhexaenoic fatty acid C 22:6 n-3; stearic 18:0 and miristoleic C 14:1 n-5 fatty acids in type-1 DM. Conclusions: Due to strict regulation of glycemia of the pregnant women suffering diabetes mellitus type-1, data from the two groups shows that there is no statistically significant difference between the two groups in maternal age, gestational age, birthweight and total lipids. Keywords: Type-1 DM, placenta, lipids, chromatography Presenter: Vito Starcevic

ID 038

EFFECT OF MATERNAL MEDICATIONS AND DISEASE ON NEONATAL HEARING SCREENING I. Ulanovsky, K. Diab, I.R. Makhoul, S. Blazer, & T. Smolkin Department of Neonatology, Meyer Children’s Hospital, Rambam Health Care Campus, Rappaport Faculty of Medicine, Technion, Haifa, Israel Brief Introduction: The effects of maternal medications and disease on neonatal hearing screening (first otoacoustic emissions test; first OAE test) have been barely investigated. We aimed to verify the effect of maternal medications and disease on first OAE result. Materials & Methods: We recorded perinatal and hearing screening data, medications during pregnancy and labor (119 kinds of medication), hypertension/pre-eclamptic toxemia (HTN/PET) and diabetes mellitus (DM). Clinical Cases or Summary Results: Of the 2312 studied infants, 167 (7.2%) failed the first OAE test. Vaginal delivery (VD) and cesarean delivery (CD) infants were analyzed separately. Multivariate logistic regression analysis: Independently significant variables associated with failed first OAE in VD infants: Birth weight (BW) 44000g [OR 2.2 (1.1–4.3) p = 0.026]; decreasing age at first OAE [OR 0.31 (0.17–0.6) p50.001] and maternal DM [OR 2.2 (1.0–4.84) p = 0.049]. CD infants: male gender [OR 1.91 (1.24–2.96) p = 0.004]; decreasing age at first OAE [OR 0.34 (0.21–0.55) p50.001]; maternal HTN/PET [OR 2.3 (1.22–4.3) p = 0.01]; SGA status [OR 2.9 (1.1–7.56) p = 0.03] and spinal anesthesia [OR 1.58 (0.99–2.52) p = 0.057]. Conclusions: Increased failure on first OAE occurs in VD infants with BW 44,000g, early first OAE and DM; and in CD infants with male

gender, early first OAE, HTN/PET and SGA status. In advance parental awareness of these risk factors minimizes their worry. Emissions (1st OAE) test in neonates. We aimed to verify whether maternal medications and disease affect 1stOAE test. Keywords: Diabetes mellitus, eclamptic toxemia, hearing screening, hypertension, otoacoustic emissions, pre-eclamptic toxemia. Presenter: Imad R Makhoul

ID 386

FLAT GLYCEMIC VARIABILITY AT THE ORAL GLUCOSE TOLERANCE TEST DURING PREGNANCY C. Schaas1, M. Titianu2, M. Stamatin3, & M. Onofriescu4 1

‘‘Gr. T. Popa’’ University of Medicine and Pharmacy, Iasi, Romania, 2‘‘Cuza Voda’’ Hospital, Iasi, Romania, 3 ‘‘Gr. T. Popa’’ University of Medicine and Pharmacy, Iasi, Romania, and 4‘‘Gr. T. Popa’’ University of Medicine and Pharmacy, Iasi, Romania Brief Introduction: Oral glucose tolerance test (OGTT) consists in analyzing the individual glycemic response on venous samples at regular intervals after an oral glucose load. Glycemic variability at the OGTT is considered flat if the difference between the glycemic peak and the minimum glycemic value is inferior to 0.45 mg/dl. The aim of the current study was to evaluate if flat glycemic variability can be considered as normal or whether it should be given special attention during pregnancies. Materials & Methods: The authors retrospectively analyzed a group of 44 patients with flat glycemic variability that were surveyed during pregnancy and delivered at Cuza Voda Obstetrics and Gynecology Hospital from Iasi, Romania during January 2011– December 2013. Clinical Cases or Summary Results: Mean age of patients included in the study group was of 28.5 ± 6.3 years and mean body mass index was of 26 ± 5.8 kg/m2. Thirty-five of these patients (79.54%) had at least one risk factor for gestational diabetes mellitus (GDM), and 28 patients (63.64%) presented familial history of type 1 or 2 diabetes mellitus. Two patients had already presented GDM at a previous pregnancy, and 3 had already given birth to macrosomic children. Twelve of the 44 patients (27.26%) had pregnancy-related diseases, and 22 patients registered excessive weight gain during the current pregnancy. OGTT was performed at an average 30 weeks of pregnancy. Transverse abdominal diameter (TAD) of the foetus in the last trimester was superior to the 90th percentile in 21 cases (47.72%) and the abdominal perimeter (AP) in 10 cases (22.73%), the two being associated in 20 cases (45.45%). The patients delivered at an average of 39 weeks of amenorrhea, with 2 premature births. At birth, 3 newborns weighted more than 4000g, and one newborn weighted between 3900 and 4000 g. concerning other newborn complications, there were registered a case of hypoglycemia, one case of cardiac septal hypertrophy, and two cases of respiratory distress, one case of an Apgar score of 7 at 5 minutes. TAD and AP were increased in all cases. Conclusions: Despite its theoretical non-importance, flat glycemic variability doesn’t exclude maternal, fetal and new born complications. Keywords: Flat glycemic variability, pregnancy, macrosomy, oral glucose tolerance test, gestational diabetes mellitus Presenter: Titianu Monica

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ID 546

CAN EITHER ORAL GLUCOSE CHALLENGE TEST (GCT) OR ORAL GLUCOSE TOLERANCE TEST (OGTT) PARAMETERS PREDICT GESTATIONAL DIABETES MELLITUS (GDM)? M. Yıldırım1, A. Ko¨s¸ u¨s¸ 2, N. Ko¨s¸ u¨s¸ 3, D. Hızlı4, B. Akc¸al5, H. Ko¨s¸ ker6, & H. Kafali7 1

Atatu¨rk educational and research hospital, Ankara, Turkey, ¨ zal University Faculty of Medicine, Ankara, Turkey, Turgut O 3 ¨ zal University Faculty of Medicine, Ankara, Turkey, Turgut O 4 ¨ zal University Faculty of Medicine, Ankara, Turkey, Turgut O and 5Tur

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2

Brief Introduction: This study aims to evaluate the relationship between the Glucose Challenge Test (GCT) levels and any of the Oral Glucose Tolerance Test (OGTT) parameters (fasting plasma Table 1. ROC Results for GCT and OGTT values in predicting GDM 95% Confidence Interval

GCT FPG 1.hour 2.hour 3.hour

AUC

SE

p

Lower Bound

Upper Bound

0.774 0.772 0.876 0.945 0.852

0.037 0.044 0.029 0.015 0.035

50.001 50.001 50.001 50.001 50.001

0.701 0.684 0.819 0.917 0.784

0.846 0.859 0.932 0.974 0.921

AUC:Area under the curve, SE: Standart error p50.05 was considered as statistically significant Table 2. Sensitivity and specificity values for GCT and OGTT at various cutoff values

GCT

FPG

1.hour

2.hour

3.hour

Cutoff

Sensitivity

Specificity

132.50 138.50 142.50 145.50 154.50 69.50 73.50 76.50 83.50 90.50 133.00 146.50 153.50 161.50 175.50 181.50 136.50 144.00 150.50 154.50 163.50 55.50 90.50 105.50 110.50 118.00 133.50

1.000 0.958 0.917 0.833 0.792 1.000 0.875 0.833 0.750 0.542 1.000 0.958 0.875 0.833 0.792 0.750 1.000 0.917 0.833 0.792 0.583 1.000 0.958 0.917 0.833 0.750 0.667

0.230 0.302 0.467 0.538 0.728 0.118 0.249 0.450 0.775 0.917 0.349 0.509 0.615 0.734 0.864 0.911 0.704 0.822 0.905 0.941 0.953 0.059 0.396 0.598 0.680 0.805 0.923

Table 3. Logistic Regression results for GCT and OGTT in predicting GDM

@GCT @FPG @1.hour @2.hour @3.hour Constant

B

S.E.

p

Exp(B)

0.016 0.005 0.075 0.087 0.059 34.389

0.027 0.022 0.023 0.028 0.017 7.904

0.544 0.817 0.001 0.002 50.001 50.001

1.016 1.005 1.078 1.091 1.061 0.000

B:Regression coefficeint, SE: Standard Error, Exp(B): Odds ratio p50.05 was considered as statistically significant.

glucose (FPG), one-hour, two-hour, or three-hour plasma glucose levels) and their effect on predicting Gestational diabetes mellitus (GDM). Materials & Methods: This analysis was carried out as a retrospective study at Obstetrics and Gynecology Clinic of Turgut O¨zal University Hospital Oral glucose challenge tests (GCT) were conducted on patients who are at 24–29 weeks’ gestation. The study participants with positive GCT results underwent a 3-h, 100-g OGTT and the resulting values were evaluated using Carpenter and Coustan diagnostic criteria to determine the gestational glucose tolerance status of patients. The data obtained from both tests (GCT, FPG, 1-h, 2-h, 3-h OGTT values) were analyzed to observe the effect of each group on predicting GDM. Clinical Cases or Summary Results: Although all of the GCT and OGTT values were found to be statistically significant (p50.001) in determining GDM, the 2-h values of OGTT detected almost all GDM cases with a very high sensitivity level (94.5%). The 1-h values on the other hand identified 87.6% of GDM (p50.001). The GCT value with the highest sensitivity and specificity for predicting GDM was calculated as 154.50 mg/dl (sensitivity and specificity rates were 79.2% and 72.8%, respectively). Conclusions: A 2-h OGTT glucose level can detect GDM with 94.5% sensitivity. This result can guide clinicians to evaluate the patients with GDM. Keywords: Oral glucose loading test, oral glucose tolerance test, predicting of GDM Presenter: A. Ko¨s¸ u¨s¸

ID 428

CHANGES IN URINE D-AMINO ACIDS IN GESTATIONAL DIABETES MELLITUS M. Skotnicki1, D. Dudzik2, MP. Lorenzo2, M. Zorawski3, G. Kozlowska4, W. Zarzycki4, & A. Garcia2 1

Clinical Department of Perinatology, Public Clinic Hospital, Medical University of Bialystok, Bialystok, Poland, 2CEMBIO (Center for Metabolomics and Bioanalysis), San Pablo CEU University, Pharmacy Faculty, Madrid, Spain, and 3 Department of Pharmacology, Me Brief Introduction: Introduction/Background: GDM has been related to relevant short-term and long-term health complications for both mother and offspring. Women with GDM have higher risk of developing postpartum diabetes mellitus type 2 (T2D) in the years following pregnancy. Therefore, deeper understanding of the pathophysiology of diabetes is nowadays of great importance. Recent studies strongly emphasized the role of several essential amino acids, in particular branched-chain amino acids– BCAA (Leu, Ile Val) and aromatic amino acids (Tyr and Phe) in the pathogenesis of

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DOI: 10.3109/14767058.2014.924236

obesity and highlight their strong correlation with insulin resistance. The aim of this study was to evaluate the alterations in free D- and L-amino acid (AA) ratio in urine in a GDM study. Materials & Methods: Patients and Methods: Urine of 21 women with GDM and 20 pregnant women with normal glucose tolerance (after 2-h 75-g OGTT), matched according to the week of gestation and age, 23–33 week of gestation and age 24–28 years, were enrolled into the study. Clinical characteristics of each participant including glucose (fasting and after 2h 75g OGTT), HbA1c, Insulin, C-peptide, CRP, TG, LDL, HDL, cholesterol have been provided. The analytical method was based on chiral gas chromatography-mass spectrometry (GC-MS) after purification of the urine sample with solid-phase extraction (SPE) on a Discovery DSC-Strong Cationic Exchange cartridge. Identification of D- and L-AAs in the urine samples was based on retention time and mass spectra.%D-AAs were calculated as: 100  D/(D + L), using respective peak area values. Clinical Cases or Summary Results: % D-Relative amounts were determined for Ala, Val, Thr, Ser, Leu, Asx (Asp + Asn), Glx (Glu + Gln), Phe, Tyr, Orn and Lys. Statistically significant differences (p50.05) were observed only for D-Phe and higher values were found in the GDM group. Some previous studies as Floegel et al. described higher concentrations of Phe, Ile, Tyr and Val indicate the association with increased risk of T2D, and moreover, although BCAA and aromatic amino acids were linked to each other, phenylalanine was independently associated with T2D risk (Floegel 2013). The biological function of L-Phe is well known, however those for D-Phe still remain unclear. Although, those studies were focusing on the total concentrations of phenylalanine, there are also some evidences that D-Phe isomer is the one that could be responsible for hypoglycaemic effect. Conclusions: % D-Relative concentration of Phe in urine of pregnant women diagnosed with GDM and their corresponding controls has demonstrated to be higher for the GDM group. Up to date the role of D-AAs in diabetes and obesity is still unrevealed. It is possible that DPhe could be involved in metabolic/signaling pathways to compensate early stages of insulin resistance although, further work is necessary to confirm that hypothesis. Floegel A, Stefan N, Yu Z, Mu¨hlenbruch K, Drogan D, Joost HG, Fritsche A, Ha¨ring HU, Hrabeˇ de Angelis M, Peters A, Roden M, Prehn C, Wang-Sattler R, Illig T, Schulze MB, Adamski J, Boeing H, Pischon T. Identification of serum metabolites associated with risk of type 2 diabetes using a targeted metabolomic approach. Diabetes. 2013 Feb;62(2):639–48. Keywords: Urine d-amino acids, gestational diabetes mellitus Presenter: M. Skotnicki

ID 612

RELATIONSHIP BETWEEN GENDER AND OBESITY S. Abdollahifard Faculty member of Nursing and Midwifery, Dept. Jahrom University of Medical & Health Sciences. Jahrom. Iran Brief Introduction: In the 21st century, general and abdominal obesity with panic entrepreneurship is a growing trend and one of the world’s greatest health challenges. Among the risk factors for noncommunicable diseases, unhealthy diet and physical inactivity are two major factors in causing weight gain and obesity. One of the important risk factors of obesity and overweight is the sex. Aim: This case study aims to examine the relationship between sex and the prevalence of obesity in adults in Iran.

Materials & Methods: This study reviewed more than 30 studies conducted over the years 2000 to 2013 published articles and sites, and Google Scholar, Pubmed and SID. Clinical Cases or Summary Results: In 2005, the prevalence of overweight and obesity in men and women respectively, 42.8% and 57% respectively. And by 2015 this number is expected to reach respectively 54% and 74%. Studies have shown that the prevalence of obesity in men and women respectively in the range 29% -67% and 54.5%, 63.7 is located. In a study the obesity in men and women is 74.1% and 93% respectively. Conclusions: About a number of studies in Iran, the combined prevalence of overweight and obesity at different ages in women and girls than men and boys have been reported. Recommended due to the effects of obesity and overweight in women, an important approach for the prevention of noncommunicable obesity as a risk factor for non-communicable diseases and reducing complications such as continuous monitoring of weight, provide nutrition and increase awareness of the correct dose weight and physical activity appropriate for us to educate the public in relation to healthy lifestyles calls for an immediate move. Keywords: Obesity, Overweight, Women, Men Presenter: Sareh Abdollahifard

ID 192

GESTATIONAL DIABETES: EPIDEMIOLOGICAL PROFILE AND OBSTETRICAL OUTCOME A. Ben Haj Hassine, R. Arfaoui, H. Siala, A. Chmima, & R. Rachdi Department of Gynecology and Obstetrics - Military Hospital of Tunis - Tunis - Tunisia Brief Introduction: Gestational diabetes is a disorder of glucose tolerance of varying severity, occurring or diagnosed for the first time during pregnancy. The prevalence of gestational diabetes is of the order of 3 to 6% of all pregnancies. Materials & Methods: We conducted a retrospective study of 60 patients with gestational diabetes. The study was conducted in obstetrics gynecology service of the Military Hospital of Tunis over a period of six months, from January 2013 to June 2013. Clinical Cases or Summary Results: The average age of our patients was 28.3 years. The average parity was 2.1. History of fetal macrosomia was found in 23.3%. History of diabetes in previous pregnancies was found in 26.6%. An association with pre-eclampsia was present in 31%. The circumstances of discovery of gestational diabetes are: routine screening in 65%, a preterm labor in 21.6%, gestational pyelonephritis in 13.3%. Diabetes was balanced by diet in most cases 73.3%. The use of insulin was required in 26.6%. The delivery was scheduled in 78.3% between 38 and 40 SA. The cesarean rate was 38.3%. Fetal macrosomia was present in 35% of cases. Conclusions: Pregnancies complicated with diabetes is a risk situation for the mother and fetus. A standardized management reduces serious complications of this disease. Keywords: Gestational diabetes, fetal outcome Presenter: A. Ben Haj Hassine

78

DOCTORS AND MIDWIVES: CARE OR CURE ID 039

MANAGEMENT OF POSTPARTUM HEMORRHAGE BY UTERINE BALLOON TAMPONADE Pauline Jeanneteau, MD1, Emmanuelle Martin, MD1, Pierre-Emmanuel Bouet, MD1, Marie-The´re`se Cheve´, MD2, Olivier Multon, MD3, Philippe Descamps, MD, Ph.D.1, & Loı¨c Sentilhes, M.D., Ph.D1, 1

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Department of Obstetrics and Gynecology, Angers Universit

Brief Introduction: The aim of this study is to evaluate uterine balloon tamponade in the management of postpartum hemorrhage (PPH). Materials & Methods: This retrospective, cohort and multicentred study included all patients who underwent Bakri balloon treatment for primary PPH from February 2011 to July 2012. Uterine tamponade was used after standard treatment (volume replacement, uterotonic medical treatment). The study population was divided into two groups-: the ‘‘success group’’ with patients for whom the method was successful (the bleeding stopped after the introduction of the balloon); the ‘‘failure group’’ represented by patients who required embolization or surgical methods. We analyzed the differences between the two groups. Clinical Cases or Summary Results: Forty-nine cases of PPH were managed with uterine tamponade. Thirty patients (61.2%) delivered vaginally and 19 (38.7%) had cesarean section. The main cause of PPH was uterine atony (89%). The overall success rate was 65.3%. Seventeen (34.7%) of the forty-nine patients needed additional procedures. Of the 17 failures, surgical treatment was required (hysterectomy (n = 9), vessel ligation (n = 6), Blynch (n = 4), HoCho (n = 2)) in 16 cases and embolization of the uterine arteries in one case. No significant difference was observed between the success and failure groups (table 1). The difference between volume of the balloon’s inflation tended to be lower in the ‘‘failure group’’ (489 ± 26mL versus 499 ± 3.8mL in the ‘‘success group’’; p = 0.05). In cases where the balloon was successful it was removed 24 hours later. In these cases no further bleeding was observed. No complications were attributed to the balloon in the postpartum period. Conclusions: Balloon tamponade seems to be an efficient, safe and readily available method to treat primary PPH, that may decrease the requirement to invasive procedures. Keywords: Uterine balloon tamponade, post partum hemorrhage Presenter: P. Jeanneteau

ID 768

J Matern Fetal Neonatal Med, Early Online: 1–437

violence because of changes in women’s physical, social, emotional, and financial needs. (1) Prevalence of abuse during pregnancy has been reported from 0.9% to as high as 20.1(2) Materials & Methods: Recently an escalation of pregnant women murders has drawn more attention to the subject of intimate partner violence. ‘‘Privacy of family life’’ may hide most of the cases of violence, and women may be afraid to express their situation with the fear of being abandoned, being left alone with the baby(ies), or at the most extreme to being murdered. Midwives, Family Physicians and Obstetricians who care for pregnant women should be aware of the danger of intimate partner violence, and its associated adverse outcomes during and after pregnancy. These health professionals should also be aware of the women who are under more risk, such as: adolescents, unmarried or divorced women, illiterate women, women of low socio economical level, low social support, and those who receive poor antenatal care. Using narcotics or alcohol is another risk factor. Clinical Cases or Summary Results: 14 cases of women murders have been found in a Google search in Turkey for the last 4 months. (3) One of them was in the first day of puerpuerium. Conclusions: Although health professionels see the intimate partner violence as an important health problem, they may have problems to define and diagnose violence and more importantly, they may not interfere with the problem enough to protect pregnant women. This is mostly due to the cultural influences of ‘‘privacy of family life’’ or ‘‘keeping it in the family’’ issues. However only diagnosing the problem is not enough, since the violence may escalate to threathen the lifes of women and fetuses. (4) Public awareness should be maintained and education of the health personnel on intimate partner violence and cooperation with the police and civil society organizations must be encouraged. References 1) JL Alhusen, et al. Intimate Partner Violence, Substance Use, and Adverse Neonatal Outcomes among Urban Women J Pediatr 2013;163:471–6 2) Gazmararian JA, Lazorick S, Spitz AM, Ballard TJ, Saltzman LE, Marks JS. Prevalence of violence against pregnant women. JAMA 1996;275:1915–20. 3) http://www.sondakikahaberleri.info.tr/kadin-cinayeti 4) S¸ en, S., Egeliog˘lu N., Kavlak O., Sevil, U¨. Determination of awareness of health professionals about violence during pregnancy_ Uluslararası Insan Bilimleri Dergisi (2012). Cilt:9 Sayı:1 Yıl:2012 ISSN 1303 - 5134 Keywords: violence, pregnancy Presenter: K.E. Karasahin

ID 839

K. E. Karasahin, U. Fidan, U. Keskin, M. Ulubay, I. Alanbay, & A. Ergun

WOMEN’S CHOICE OF POSITIONS DURING LABOUR: RETURN TO THE PAST OR A MODERN WAY TO GIVE BIRTH? A COHORT STUDY IN ITALY

Gulhane Military Medical Academy Dept. of Obstetrics and Gynecology

S. Gizzo, S. Di Gangi, M. Noventa, L. Righetto, C. De Santis, D. D’Antona, & E. Cosmi

Brief Introduction: Intimate partner violence is a public health problem which exists in many countries, regardless of demographic, ethnic cultural and socioeconomic classes. Women of child-bearing age have the highest risk for intimate partner violence. Pregnancy may represent a period of unique vulnerability to intimate partner

Department of Woman and Child Health, University of Padua, Padua, Italy

BEING AWARE OF INTIMATE PARTNER VIOLENCE IN PREGNANCY

Brief Introduction: In developed Countries, childbirth medicalization has reduced the parturient’s opportunity to labour and deliver in a

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DOI: 10.3109/14767058.2014.924236

spontaneous position, constricting her to assume the recumbent one. Unfortunately, existing evidences in this topic are often controversial and unclear, not providing to obstetrical practice improvement. Aim of the study was to compare recumbent and alternative positions in terms of labour process, type of delivery, neonatal wellbeing and intra-partum fetal head rotation (when occiput posterior position (OP) is detected). Materials & Methods: We conducted an observational-cohort-study on women at pregnancy term admitted to our Unit in 2013. Primiparous women with physiological pregnancies and single cephalic fetuses were eligible for the study. We considered data about maternal general characteristics, labour process, type of delivery, neonatal wellbeing at birth. Patients were divided into two groups respectively to the first if they spent more than 50% of labour in a recumbent position (supine/lateral: Group-A) and in the second when in alternative ones (upright – squatting -sitting on the ball - ‘‘on all fours’’: Group-B). Clinical Cases or Summary Results: 225 women were recruited (69 in Group-A and 156 in Group-B, homogenous for general characteristics). We found significant differences between the groups in terms of labour length (both first and second stages), Numeric Rating Scale (NRS) score and analgesia request rate, type of delivery, need of episiotomy and fetal OP rotation to anterior position (OA). No differences were found in terms of neonatal outcomes. Conclusions: Our data suggest that the alternative maternal positioning may positively influence labour process reducing maternal pain, operative vaginal delivery, caesarean section and episiotomy rate, In absence of prepartum/intrapartum materno-fetal complications, all women should be encouraged to move and deliver in the most comfortable position, preferring a vertical position when OP is diagnosed. Keywords: alternative labouring positions; labour process; type of delivery, neonatal wellbeing, fetal occiput rotation Presenter: Marco Noventa

ID 933

PREVALENCE OF URINARY INCONTINENCE IN PREGNANT WOMEN AND ITS EFFECT ON QUALITY OF LIFE G. Kok1, M. Seven2, & G. Guvenc1

Clinical Cases or Summary Results: The prevalence of urinary incontinence was 21.3%. Factors significantly associated with urinary incontinence included age group, week of pregnancy, parity, vaginal delivery, Body Mass Index, previously not using hormonal contraception, urinary incontinence in mother and sister. ICIQ-SF scores in incontinent group was 91.62 + 18.69. The majority of pregnant women have UI, negatively affecting the quality of their lives. Conclusions: The results of this study have shown that the prevalence of urinary incontinence during pregnancy is high. The quality of life of pregnant women was found to be affected by urinary incontinence. Understanding UI can be useful for health-care professionals when informing and counseling pregnant women to help prevent UI during pregnancy. Keywords: Urinary incontinence; pregnancy; quality of life Presenter: G. Guvenc

ID 669

THE ADVANTAGES OF MIDWIFE-LED OBSTETRIC UNITS I. Verdenik & A. Prelec University Medical Centre Ljubljana, Division of Gynaecology, Ljubljana, Slovenia Brief Introduction: The increase of medicalization of childbearing and delivery has been publicly uttered worldwide. Different models of care for childbearing women were introduced: home births, the development of midwife-led services and the development of birth centres, either inside or outside the hospital. However, too many healthy pregnant women were still giving birth in obstetric settings. A case control study was carried out to compare the frequency of medical interventions and perinatal outcome between the midwivesled unit and ordinary labour ward. Materials & Methods: In a prospective case-control study 154 women were allocated to a midwife-led unit, whereas 343 women gave birth in an ordinary labour ward and served as controls. The inclusion criteria were: low risk primiparous women, singleton term pregnancy, normal foetal heartbeat; cephalic presentation, spontaneous onset of labour and active phase of labour. The 1 to 2 case-control ratio was chosen due to limited resources in the midwife-led unit. The power analysis was used to determine the total number needed. As a primary outcome we chose caesarean section rate as a most important and frequent intervention.

1

Gulhane Military Medical Academy, School of Nursing, Ankara, Turkey, and 2Koc University, School of Nursing, Istanbul, Turkey Brief Introduction: The standardization committee of the International Continence Society (ICS) defines urinary incontinence (UI) as ‘‘any involuntary urine leak complaint. UI is a symptom frequently observed during the pregnancy period, mainly in the third trimester of pregnancy, and generally presents a spontaneous resolution after delivery, with prevalence between 20% and 60%. The aim was to investigate the prevalence of urinary incontinence UI in pregnant women and its relationship with socio-demographic variables and quality of life. Materials & Methods: This study was designed as a cross-sectional and descriptive survey. A total of 287 pregnant women participated in the study between April and June 2013. The data was collected using the International Consultation on Incontinence Questionnaire Short Form and Wagner’s quality of life scale. The SPSS 15.0 package software was used for the evaluation of the data obtained from the study. In the first analysis, participants were divided into two groups according to the self-report of urinary incontinency as ‘‘incontinent’’ and ‘‘continent’’. Potential risk factors were investigated through logistic regression analysis.

Table 1. Demographic data

Characteristic Marital status Single Married Cohabitation Widow Education less than higher degree higher degree and more Presence of a companion Yes No Prenatal classes Yes No Age (average)

Study group (n = 154) No (%)

Control group (n = 343) No (%)

4 (2.6) 66 (42.9) 84 (54.5)

11 (3.2) 152 (44.3) 179 (52.2) 1 (0.3)

70 (45.5) 84 (54.5)

161 (46.8) 182 (53.2)

141 (91.6) 13 (8.4)

314 (91.5) 29 (8.5)

143 (92.9) 11 (7.1) 28.51 years

307 (89.5) 36 (10.5) 28.67 years

p 0.894

0.846 0.749 0.238 0.864*

*Mann Whitney test was used for comparison of continuous variables

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80 Furthermore, we also compared secondary outcomes: interventions during the labour, use of pharmacological pain relief, perineal lacerations of various degrees, episiotomy, postpartum haemorrhage, Apgar score less than 6 at one and five minutes and admission to the Neonatal Intensive Care Unit. The study was approved by the Ethics Committee of the University Medical Centre Ljubljana. All women signed an informed consent before entering the study. Clinical Cases or Summary Results: Base demographic characteristics were similar in both groups (table 1). We found no statistically significant difference in marital status, age, level of education, attending prenatal classes or the presence of a partner in the delivery room. In addition, the onset of labour with spontaneous rupture was almost equal (45% in study vs. 49% in control group). The similarity points to the fact that the study and control group were, to a large degree, comparable and that the differences in outcomes could not be attributed to baseline differences. Table 2 holds the description of interventions. There was a statistically significant difference in the caesarean section rate (1.9% vs. 13.4%), augmentation (31.2% vs. 84%), analgesia (92.2% vs. 98.3%) and vacuum delivery (0.6% vs. 4.7%). The episiotomy rate (in those delivering vaginally) was also significantly lower in the study group (33% vs. 52%). We found no statistically significant differences between the two groups in regard to maternal complications (lacerations, postpartum haemorrhage and blood transfusion) (table 3). We also presented the result of the assessment of the newborns, which can be found in table 4. There was no statistically significant difference regarding resuscitation, admission to NICU or low Apgar score. However, we found statistically significant higher proportion of exclusively breastfed children in the study group (80.5% vs. 69.1%). Conclusions: Midwife-led units represent a clear advantage over the current obstetric practice for healthy primiparous women with unproblematic pregnancies in terms of much lower intervention rates (caesarean sections, augmentation, need of analgesia, vacuum, episiotomy) with comparable or even better results (breastfeeding). Keywords: midwife led units, obstetric interventions, perinatal outcome Presenter: Ivan Verdenik

ID 041

POLICY OF TRANEXAMIC ACID FOR TREATING POSTPARTUM HEMORRHAGE AFTER A VAGINAL DELIVERY P. Jeanneteau, MD, P.-E. Bouet, MD, V. Ruiz, MD, S. Madzou, MD, P. Gillard, MD, P. Descamps, MD, Ph.D., & L. Sentilhes, MD, Ph.D Department of Obstetrics and Gynecology, Angers University Hospital – Angers – France

Brief Introduction: The objective of this study is to determine whether a policy of administation of high-dose tranexamic acid (TA) at the time of diagnosis of postpartum hemorrhage (PPH) could reduce blood loss after vaginal birth. Materials & Methods: This was a controlled before-after unicentred study. From January 2011 to August 2011, the control group included all patients with PPH  500 mL after vaginal birth without use of TA. From September 2011 to March 2012, the TA group included all patients with PPH  500 mL after vaginal birth. Since the publication of the EXADELI trial (Crit Care 2011) our protocol for the management of PPH has included in September 2011 the use of high-dose TA (4g of TA intravenously then 1g/h over 6 hours) from 800 mL of blood loss after vaginal birth. The primary objective was to assess the efficacy of policy of high-dose TA administration in the reduction of blood loss in PPH.

J Matern Fetal Neonatal Med, Early Online: 1–437

Table 1. Principal characteristics of the participants and assessment of PPH-related outcome.

Age (year)* Parity (range)* Body Mass Index (kg/m2)* Antenatal risk factors, n (%)  Multiple gestation  Previous cesarean section  Previous PPH Oxytocin (mUI) Birth weight (g)* Hemorrhagic episiotomy, n (%) Blood loss 800 mL, n (%)* Blood loss 1500 mL, n (%)* Additional uterotonic agent, n (%) Embolisation, n (%) Surgical arterial ligature or hysterectomy, n (%) D Hemoglobin** (g/dL) Iron sucrose injection, n (%) Blood transfusion, n (%) Thromboembolic events, n (%)

Control group (n = 151)

TA group (n = 138)

p Value

27.7 ± 4.7 1.6 ± 0.9 24.1 ± 5

28.3 ± 5.2 1.7 ± 0.9 23.6 ± 5

0.28 0.62 0.65

3 (2) 14 (9.3) 10 (6.6) 1566 ± 21.6 3406.1 ± 540.1 2 (1.3) 99 (65.6) 14 (9.3) 25 (16.6)

2 (1.4) 13 (9.4) 10 (7.2) 1431 ± 19.2 3375.3 ± 488.1 3 (2.2) 92 (66.7) 9 (6.5) 17 (12.3)

0.25 0.64 0.76 0.66 0.60 0.56 0.84 0.38 0.31

1 (0.7) 0 (0)

1 (0.7) 0 (0)

0.94

2.9 ± 1.3 15 (9.9) 10 (6.6) 1 (0.6%)

2.6 ± 1.2 3 (2.2) 12 (8.7) 0 (0%)

0.09 50.05 0.50 0.86

*Values are given as mean ± standard deviation. ** The difference between predelivery hemoglobin and postdelivery hemoglobin Clinical Cases or Summary Results: The maternal characteristics did not differ between the two groups. The mean estimated blood loss was not significantly lower in the TA group (n = 138) compared to the the control group (n = 151) (respectively 915.7 ± 321mL versus 944.8 ± 313.8mL; p = 0.47). The difference between predelivery hemoglobin and postdelivery hemoglobin tended to be lower in the TA group (2.6 g/dL ± 1.2 versus 2.9 g/dL ± 1.3; p = 0.09) without significance. In the TA group, postpartum iron sucrose injection was significantly less frequent compared to the control group (2.2% vs 9.9%; p50.05). No thrombo-embolism event occurred in both group. A subgroup analysis among women who had an estimated blood loss 800 mL (indication of a TA administration) showed no significant difference between the two groups. Conclusions: A policy of high-dose TA after a vaginal delivery was not associated with a significant reduction of blood loss. However, its use was associated with a significantly reduced postpartum iron sucrose injection use in this before-after study. Keywords: Tranexamic acid, postpartum hemorrhage, vaginal delivery Presenter: P. Jeanneteau

ID 445

PREVENTION OF PERINEAL INJURIES: EFFICACY OF A TRAINING PROGRAM M. Manresa1, S. Buob2, O Gracia3, & A. Pereda4 1

Midwive. Department of Obstetrics and Gynaecology, Hospital General Granollers, Barcelona, Spain, 2Midwive. Department of Obstetrics and Gynaecology, Hospital General Granollers, Barcelona, Spain, and 3Midwive. Department of Obstetrics and Gynaecology, Ho

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DOI: 10.3109/14767058.2014.924236

Brief Introduction: Anal incontinence (AI), i.e. involuntary loss of flatus or feces, is an ailment associated with many health problems and results in a significant loss of patients’ quality of life. Obstetric highgrade injuries which concur with an anal sphincter injury are the most important factor in the development of AI in women. Also, patients with spontaneous delivery and low-grade injuries–above all, secondgrade perineal tear–may also show symptoms of IA related to occult or high-grade undiagnosed injuries. In our hospital, we created a training program in order to improve the protection of the perineum as well as to lessen the number of second-degree perineal tears, and therefore minimizing the risk of high-grade undiagnosed injuries. Materials & Methods: The training program consisted of five training sessions held during 2010. It was attended by 74.6% of the staff trained to assist deliveries and who work in the delivery room of the Hospital General de Granollers. The study was conducted as a retrospective cohort study of spontaneous deliveries in the delivery unit of the Hospital de Granollers across two periods (2008–2009 and 2012–2013). In these two periods the factors studied were: parity, birthweight, episiotomy and perineal tear’s degree. We excluded third- and forth-degree injuries, preterm delivery (before 32w), stillbirths and medial episiotomy. We also excluded firstdegree injuries as they result in statistical deviations. The final population of the study amounted to 4,109 deliveries. For each group we calculated the frequency of second-degree tears, the number of episiotomies performed, and the infant’s birthweight. We also analyzed and compared these frequencies with the Chi-square statistic test. The level of statistical significance was set at p50.05. Data were analyzed using SPSS 20 statistical program. Clinical Cases or Summary Results: When comparing the two populations before and after the training program, we established that the number of episiotomies remained the same (45.9%), and that there was a statistically relevant increase of tears (p = 0.004). After analyzing the subpopulations, we observed a 3.1% increase of episiotomies in primiparous women and high weight, as well as a 3.2% decrease in second-grade tears, although not statistically significant. These figures do not appear in the rest of the population. This subgroup was identified as a risk group during the training sessions. Conclusions: Although the number of second-degree tears amongst the population who attended the training program did not decrease, we observed an improvement in the praxis which resulted in less second-degree perianal tears and an increase in the number of episiotomies conducted amongst women who had infants whose weight 43,500 g. These women had been identified as a risk group during the training sessions. The care and cure of the perineum at the time of delivery should be applied to all women, regardless of parity and the infant’s weight. A single training program of prevention of perineal injuries is clearly insufficient; training should be comprehensive, continuous and necessary for all the staff involved in deliveries. Keywords: Spontaneous birthweight

delivery,

perineal

tears,

episiotomy,

Presenter: M. Manresa

Table. Adolescent pregnancies: does the age really count? A Maternal age (years) BMI (Kg/m 2) Weight gain in pregnancy (Kg) Gestational age at first access (weeks) Request for prenatal diagnosis (%) Number of obstetrical controls Risk behaviours (%) Rate of vaginal delivery (%) Gestational age at delivery (weeks) Fetal weight at birth (g) Placental weight (g) Apgar score at 5 minutes Umbilical cord pH

NA

P

18.2 ± 1.8 22.9 ± 3.5 13 ± 4.4 17.6 ± 7.4

31.0 ± 8.2 50.001 23.8 ± 4.3 NS 13 ± 5.1 NS 12.5 ± 3.6 50.001

11.1 4.1 ± 1.4 14.8 96.2 39.3 ± 0.7

42.2 50.01 5.7 ± 1.0 50.001 6.7 NS 81.4 0.05 39.5 ± 1.2 NS

3222 ± 291.1 569.4 ± 104.7 9.95 ± 0.20 7.268 ± 0.08

3241 ± 425.2 528.5 ± 109.6 9.97 ± 0.17 7.272 ± 0.07

NS NS NS NS

Materials & Methods: We compared 43 singleton pregnancies in patients aged 21 years (A) followed at our outpatient clinic for adolescent gynecology to a control group of women 421 years (NA) who deliverd at our Institution from November 2011 to August 2013. We evaluated gestational age at first access, maternal prepregnancy BMI, weight gain in pregnancy, number of obstetrical controls, request for prenatal diagnosis, rate of risk behaviour (smoke, alcohol, hygiene habits), rate of obstetrical complications, mode of delivery, fetal and placental weight, gestational age at delivery. Data are presented as mean ± standard deviation. Significance was calculated with t-test for independent samples and chi square method. Clinical Cases or Summary Results: Results are shown in Table 1. A and NA groups did not differ for BMI, weight gain, risk habits, gestational age and outcome at delivery. The gestational age at first access to the obstetric outpatient clinic, the number of obstetrical controls during pregnacy and the request for prenatal diagnosis were significantly different in A versus NA pregnant patients. Conclusions: Our data clearly show that A pregnancies access later and with a decreased rate to obstetrical services than NA. Although A group mantain risk behavoiurs more frequently during pregnancy than NA, the rate of vaginal delivery and neonatal outcome in our experience seem not to be affected. Keywords: Presenter: E. Calvi

ID 956

ANALYSES OF TRAUMA EXPERIENCES AND RELATED FACTORS DURING PREGNANCY S. Ozdemir1, A. Karaoglu2, & E. Yel3

ID 044

ADOLESCENT PREGNANCIES: DOES THE AGE REALLY COUNT? E. Calvi1, C. Garo`2, & C. Paolini3 Department of Obstetrics and Gynecology, San Paolo Hospital Medical School, Universita` degli Studi di Milano, Milano, Italy Brief Introduction: The aim of the study was to compare obstetrical management and outcome in adolescent (A) versus non adolescent pregnancies (NA).

1

Gulhane Military Medical Academy, School of Nursing, Public Health Nursing Department, Ankara, Turkey, 2Gulhane Military Medical Academy, School of Nursing, Ankara, Turkey, and 3Gulhane Military Medical Academy, Ankara, Turkey Brief Introduction: Trauma is an important problem during pregnancy due to its maternal and fetal mortality and morbidity. This study aims to analyze trauma experiences and related factors during pregnancy. Materials & Methods: This cross-sectional study was conducted between April 2013 and January 2014. The sample was 123 volunteer females, who are pregnant or in the postpartum first six months, admitted to Gu¨lhane Military Medical Faculty Training and Research Hospital. Data collection form comprised of socio-demographic

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82 enquiry (13 items) and trauma history enquiry (18 items). Data was analyzed with SPSS 15.0 Program Package. Relation among dependent and independent variables was investigated with Mann Whitney U test. Clinical Cases or Summary Results: Mean age of the participants was 31.25 ± 10.29 years and 26% (n = 32) reported to have trauma during pregnancy. Among these cases 87.5% (n = 28) were falls, 12.5% (n = 4) in vehicle traffic accident and 6.3% (n = 2) burns. Nearly half of the trauma experiencing pregnancies (59.4%, n = 19) reported not to consult a treatment facility after the trauma. The most frequent causes of falls were walking on wet and slippery floor (46.9%, n = 15), problem in balance/movement/strength (31.3%, n = 10), dizziness (15.6%, n = 5). Mean fear of trauma score was 4.44 ± 3 (0–10) and the most common time of fear was third trimester (38.2%, n = 47). Fear of trauma score of pregnancies who experienced trauma was statistically significantly higher than the ones who did not (Z = 2.926; p = 0.003). Conclusions: In Turkey, no study analyzing trauma experiences and related factors during pregnancy was found. Our findings show that one of four pregnancies experience trauma and this may effect maternal and fetal health negatively. It is suggested that proper nursing interventions and measures should be practiced to prevent trauma. Keywords: Pregnancy, nursing, trauma Presenter: Serpil Ozdemir

ID 729

IMPROVING INFORMATION PROVISION IN PAEDIATRIC DELIVERY CALLS J. Parasuraman Musgrove Park Hospital, Taunton, United Kingdom Brief Introduction: Paediatric junior doctors are the first port of call for the midwives when faced with complicated deliveries. The doctor’s support at these deliveries is important as it is anticipated that the baby may need initial resuscitation. The junior doctors are often faced with lack of information surrounding the delivery when being called, hence could not decide whether senior support is needed prior to attending the delivery.This quality improvement project assesses the current information provision, with the aim to set a system in place to improve this provision. System to enhance the information given to paediatric doctors has been explored previously1 and serves as the guideline for this project. Materials & Methods: Paediatric delivery calls were monitored over a period of 2 weeks. Data was collected on the information given to the paediatric doctors. The data collected included the location of the delivery, gestation of the baby, mode of delivery, presence of meconium and CTG abnormalities. This project was carried out at a district general hospital in the United Kingdom, with a level 2 neonatal unit, in December 2013. Clinical Cases or Summary Results: 23 paediatric delivery calls were monitored over a period of 2 weeks. The deliveries were attended by the paediatric SHO, paediatric registrars and Advanced Neonatal Nurse Specialist (ANNP). All requests to attend deliveries were made by the midwives, however in some cases, not the midwife looking after the mother. The doctors were not informed about the mode of delivery in 34.7% of delivery calls. In 60.86% of the delivery calls, the midwife making the request did not provide the gestation of the baby, in one instance, inaccurate information was provided for a preterm delivery as term. Information about the presence of meconium was lacking in 78.2% of the delivery calls. In 78.2% of the requests, vital information regarding CTG like the presence of pathological CTG was not given to the doctors.

J Matern Fetal Neonatal Med, Early Online: 1–437

Conclusions: This project highlighted the inadequate information provision to the paediatric doctors when requested by the midwives to attend delivery. This especially affects the junior paediatric doctors, who without the correct information at the time of the call, could not involve the senior staff appropriately in the early stages. In response to this, a structured system for the delivery calls is being implemented so that any staff requesting paediatric delivery attendance can provide vital, standardized information. This is in the form of the acronym LAMDA (L-Location, A- Age/Gestation, MMeconium, D-Delivery Mode and A-Abnormality in CTG). Improved information provision is really important if we are to provide safe and good care to babies at birth. Keywords: Presenter: J Parasuraman

ID 036

TOTAL SERUM OXIDANT/ ANTIOXIDANT STATUS IN HYPEREMESIS GRAVIDARUM S. Yilmaz1, A. Seval Ozgu-Erdinc1, C. Demirtas2, G. Ozturk3, S. Erkaya1, & D. Uygur1 1

Zekai Tahir Burak Women Health Care, Education and Research Hospital, Department of Perinatology, Ankara, Turkey, 2Gazi University Faculty of Medicine, Department of Biochemistry, Ankara, Turkey, and 3Diskapi Yildirim Beyazit Education and Research Hospit Brief Introduction: We aimed to determine the status of oxidative stress (OS) in hyperemesis gravidarum (HG) patients by measuring the levels of total oxidant status (TOS), total antioxidant status (TAS), and oxidative stress index (OSI). Materials & Methods: In a case-control trial, blood samples were collected from patients with HG (n = 41) and healthy pregnant women (n = 39) as control group. Serum total oxidant status and total antioxidant status were measured. Oxidative stress index was calculated according to the formula: OSI = TOS/TAS Clinical Cases or Summary Results: Serum TOS levels were similar in both groups. However, serum TAS levels were significantly lower in the HG patients when compared with the control group (p = 0.014). The OSI, was significantly higher in HG patients than the control group (p = 0.006). Conclusions: The present study revealed that there was a systemic oxidative stress reflected by an imbalance between the total oxidant and antioxidant status in patients with HG. We have found that oxidative stress in HG patients is associated with reduction of antioxidants rather than the increase of oxidants. Keywords: Hyperemesis gravidarum, oxidative stress index, total antioxidant status, total oxidant status Presenter: A. Seval Ozgu-Erdinc Total antioxidant status, total oxidant status, and the oxidative stress index of HG patients and control groups

HG (n = 41)

CONTROL (n = 39)

p Value

TAS Mean and SD 1.5478 ± 0.68624 1.9077 ± 0.58737 0.014* TOS Median 4.4800 (3.39 8.12) 4.4800 (3.39–7.39) 0.657** and Range OSI Median 2.93 (1.37–18.56) 2.26 (1.50–7.03) 0.006** and Range *Independent Samples Test **Mann-Whitney U

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significant difference in overall pain scores evaluated by VAS, VRS or ADL, nor in analgetic use Incidence of hematoma in episiotomy 24hours postpartum was significantly more frequent in LE (p = 0.009). Rate of infection, dehiscence, resuturing, and painful defecation were not significant in follow-up. Conclusions: Incidence and extent of pain and healing complications after LE correspond to those after adequately performed MLE.

ID 740

CLINICAL EVALUATION OF EARLY POSTPARTUM PAIN AND THE HEALING OUTCOMES OF MEDIOLATERAL VERSUS LATERAL EPISIOTOMY

Keywords: mediolateral episiotomy, lateral episiotomy, pain, wound healing, painful defecation, Visual Analogue Scale

J. Karbanova1, Z. Rusavy1, L. Betincova1, M. Jansova2, P. Necesalova1, & V. Kalis1

Presenter: J. Karbanova

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

1

Department of Gynecology and Obstetrics, University Hospital, Faculty of Medicine, Charles University, Pilsen, Czech Republic, and 2NTIS - New Technologies for the Information Society, Faculty of Applied Sciences, University of West Bohemia, Pilsen, Czech R

EPIGENETICS AND METABOLOMICS IN PERINATOLOGY

Brief Introduction: Evaluation of short-term perineal pain and healing complications at 24 and 72 hours and 10 days postpartum amongst primiparous women after mediolateral (MLE) and lateral (LE) episiotomies. Materials & Methods: In a prospective randomized study 705 consecutive primiparas were enrolled. The primary aim was to evaluate short-term pain using Visual Analogue Scale (VAS), Verbal Rating Score (VRS), Interference with Activities of Daily Living (ADL) and amount of analgetic use. Secondary aims were healing complications: infection, dehiscence, resuturing, and painful defecation. Clinical Cases or Summary Results: 266 (78.2%) women with MLE and 297 (81.4%) women with LE responded in time. The groups did not differ in maternal or neonatal characteristics. A complete recession of pain 24 hours, 72 hours and 10 days postpartum was observed in 2.2%, 8.0% and 29.1% respectively in MLE and in 3.9%, 7.7% and 26.4% in LE (p = 0.36). There was no

Table 2. Evaluation of pain between mediolateral and lateral episiotomies 24 and 72 hours and 10 days postpartum

24 hours

72 hours

10 days

a

Evaluation of pain Scores/domains

MLE mean (IQR)

LE mean (IQR)

pa

VAS VRS ADL Pain at Pain at Pain at Pain at Pain at

rest sitting moving voiding sleep

39 (20–50) 4.4 (3–6) 3.7 (2–6) 0.9 (0–1) 1.9 (1–3) 1.6 (1–2) 0.8 (0–1) 0.5 (0–1)

37 (18–50) 4.2 (3–6) 3.5 (0–6) 0.8 (0–1) 1.9 (1–2) 1.5 (1–2) 0.8 (0–1) 0.5 (0–1)

0.30 0.44 0.16 0.70 0.76 0.26 0.73 0.36

rest sitting moving voiding sleep

24 (8–43) 2.4 (1–3) 2.0 (0–3) 0.3 (0–1) 1.2 (1–2) 1.0 (0–1) 0.4 (0–1) 0.2 (0–0)

22 (0–40) 2.4 (1–3) 2.0 (0–3) 0.3 (0–1) 1.2 (1–2) 0.9 (0–1) 0.5 (0–1) 0.2 (0–0)

0.25 0.94 0.62 0.37 0.97 0.55 0.55 0.85

rest sitting moving voiding sleep

24 (6–40) 2.0 (1–3) 1.8 (0–3) 0.3 (0–1) 1.0 (0–1) 0.7 (0–1) 0.4 (0–1) 0.1 (0–0)

25 (6–50) 2.1 (1–3) 1.8 (0–3) 0.3 (0–1) 0.9 (0–1) 0.8 (0–1) 0.3 (0–1) 0.1 (0–0)

0.75 0.38 0.57 0.10 0.55 0.23 0.53 0.06

VAS VRS ADL Pain at Pain at Pain at Pain at Pain at VAS VRS ADL Pain at Pain at Pain at Pain at Pain at

non-parametric ANOVA (2-sample Wilcoxon test) IQR interquartile range

ID 165

SERUM MICRORNAS AS DIAGNOSTIC BIOMARKERS FOR MACROSOMIA H. Jiang1, Y. Weng2, L. Hu1, Tingting Miao1, Ming Zhang1, Jing Dong2, Haiyan Zhu1, & Qiuwei Wang1 1

Changzhou Maternity and Child Health Care Hospital affiliated Nanjing Medicial Universty, Changzhou, Jiangsu, P.R. China, and 2Department of Epidemiology and Biostatistics, State Key Lab of Reproductive Medicine, School of Public Health, Nanjing Medical Brief Introduction: Background: Macrosomia is defined as an infant’s birth weight of more than 4000 g at term because of excessive intrauterine fetal growth occurence. The rapid increase in the rate of macrosomia is a worldwide problem. Growing evidence indicates that miRNAs are involved in the pathogenesis of various diseases.However, no reported study investigates the associations between serum miRNAs and macrosomia. Materials & Methods: Methodology: We pooled serum samples one week before delivery of 30 cases and 30 matched controls, respectively, to subject them to TLDA chip screening in the discovery stage. Then, we performed RT-qPCR on the discovery-stage samples individually to further filter signals of the screened miRNAs due to heterogeneity in the subjects. Top candidate associations were evaluated in a validation set by RT-qPCR. Clinical Cases or Summary Results: Principal Findings Profiling results showed 1 miRNA was concordantly up-regulated and 10 miRNAs were concordantly down-regulated in serum samples of macrosomia(DDCt 43folds). The expression levels of two miRNAs (miR-21 and miR-20a) were significantly decreased in macrosomia pregnant women with respect to the controls in the third trimester in our discovery evaluation and internal validation, and miR-21were also consistently validated in external validation sample sets. Receiver operating characteristic (ROC) curve analyses showed that the ROC curve areas for miR21 was 67.7%,(sensitivity = 66.7% and specificity = 70.0%). But the expression levels of the two miRNAs were no differential among early second-trimester serum sample of macrosomia cases compared with controls. Conclusions: Conclusions/Significance: Our study is one of the first to investigate serum miRNA expression associated with macrosomia status. Serum miR-21 are differentially expressed between macrosomia pregnant women and controls which could be used as candidate biomarkers for predicting macrosomia. Keywords: MicroRNA, Serum; macrosomia, TLDA, Biomarker Presenter: Hua Jiang

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ID 584

METABOLOMIC APPROACH FOR DIAGNOSIS OF INHERITED ERRORS OF METABOLISM IN NEONATAL LIFE N. Jekova1, M. Ivanova2, & D. Dimitrov3

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

1 Department of Neonatology, University hospital of Obstetrics and Gynecology, Sofia, Bulgaria, 2National Genetic Laboratory, University hospital of Obstetrics and Gynecology, Sofia, Bulgaria, and 3National Genetic Laboratory, University hospital of Obs

Brief Introduction: Inherited errors of metabolism manifesting with organic acidurias are a clinically important heterogeneous group of rare inherited disorders. The diagnosis requires an application of many highly specialized methods and a comprehensive approach because of the unspecific clinical manifestation of this polyetiologic pathology. The objective of this study was to present the metabolomic approach applied in the diagnosis of inherited errors of metabolism manifested in the neonatal period. Materials & Methods: Blood spot filter papers and urine samples from high risk infants were investigated in our perinatal center during the last five years. Clinical manifestation of the examined infants presented with respiratory, neurologic, cardiovascular and feeding disorders and laboratory signs as metabolic acidosis, lactatemia, hypoglycemia, hyperammoniemia, thrombocytopenia and leucopenia The metabolomic approach included the following steps of investigation: urine qualitative target analysis of certain metabolites, tandem mass spectrometry (MS/MS) of blood spot aminoacid and acylcarnitine profiles, gas chromatography – mass spectrometry(GC/ MS) of urine organic acid profile and DNA analysis for confirmation of diagnosis. The main analytical techniques in our approach were the tandem MS/MS and GC/MS Clinical Cases or Summary Results: More than 2000 high risk patients were investigated by using a metabolomic approach. A total of 131 infants (5.4%) were diagnosed and classified into eleven basic organic acid disorders’ groups as follows - defects of: aromatic aminoacid metabolism – 16, propionate and methylmalonate metabolism – 8, branched chain amino-acid metabolism – 13, mitochondrial fatty acid oxidation – 14, pyrimidine metabolism – 1, dibasic aminoacid metabolisim – 2, g-glutamyl cycle defects – 2, glycolysis and Krebs’ cycle – 8, urea cycle – 21; lactic aciduria -38 and miscellaneous inherited metabolic disorders – 5. The diagnostically informative metabolite profiles were detected for each disease. Conclusions: Our results show that the application of a metabolomic approach is a useful, rapid and feasible tool for diagnosis of inherited errors of metabolism in the neonatal period. Keywords: Metabolomics, high risk neonates, diagnosis of inherited errors of metabolism Presenter: Neli Jekova

ID 636

TWO INNOVATIVE INFLAMMATION BIOMARKERS FOR THE MEASUREMENT OF INFLAMMATION IN PREGNANCY G. Piuri1, C. Bulfoni2, A.L. Mastricci2, I. Liguori2, A.F. Speciani3, & E. Ferrazzi2

1

SMA srl, Milan, Italy, 2Dept. of Woman, Mother and Neonate, Buzzi Children’s Hospital. Biomedical and Clinical Sciences School of Medicine, University of Milan, Italy, and 3GEK srl, Milan, Italy Brief Introduction: The idea that pregnancy is associated with immune suppression has been replaced by the concept of an immune tolerance mounted by the endometrial niche toward trophoblastic antigens. Platelet-activating factor (PAF) is a mediator of many immune functions, including platelet aggregation and degranulation, inflammation and anaphylaxis. B cell activating factor (BAFF) is a member of the TNF superfamily and an important regulator of peripheral B cell survival and immunoglobulin class-switch recombination. BAFF and PAF have already been linked in non-atopic subjects to food reactions and many studies suggest that BAFF could probably be one of the cornerstones of IgG pathway of immune reaction to foods. The aim of this study is to evaluate the correlation between BAFF and PAF in pregnant women. Materials & Methods: We measured the concentration of PAF and BAFF in sera of 75 pregnant women (mean age 33.4 ± 0.5 years) three times during pregnancy at first, second and third trimester on average at the 16th, 32nd and 39th week of gestation, respectively. Correlations between variables were calculated by Pearson Rank Correlation Coefficient. Clinical Cases or Summary Results: PAF and BAFF mean values were 6.32 pg/ml (95% CI 5.48 to 7.16) and 1.61 ng/ml (95% CI 1.39 to 1.82) respectively without significant changes in the different gestational ages. A highly significant correlation was found between PAF and BAFF values in all three trimesters of pregnancy (R = 0.9489 for the first trimester, R = 0.9602 for the second trimester, R = 0.9748 for the last trimester with p50.0001 at all times). Conclusions: To the best of our knowledge this is the first time that these markers are interrogated in pregnancy and prove a highly significant correlation throughout gestation. This will probably allow the use of any of these two molecules as a marker of inflammation in pregnancy and as marker of the role of IgG pathway in immune reaction. These data are part of a wider research in immune system adaptation in pregnancy and their relation with the production of specific IgG for food, the enteric immune system and the accelerated inflammation in pregnancy of women at risk of metabolic syndrome. Keywords: BAFF, PAF, Inflammation, Tolerance Presenter: C. Bulfoni

ID 555

HOW CORTICOSTEROIDS AFFECT PLACENTAL METABOLISM C. Alvarez1, G. Jimenez2, F. Visiedo3, F. Suarez4, M.A. Rodriguez5, G. Perdomo6, & A.M. Lechuga7 1 2

Hospital of Jerez de la Frontera, Jerez de la Frontera, Spain, University Hospital Puerta del Mar, Cadiz, Spain, 3University

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DOI: 10.3109/14767058.2014.924236

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Hospital Puerta del Mar, Cadiz, Spain, 4University Hospital Puerta del Mar, Cadiz, Spain, 5Hospital of Jerez de la Frontera, Jerez de la Frontera, Spain, 6University of Castilla La Mancha, Toledo, Spain, and 7University Hospital Puerta del Mar, Cadiz, Spain Brief Introduction: Newborns from mothers with hypercortisolemia during pregnancy have a higher risk of being small for gestational age (SGA). However, the mechanism underlying this effect remains unknown. The placenta is a metabolically active organ, capable of regulating the nutrient transport to the fetus. Glucocorticoids have a relevant impact in metabolism, in multiple organs, but the impact on placental metabolism has not been well documented to date. The aim of this study was to determine the metabolic response to corticosteroids of placental explants, in terms of glucose uptake and lipid oxidation and sterification. Materials & Methods: We used five placentas from physiological pregnancies that resulted in term newborns of adequate weight. Placentas from mothers under chronic therapies or with toxic habits were excluded. Explants were incubated for 18 hours, with different cortisone concentrations, ranging from phsysiological to supraphysiological levels. Glucose uptake, lipid oxidation and sterification were measured by isotopic methods. Cellular death was measured in terms of activated Caspase 3 by immunoblotting. Clinical Cases or Summary Results: Cortisone induced a significant decrease in glucose uptake and lipid oxidation by the placental explants. This decrease in lipid oxidation did not correlate with an increased sterification. Levels of activated caspase 3 remained unchanged. Conclusions: Taken together, these data suggest that corticosteroids decrease overall placental metabolism by limiting the tisular intake of nutrients. This effect does not seem to be mediated by an increase in cellular death. This could at least partially explain how newborns from mothers with hypercortisolemia during pregnancy, have a higher risk of being born small for gestational age. Keywords: Presenter: C. Alvarez

Materials & Methods: 60 women were randomly assigned to two intervention groups: A) Control Group (n = 30): They will intake 2 glasses/day of the control dairy drink, and B) Supplemented Group (n = 30): The women will take 2 glasses/day of the supplemented dairy drink (400 mg DHA/day). Dietary intervention began in week 28th of pregnancy of pregnancy and concluded when breastfeeding stopped. Samples of blood were obtained from the mothers, from the umbilical vein and arteries and the newborn at 2.5 months postpartum. Adiponectin, resistin, leptin and active PAI-1 plasma levels were determined using a panel from Luminex xMAP technology. Clinical Cases or Summary Results: Adiponectin was higher in the supplemented group in umbilical cord artery, whereas active-PAI showed a lower value in this group, although we observed an increase in mother’s blood during delivery. Resistin did not show any difference between groups and leptin was higher in the supplemented group in umbilical cord vein and artery. Conclusions: The most noteworthy result is the effect of DHA supplementation in umbilical cord artery adipokine levels, increasing the adiponectin and decreasing the active PAI-1. In addition, active PAI-1 increases in mothers during delivery, promoting the coagulation process. It is also interesting the increase in the supplemented group of leptin, which has been related to positive energy balance. Keywords: DHA supplementation, adipokines, pregnancy, breastfeeding, newborn Presenter: E. Martin

ID 734

THE SPECIAL FEATURES OF THE ENDOCRINE SYSTEM OF THE FETUS IN PLACENTAL INSUFFICIENCY A.N. Strizhakov, I.V. Ignatko, M.A. Kardanova, & S.S. Baibulatova

ID 347

EFFECT OF DHA SUPPLEMENTATION DURING PREGNANCY AND LACTATION ON SEVERAL ADIPOKINES IN PREGNANT WOMEN AND THEIR NEONATES E. Martin1, M. Pen˜a1, N. Kajarabille2, J.A. Hurtado1, F. Lara-Villoslada3, & J.J. Ochoa2 1 Neonatal Unit. Pediatrics Service, Hospital Virgen de las Nieves, Granada, Spain, 2Institute of Nutrition and Food Technology ‘‘Jose´ Mataix’’, University of Granada, Granada, Spain, and 3R&D, Department, Bioserch Life

Brief Introduction: Most studies of DHA supplementation during pregnancy and infant development are focused on visual and neural development. However, scarce information is available about the influence of DHA supplementation on other areas, in particular its effect on adipokines expression, which are related to adipose tissue metabolism and obesity. Aim: Evaluate the effect of DHA supplemented dairy drink consumption during pregnancy and breastfeeding on the expression of several adipokines in mothers (pregnancy, delivery and breastfeeding) and their newborns (birth and 2.5 months of age).

Department of the obstetrics, gynecology ana perinatology, First Moscow State Medical University I.M. Sechenov, Moscow, Russia Brief Introduction: The first 1,000 days of the life of a person determine his health, life expectancy, and of these 1,000 days first 270 (during pregnancy) play an important and often pivotal role. Disturbancies of intrauterine growth increases the incidence of obesity, coronary heart disease, insulin resistance, metabolic syndrome, and several other diseases in adulthood. Tendency to the formation of these diseases is the result of violations of intrauterine environment/food that is often accompanied by fetal growth retardation syndrome. Process of influence of unfavorable factors in the early critical stages of fetal development on the state structure of tissues, organs and their functioning is called intrauterine programming. Materials & Methods: Aim of this study was to determine the endocrine status of the fetus in uncomplicated pregnancy and placental insufficiency of varying severity. A comprehensive examination (clinical, echographic, Doppler, hormonal) 90 pregnant women with uncomplicated pregnancies and 230 – with placental insufficiency of varying severity. Studied ultrasound morphology (size of the lobes, circumference, ehostruktura, echogenicity) and peculiarities of organ blood flow of fetal thyroid during uncomplicated pregnancy and placental insufficiency of varying severity. Clinical Cases or Summary Results: First studied features of the development on the basis of fetal adrenal ultrasound evaluation of their size and structure, as well as the formation of hemodynamics in their arteries during uncomplicated pregnancy and PI of the various origins and severity. Found that there is a reduction in FGR all sizes fetal thyroid compared with the normative for the duration of

86 pregnancy. Degree of lag depends on the severity of IUGR - 31% of normal in FGR III degree. When PI there is a decrease in vascular resistance in the thyroid arteries - by 22.2% from the norm in FGR III degree. In FGR II-III degree decreases the concentration of thyroid hormones and increased TSH: T3 total was reduced by 22%, total T4 - 66.7%, TSH increased - by 42%. In FGR II-III degree a marked lag growth adrenal compared with uncomplicated pregnancy - 25.3% width, 26% height and 15.5% in thickness. In FGR I degree the growth of vascular resistance occurs in the adrenal arteries - 16% of normal. In FGR III degree reducing vascular resistance - 27% of normal. Conclusions: In FGR II-III degree decreases the concentration of cortisol in the blood of a newborn - below 105 nmol/L, indicating that violations of adaptation followed by the appearance of severe complications in the early neonatal and postnatal periods.

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Keywords: Placental insufficiency, intrauterine growth restriction, metabolic programming Presenter: I.V. Ignatko

J Matern Fetal Neonatal Med, Early Online: 1–437

statistically significantly correlate with risk of fetal macrosomia in normal BMI patients. Keywords: PAI-1, overweight, pregnacy, labor complications Presenter: Karlina Elksne

ID 588

PERINATAL EPIGENETICS: LOW BIRTH WEIGHT AND ADULT ONSET SYSTEMIC SCLEROSIS C. Amador1, G. Carnesecchi2, M. Di Tommaso3, L. Filippi1, R. Caporali4, V. Codullo4, V. Riccieri5, G Valesini5, A. Gabrielli6, R. Bagnati6, S. De Masi1, M. Matucci Cerinic2, & G. Donzelli1 1

ID 788

PLASMINOGEN ACTIVATOR INHIBITOR - 1 IN MATERNAL PLASMA OF OVERWEIGHT AND NONOVERWEIGHT PREGNANT WOMEN AND ITS RELATIONSHIP TO LABOR COMPLICATIONS K. Elksne1, Z. Paunin¸a2, I. Marksa3, A. Jurka4, D. Rezeberga1, & P. Tretjakovs4 1

Department of Gynecology and Obstetrics, Rigas Stradins University, Riga, Latvia, 2Department of Continuing Education, Rigas Stradins University, Riga, Latvia, 3P. Stradins Clinical University Hospital, Riga, Latvia, and 4Department of Normal physiolog Brief Introduction: Overweight is a rising problem worldwide. It increases the risk of various pathologies, including those related to pregnancy and childbirth. Plasminogen activator inhibitor-1 (PAI-1) plays an important role in a pathogenesis of variety of overweightrelated diseases. The aim of this study is to determine PAI-1 concentration in maternal plasma of pregnant women with and without overweight, follow the changes during the first and second trimesters, and to find out whether there is a correlation between PAI-1 and childbirth complications. Materials & Methods: It is a prospective study involving pregnant women at their first antenatal visit. According to body mass index (BMI), the patients were divided into groups with (n = 20) and without overweight (n = 41). At 9th-12th, 15th-18th and 24th-28th weeks of pregnancy plasma samples were collected and PAI-1 concentrations was established using Luminex-200 system. From the medical records clinical data on parturition were collected. Statistical analysis was carried out by programms R and LibreOffice Calc. Clinical Cases or Summary Results: During pregnancy PAI-1 plasma concentration is gradually rising, and it is higher in women with excessive weight. Statistically significant differences were found between PAI-1 levels in patients with normal BMI and with or without fetal macrosomia - maternal cytokine concentration was higher when fetal macrosomia was found, and this relationship persists in both first and second trimester. Conclusions: PAI-1 concentrations in the plasma of pregnant women starts to increase from the first trimester and is significantly higher in women with excessive weight. In addition, PAI-1 concentrations

Department of Foetal-Neonatal Medicine, Meyer Children’s Hospital, University of Florence, 2Department of Experimental and Clinical Medicine, University of Florence, 3Department of Health Sciences, University of Florence, and 4Department of Rheumatology, Brief Introduction: Many lines of research require further development for the purpose of better understanding the mechanisms of fetal programming, clarifying the role of maternal nutrition, and more importantly, determining whether impaired fetal growth could have potentially adverse effects on chronic disease at an adult age. Low birth-weight, due to preterm birth or foetal growth restriction, is a marker of a lack of nutrients during ‘‘critical’’ periods of rapid cell division, that could programme the immune system. According to this new epigenetic developmental model, the aim of our study was to evaluate whether a significant correlation exists between low birth weight, other perinatal variables and the subsequent development of systemic sclerosis (SSc), a chronic systemic autoimmune disease. Materials & Methods: During the period from June 2012 to November 2013, a multicenter case-control study was conducted with 332 consecutive prevalent cases of SSc and 243 controls, asking them to fill out a questionnaire regarding their demographic and perinatal information: gender, age, birth-weight, gestational age at birth, their mother’s age at birth, breastfeeding, mother’s smoke habit. A subsample of 40 cases and 40 controls was re-questioned later to verify the accuracy of the first response. Birth-weight was always treated as a dichotomous variable (52500 g vs. 2500 g), low birth-weight was defined as weight less than 2500 g and small for gestational age was defined as a weight52500 g in patients born at term. The association between both low birth-weight and small for gestational age with systemic sclerosis was expressed with the crude (univariate analysis) and adjusted (multivariate analysis) odds ratio. Clinical Cases or Summary Results: Low birth weight infants (52500 gr) had an increased risk of SSc when compared with higher birth weight infants (2500) (OR 2.59, 95% CI 1.39 to 5.05). When the analysis was limited to female subjects only, this value increased to an OR of 2.90. A similar result was found when we considered the exposure to small for gestational age (SGA) status (OR 2.60, 95% CI 1.34 to 5.32, that increases to 2.73, 95% CI 1.38 to 5.73 in female subjects). In the multivariate analysis, the odds of disease in the low birthweight female group was approximately 4 fold higher than in the normal birth-weight group. Conclusions: Our study documents that the risk of developing SSc is higher when the patient was a LBW newborn. The precise cellular and molecular mechanisms which could explain the correlation between SSc and weight at birth, remain poorly understood. Environmental agents including, maternal diet or illness, endocrine disruptors or exposure to toxic levels of chemical agents, could act epigenetic mechanisms and cause modifications to the fetal immune system with the result of altering the phenotype in the off spring.

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These results suggest that the fact of being born with a low weight could be an additional anamnestic element to be considered in the clinical evaluation of suspected SSc in the patient.

diagnostic test for all the types of CDG is analysis of serum transferrin glycoforms, also called transferrin isoforms analysis. No treatment is available for most of these disorders.

Keywords: Systemic sclerosis, perinatal epigenetics, low birth-weight, small for gestational age, early origin of adult disease, foetal programming.

Keywords: Fracture of long bones, congenital disorder of glycosylation, transferrin isoforms analysis

Presenter: Carolina Amador

ID 525

CONGENITAL DISORDER OF GLYCOSYLATION J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

B. Marqueta, E. Calvo, S. Cabre´, B. Del Rey, C. Lao, & M.D. Go´mez-Roig BCNatal. Barcelona Center for Maternal Fetal and Neonatal Medicine, Hospital Sant Joan de De´u and Hospital Clı´nic, Universitat de Barcelona, Barcelona Brief Introduction: The fracture of long bones occurs in 0.1% of cases during cesarean section and 0.5% for vaginal delivery. We present a case of right femur fracture that occurred in the course of a cesarean section for breech presentation. First exploration revealed an abnormal neurological examination with poor response to audio and visual environment and hypotonia, which could explain the femur fracture. After performing the complementary examinations the newborn was diagnosed a congenital disorder of glycosylation. Materials & Methods: Analysis of a case of congenital disorder of glycosylation reported in our hospital. Clinical Cases or Summary Results: The case concerns a 32-year-old Caucasian patient who underwent a cesarean section for breech presentation at 39 + 2 weeks of gestation. Pregnancy course was uneventful. During the extraction the breech was engaged without difficulty but a suspicious sound was heard. The neonatology team performed an X-ray of the legs of the newborn, showing an upper third fracture of the right femur, and a transfontanelar ultrasound showing germinolytic cysts, discrete ventriculomegaly and hypoplastic cerebellar vermis Conclusions: Congenital disorder of glycosylation (CDGs) is an autosomal recessive disorder in which gycosylation of a variety of tissue proteins and or lipids is deficient. Prevalence is estimated in 1/ 20000. Neurologic and gastrointestinal symptoms and signs are the most common presenting features, including lethargy, coma, seizures, developmental delay or regression, abnormalities of tone, weakness, ataxia, and neuropsychiatric manifestation. If an MRI is obtained, cerebellar atrophy and hypoplasia are common findings. The

Presenter: B. Marqueta

ID 361

ORNITHINE TRANSCARBAMYLASE DEFICIENCY IN A YOUNG BOY WITH ACUTE LIVER FAILURE L. Yargui1, M. Djeddou1, F. Choubane2, & A. Berhoune1 1 Biochemistry Central Laboratory, Mustapha Hospital, Algiers, Algeria, and 2Pediatric service, EPH El Afroun, Blida, Algeria

Brief Introduction: Pediatric acute liver failure is defined as hepatic necrosis resulting in loss of liver function within weeks or a few months of the onset of clinical liver disease. It may be caused by a variety of diseases including inborn errors of metabolism. Considering urea cycle disorders, acute liver failure has occasionally been reported as the presenting symptom. In this work, we report the joint occurrence of ornithine transcarbamylase deficiency (OCTD) and describe the metabolic diagnosis pitfalls and challenges of biological follow up. Materials & Methods: Our patient is a male, the second child of nonconsanguineous Algerian parents. He was born at 40 weeks after an uneventful gestation and delivery, with birth weight 3,600 g, and Apgar scores 9 and 10. He was breastfed until 2 months and then received an adapted cow’s milk formula (Biomyl1). At the age of 4 months, the child was hospitalized for increased fatigue with episodic somnolence and coma. His weight 6 kg (50th percentile). Liver was slightly enlarged and truncal hypotonia was noticed. Laboratory results revealed elevated transaminases and decreased prothrombin level (32.5%). Physicians have immediately contacted our laboratory center for more investigations. Clinical Cases or Summary Results: Urgent biochemical evaluation showed lactate 1.4 mmol/L, ammonia 309 mmol/L, albumin 27 g/L, ASAT 648 UI/L, ALT 988 UI/L, gGT 21 UI/L, alkaline phosphatase 307 UI/ L, glucose 5.4 mmol/L (4.0–7.8 mmol/L), creatinin 18 mmol/L, urea 1.7 mmol/L, total bilirubin 20 mmol/L, conjugated bilirubin 4 mmol/L. Metabolic work-up revealed citrulline 1.93 g/L (healthy subjects 2.5 - 3 g/L), orotic acid excretion of 193.95 mg/g creatinine (healthy subjects 20 mg/g creatinine). Other selective metabolic tests provided have been normal (tyrosine, alpha1-antitrypsine, cooper, galacose-1P, glycogen in leukocytes and urinary succinylacetone. The boy was diagnosed with OCTD. Treatment was started with intravenous infusion of glucose and L-arginine, oral sodium benzoate, and restriction of natural protein intake. Concentrations of ammonia, transaminases and orotic acid excretion normalised within two days, three weeks and one month respectively and the child improved markedly. Conclusions: Our case report shows the importance of urgent and thorough metabolic investigations in young children presenting hyperammonemia with acute liver failure. OCTD should be included in the differential diagnosis. Keywords: Urea cycle disorders, Acute liver failure, Hyperammonia Presenter: Lyece Yargui

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ID 704

SANJAD SAKATI SYNDROME IN A TUNISIAN NEWBORN F.Z. Chioukh1,2, K. Ben Ameur1,2, R. Sakka1,2, E. Kerkni1,2, H. Ben Hamida1,2, & K. Monastiri1,2 1

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Department of Neonatal Intensive Care, Teaching Hospital of Monastir, and 2Research unit 01/UR/08.14-Faculty of Medicine of Monastir-Tunisia Brief Introduction: The Sanjad-Sakati-Syndrome (SSS) (OMIM #241410) is a rare autosomal recessive disorder characterized by congenital hypoparathyroidism with growth and mental retardation. In this paper, we aimed to clarify SSS clinic-genetic spectrum in a Tunisian child. Materials & Methods: The patient is a 5 months-old girl with facial dysmorphism in the form of microcephaly, deep-set eyes, a beaked nose, abnormal external ear and micrognathia and short hands and feet. Biochemical analysis of calcium, phosphate, magnesemia and PTH has been performed and molecular analysis was carried using direct sequencing of the exon 3 of the TBCE gene. Clinical Cases or Summary Results: A 32 week preterm girl (birth weight 1840 g) was born to a Tunisian lady (G2P2). The child had facial dysmorphism in the form of microcephaly, deep set eyes, beaked nose, abnormal external ear and micrognathia, short hands, and feet. She had hypocalcaemic seizures at the age of one month.The clinical and biochemical features of the child were consistent with the diagnosis of SSS. The mutation analysis revealed that the affected individual was homozygous to the12 bp (155–166del) mutation. Conclusions: Our findings provide additional support of the common (155–166del) deletion fonder effect in exon 3 of the TBCE gene in Arabic patients. Keywords: Presenter: F.Z. Chioukh

ETHICS ID 971

EVALUATION OF ACUTE NEONATAL PAIN DURING ROUTINE PROCEDURES C.V Bellieni, M. Tei, G. Stazzoni, S. Cornacchione, S. Bertrando, A. Ermini, M.G. Alagna, & G. Buonocore Department of Pediatrics, Obstetrics and Reproductive Medicine, University of Siena, Siena, Italy Brief Introduction: Neonates undergo many painful procedures daily, such as heelpricks or venepuncture. Among more than 40 acute pain scales for infants currently available, the Premature Infant Pain Profile (PIPP) is thoroughly developed and it is widely used for term and preterm babies, since it has a correction factor to overcome the difference of response to pain due to gestational age. We performed a review of the literature regarding papers using PIPP and we provided a comparison between different level of pain recorded with or without analgesic treatment, in order to assess how effective are the analgesic treatment, in order to assess how effective are the analgesic strategies commonly used in neonatology during these spells. Materials & Methods: We performed a PubMed research from January 1999 to December 2013, using as keywords: ‘‘newborn’’, ‘‘pain’’ and ‘‘PIPP scale’’. We retrieved all papers in English language

J Matern Fetal Neonatal Med, Early Online: 1–437

that evaluated pain during neonatal heelpricks or venepuncture. For comparative purposes, we included only papers that evaluated pain using PIPP scale and expressed PIPP scores as mean and standard deviation. The selection of those for wich only PIPP scale has been used is a limit, but is also a guarantee of homogeneity. Clinical Cases or Summary Results: We finally retrieved 11 studies. Venipuncture seems to be less painful than heelprick (mean range 7.71–1.1 and 13.33–2.7 respectively). The use of morphine or topical ansthetic such as tetracaine are scarcely effective in preventing pain during heelprick. Sensorial saturation and non nutritive sucking are the most effective analgesic tools. Conclusions: Pain assessment is crucial for establishing protocols and routines for analgesia of critically ill neonates. Sensorial saturation is an effective non-pharmacological approach. Keywords: pain assessment, analgesic, care Presenter: Carlo Valerio Bellieni

ID 785

LEGAL AND ETHICAL QUESTIONS POSED BY FETAL ALCOHOL SPECTRUM DISORDER (FASD) David Townend1, Sylvia Roozen2,3, Gjalt-Jorn Peters4, Gerjo Kok2,3, Jan Nijhuis5, & Leopold Curfs2,6 1 Department of Health, Ethics and Society, Maastricht University, 2Governor Kremers Centre, Maastricht University Medical Centre+, 3Department of Work and Social Psychology, Maastricht University, and 4Faculty of Psychology and Education Science, Open Univer

Brief Introduction: The extent of the potential risk to the developing foetus posed by the use of alcohol by the mother during pregnancy is increasingly understood, although the precise nature of the threat requires a great deal of further work. Whereas Fetal Alcohol Spectrum Disorder (FASD) is increasingly researched and acknowledged in some places, for example, South Africa, in Europe it is not as firmly on the agenda. It is therefore interesting in its own right. Equally, as more is understood about genomics, FASD becomes an example of other questions about the impact of parental behaviour on the embryo and foetus. Materials & Methods: This paper is based on normative reflection of the issues drawn from the systematic literature review discussed in the paper for this conference by Roozen et al. It considers the legal issues from the perspective of the Dutch (Civil Law) and the UK (Common Law) traditions, and the ethical issues from Kantian, Utilitarian, and Virtue Ethics perspectives. Clinical Cases or Summary Results: FASD poses a number of difficult ethical and legal questions. Two will be addressed in this paper: 1. Prevention. As it becomes clearer that some patterns of alcohol consumption during pregnancy can have severe long-term effects for the child, is intervention ethical in pre- and proscribing behaviour to women in pregnancy? This is set against the challenge of the concept of the status of the ‘future child’ in moral philosophy, and the practical problem of the seemingly contradictory positions that prevention would require when considered against many jurisdictions’ construction of abortion. 2. Proportionality. It is apparent that there are risks through the use of alcohol, and compared with other risks - for example, from tobacco or other drug use during pregnancy - the risks from alcohol are high. However, whilst the risks are not fully understood, and the potential for discrimination and disproportionate responses are high, FASD poses again the question, how can Laws be framed to create an appropriate balance of precaution and proportionality when risks are not fully understood?

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Conclusions: Creating a legal framework to accommodate all the stakeholder interests in relation to FASD is difficult, but not insurmountable, particularly through the use of the English law concept of the ’fiduciary duty’. Whereas a Kantian approach to the "Future Child" is somewhat problematic, other ethical approaches can be more accommodating of the competing interests at stake. However, the major issue is a cultural one concerning the construction of autonomy and the perception of alcohol in society, and policy-making should focus on the cultural more than the ethical questions to produce an effective response to FASD. Keywords: Fetal Alcohol Spectrum Disorder, prevention, autonomy, proportionality

everything for love, tenderness and compassion between the couple, their children, friends and family, helped them defeat suffering and grief. Conclusions: A seemingly paradoxical experience where the meaning of life, love and truth combine to shine the fraternal bonds and the requirement of humanity towards death. Reported as a lesson for health professionals to provide mothers, faced with similar diagnoses, an informed, free, informed and also strengthen the role of hospitals as places where one awakens to life. Keywords: Ethics; Fetus with malformations; Induced abortion; Compassion Presenter: E. Silva1

Presenter: David Townend

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

ID 656

A CHILD FOR ETERNITY: A CONTRIBUTION TO THE DEVELOPMENT OF ETHICS E. Silva1, & D. Silva2 1

Higher School of Health CIDETS, Polytechnic Institute of Viseu, Portugal, and 2Higher School of Health CIDETS, Polytechnic Institute of Viseu, Portugal Brief Introduction: The book ‘‘A Child for Eternity’’, by Isabelle de Me´zerac, is of a major contribution to the development of ethics. It portrays the human sense of a mother, who bravely decided to continue with the pregnancy of a child with a severe disability. Also depicts the behaviour of health professionals in the transmission of bad news which, initially, does not value compassion nor promote autonomy in the decision, contrasting later with statements of support, serenity and unconditional zeal during surveillance of pregnancy and the birth of a baby who dies a few minutes later. Materials & Methods: Case report Clinical Cases or Summary Results: Isabelle, despite having four children, received the news of a new pregnancy with great joy and excitement. However, after medical examination, is informed that her son is carrying a serious disability and is recommended termination of pregnancy - induced abortion. The confrontation with the fateful news of a fetus with severe malformations leaves the couple heartbroken. Supported by family, friends and health professionals, they decide to continue the pregnancy and live that period loving their son until the end of his short life. Accepting to see their heart broken in the myth of a perfect baby, they gave their son his own time to live, and to feel the love of parents before leaving. This way they do not feel remorse or guilt by deliberately anticipating the life of their little son. The pregnancy is progressing normally and the delivery was marked by caesarean section with epidural anaesthesia. The doctor assured the presence of a multidisciplinary team that was able to support the hosting of that different baby and give Isabelle all the support, so that she could remain aware and welcome their child. Present was the joy of birth and the unbearable grief of his approaching death, but having lived in an atmosphere of calm and love. The Life of Emmanuel was only 72 long minutes, in which he was caressed, dressed and presented to his father and brothers, and the priest celebrated his baptism with great delicacy. Fifteen photographs were taken to later tell a whole lifetime... a baby with a delicate face who didn’t suffered and fell asleep in peace. In the pangs of separation rose an immense comfort, because everything was fulfilled: they had been with him, for him and to him, until the end of his life path and in full performance of their role as parents. The grieving process was also special because, as is the case of a newborn, in which the separation of the child, silence and absence, caused excruciating pain. However, the certainty they made

ID 613

EVALUATION OF PATIENT EDUCATION BARRIER TO THE CLINICAL ENVIRONMENT FROM THE PERSPECTIVE OF NURSES AND MIDWIVES IN PYMANYH AND MOTAHARI HOSPITAL ARRANGED IN 2014 S. Abdollahifard1, & A. Dehghani2 1 Faculty member of Nursing and Midwifery, Dept. Jahrom University of Medical & Health Sciences. Jahrom. Iran, and 2 PhD Candidate in nursing education, Tehran University of Medical Sciences (TUMS), Faculty Member of Nursing Dept. School of Nursing and Mid

Brief Introduction: Patient education is as a standard of nursing care quality and an accrediting criterion of the organizations which provide health services that evidence suggests of failure in this area. This study aimed to determine barriers to Patient education from viewpoints of nurses and midwives’ in year 2014. Materials & Methods: This descriptive cross-sectional study was conducted on a census sample of nurses and midwives working in hospitals affiliated to Jahrom University of Medical Sciences (n = 271). Data gathering tool was a researcher-made questionnaire about three categories of barriers to Patient education, including ‘‘managerial’’, ‘‘individual care-giving’’ and ‘‘Patients and Caregivers’’ obstacles. Data was analyzed by calculating frequency of responses to items, and weighted frequencies in each category. Clinical Cases or Summary Results: Most responders agreed to the barrier role of managerial (88.9%), individual care-giving (52%) and Patients and Caregivers (76.8%) items in Patient education program. The most important barriers were Lack of time due to workload density (87.1%) regarding management area, Lack of patient education planning for nurses and midwives in their daily work as a duty (64.2%) regarding individual care-giving area, and not known of nurses and midwives role as teacher to patients and the community (72.3%) regarding Patients and Caregivers. Conclusions: Management agents were the most important barriers of Patient education. Therefore it is recommended that Managers actions such as taking a sufficient number of personnel, prioritize education by nurses and midwives in daily tasks and Culture for the education accept by patients, to encourage nurses and midwives. Keywords: Patient education, Education barriers to patient, Nurses and Midwives Presenter: Sareh Abdollahifard

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neonatal survival in cases of isolated CDH, confirming the findings of previous studies.

FETAL DISEASE ID 737

Keywords: Prenatal diagnosis; fetal anomaly; diaphragmatic hernia Presenter: Viola Seravalli

PRENATAL ULTRASOUND PREDICTORS OF NEONATAL SURVIVAL IN CASES OF ISOLATED CONGENITAL DIAPHRAGMATIC HERNIA

ID 520

OPEN FETAL MYELOMENINGOCELE REPAIR AT THE ZURICH CENTER FOR FETAL DIAGNOSIS AND THERAPY

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

V. Seravalli, R. Biagiotti, B. Noccioli, E. Severi, P. Fiorini, E. Cariati & G. Donzelli Medical Surgical Fetal-Neonatal Department, "A. Meyer" University Children’s Hospital, Florence, Italy Brief Introduction: Congenital diaphragmatic hernia (CDH) is associated with high neonatal mortality rate. Prenatal prediction of those fetuses that will present with a severe form of CDH at birth is necessary in order to determine the best perinatal management. Our aim was to determine the prenatal factors associated with the neonatal survival in cases of isolated congenital diaphragmatic hernia diagnosed antenatally Materials & Methods: Retrospective observational study on cases of CDH with prenatal diagnosis followed at our Institution between 2005 and 2012. Pregnancy characteristics, ultrasound parameters and delivery and neonatal outcome were reviewed. Exclusion criteria were presence of aneuploidy, association with other major abnormalities, intrauterine fetal demise. Primary outcome was neonatal survival. The following parameters were evaluated: gestational age at diagnosis, side of the diaphragmatic defect, presence of polyhydramnios, stomach and liver herniation into the fetal thorax, observed/expected lung-to-head ratio (o/e-LHR). Univariate analysis was performed to evaluate the association between variables and outcome, followed by a multivariate logistic regression to determine which variables were independent predictor of neonatal mortality. Clinical Cases or Summary Results: During the study period, 34 cases of CDH were identified. In 79% of cases the hernia was left-sided. Median gestational age at diagnosis was 22.5 weeks, and at delivery 37. Overall survival rate was 68% (74% for left sided, 43% for right sided hernias). The group of babies who survived presented a significantly higher antenatal o/e LHR (p50.001) and a lower frequency of liver herniation compared to the group who did not survive (p = 0.045). No significant difference was found between expired and survived neonates for the other parameters investigated (see Table). Logistic regression analysis demonstrated that only the o/e LHR was an independent predictor of neonatal survival (p = 0.03) Conclusions: Our study showed that among the ultrasound parameters evaluated, the o/e LHR was the only independent predictor of Table. Ultrasound characteristics and delivery outcomes in fetuses with congenital diaphragmatic hernia

GA at diagnosis Left side Stomach herniation Liver herniation O/E LHR (%) Polyhydramnios GA at delivery C-section Birth-weight Use of diaphragmatic patch

SURVIVED (n = 23)

EXPIRED (n = 11)

p

22.3 (20.9,29.7) 20 (87%) 15 (65%) 4 (17%) 50.3 ± 13.7 5 (22%) 37 (37,38) 21 (91%) 2,888 ± 377 3 (13%)

23.7 (22.0,28.9) 7 (64%) 7 (64%) 6 (55%) 34.0 ± 12.9 5 (45%) 37 (37,38) 8 (80%) 2,617 ± 612 3 (27%)

0.40 0.18 0.90 0.045 0.002 0.23 0.66 0.35 0.12 0.36

Data are presented as n (%), mean ± SD or median (IQR)

M. Meuli1,2, L. Mazzone1,2, U. Moehrlen1,2, A. Flake6, N. Ochsenbein1,3, M. Huesler1,3, F. Kra¨henmann1,3, P. Biro1,4, I. Scheer1,5, & R. Zimmermann1,3 1 The Zurich Center for Fetal Diagnosis and Therapy, Zurich, Switzerland, 2Department of Pediatric Surgery, University Children’s Hospital Zurich, Zurich, Switzerland, 3Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland, and 4Depar

Brief Introduction: The randomized trial of prenatal versus postnatal repair of myelomeningocele (MOMS-trial) has provided evidence that prenatal repair significantly reduces ventriculoperitoneal shunt placement at one year of age and substantially improves overall neuromotor function at 30 months. Based on these data, we have started a fetal surgery program for open fetal spina bifida repair at our center in December 2010. We report our experience with the first 12 cases and compare our data with the benchmark data generated by the MOMS-trial. Materials & Methods: Patient selection criteria, pre- and postoperative management regimens, as well as operative procedures were strictly adopted from the guidelines set forth by the MOMS-trial and were basically identical with the ones used in Philadelphia, one of the MOMS-trial centers. All open fetal surgeries were carried out in close collaboration with our partners from the Children’s Hospital of Philadelphia. Pertinent data were collected prospectively. Clinical Cases or Summary Results: Between December 2010 and March 2014, 31 women carrying a fetus with an open spina bifida were evaluated for fetal repair. 16 patients did not meet inclusion criteria and three eligible patients decided to interrupt pregnancy. The remaining twelve patients underwent open fetal spina bifida repair (mean operation time 125 ± 17min). There were no fetal deaths. Within four weeks postoperatively, all patients (except for the last one not evaluated yet) showed complete resolution of hindbrain herniation. Eleven infants were delivered via cesarean section performed between 33 + 6 and 37 + 3 weeks of gestation (median 36 + 2 weeks). There was one neonatal death due to lung hypoplasia and respiratory failure. To date, three infants required ventriculoperitoneal shunting (implantation at age 5 weeks, 3 months, and 7 months respectively) and one patient underwent endoscopic third ventriculostomy at age 8 months. Lower extremity function was better than predicted in 10 infants One patient was born with severe (prenatally known) talipes and knee contractures. There were no maternal deaths or significant complications. Conclusions: Our preliminary results are in line with the benchmark data produced by the MOMS-trial. This not only corroborates the MOMS-Trial conclusion that fetal surgery is the new standard for select fetuses with myelomeningocele, it also justifies continuation of our program. Keywords: Fetal Surgery, Spina bifida, Myelomenigocele, open in utero repair Presenter: M. Meuli

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DOI: 10.3109/14767058.2014.924236

ID 427

NONLINEAR ANALYSIS OF FETAL HEART RATE DYNAMICS IN FETUSES COMPROMISED BY MATERNAL SYSTEMIC LUPUS ERYTHEMATOSUS M. I. Park1, Y. S. Park2, & J. K. Hoh3 1

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Department of Obstetrics and Gynecology, Dongtan Cheil Women’s Hospital, Gyeonggi, Korea, 2Department of Mathematics and Research Institute for Natural Sciences, Hanyang University, Seoul, Korea, and 3Department of Obstetrics and Gynecology, College o Brief Introduction: We analyzed fetal heart rate (FHR) parameters, dynamics and pregnancy outcomes between fetuses of normal pregnancies and those of pregnancies complicated by maternal systemic lupus erythematosus (SLE). Materials & Methods: We performed a retrospective observational study using nonstress test (NST) data previously recorded with the computerized Hanyang Fetal Monitoring system. Normal pregnancies (n = 44) were matched with 14 SLE cases which was diagnosed with no flare up. FHR parameters and perinatal outcomes were analyzed using a linear method. Approximate entropy (ApEn) was used to interpret the complexity and irregularity of FHR time series. Clinical Cases or Summary Results: Neonatal outcomes including birth weight (median SLE weight: 3,490 g; median normal weight: 3,100 g; p40.05), height, 1-min Apgar score, and 5-min Apgar score (p40.05, respectively) were similar between groups. No significant differences were found in fetal heart rate parameters (baseline rate, number of fetal movements, amplitude, mean minute range, and number of accelerations and decelerations). The ApEn of the fetuses of the SLE group was lower than that of the normal controls, but statistically insignificant (0.82 ± 0.17 vs. 0.88 ± 0.17, p = 0.5429). Conclusions: Maternal SLE with no flare up showed no relationship to FHR tracings. Also, FHR dynamic of SLE group is not quite different from normal one. Based on these findings, we propose that fetuses complicated by maternal SLE with no flare up having normal FHR findings does not represent a risk that would justify an early intervention such as cesarean section, at least in a term pregnancy. Keywords: Fetal heart Approximate entropy

rate;

Systemic

lupus

erythematosus;

of disease is based on invasive procedures. We wanted to study weather fetuses affected by beta-thalassemia major showed any differences on the first trimester ultrasound examination (11–13 + 6 weeks ultrasound examination), compared to normal fetuses Materials & Methods: METHODS: A three year prospective study from April 2010 to March 2013, where first trimester ultrasound examination was performed to all women who attended our department for prenatal diagnosis of thalassemia. All the NT tests were performed at the same time that chorionic villus sampling (CVS) was performed, and all measurements were documented (Nasal Bone-NB, Ductus Venosus-DV, Tricuspid Valve-TC, Facial Angle-FA). The first trimester ultrasound examination was performed according to the guidelines of the Fetal Medicine Foundation (FMF) and all examiners were accredited by the FMF. The measurements of fetuses affected by homozygous b-thalassemia were compared with the measurements of fetus that were not affected (Heterozygous or non-carriers). Clinical Cases or Summary Results: RESULTS: A total of 258 fetuses were examined during the three year period. 39 of these fetuses were found to be affected by homozygous b-thalassemia and 131 were found to be carriers of the b-thalassemia trait (heterozygous). Two cases with abnormal karyotype were identified and they were excluded from the study. There were no statistically significant differences in the measurements of NT and TC between the affected and normal fetuses. However, fetus affected by b-thalassemia major appeared to have wider FA and differences in DV PI, but with low sensitivity Conclusions: CONCLUSION: First trimester ultrasound examination is not diagnostic of fetuses affected by beta-thalassemia major. Our study showed differences in FA and DV measurements, which however have low sensitivity. Larger studies are needed to examine if these findings can be significant for the assessment of fetuses with beta-thalassemia major. Keywords: Presenter: G Daskalakis

ID 919

REFERRAL TO A PEDIATRIC CARDIOLOGIST FOLLOWING LEVEL II ULTRASOUND: IS IT NECESSARY FOR ALL INDICATIONS?

Presenter: Jeongkyu Hoh

A. Athanasiadis1,2, A. Karavida1, F. Rouvalis1, A. Zavlanos1,2, A´. Kyriakidou2, E. Assimakopoulos2, & B. Tarlatzis2

ID 893

Prenatal Diagnosis, Thessaloniki, Greece, and A’ Department of Obstetrics & Gynaecology, Aristotle University of Thessaloniki, Greece

APPLICATION OF THE FIRST TRIMESTER ULTRASOUND MEASUREMENTS (11–13 + 6) FOR THE PREDICTION OF BETA THALASSAEMIA P. Antsaklis1, G. Daskalakis1, U. Honemeyer2, M. Theodora1, N. Papantoniou1, & A. Antsaklis1 1

First Department of Obstetrics & Gynaecology, ‘‘Alexandra’’ Maternity Hospital, University of Athens, Greece, and 2 Department of Obstetrics and Gynecology, Wellcare Hospital, Dubai, UAE Brief Introduction: AIM: Thalassemia syndromes are a group of blood disorders inherited in autosomal recessive manner. Prenatal diagnosis

1

2

Brief Introduction: Comparison of the findings of the fetal heart examination during level II 2nd trimester ultrasound, performed by fetal medicine specialists, with the subsequent examination by a pediatric cardiologist (fetal echo). Materials & Methods: 583 pregnant women who were referred to a pediatric cardiologist following 2nd trimester level II ultrasound by an obstetrician were retrospectively analyzed. They were classified into four groups according to the indication for referral: A) Suspected abnormal fetal heart findings on level II ultrasound (167). B) Increased nuchal translucency in the 1st trimester (128). C) Fetal single umbilical artery (148). D) Maternal diabetes melitus type 1 and family history of congenital heart disease (CHD) (140). Clinical Cases or Summary Results: In group A 76/167(45.5%) proceeded to fetal echo. There were 57/76(75%) cases of CHD, 52/ 57 (91.2%) of which were diagnosed in level II ultrasound. In group B 41/128(32%) proceeded to fetal echo. There were 5/41(12.1%) cases of CHD, 3(60%) of which were diagnosed in level II ultrasound. Both of

92 the missed cases were minor, one of a small membranous VSD and another of mild tricuspid insufficiency. In group C 56/149(37.5%) proceeded to fetal echo. There were no cases of CHD in this group, which was in complete agreement with level II ultrasound. In group D 33/140 proceeded to fetal echo. There were2/33(6%) cases of CHD, both of which (100%)were diagnosed in level II ultrasound. Conclusions: Pregnancies without suspected CHD on level II ultrasound performed by fetal medicine specialists may not warrant further pediatric cardiology assessment. Keywords: Presenter: A. Zavlanos

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ID 052

PRENATAL AND POSTNATAL TREATMENTS OF SPINA BIFIDA IN POLAND J. Zamłyn´ski1, A. Olejek1, J. Bohosiewicz2, T. Koszutski2, G. Ziomek1, E. Horzelska1, A. Gajewska-Kucharek1, I. Maruniak-Chudek3, I. Herman-Sucharska4, E. Kluczewska5, S. Horak1, P. Bodzek1, M. Zamłyn´ski1, J. Kowalik2, & K. Tomasz Horzelski1 1

Department of Gynecology, Obstetrics and Gynecologic Oncology in Bytom, Medical University of Silesia, 2Department of Paediatric Surgery and Urology, Medical University of Silesia, Upper Silesian Child’s Health Center, Katowice, 3 Department of Neonatal Intensive and Special Care, Medical University of Silesia, 4Department of Electroradiology, Collegium Medicum, Jagiellonian University, Krakow, and 5 Chair and Department of Radiology and Radiodiagnostics Brief Introduction: Myelomenigocele (MMC) is the most common and severe congenital malformation of the central nervous system. Clinical presentation of MMC in approximately 90% of the cases overlaps with the Arnold-Chiari syndrome (known as the Chiari malformation-II CM). The main consequences in later life include MMC location-dependent lower extremity paresis, urinary and bowel incontinence, and impaired psychomotor development. As the pregnancy progresses, gradual loss of motor skills of the lower extremities, progressive hindbrain hernia (HH) and hydrocephalus are reported in the literature on prenatal evolution of type II CM. Further mental development of type II CM patients is strongly impaired. Materials & Methods: The aim of the study was a comparison of the outcomes of intrauterine myelomeningocele repairs (IUMR) in type II Chiari malformation (II CM) fetuses with clinical data of newborns and infants operated on postnatally. The study group (SG) comprised of 46 pregnant women whose type II CM children underwent IUMR, while 47 pregnant women whose type II CM children were operated on postnatally constituted the control group (CG). A total of 24 SG and 20 CG patients reached the endpoint of the study. Clinical Cases or Summary Results: Mean gestational age on the day of IUMR was 24.7 ± 9.9 weeks. Maternal complications due to IUMR were sporadic. Complete healing of the hysterotomy site was observed during cesarean section in 73.9% patients. Uterine scar dehiscence occurred in 2 cases and in 1 case fetal extrusion into the peritoneal cavity was diagnosed. Control MR test between 31–33 weeks of gestation revealed significant partial HH reduction in the study group. High incidence of PROM and the premature delivery 537 weeks was noted in the group of prenatal surgeries. Intracranial hemorrhage was observed significantly more frequently in the control group. The need for VP shunt implantation was statistically significantly lower in the group of children after IUMR as compared to controls. Two children from the study group are able to walk independently. Conclusions: Prenatal MMC closure significantly lowers further adverse evolution of the type II Chiari malformation. Further studies are

J Matern Fetal Neonatal Med, Early Online: 1–437

needed, especially on preventive measures for preterm labor and IPPROM in the postoperative course of IUMR. Keywords: myelomenigocele, type II Chiari malformation, intrautrine repair Presenter: Katarzyna Olszak-Wa˛sik

ID 826

A COMPREHENSIVE EUROCAT AUDIT OF NEURAL TUBE DEFECTS IN IRELAND 2009–2011 A. McKeating1, R. McDonnell2, V. Delany3, M. O’Mahony4, C. Mullaney5, & M.J. Turner6 1,6 UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Dublin, Ireland, and 2,3,4,5 EUROCAT, Health Services Executive, Dr Steevens Hospital, Dublin, Ireland

Brief Introduction: Neural tube defects (NTDs) are strongly associated with maternal folic acid deficiency. In Ireland, however, mandatory food fortification with folic acid has not been introduced because a 2005–2006 report showed a reduction nationally in NTDs to 0.92/ 1000. This comprehensive national audit updated the epidemiology and clinical outcomes of NTD cases in 2009–11. Materials & Methods: NTD cases included anencephaly, spina bifida and encephalocoele. Cases were ascertained from multiple sources. A single researcher reviewed individual case records. Clinical Cases or Summary Results: There were 226,000 births weighing 500g. Overall, 236 NTDs were identified (1.04/1000), an increase from the previously reported 0.92/1000. Of 236 cases, 45% (n = 106) were diagnosed with anencephaly, 49% (n = 115) with spina bifida and 6% (n = 15) with an encephalocoele. In total, 78% (n = 184) delivered in Ireland and 22% (n = 52) delivered abroad. Of the 184 delivered in Ireland, 39 (21.2%) resulted in a stillbirth and 145 (78.8%) in a livebirth. Folic acid usage by women for whom data were available (n = 96) showed that 14.5% (n = 18) had not taken folic acid, 13.7% (n = 17) had taken it pre-conceptionally, while 49.2% (n = 61) had taken it post-conceptionally. The rate of NTDs was lower in the capital, Dublin (0.76/1000), compared with elsewhere (p50.01). In Dublin, 96% were diagnosed antenatally compared with 86% outside Dublin (p50.03). Conclusions: The incidence of NTDs appears to have stopped declining. Prevalence is lower in Dublin than in other regions. A higher percentage were diagnosed antenatally in the capital compared to outside. Our audit should prompt a review of public health policies and practices on folic acid supplementation as well as antenatal ultrasound services in Ireland. Keywords: Neural tube defect; folic acid supplementation Presenter: Aoife McKeating

ID 379

ANTENATAL DIAGNOSIS OF UPPER URINARY TRACT DILATION AND POSTNATAL OUTCOME P. Morales1, N. Rodrı´guez2, I. Mun˜oz1, L. Brea1, & L. Sa´nchez de Leo´n1 1

Neonatology Department. University Hospital of Mo´stoles. Mo´stoles. Madrid. Spain, and 2Obstetrics and Gynecology

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Table.

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Upper urinary tract dilation Pyelectasis – Transient – Vesicoureteric Reflux Hydronephrosis 1–2 – Transient physiological hydronephrosis – Ureteropelvic Junction Obstruction – Vesicoureteric reflux Hydronephrosis 3–4 – Transient physiological hydronephrosis – Ureteropelvic Junction Obstruction – Vesicoureteric reflux – Non obstructive megaurether TOTAL

ID 530 Cases

Surgery

Nephropathy

24 3 6

PREVALENCE AND PRENATAL ULTRASOUND DETECTION OF CLUBFOOT IN A NON-SELECTED POPULATION: AN ANALYSIS OF 549,931 BIRTHS IN TUSCANY

1

V. Seravalli1, A. Pierini2, F. Bianchi2, S. Giglio3, F. Vellucci4, & E. Cariati1

3

1

9

9

2

2 1 49

2

1

11

3

Department. University Hospital of Mo´stoles. Mo´stoles Madrid. Spain Brief Introduction: Antenatal dilation of upper urinary tract is usually a self-limited condition that resolves by the third trimester of pregnancy. The antenatal screening with ultrasound examination allows the recognition of persistent hydronephrosis at 35 weeks of gestation. Subsequent evaluation and outcome of fetal hydronephrosis depend on the diameter of the renal pelvis. Objective: Using the prenatal grading score of hydronephrosis we intend to determine the relationship between the diameter of renal pelvis and postnatal diagnosis of urinary tract pathologies that required intervention. Materials & Methods: We limited our research to the period between January 2001 and December 2013, a total of 49 infants were reviewed. They were followed for a median time of 4 years. The inclusion criteria was prenatal diagnosis of pyelectasis 49 mm or hydronephrosis at 35 weeks of gestation, the postnatal evolution was retrospectively reviewed. Antenatal hydronephrosis was classified as mild (7–9 mm), moderate (9–15 mm) and severe (415 mm) depending on the renal pelvis anteroposterior diameter (APD). Anatomical abnormalities such as obstructive megaurether (3), multicystic dysplastic kidney (7), posterior urethral valves (2) and renal agenesis (8) were excluded. Postnatal hydronephrosis was graduated from 0 to 4 according to the Society of Fetal Urology (SFU) system score. We considered the outcome to be positive in the presence of a spontaneous resolution or with a postnatal diagnosis of hydronephrosis 515mm. The statistical analysis was performed with the software SPSS version 21. Clinical Cases or Summary Results: Forty-nine infants were included in the analysis (37 males, 12 females). 19 cases were bilateral and 30 unilateral. 66% of severe prenatal hydronephrosis had postnatal urinary tract pathology. 22% of the patients included, required surgery. Only 3 had nephropathy in the long term. Etiology and postnatal classification is shown in table 1. Conclusions:  In our group most of the patients had a positive postnatal outcome. An APD 49 mm and a SFU grade 43 correlates with a greater risk of urinary tract pathology and postnatal surgery.  The APD has by itself a sensitivity of 80% and a specificity of 20% to predict unfavorable outcome and is also associated with the presence of obstructive uropathy in the postnatal period (p 7 mm in the third trimester should indicate postnatal follow up. Keywords: Hydronephrosis, pelvis diameter, uropathy Presenter: P. Catalina Morales Betancourt

Medical Surgical Fetal-Neonatal Department, "A. Meyer" University Children’s Hospital, Florence, Italy, and 2CNR Institute of Clinical Physiology, Unit of Environmental Epidemiology, Pisa, Italy; CNR-Tuscany Region ‘‘Gabriele Monasterio’’ Foundation, Unit Brief Introduction: Clubfoot is one of the most common congenital defects. Its incidence is around 1/1,000 newborns, but may vary between countries and populations. The objective of our study was to evaluate the prevalence and prenatal detection of clubfoot in Tuscany during a period of 20 years. Materials & Methods: This is a descriptive analysis on data from the Tuscan register of congenital defects, covering a 20-year period from January 1992 to December 2011. The Tuscan registry of congenital defects is a population-based register for the epidemiologic surveillance of congenital anomalies. The study included all cases of pre- or postnatally diagnosed clubfoot (isolated clubfoot or cases associated with other congenital defects). Overall prevalence and prenatal detection rates were calculated. The study period was divided into four 5-years periods to evaluate changes in detection rate over time. Clinical Cases or Summary Results: Among the 549,931 deliveries recorded in Tuscany between 1992 and 2011, 858 cases of clubfoot were registered, with a prevalence of 1.56/1,000. Seventy-eight percent of cases were isolated, the remaining 22% were associated with other congenital defects. A chromosomal abnormality was diagnosed in 3.8% of cases. The detection rate was higher when the Table I. Total cases of clubfoot.

Period 1992–1996 1997–2001 2002–2006 2007–2011 Total

Total live Prevalence Prenatal Detection births Cases (on 1,000 births) Diagnosis Rate** 123,738 129,710 142,776 153,707 549,931

211 226 213 208 858*

1.7 1.74 1.49 1.35 1.56

24 41 39 64 168

11.4% 18.3% 18.3% 31.2% 19.7%

*In seven cases the time at which the diagnosis was made was not reported **Percentage are calculated on the total cases with known time of diagnosis Table II Cases of isolated clubfoot.

Period 1992–1996 1997–2001 2002–2006 2007–2011 Total

Total live Prevalence Prenatal Detection births Cases (on 1,000 births) Diagnosis Rate** 123,738 129,710 142,776 153,707 549,931

169 178 172 153 672*

1.36 1.37 1.2 0.99 1.22

6 18 20 24 68

3.6% 10.3% 11.6% 15.9% 10.2%

*In six cases the time at which the diagnosis was made was not reported (one in the period 1992–1996, three in the period 1997–2001 and two in the period 2007–2011) **Percentage are calculated on the total cases with known time of diagnosis

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defect was associated with other anomalies compared to isolated forms. Over the study period, there was a substantial improvement in the prenatal detection of clubfoot (from 11 to 31% overall). For isolated forms, detection rate improved from 4 to 16%, and for cases associated with other congenital defects, it increased from 43 to 73%. Conclusions: Prevalence of clubfoot in Tuscany is 1.56 per 1,000 pregnancies, in agreement with the incidence reported in epidemiological studies in Europe. Prenatal diagnosis of clubfoot in Tuscany improved over the past 20 years. The detection rate remains low for isolated forms while it reached 73% in recent years for cases associated with other anomalies.

Clinical Cases or Summary Results: Twenty-eight cases of apparently isolated SB were identified. They included myelomeningocele/MMC (n = 26) and meningocele/MC (n = 2). There were a total of 8 (29%) terminations of pregnancy (one trisomy 18). Of the remaining 20, 75% (n = 15) were liveborn with two neonatal death. 15% (n = 3) died in the antepartum period. Of the other 15, 87% (n = 14) delivered at term. 53% (n = 8) of those that continued were delivered by caesarean section and 47% by spontaneous/assisted vaginal delivery. The majority of lesions were in the lumbar and sacral regions. Nineteen cases had ventriculomegaly, ranging from mild (n = 2), moderate (n = 4) to severe (n = 13). A total of fourteen cases underwent repair, with the median time to repair of 3 days (1 day to 3 months). Of these, 57% (n = 8) of cases had a ventriculoperitoneal shunt inserted. The median interval to shunt insertion was 8 days, ranging from 4 days to 30 days. 43% (6/14) of those repaired had postoperative complications. Lesion level in cases of MMC and MC was accurately assigned iN490% cases when compared with postnatal Magnetic Resonance Images. There were no undiagnosed associated abnormalities. Conclusions: Functional outcome can be determined antenatally with the use of fetal ultrasound. It is imperative to counsel the parents accordingly, with a combination of obstetricians, neonatologists, paediatric neurosurgeons and clinical nurse specialists, clearly outlining the possible challenges that they may face. It must be clearly outlined that long term multidisciplinary input will be an integral part of these children’s lives, and that life long therapy is likely.

Keywords: Clubfoot; prenatal diagnosis; ultrasound; congenital abnormalities.

Keywords: Spina Bifida, Antenatal diagnosis, Neurological outcome, Postnatal repair of spina bifida

Presenter: Mauro Cozzolino

Presenter: Breffini Anglim

Table III Cases of clubfoot associated with other congenital defects.

Period 1992–1996 1997–2001 2002–2006 2007–2011 Total

Total live births

Prevalence (on 1,000 births)

Prenatal Diagnosis

Detection Rate**

123,738 129,710 142,776 153,707 549,931

0.34 0.37 0.29 0.35 0.34

18 23 19 40 100

42.9% 47.9% 46.3% 72.7% 54.1%

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*In one case the time at which the diagnosis was made was not reported (in the period 2007–2011) **Percentage are calculated on the total cases with known time of diagnosis

ID 750

THE DIAGNOSIS AND MANAGMENT OF SPINA BIFIDA IN A TERTIARY REFERRAL CENTRE B. Anglim1, T. Mandiwanza2, J. Miletin3, M. Turner4, & M. Kennelly4,5 1

Coombe Women and Infant University Hospital, Dublin, Ireland, 2Dept Paediatric Surgery, Temple Street Hospital, Dublin 1., 3Dept Paediatrics, Coombe Women and Infants University, 4UCD Centre for Human Reproduction, and 5 Ultrasound and Fetal Medicine Centre Brief Introduction: Spina Bifida (SB) carries a heavy burden for individuals affected and their family. Physical and neurological outcome measures may help in counselling mothers. The aim of this audit was to review all cases of SB delivered in a large referral centre between 2010 and 2013. The aim of our study was to report the natural history of Spina Bifida within a tertiary referral fetal medicine unit in a country where termination of pregnancy is not available. We report the correlation between antenatal ultrasound parameters with postnatal lesion size, level and ventriculomegaly requiring ventriculoperitoneal shunting. We report on bladder and bowel continence and ambulatory function. These outcome measures may help counselling women of affected pregnancies and may aid them in decision-making. Materials & Methods: A systematic review of all high risk pregnancies referred to Fetal Medicine Centre with Spina Bifida from February 2010 to July 2013 was undertaken. A search of the fetal medicine database was carried out in order to include all NTDs, with or without concurrent anomalies. Antenatal information was obtained from Viewpoint ultrasound reports and patient charts. Postnatal information was obtained from imaging reports, patient charts and multidisciplinary letters. Surgical findings and postoperative course was retrieved from records at Temple Street Children’s University Hospital (TSH) the Irish Centre for Paediatric Neurosurgery since 2008.

ID 693

IMPROVING HEALTH PROMOTION RELATED TO FETAL ALCOHOL SPECTRUM DISORDER (FASD): A SYSTEMATIC LITERATURE REVIEW Sylvia Roozen1,2, Gjalt-Jorn Peters3, Gerjo Kok1,2, David Townend4, Jan Nijhuis5, & Leopold Curfs1,6 1

Governor Kremers Centre, Maastricht University Medical Centre+, 2Department of Work and Social Psychology, Maastricht University, 3Faculty of Psychology and Education Science, Open University of the Netherlands, 4Department of Health, Ethics & Society, Maastricht University, 5Department of Obstretrics & Gynaecology, Maastricht University Medical Centre+, and 6Department of Clinical Genetics, Maastricht University Medical Centre+ Brief Introduction: Alcohol use during pregnancy is one of the leading preventable causes of intellectual or developmental disability. Fetal Alcohol Spectrum Disorder is the non-diagnostic umbrella term used to characterize the full range of damage caused by prenatal alcohol exposure. This situation clearly warrants intervention. Development of a focused, effective and evidence based intervention requires insight in the burden of FASD and the underlying dynamics. The current literature synthesis aims to provide the required evidence base by compiling the literature on FASD, specifically addressing what we know of the prevalence of FASD, which behaviors contribute to FASD, and which preventive measures have been recommended so far. Materials & Methods: A search was conducted in multiple electronic bibliographic databases up to April 2014, including PubMed, PsychInfo, PsychArticles, ERIC, CINAHL and EMBASE. A query was generated and the resulting hits were exported and screened by two independent screeners. All hits marked for inclusion by at least one screener were acquired, after which a second screening was conducted based on the full texts. Resulting articles will be examined

95

DOI: 10.3109/14767058.2014.924236

to determine whether meta-analysis is feasible or whether a systematic review will be conducted. All materials, data, and analysis scripts will be made available publicly. Clinical Cases or Summary Results: n/a Conclusions: Results of the systematic literature search will be presented and specific recommendations for prevention efforts will be discussed.

(45.0% vs. 16.2% in the NCG), meaning that other causes mainly preterm births were also higher in the ART-G.

Keywords: Fetal Alcohol Spectrum Disorder

HUMAN IMMUNOGLOBULIN IN TREATMENT OF FETAL HEMOLYTIC DISEASE

Presenter: Sylvia Roozen

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ID 276

FETAL GROWTH RESTRICTION: COMPARATIVE ASSESSMENT BETWEEN NATURALLY CONCEIVED PREGNANCIES AND BY ASSISTED REPRODUCTIVE TECHNIQUES J.R. Cervilla, A. Perez-Mun˜uzuri, M.L. Couce Pico, A. Ban˜a Souto, A. Alshweki, & J.M. Fraga Neonatal Unit, Pediatric Assistance Area. Hospital Clinico Universitario (CHUS). Santiago de Compostela (SPAIN) Brief Introduction: Fetal growth restriction (FGR) is a cause of early perinatal complications such as hypoglycemia, jaundice, hypernatremia, sucking and swallowing disturbances among others that require immediate attendance by neonatologists. These neonates may also have other long-term metabolic disturbances and stunted growth. The increasing use of assisted reproductive techniques (ART) by women, especially older than 35 years, lead to an increasing rate of pregnancies where twinning, preterm birth and FGR are more frequent issues which increase rates of morbidity and mortality. The aim of this study was to compare incidence rates and need of admission to neonatal unit (NU), between two groups of live births, one achieved by natural conception (NCG) and other by ART-G regarding especially those with FGR. Materials & Methods: Two cohorts of neonates consecutively born were retrospectively studied. These births occurred consecutively during a 5 years period (2008–2012) in the maternity hospital. One group of 384 live births ART-G and another group of 405 live births NCG. We have compared FGR rates (weight 52.500g and below 10th centile for GA). and admission rates in two aspects. One due to complications related directly to FGR and another by type of conception group itself. A statistical analysis was made to assess if the differences were significant. Clinical Cases or Summary Results: FGR rate in the ART-G was significantly higher that in NCG (106 cases overall 384 newborns (27.6%) vs. 39 newborns overall 405 (9.6%) in the NCG (p50.01). The need of admission to NU rate for symptoms related to FGR was lower in the ART-G, 4 cases over 173 hospitalizations in the entire group (2.3%) vs. 7 cases over 66 hospitalizations in the NCG (10.6%). From 106 FGR cases in the ART-G, 4 were admitted to NU (3.7% rate). In the NCG from 39 cases of FGR 7 cases were admitted to NU (17.9% rate), a percentage almost five-fold higher. The overall admission rate to NU for any problem, was in the ART-G (45.0%), 173 cases from 384 livebirths significantly higher than in the NCG 16.2% (66 from overall 405 cases of the entire group) p50.001. Conclusions: The FGR rate was significantly higher in the ART-G. Probably among other reasons due to the elevated maternal age in that group (37.3 median age vs. 33.2 median age in the NCG). Although the admission rate to NU due to abnormal signs related with FGR is lower in the ART-G (2.3% vs. 10.6%), the overall admission ratio between both groups, was significantly higher in the ART-G

Keywords: Presenter: JR Cervilla

ID 528

M. Bialuha1, A. Barsukov1, I. Kurlovich1, V. Semenchuk1, I. Iljich1, T. Vashchilina1, & V. Bialuha2 1

Republic Research and Practical Center, Laboratory of Obstetrical and Gynecological Pathology, Minsk, Belarus, and 2 Grodno State Medical University, Obstetrics and Gynecology Department, Grodno, Belarus Brief Introduction: Fetal and neonatal hemolytic disease results from maternal alloimmunization to red cell antigens, for which mother and fetus are incompatible. Maternal antibodies pass the placenta into the fetal circulation and cause destruction of fetal red cells. The resulting progressive fetal anemia leads, when untreated, to fetal hydrops and perinatal death in 18%. The best way of treatment of fetal anemia is intrauterine blood transfusion. But it is only a symptomatic treatment. We suggest that intrauterine intravenous supplementation of human immunoglobulin in complex with blood transfusion is a pathogenic treatment. Objectives: To study the usefulness of fetal intravenous infusion of human immunoglobulin along with intrauterine blood transfusion in the treatment of hemolytic disease. Materials & Methods: Severe fetal anemia was diagnosed by blood sampling performed by cordocentesis in 51 fetuses with hemolytic disease. In the first group (36 cases (70.6%)) only repeated intrauterine blood transfusions were used in treatment of anemia. Infusion of human immunoglobulin 800 mg/kg into umbilical vein obtained by cordocentesis was used in complex treatment of fetal hemolytic disease in 15 cases (29.4%) – second group.

Figure 1. Pahtogenesis of polyuria and metabolic abnormality in Bartter syndrome (Adopted from Avner’ Textbook of Paediatric Nephrology sixth edition)

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Clinical Cases or Summary Results: Anemia was diagnosed in 36.1% of newborns (13/36) in the first group and only in 13.3% (2/15) cases in the second group. Mild anemia was diagnosed in 8 out of 36 cases (22.2%) in the first group which was significantly more frequently than in the second group (2/15 (13.3%) (2(gr. 1, gr. 2) = 4.0, p0.05). Serum protein and albumin concentrations were significantly lower in the first group (protein - 44.6 ± 1.2 vs. 52.1 ± 2.02 g/L, p50.05; albumin – 31.0 ± 1.0 vs. 34.1 ± 1.2 g/L, p0.05). Without any sings of neonatal hemolytic disease were 4/15 newborns (26.7%) in the second group vs. 0/36 in the first group and follow-up 6–12 months found no indications of anemia or developmental delay in those children (2(gr. 1, gr. 2) = 10.4, p50.05). Conclusions: This is the report of fetal anemia in Rh-incompatible pregnancies that were treated successfully with complex direct immunoglobulin injection and blood transfusions into UV. The immunoglobulin have functioned as a neutralizing antibody causing the anemia to improve. Keywords: Fetal immunoglobulin

hemolytic

disease,

cordocentesis,

human

Presenter: Maksim Bialuha

ID 241

DIAGNOSIS AND MANAGEMENT OF ANTENATAL BARTTER SYNDROME- EXPERIENCE FROM AN AUSTRALIAN TERTIARY NEONATAL UNIT S. Subiramanian1, A. Stewart2, L. Johnstone3 1

Monash Newborn, Monash Medical Centre, Melbourne, Australia, 2Monash Newborn, Monash Medical Centre, Melbourne, Australia, and 3Paediatric Renal Dept, Monash Medical Centre, Melbourne, Australia Brief Introduction: Bartter syndrome (BS) is a rare inherited tubulopathy defined (Bartter et al. 1962) as the association of hypokalemia with metabolic alkalosis, hyperaldosteronism with normal blood pressure and hyperplasia of the juxtaglomerular apparatus (figure 1). There is marked variation in age of onset, clinical presentation and severity of symptoms in accordance with different genetic abnormalities identified and the different transporter channels that they affect (table 1). The incidence of antenatal variant of BS varies between 1 to 2 cases per 100,000 live births per year. Early recognition and management of the antenatal form of BS is critical to patient survival. However, the low incidence and the presence of other morbidities, especially in premature infants, may impede timely diagnosis. Materials & Methods: The aim of this study was to describe the presenting features, management and short-term outcomes of infants diagnosed with antenatal Bartter syndrome (aBS). The study was a retrospective case series of all infants who were admitted to a tertiary neonatal intensive care unit, and who were diagnosed with antenatal onset of Bartter syndrome between January 2007 and December 2013. Clinical Cases or Summary Results: Six cases of antenatal onset of Bartter syndrome were identified (table 2). All infants had an antenatal history of unexplained polyhydramnios and premature labour and delivery. Amnioreduction was performed in four cases. Fluid chloride analysis was performed in only one of these cases and the level was significantly elevated. The median gestation of delivery was 32 weeks (range 25 to 34 weeks). There was a male predominance of 5:1 and all had weights appropriate for gestational age. All infants had 410% weight loss within the first 48 hours of life due to polyuria, and required fluid replacement therapy with saline

infusion as high as 40 millilitres/kilogram/hour in the first few weeks of life. All except one exhibited significant electrolyte abnormalities requiring intensive care management. All infants required supplementation of milk with additional calories for catch up growth, as there were significant drop in weight centile during their stay in the neonatal unit. Nephrocalcinosis was a consistent finding on follow up renal imaging studies. Other complications included urinary tract infection due to indwelling catheters leading to gram negative sepsis, central line related venous thrombosis, hyperparathyroidism and cardiac arrhythmia. Conclusions: Early recognition and fluid and electrolyte management is critical in aBS. If not diagnosed early, this condition can lead to significant electrolyte abnormality and weight loss, with associated significant risk of mortality and morbidity. Where there is polyhydramnios in the setting of a normal morphology ultrasound, normal TORCH screen and normal or low Alpha-Foeto Protein level, a genetic renal or colon salt transport defect should be considered. If amniocentesis is performed for amnioreduction, or for other indications such as foetal chromosome analysis, fluid chloride analysis is recommended. The normal median amniotic fluid chloride concentration is 109 mEq/L at a gestational age of 25 weeks and 107 mEq/L at 37 weeks. A higher amniotic fluid chloride concentration is consistent with a diagnosis of aBS or congenital chloride diarrhoea. However, congenital chloride diarrhoea can readily be differentiated by serial antenatal ultrasound showing progressive dilatation of bowel loops, small for gestational age at birth and postnatal predominance of bowel symptoms. Although genetic analysis is available for prenatal diagnosis for families with affected children, in the absence of this, a high degree of suspicion is necessary to diagnose aBS in an otherwise healthy pregnant mother with normal foetal anomaly scan and routine antenatal blood screening. Antenatal diagnosis carries the benefit of facilitating early monitoring for and treatment of fluid and electrolyte disturbances. In the absence of amniotic fluid chloride analysis, the low prevalence of aBS and co-morbidities of associated prematurity may pose difficulty to the neonatal team in recognising infants with aBS but the combination of antenatal features with the immediate postnatal polyuria should help them in making the diagnosis. This case series highlights the knowledge and vigilance required for early recognition of this condition both antenatally and postnatally, including consideration of amniotic fluid chloride analysis, close monitoring of fluid and electrolyte balance postnatally, early creation of central venous access and appropriate initiation of fluid and electrolyte management. Our study also highlights the sporadic, multi-ethnic and diverse clinical spectrum of aBS. This case series highlights the knowledge and vigilance required for early recognition of this condition both antenatally and postnatally, including consideration of amniotic fluid chloride analysis, close monitoring of fluid and electrolyte balance postnatally, early creation of central venous access and appropriate initiation of fluid and electrolyte management. Our study also highlights the sporadic, multi-ethnic and diverse clinical spectrum of aBS. Keywords: bartter syndrome, polyhydramnios, prematurity, antenatal diagnosis, electrolyte imbalance, indomethacin Presenter: Sabapathi Subiramanian

ID 557

CONTRIBUTION OF CONGENITAL ANOMALIES TO PERINATAL MORTALITY IN THE PLEVEN REGION K. Kovacheva1, V. Atanasova2, M. Simeonova1, M. Yonov2 Section of Medical Genetics, and 2Department of Neonatology, University Hospital, Medical University of Pleven, Bulgaria 1

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DOI: 10.3109/14767058.2014.924236

Brief Introduction: Aim: To determine the contribution of congenital anomalies (CAs) to perinatal mortality (PM) and time trend in perinatal deaths due to CAs, using data from the Registry of CAs in the Pleven region for 19 year period. Materials & Methods: Materials and methods: The source of the data was the regional population-based registry of CAs using criteria according to EUROCAT recommendations. During the study period 1988–2006, 47 622 births were surveyed in the University hospital, City of Pleven. Clinical Cases or Summary Results: Results: A total of 728 cases of perinatal death were ascertained. In about 27% of all cases, the cause of the death was lethal congenital malformations. The overall PM rate due to CAs was 4.12/1000 and remained stable over the study period. In 63% of all cases with CAs, the death was occurring within 7 days after birth. The percentage of early neonatal deaths and fetal deaths/ stillbirths attributed to CAs is 37% and 18% respectively. The most common types of CA causing death in perinatal period were conditions with multiple malformations (54%), neural tube defects and other CAs of nervous system (16%), congenital heart diseases (12%). Conclusions: Conclusions: Congenital anomalies account for about one quarter of deaths in perinatal period, more often early neonatal death than fetal death. There has been no reduction in PM due to CAs over the study 19 year period. Keywords: congenital anomalies, perinatal mortality, neonatal death, fetal death

(25% each); 2nd: Genitourinary (16%); 3rd:. Gastrointestinal (13.5%); 4th: Chromosomal abnormalities (10.7%); 5th: Polymalformed and hydrops fetalis (3.6%); 6th: Arthrogriposis and hemochromatosis (1.8%). A decreasing trend was noticed over the period studied, both in neonatal extended mortality rate (4.6 % vs 1.4 %) between 1992 and 2012), and the percentage rate of MA causing ND (30% vs 10% between 1992 and 2011) a decline of (– 67%). The median rate of MAND vs. total LB was 1.03 %. In 2012, there were no death due to MA. Conclusions: Our median rate of MA 1.5% was lower than the reported by EUROCAT for 2006–2010 (2.55%), Germany authors in Mainz over 40.083 births (6.4%) and US recent studies (4%). Our 32% median rate of MAND, was higher than in US (20%). Leading MAND were: cardiovascular (severe heart anomalies) and lethal CNS anomalies (hydroanencephalies and anencephalies) sharing both a 25% of each one. Our median rate of MAND 1.03%, even though we have considered a extended neonatal period, it is in the range published by EUROCAT 2010 report over 13 countries of 0.81% and it’s between the lowest 0.27% in Portugal and the highest 1.11% in Switzerland. The decline observed in the percentage MAND, may be related with early prenatal diagnosis followed by gestation’s interruption once a MA is detected. Keywords: Presenter: JR Cervilla

Presenter: V. Atanasova

ID 081 ID 279

ASSESSMENT OF THE PREVALENCE OF MAJOR ANOMALIES AS A CAUSE OF NEONATAL DEATH. STUDY IN A COHORT OF 55.140 NEWBORN INFANTS J.R. Cervilla, A. Perez-Mun˜uzuri, A. Garcia Deus, M.L. Couce Pico, A. Alshweki, & J.M. Fraga Neonatal Unit. Pediatric Assistance Area. Hospital Clinico Universitario (CHUS). Santiago de Compostela (SPAIN) Brief Introduction: Major anomalies (MA) are not frequently found in neonatal practice, European and US rates ranging widely between 1.5% and 6.4% of all live births (LB). A major goal of MA surveillance is to study potential preventive measures, environmental risk factors, drug exposures or the role played by assisted reproductive techniques. Our goal was to review and assess the prevalence and rate of MA regarding neonatal deaths (MAND) over a period of the last 21 years in the maternity hospital. Materials & Methods: In the period between 1992–2012 the record of the successive 55.140 LB were reviewed regarding the presence of MA. MAND were considered till the 3 months of life, while the affected infants are hospitalized. All the LB infants were examined and classified by the same neonatologist’s team using similar diagnostic criteria. Type of MA using ICD-10 classification criteria were used. Stillbirths with MA were not considered in the study. Clinical Cases or Summary Results: There were 55.140 LB and of them 855 were affected by a MA (1.5%). Overall neonatal mortality rate was 3.2 % of LB (from 178 ND), and 57 LB infants died due to MA, a rate of 0.67% MAND overall 855 LB with MA. The median percentage of MAND overall NM rate was 32.0%. Systems or organs affected by MA causing death, in decreasing order were: 1st: CNS and cardiovascular

NON-INVASIVE FETAL SEX DETERMINATION BY MATERNAL PLASMA SEQUENCING AND APPLICATION IN X-LINKED DISORDER COUNSELING X. Pan1,2, C. Zhang1, X. Li1, S. Chen1, F. Chen1, & W. Xie1 BGI-Shenzhen, Shenzhen, China, and 2South China University of Technology, Guangzhou, China 1

Brief Introduction: In this study, we developed a fetal sex determination method based on maternal plasma sequencing (MPS), assessed its performance and potential use in X-linked disorder counseling. Materials & Methods: 900 cases of MPS data from a previous study were reviewed, in which 100 and 800 cases were used as training and validation set, respectively. The percentage of uniquely mapped sequencing reads on Y chromosome was calculated and used to classify male and female cases. Eight pregnant women that are carriers of Duchenne muscular dystrophy (DMD) mutations were recruited, whose plasma were subjected to multiplex sequencing and fetal sex determination analysis. Clinical Cases or Summary Results: In the training set, a sensitivity of 96% and false positive rate of 0% for male cases detection were reached in our method. The blinded validation results showed 421 in 423 male cases and 374 in 377 female cases were successfully identified, revealing sensitivity and specificity of 99.53% and 99.20% for fetal sex determination, at as early as 12 gestational weeks. Fetal sex for all 8 DMD genetic counseling cases were correctly identified, which were confirmed by amniocentesis. Conclusions: Based on MPS, high accuracy of noninvasive fetal sex determination can be achieved. This method can potentially be used for prenatal genetic counseling. Keywords: Fetal sex determination; next generation sequencing; X-linked disorder Presenter: Xiaoyu Pan

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ID 912

DIFFERENCES IN THE INCIDENCE OF CONGENITAL MALFORMATIONS IN A HIGH POLLUTION AREA COMPARED WITH AN AVERAGE INDUSTRIAL CITY IN NORTHERN GREECE A. Athanasiadis1,2, A. Zavlanos1,2, A. Karavida1, D. Aivazi2, E. Assimakopoulows2, & B. Tarlatzis2 1

Prenatal Diagnosis, Thessaloniki, Greece, and A’ Department of Obstetrics & Gynaecology, Aristotle University of Thessaloniki, Greece

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2

Brief Introduction: The purpose of this study was to examine the incidence of congenital fetal dysplasias during second trimester of pregnancy in a high pollution area compared with an average industrial city in Northern Greece Materials & Methods: In this study, we included second trimester ultrasound scans from Western Macedonia, where five lignite power plants are based (Group I), and compared them with randomized second trimester ultrasound scans from Thessaloniki of Central Macedonia (Group II). The ultrasounds were performed in two prenatal diagnostic centers by the same operators between 2010 and 2013 Clinical Cases or Summary Results: 722 second trimester ultrasound scans (mean gestational week 21 + 4 ± 1.9 SD) were studied from Group I, which were compared with 5912 randomized 2nd trimester ultrasound scans (mean gestational week 21 + 3 ± 1.8 SD) from Group II. In Group I there were 23/722 (3.2%) and in Group II 122/5912 (2.1%) cases of congenital dysplasias, with an odds ratio 1.56 (95% CI 0.99 – 2.45) and weak statistically significant difference (p = 0.053) Statistically significant difference between two groups was found in cases of fetuses with major congenital heart disease [group I: 7/722 (0.97%) and group II: 20/5912 (0.34%)], odds ratio 2.9 (95%CI 1.2–6.8) with p = 0.016. Despite the grater incidence of other congenital fetal malformations in Group I compared to Group II, there was not a statistically significant difference. Conclusions: A statistical difference in the incidence of congenital heart disease, during second trimester of pregnancy, was found in a high pollution area compared with an average industrial city in Northern Greece. In general, congenital malformations did not appear to be significantly increased in the same areas Keywords: Presenter: A. Zavlanos

ID 838

RETROSPECTIVE ANALYSIS OF THE DIAGNOSTIC PRECISION FOR FETAL COARCTATION OF THE AORTA AT A SINGLE REFERRAL CENTER C. Cavalli1, A. Weiss1, M.A. Salvati2, C. Kaihura2, S. Fieni2, C. Verrotti2, A. Agnetti1, & T. Frusca2 1

Unit of Pediatric Cardiology, Dept. of Maternal and Child Health, University Hospital of Parma, Parma, Italia, and 2 Center for Prenatal Diagnosis, Unit of Obstertrics and Gynecology, Dept. of Maternal and Child Health, University Hospital of Parma, Parma,

J Matern Fetal Neonatal Med, Early Online: 1–437

Brief Introduction: Aortic coarctation (CoA) is one of the most difficult cardiovascular malformations to detect by fetal echocardiography as reported in literature. Thus a relevant number of false positive and false negative cases are described in most series. Despite this the prenatal diagnosis of CoA lowers perinatal morbidity and mortality, mainly due to a better perinatal management and a prompt neonatal stabilization in subjects presenting with hemodynamic impairment. Ultrasound screening programs during pregnancy are widely used for the detection of CoA with widespread significant variability in their detection rates (DR). Materials & Methods: Herein we report the DR of the prenatal diagnosis of CoA at our 3rd level center for Prenatal Diagnosis. As well, we report the flow-chart of the organization we adopted so far. The regionalization system of our territory is based upon a "hub & spoke" model whereby our 3rd level center (Parma, hub) is linked to one 2nd level hospital and three 1st level centers (spokes). At our unit fetal echocardiographies are performed by an obstetrician skilled in fetal cardiac scans and a perinatal cardiologist altogether. Pregnant women are sent to our center for referral after a suspicion of CoA emerged from a 1st level fetal ultrasonographic screening. The final diagnosis is eventually assessed at our center by considering and evaluating the puzzle of the multiple echocardiographic markers described in literature for the diagnosis of CoA in the fetus. Afterward a follow-up program is proposed to the family up to the delivery and the postnatal management. We report a retrospective analysis of DR, accuracy and precision at our center. Clinical Cases or Summary Results: From September 2008 through August 2011, 573 fetal echocardiographies were performed at our unit. From this database 14/573 (2.4%) fetuses with a suspicion of CoA were extracted. In 2 cases intrauterine fetal demise occurred (2/14, 14.3%) and in 1 case the pregnant woman chose to terminate the pregnancy (1/14, 7.1%). Postmortem confirmed the CoA in 2 of the 3 latter fetuses, while the third one had an interrrupted aortic arch associated with a cerebral malformation. There were 11 liveborn infants: CoA was confirmed after birth in 7 of them, and was not in the 4 remnants (false positive cases). In the experience we reported here one more case suffering from CoA represented the only false negative subject at fetal echocardiography in our laboratory. Overall, DR was 90%, the negative predictive value was 99.8%, the positive predictive value was 64.2%, the alfa-error was 0.9%, and the specificity was 99.1%. Conclusions: We described an hypothesis of working group and regional flow-chart in a low sized series. Nevertheless, a setting of continuing and effective cooperation among professionals from different areas might influence efficacy somehow, while accepting some overestimation as indicated by the comparison between the positive and the negative predictive values. Lastly, it could be a point of open discussion to report prenatal statistical data regarding specific cardiovascular anomalies like CoA, which perinatal management is still debatable. Keywords: fetal echocardiography, coarctation of the aorta, preinatal management Presenter: Claudio Cavalli

ID 465

COSTELLO SYNDROME, CHANGES IN CHROMOSOME 11 UNDERESTIMATE ITS IMPACT? A PURPOSE OF A CASE A. Mun˜oz Ledesma, M. Navarro Monje, C. Montoya Garcı´a, M. Garcia-Yuste Gonza´lez, M. Azpeita Rodrı´guez, A. A´lvarez Gonza´lez, S. Del Olmo Bautista, & F. Vazquez Camino Department of obstetrics and gynecology, section of obstetrics, university hospital rio hortega, Valladolid, Spain

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DOI: 10.3109/14767058.2014.924236

ventriculomegaly should lead to a suspicion of Costello syndrome, and would be strengthened if fetal atrial tachicardia appears. Amniocentesis should be offered to exclude most common causes of polyhydramnios but HRAS testing should be considered when Costello syndrome is suspected. This syndrome may have a higher than expected prevalence. Fetal death and neonatal death may be related to Costello syndrome when polyhydramnios or phenotypic features appear but chromosome 11 is not typically studied in fetal karyotype or in postmortem karyotype, so the diagnosis could be missed. Keywords: Costello syndrome, polyhydramnios, macrocephaly, hromosome 11 Presenter: A. Mun˜oz Ledesma

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ID 625

FETAL CARDIAC MANIFESTATIONS ASSOCIATED TO MATERNAL ANTI-RO/SSA ANTIBODIES AND THE EFFECT OF A TRIPLE THERAPY IN ANTIBODIES LEVELS N. Martı´nez1, A. Robles2, L. Sotillo1, R. Alvarez-Doforno3, E. Antolı´n1, L. Deiro´s4, & J.L. Bartha 1

Brief Introduction: Costello syndrome is a rare multiple congenital abnormality syndrome with an incidence of 5 cases per 10,000 newborns. At least, 300 cases had been described worldwide and it affects 10 families in Spain today. Costello syndrome overlaps with other syndromes of the Ras/MAPK pathway, especially Noonan syndrome, but HRAS is considered as the single etiologic gene of Costello syndrome. Cardiofaciocutaneous syndrome (CFCS) and Beckwith-Wiedeman syndrome should also be included in the differential diagnosis. Materials & Methods: A 31 year-old G2 mother was receiving prenatal care. She had a previous cesarean due to failed progress in labor. Clinical Cases or Summary Results: First-trimester combined screening was normal. Nucal thickening was 1.8 mm. 27-week ultrasound showed polyhydramnios, with an amniotic fluid index of 25. At 37 weeks, AFI was 35. Ultrasonic fetal weight estimation was over P85 in third trimester and showed pulmonary stenosis and mild ventricular hypertrophy. The digestive, renal and urologic systems had no abnormal findings. ToRCH serology results were negative. A scheduled cesarean was performed at 37 weeks of gestation because of placenta previa and polyhydramnios. A 3620 g female was delivered. Apgar scores were 5, 6 and 9 at 1, 5 and 10 minutes, respectively. Umbilical artery blood pH was 7.11. The amniotic fluid was brown. The newborn was admitted into neonatal intensive care unit because of respiratory distress and hypoglucemia. She had coarse facial features, dysplastic ears, protruding tongue and angiomas on her forehead. Neonatal ultrasound showed hepatosplenomegaly and kidney stones. Chromosome analysis was 46, XX. Cytogenetic analysis of chromosome 11 and molecular testing for KRAS, HRAS, BRAF, MEK1, MEK2, PTPN11 mutations were performed and final diagnosis was Costello syndrome. Conclusions: Prenatal amniocentesis diagnosis of Costello syndrome is possible but difficult. Ultrasound findings of polyhydramnios, macrocephaly, large size for gestational age, shortened long bones and

Obstetric and Gynecology Departmente, University Hospital La Paz, Madrid (Espan˜a), 2Internal Medicine Department University Hospital La Paz, Madrid (Espan˜a), 3Immunology Department, University Hospital La Paz, Madrid (Espan˜a), and 4 Pediatrics Departme Brief Introduction: Congenital heart block (CHB) is the main feature of lupus erythematosus neonatal (LNE) with a prevalence of 1–5% in pregnancies of mother exposed to anti-Ro/SSA and anti-La/SSB level. CHB is the only permanent clinical manifestations. The majority of these babies had to be placed peacemakers to mantain a corret heart beat frequency. The objective is to evaluate the efficacy of the combination of steroids, plasmaferesis and intravenous immunoglobulin (IVIG) on maternal anti Ro/SSA antibodies levels in the prevention of mild fetal cardiac affectation to progress to CHB. Materials & Methods: A series of 3 cases of fetuses with mild cardiac affectation and positive anti Ro/SSA antibodies mothers treated with a triple therapy composed by steroids during all pregnancy and plasmaferesis and IVIG each three-four weeks. Maternal antibody levels were measured several times before and after the application of each cycle of therapy. The effect of the treatment on fetal cardiac manifestations was also evaluated. Clinical Cases or Summary Results: Maternal antiRo/SSA antibodies levels significantly decreased after each cycle of triple therapy. The most significant decrease occurred after the first cycle. In the first case complete heart block (CHB) could not be prevented but in the other two cases, incomplete heart block and cardiac hyperechogenicity in the cross of the heart were stopped and also this sign of cardiac inflammation decreased. None of the newborns needed neonatal pacemaker even in the first case because a well tolerate heart beat. Conclusions: A triple therapy may stop the natural evolution of the fetal cardiac affectation in positive anti Ro/SSA antibodies levels by decreasing inflammation, lowering the hurting antibodies in maternal serum that cross the placenta to the fetus and decreasing placental transfer of these antibodies. Further studies are needed in order to validate clinical applications of this treatment approach. Keywords: congenital heart block, anti-Ro/SSA antibodies, treatment Presenter: Nuria Martı´nez Sa´nchez

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ID 580

ID 915

INCIDENCE OF A POSITIVE TORCH AND PARVOVIRUS B19 SCREENING IN PREGNANCY COMPLICATED BY POLYHYDRAMNIOS

SECOND TRIMESTER PRENATAL DIAGNOSIS OF ABERNETHY MALFORMATION

L. Pasquini, V. Seravalli, C. Gaini, C. Franchi & M. Di Tommaso Department of Health Sciences, University of Florence, Florence, Italy

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

J Matern Fetal Neonatal Med, Early Online: 1–437

Brief Introduction: Infectious disease serum screening is routinely performed in pregnancy diagnosed with polyhydramnios. However, the real necessity of this screening in such condition has been questioned recently. The aim of this study was to evaluate the rate of women with polyhydramnios who resulted positive to infectious disease testing. Materials & Methods: This is a retrospective observational study on singleton pregnancies with a diagnosis of polyhydramnios who had serum screening for TORCH and Parvovirus B19. Patients were followed with serial ultrasounds at our tertiary-care center between 2006 and 2013. Maternal characteristics, medical and obstetric history were reviewed. Ultrasound parameters, including amniotic fluid index and fetal anomalies, and the results of serologic tests were reviewed. Pregnancy and delivery outcomes were ascertained. Cases with no infectious disease testing or with unknown delivery outcome were excluded. Clinical Cases or Summary Results: 290 patients met the inclusion criteria. Of these, 56 (19%) presented one of the following pathological conditions associated with polyhydramnios: diabetes (13% of total cases), obstructive gastrointestinal lesions (5%), Rhesus isoimmunization (0.3%), chromosomal abnormalities or genetic syndromes (1%). Among the remaining 234 patients, only three had a positive test result for infectious disease (1%): two women were positive for Parvovirus B19 and one for Toxoplasmosis infection. In no cases the fetus was affected, as confirmed by serum testing after birth. Conclusions: The majority of patients with isolated polyhydramnios resulted negative to TORCH and Parvovirus B19 screening. In the only three cases in which the mother was affected, the neonate resulted negative. Infectious disease screening seems not to be beneficial in women in whom polyhydramnios is an isolated ultrasound finding.

A. Athanasiadis1,2, A. Karavida1, A. Zavlanos1,2, K. Chondromatidou3, E. Iordanidou2, S. Goulvanidou3, &. H. Kariki3, J. Tsitouridis3 Prenatal Diagnosis, Thessaloniki, Greece, 2A’ Department of Obstetrics & Gynaecology, Aristotle University of Thessaloniki, Greece, and 3Radiology Department of General Hospital Papageorgiou of Thessaloniki, Greece 1

Brief Introduction: Abernethy malformation is rare and refers to an abnormal shunt between portal and systemic venous circulation. Materials & Methods: A large diameter abnormal blood vessel in the fetal abdomen was detected at 23 weeks of gestation. Clinical Cases or Summary Results: Abnormal blood vessel originated from the intrahepatic segment of the umbilical vein(UV), coursing towards the left side of the fetal abdomen and anastomosing with the systemic veins in the pelvis. Doppler waveform was similar to that of the umbilical vein and direction of flow was towards the pelvis. Inferior vena cava (IVC) was dilated. Ductus venosus was present and no other abnormalities were detected. Fetal MRI confirmed the vessel’s association with the UV, but was not conclusive regarding the portal system. The parents declined amniocentesis. Analysis of 3-D Doppler images showed possible absence of the right portal vein. The main portal vein (MPV) was also not visualized, as well as the exact site of anastomosis in the pelvis. Abernethy malformation type I with complete portal agenesis and extrahepatic portosystemic shunt was suspected prenatally. Postnatal MRI with iv contrast on day five demonstrated the existence of the MPV, formed by the confluence of splenic and superior mesenteric vein, and imaged the shunt between the portal system and the IVC. The malformation was reclassified as type II, with a significantly better prognosis than type I which is associated with hepatic failure and tumors. Conclusions: The fetal venous system can be effectively imaged with 3-D reconstructed Doppler images that are comparable to MRI. Knowledge of the relevant anatomy is essential for the diagnosis of these rare anomalies. Keywords: Presenter: A. Zavlanos

Keywords: Infectious disease screening, polyhydramniis, fetal anomalies Presenter: Mauro Cozzolino

ID 662

MANDIBULOFACIAL DYSOSTOSIS (TREACHER-COLLINS SYNDROME) IN THE FETUS: NOVEL ASSOCIATION WITH PECTUS CARINATUM IN A MOLECULARLY CONFIRMED CASE AND REVIEW OF THE FETAL PHENOTYPE A. Konstantinidou1, I. Tassoulas2, G. Kallipolitis3, S. Gasparatos2, V. Velissariou4, H. Paraskevakou1, & S. Sifakis5 1

1st Department of Pathology, School of Medicine, University of Athens, Athens, Greece, 2School of Dentistry, University of Athens, Athens, Greece, 31st Department of Obstetrics and

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DOI: 10.3109/14767058.2014.924236

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Gynecology, University of Athens, Alexandra Hospital, Athens, Greece, and 4D Brief Introduction: Treacher Collins syndrome is the most common mandibulofacial dysostosis of autosomal dominant or, rarely, recessive inheritance. Affected fetuses may be identified by prenatal ultrasound or diagnosed at autopsy in case of perinatal death or pregnancy termination. Materials & Methods: We describe the ultrasonographic, autopsy and molecular findings in a 25-week-gestation affected fetus, and review the clinical, prenatal and postmortem findings in 15 previously reported fetal and perinatal cases. Clinical Cases or Summary Results: In affected fetuses, a nearly complete spectrum of the typical facial characteristics can be present by the early second trimester of gestation, including subtle defects such as lower eyelid colobomas. Mandibular hypoplasia and bilateral auricle defects were constant findings in the affected fetal population. Downward slanting palpebral fissures were the second more common feature, followed by midface hypoplasia, polyhydramnios and ocular defects. The association of Treacher Collins syndrome with Pierre Robin sequence (severe micrognathia and clefting of the hard and soft palate) was common (38%) in the reviewed series. Uniquely reported fidings include pectus carinatum, tracheo-esophageal fistula, salivary gland hyperplasia and single umbilical artery. Conclusions: Treacher Collins syndrome, apart from being prenatally detected by ultrasound, should be included in the wide range of single gene disorders that can be met and diagnosed by the perinatal pathologist at autopsy. The reported association of the autosomal dominant Treacher Collins syndrome type 1 and pectus carinatum expands the phenotype, provides information on genotype-phenotype correlation, and suggests possible pathogenetic interactions between neural crest cells disorders and the formation of the sternum, that merit investigation. Keywords: Treacher Collins syndrome, Pierre Robin sequence, micrognathia, cleft palate, pectus carinatum, fetus, autopsy, sonography Presenter: S. Sifakis

ID 811

CAUSES OF STILLBIRTHS AND EARLY NEONATAL DEATHS – 2012 IN 8 VOIVODSHIPS IN POLAND T. Maciejewski1, & M. Troszyn´ski2 1

Department of Obstetrics and Gynecology, Institute of Mother and Child, Warsaw, Poland, and 2Department of Reproductive Health, Institute of Mother and Child, Warsaw, Poland Brief Introduction: The aim of this study was to evaluate the frequency of stillbirths and early neonatal deaths in 8 voivodships. They are in collaboration in this field with Institute of Mother and Child in Warsaw. Data were collected on the specially prepared form. Materials & Methods: Our study was done among women who delivered in year 2012. Causes of deaths were described according to ICD-10 classification. Data were collected from 185 hospitals in 8 voivodships. There were 157 908 deliveries - 41% of births in Poland in 2012. In this amount there were 68 hospitals with a number of deliveries less than 500, 91 hospitals with 500 to 1500 deliveries, 15 hospitals with 1500–2000 deliveries and 11 hospitals with over 2000 deliveries per year. Clinical Cases or Summary Results: Stillbirths There were 621 stillbirths, in this number 120 weighted below 500g. Our study showed that the most common cause of stillbirths were complications of placenta: abruptio placenta and placenta

praevia or other anomalies of placenta or fetal membranes (75 cases -12%), then abnormal umbilical cord twisted around neek or corps or other anomaly of the cord (62 cases - 10%) and malformations of the fetus – also 62 cases (10%). There was still a great number of unknown causes of stillbirths – 234 cases (38%). One hundred and eighty eight fetuses died of other causes. Neonatal deaths There were 412 deaths in the period of the first week after delivery. Early neonatal deaths were caused by microsomia and prematurity in 166 cases (40%). The pulmonary system disorders caused by hypoxia and immaturity were responsible for 83 early neonatal deaths (20%). The other causes were 16 cases of bacterial sepsis and 95 cases of malformations (23%). The remaining causes of early neonatal death were lethal, especially among newborns with extremely low birth weight and cases of brain injuries among premature newborns. Description include three tables of data and two graphs. Conclusions: The causes of perinatal deaths were collected according to ICD-10 classification. There is a great need to have a wider information about social, economical, cultural and family status of patients. These informations would be very useful in preparing proper data about causes of stillbirth and neonatal deaths. There is still a high number of pathomorphological examinations, which are very useful for finding the main reason of death in the perinatal period. Keywords: stillbirths, early neonatal deaths, cause of perinatal deaths Presenter: T. Maciejewski

ID 616

FETAL AXILLARY LYMPHANGIOMA DETECTED BY PRENATAL ULTRASONOGRAPHY: A CASE REPORT T. Tsokaki, V. Tsitsis, S. Galanopoulou, G. Kousavelou, D. Ziata, & I. Miliordou Department of Obstetrics & Gynecology, General Hospital of Pirgos, Peloponnisos, Greece Brief Introduction: Lymphangioma or cystic hygroma (CH) is a congenital malformation of the lymphatic system which has been commonly associated with fetal aneuploidy, hydrops, structural malformations and intrauterine death. 75% involve the posterior neck, 20% the axilla and 1% the mediastinum, groin and retroperitoneum. Two distinct categories of fetal CH have been described: those diagnosed in later pregnancy, which mainly represent isolated lymphangiomas, and those diagnosed in early pregnancy, which are commonly associated with other malformations. The CH in later gestation, mostly being a lymphangioma that is not associated with either aneuploidy or other fetal malformations, is expected to have a good prognosis. Materials & Methods: A 30-year-old woman, gravida 2, para 1, was referred at 32 weeks of gestation in our clinic for targeted evaluation through ultrasound of the fetal anatomy, where a cystic formation at the left axilla, consistent with cystic lymphangioma, was diagnosed. Clinical Cases or Summary Results: The mass, 40  50mm approximately, was septated and extended to the lateral chest wall of the fetus, from the level of the stomach until the level of the heart. There was no flow on doppler sonography and it didn’t seem to invade into adjacent anatomical structures or communicate with the thoracic cavity. Nuchal translucency measurement at 12 weeks appeared to be normal. The 22 - week scan demonstrated fetal organ measurements appropriate for gestational age, with the amount of amniotic fluid and the movements showing no abnormalities. The patient

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underwent frequent ultrasound monitoring, where the fetus was found normal by the end of pregnancy. Childbirth, however, took place in a university obstetrical unit, where there would be the possibility of prompt neonatal surgical intervention. The birth was induced at 38 weeks of gestation and a female weighing 3850gr was born vaginally with a good perinatal result. The neonate remained for one day in the intensive care unit, where it was certified through imaging scans, that the mass was an axillary subcutaneous lymphangioma, 4  4,8  4.2 cm, extending until the lower thoracic sides. Conservative management with monitoring was decided, as the lymphangioma showed signs of spontaneous resolution at the followup visit one month later.

J Matern Fetal Neonatal Med, Early Online: 1–437

Conclusions: Late-onset cystic hygroma is located mainly in the axilla and anterior abdominal wall. The short-term risk of this lesion is dystocia during labor and the long-term risk may be the presence of an infiltrative microcystic formation with or without organ involvement. In such cases, consequences are chronic lymphorrhea, infections, hemorrhage and relapses of the lymphatic lesion. It is certain that prenatal diagnosis permits planned delivery and prompt postnatal resuscitation. Conservative management with observation has been recommended by some surgeons in asymptomatic patients. Keywords: fetal, axilla, hygroma, lymphangioma, prenatal, ultrasound Presenter: T. Tsokaki

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DOI: 10.3109/14767058.2014.924236

ID 719

WHAT DO WE KNOW ABOUT NEONATAL ABSTINENCE SYNDROME IN NEONATES EXPOSED TO METHADONE V. Saftic´1 & N. Bilic´2 1

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University of Zagreb, »Sestre milosrdnice« University Hospital Center, Department of Gynaecology and Obstetrics, Division of neonatology, Zagreb, Croatia, and 2University of Zagreb, »Sestre milosrdnice« University Hospital Center, Department of Anesthesi

Brief Introduction: During pregnancy, drug addicted mothers receives substitution therapy with methadone or buprenorphine. This paper aims to show the incidence of neonatal withdrawal syndrome and risk characteristics in newborns whose mothers were on methadone substitution therapy during pregnancy. Materials & Methods: We prospectively followed the early neonatal period in 31 neonates of drug addicted mothers, who were on methadone substitution therapy during pregnancy. We analyzed the risk factors and the incidence of neonatal withdrawal syndrome in observed group. The children were hospitalized and treated at the Center for premature babies and vulnerable newborns Clinical Cases or Summary Results: During the period 2008–2013 at the Clinical Hospital Centre "Sestre milosrdnice ", there were 81 children born from addicted mothers. Of these, 45 mothers at the time of birth were on methadone substitution therapy. There were boy 18 (41.9%) and 27 girls (58%). Full term was 36 children, nine were born prematurely. The shortest gestational age was 33 weeks (4 children). There were 26 mothers seropositive for hepatitis C, and six mothers for Hepatitis B. There were 21 uncontrolled pregnancies. The average weight was 3170 g. (min 1740 g, 4320 g max). Intrauterine growth restriction was registered in 6 children. Microcephaly was noted in 3 children. Ultrasound of a brain registered intracranial hemorrhage grade III in five children and stages I and II in 23 children. Newborn withdrawal syndrome occurred at the earliest within the first 24 hours, but not later than the seventh days of child life. Most often the clinical presentation symptoms of withdrawal syndrome were: tremor, agitation, ravenously eating and vomiting. Seizures occured in 29 children and 10 children had apnea. Average medication treatment lasted 10.2 days, and the average hospital stay was 18 days. Conclusions: Children born from pregnancy during which the mother took methadone as a substitution therapy are significantly more vulnerable in the newborn period compared with other infants. There was no significant incidence of preterm birth or intrauterine growth restriction in the study group. Withdrawal symptoms are a major risk factor, which in these children leads to significant morbidity. Further research are needed to be conduct to test the long-term impact on the growth, development, and eventual disabilities off these vulnerable population.

Family history

GA

Ultrasound findings

Definitive diagnosis

No No

20 32

Thanatophoric dysplasia Hypophosphatasia

Yes No No

22 17 24

No ? No

19 19 18

No No

19 20

No

17

No No No

21 19 17

Short femur and ribs Ausence of craneal ossification Rizomielic dysplasia Short limbs Discordeant BPD/femur lenght Short limbs Incurvated femur Hypoplastic to´rax, craneal anomaly Short limbs, femur absent. Pulmonar hipoplasia, hidrocephalia Hypoplastic to´rax, short limbs Clover leaf skull Short ribs, equinovaro foots Short and incurvated femur

Diastrophic dysplasia Imperfect osteogenesis Short rib syndrome Achondrogenesis Boomerang dysplasia Thanatophoric dysplasia Thanatophoric dysplasia Imperfect osteogenesis Campomielic dysplasia Imperfect osteogenesis Thanatophoric dysplasia Thanatophoric dysplasia

Keywords: Methadone, neonatal abstinence, outcome

Brief Introduction: The term osseous dysplasia (OD) represents a variety of diseases which primarily affect the development of chondro-osseous tissue. They have a prevalence of 2.4/100.000 and an elevated perinatal mortality. It is important an appropriate prenatal diagnosis for genetic counseling. It is often difficult making the precise diagnosis of OD, before birth. It is done to asses the efficacy of prenatal ultrasound and X-ray for detection and diagnosis and to explore diagnostic accuracy and improve management. Materials & Methods: Retrospective review of 14 cases prenatally diagnosed at our institution in the last 20 years. The diagnosis was confirmed by fetal X-ray (Pre and postnatal) and anatomopathological analysis. In all cases, but one (newborn death), interruption of gestation was done. Clinical Cases or Summary Results: The results are shown in the upload table below Conclusions: When it is suspected diagnosis of OD can perform various imaging techniques that support the diagnosis: Real time ultrasound is an effective and reliable diagnosis procedure for prenatal OD identification and fetal X-ray may help when considering the diagnostic possible, but can be difficult to obtain appropriate images due to technical problems. Accurate prenatal diagnosis is done by DNA analysis fetal. It has been identified approximately 50% of genetic defects, allowing prenatal diagnosis, preimplantation diagnosis in families with high risk or confirmation of diagnosis in advanced pregnancies with ultrasound suspected, performing the same time fetal karyotype. It is important a genetic counseling and following up of subsequent pregnancies, due to the high recurrent rates Parents must become aware of that detailed postnatal pathological and radiological examination are usually required for an accurate diagnosis.

Presenter: V. Saftic´

Keywords: Presenter: Natalia Rodrı´guez Go´mez-Hidalgo

ID 597

PRENATAL DIAGNOSIS OF OSSEUS DYSPLASIA N. Rodrı´guez1, M. Go´mez1, C. Morales2, L. Brea2, R. Pe´rez2, A. Abdulkareen2, & L. Sanchez de Leo´n2 1 Servicio de Obstetricia, 2y Neonatologı´a, Hospital Universitario de Mo´stoles. Madrid

ID 720

DRUG USE DURING PREGNANCYFETAL IMPLICATIONS N. Bilic´1, V. Saftic´2, & S. Radovic´ Radovcˇic´2 1

University of Zagreb, »Sestre milosrdnice« University Hospital Center, Department of Anesthesiology and intensive Therapy,

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Zagreb, Croatia, and 2University of Zagreb, »Sestre milosrdnice« University Hospital Center, Department of Gynaecology and Obstetric Brief Introduction: Neonates of addicted mothers are exposed to a high risk of the development of neonatal abstinence syndrome. They show a wide spectrum of aberrations in neurological and cognitive development. During the neonatal period, most frequent symptoms are those associated to the central nervous and digestive system. Symptoms are most frequently correlated with dose and type of substances that mother used. Materials & Methods: A retrospective-prospective study was undertaken from 2008 to 2013, when 81 children of addicted mothers were received at our Clinic. We have described the characteristics of mother addicted newborns, the prenatal anamnesis of their addiction, postnatal occurrences and tests results associated to this vulnerable population. Clinical Cases or Summary Results: From 2008 to 2013, 81 neonate off addicted mother were admitted at the Department of neonatology. Uncontrolled pregnancy was documented at 23 children (28, 5%). The duration of pregnancy was 39.1 week on the average (35–41). Thirty four mothers were on a methadone therapy (42%), and forty received a buprenorphine therapy (51%). Nine mothers had consumed heroin immediately before the actual birth, while three had consumed marihuana. Sixty-six mothers were tested for hepatitis C antenatally: 60.8% tested positive. Symptoms appeared with new-borns from their 1st to 11th day. Serious symptoms were documented with 28 children (32%), 11 of which experienced repetitive convulsions (12.7%). The criteria for the introduction of therapy were set according to the Finnegan score. The treatment with Phenobarbiton (4–10 mg/kg/per day) continued for 19.6 days on average. Brain ultrasound pathological test result were documented in 27 children (28.5%). Average hospitalisation was 17 days, which results to total of 1377 hospital days for all treated children. Conclusions: Addiction pregnancies present a small but high-risk group according to perinatal outcome. Children suffer the withdrawal symptoms of their mother’s addiction. So we have to be aware the multidisciplinary approach gives best opportunity to treatment of those children Keywords: drug abused mothers, neonate, symptoms Presenter: V. Saftic´

ID 278

EARLY EXTRAUTERINE LIFE ADAPTATION. ASSESSMENT BETWEEN TWO COHORT GROUPS OF LIVEBIRTHS IN THE LAST TEN YEARS J.R. Cervilla, A. Perez-Mun˜uzuri, A. Alshweki, O.E. Lopez Suarez, A. Ban˜a Souto, & J.M. Fraga Neonatal Unit. Pediatric Assistance Area. Hospital Clinico Universitario (CHUS). Santiago de Compostela (SPAIN) Brief Introduction: Apgar score (AS) is the best clinical test to checkup newborn adaptation. AS remains a worth marker of perinatal outcome The great majority of life births (LB), do not need resuscitation maneuvers, mainly positive pressure ventilation (PPV), to reach a successful adaptation. When AS at 1 minute is below 3, the need of suitable resuscitation with PPV is mandatory to avoid asphyxial damage and seizures after birth. Our goal was to review AS 7 at 5 minute and the need of PPV in two cohorts of consecutively 55.140 LB at the Maternity Hospital, and make a comparison between two periods of time 10 years apart, to assess if there were any

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

differences in the rate of PPV due to miss adaptation, and for that reason, needing to admission at the neonatal unit. Materials & Methods: The median rate of AS 7 at five minutes of 27.453 LB in the period 1992–2002 and of a cohort of 27.687 consecutive LB in the 2003–2012 period was calculated. A comparison of the median percentages of LB with AS 7, and also those LB who needed hospitalization for that reason regarding total LB hospitalized, were made, to assess if there was differences between the two time apart periods. Clinical Cases or Summary Results: In the 1st period 784 LB needed PPV due to AS 7, a median percentage of 2.8 (SD ± 0.5). There were a significant decline (-24%) of the LB who needed PPV (580 LB) median 2.0 percent (SD ± 0.4) p  0.01 in the 2nd period. Regarding median percentage rate of those with AS below 7 in comparison with the total newborn hospitalizations, there were a significant decreasing of 36% (18.9% ± SD 4.2 vs 12.5% ± SD 2.3) p  0.0005 between the two cohort groups. The total rate of LB who needed hospitalization at the Neonatal Unit, rose from 4.178 to 4.612 (10.5%) between both periods. Conclusions: Prevalence of early extrauterine life miss adaptation estimated in two cohort group of LB ten years apart, by AS below 7 at 5 minutes who needed PPV to resuscitate, diminished significantly in both median percentage (-24%) regarding overall number of LB, as well as the overall gross rate of hospitalized newborns due to miss adaptation (- 36%). Better assessment of prenatal diagnosis and preventive measures taken by obstetricians to avoid critical decreasing of placenta-fetal blood flow, besides suitable management of depressed newborns by neonatologist, are the main causes of these improvement of neonatal outcomes in the last ten years Keywords: Presenter: J.R. Cervilla

ID 921

PLACENTAL MESENCHYMAL DYSPLASIA: A CASE OF SUCCESS M. Mouraz, J. Cominho, S. Saramago, S. Proenc¸a, M.I. Reis, L. Martins, S. Pedroso, J. Colac¸o, R. Rodrigues, & F. Nunes Obstetrics and Gynecology Dept., Hospital Dr. Jose´ de Almeida, Cascais, Portugal Brief Introduction: Placental mesenchymal dysplasia (PMD) is a rare benign condition of placentomegaly and abnormal chorionic villi, with high incidence of intrauterine growth restriction and fetal demise. Differential diagnosis from gestational trophoblastic disease is important because different management and outcomes. The etiology is unknown. Materials & Methods:. Clinical Cases or Summary Results: We reported a case of a 32-year-old woman, gravida 2, para 0, referred to our department at 17 weeks of gestation, presenting an abnormal ultrasound in the first trimester with an enlarged placenta with multicystic, anechoic regions impression of partial hydatidiform mole. We performed an amniocentesis and a normal karyotype was found. The ultrasound revealed a normal female fetus with an enlarged, cystic placenta with dilated chorionic vessels. PMD was suspected. An heightened surveillance with serial growth scans and assessment of fetal wellbeing in the third trimester followed by an elective induction of labor at 35 weeks of gestation was performed. There were no apparently anomalies in the newborn or in the umbilical cord. PMD was histopathologically confirmed. Conclusions: PMD is a rare placental vascular malformation commonly confused with partial mole antenatally. Despite its rarity, this condition should be kept in mind to rigorous follow-up and to avoid unnecessary termination of pregnancy.

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DOI: 10.3109/14767058.2014.924236

Keywords: placental mesenchymal dysplasia, placentomegaly, intrauterine growth restriction, prenatal diagnosis Presenter: M. Mouraz

ID 511

MANAGEMENT OF FETAL ANEMIA (CASE REPORT) V. Kazliakova1, M. Beluga2, M. Artsiusheuskaya1, & A. Korolik3 1

Belorusian Medical Academy of Postgraduate Education, Minsk, Belarus, 2Mother and Child National Research Center, Minsk, Belarus, and 39th City Clinical Hospital, Minsk, Belarus Brief Introduction: Introduction: Hemolytic disease of the fetus and newborn due to red cell alloimmunization remains an urgent problem of modern perinatology. Materials & Methods: (CASE REPORT) Clinical Cases or Summary Results: Case report: A 37-year-old woman, gravida 6, para 4 was monitored with control of Indirect Coobs, level of antibody (IgG1 and 3), and fetal ultrasound scans and Doppler from 18 weeks of gestation. Her first pregnancy was in 2000 without any complications, and finished with vaginal labor at 40 weeks of gestation. A healthy girl was delivered with a birth weight of 3200 g, a length of 52 cm. APGAR score values were 8 and 9 at 1 and 5 min. The newborn has B (III) blood group, D-positive. Direct Coombs didn’t detect any antibody. Her second pregnancy finished in 2001 with menstrual aspiration. Her third pregnancy was complicated in 2007 with abortion due to the fact that the fetus stopped development at 12 weeks of gestation. After the 2nd and 3d pregnancy Rh-D-immunoglobulin prophylaxis was performed. The fourth pregnancy was in 2009 without any complications, finished with vaginal labor at 38 weeks of gestation. A healthy boy was delivered with a birth weight of 4510 g, a length of 54 cm. APGAR score values were 8 and 9 at 1 and 5 min. The newborn has B (III) blood group, D-positive. Direct Coombs didn’t detect any antibody. Her fifth pregnancy was complicated by Rh-D-isoimmunization. Anti-D-antibody was detected from 12 weeks of gestation (1:128), ccdee, Kell-negative –phenotype, high level IgG1 and IgG3. We didn’t expect delivery with RhD-negative fetus, because the husband of our patient had D/D genotype. He had been examined in Smolensk. We used plasmapheresis at 23, 27 and 31 weeks of gestation with maternal administration of intravenous immunoglobulin (Octagam) 0.4g/kg/day for 3–4 days. There were no signs of fetal anemia detected by Doppler ultrasound before 35 weeks and 6 days of gestation. The level of anti-D-antibody was 1:512 at 34 weeks of

gestation. Because of increasing signs of fetal anemia (peak systolic velocity), a male infant was born by cesarean section with a weight of 3150 g, a length of 49 cm at 35 weeks and 6 days of gestation. APGAR score values were 8 and 8 at 1 and 5 min. The blood group of the newborn was A (II) Rh + (Positive), Direct Coombs positive, hemoglobin level of 8.2 g/dL, total serum bilirubin – 78.5 mkmol/l. He was treated with one transfusion of one packet of red blood cells (10 ml kg 1), human intravenous immune globulin (IVIG) (Octagam), phototerapy, fluid therapy. The sixth pregnancy happened in 2011 and began from the level of anti-D antibody of 1:512 and there was a bad prognosis. We used plasmapheresis + intravenous immunoglobulin 0.4/kg/day at 17–18, 21–22, 24–25 weeks of gestation. Moreover, the anti-C-antibody was revealed at 24 weeks of gestation. The intrauterine transfusion of red cells was necessary and began from 29 weeks of gestation because of evaluating the peak systolic velocity in the middle cerebral artery (58– 60 cm/s). Intrauterine transfusions were used at 29, 31, 33 and 35 weeks of gestation. A male infant was born by cesarean section with a weight of 3580 g, a length of 53 cm at 37 weeks of gestation. APGAR score values were 8 and 8 at 1 and 5 min. The blood group of the newborn was B (III) Rh - (negative), Direct Coombs negative, hemoglobin level of 13.7 g/dL, total serum bilirubin – 78.5 mkmol/l. Conclusions: Conclusion: Thus applying the phase-treatment (plasmapheresis + intravenous immunoglobulin + intrauterine transfusion) in patients with Rh-isoimmunization and a high risk of hemolytic disease of the fetus, contributes to the preservation and prolongation of pregnancy, which in its turn leads to a decrease in perinatal mortality and improves the demographic situation in the country. Keywords: Rh-izoimmunization, hemolytic disease, plasmapheresis, intrevenous immuniglobulin, intrauterine transfusion Presenter: Volha Kazliakova

ID 770

FETAL AND NEONATAL DIAGNOSIS AND EVOLUTION OF CARDIAC TUMOURS L. Dimitriu1, A.G. Dimitriu2, & M. Stamatin2 Medex Medical Center Iasi, Romania, and 2University of Medicine and Pharmacy Iasi, Romania 1

Brief Introduction: Cardiac tumors are rarely symptomatic and highlighted in the fetus when the size and position do not interfere with intracardiac hemodyna-mic, situation when can detect at screening or fetal

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106 echocardiography per-formed for suspected fetal congenital cardiac anomalies Purpose.Assessing the utility of fetal echocardiography and echocardiography (echo) during neonatal period for diagnosis of cardiac tumors. Materials & Methods: Cases presentation: 6 cases of cardiac tumors, confirmed by Doppler echo performed in the first 14 days postnatal, 3 of which were already highlighted by fetal echo. Clinical Cases or Summary Results: There was no evidence of obstruction of intracardiac blood flow at echo examinations. Fetal echo showed: 3 and respetivelly 4 intracardiac mass, well circumscribed, round/oval, with echogenic appearance increased from normal cardiac structure, 6–12 mm diameter, located in the IVS and the posterior wall of the LV.The tumours slightly protrudes in the lumen, no significant obstruction of LV outflow tract and suggests the appearance of multiple cardiac rhabdomyama. Postnatal echo confirmed the fetal echo diagnosis. ECG: no suggestive changes. Chest X-Ray: important cardiomegaly. One of cases, the pregnancy with normal development and birth weight, was later diagnosed with tuberous sclerosis. The 5 cases of rhabdomyoma evolved according to age, without major cardiac distress and while echo showed mild involution of tumors size without complete disappearance. In one case, color Doppler echo in the neonatal period revealed atrioventricular septal defect with intracardiac masses, 2 of 3 pedicled, non obstructive, pleading for a multiple cardiac fibroma. Not cardiac arrhythmias were detected fetal and postnatal. Conclusions: Conclusions. Cardiac tumors are rarely symptomatic and highlighted in the fetus when the size and position do not interfere with intracardiac hemodynamic, situation when can detect at screening or fetal echocardiography performed for suspected fetal congenital cardiac anomalies. Fetal ultrasound screening and especially at older age of pregnancy may reveal the presence of cardiac tumors, mainly rhabdomyoama, then confirmed by color Doppler echocardiography. Monitoring these tumors both in utero and postnatally to allow early detection of obstructive disorders, with sometimes severe cardiac distress and requiring cardiovascular surgery. Keywords: Presenter: L. Dimitriu

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

ID 156

SPINAL MALFORMATIONS: MRI CONTRIBUTION IN THE PRENATAL DIAGNOSIS A. Korostyshevskaya & A. Savelov MRT Technologies Dept., The Institute International Tomography Center of the Russian Academy of Sciences, Novosibirsk, Russia Brief Introduction: Accurate prenatal diagnosis of spine malformations and associated anomalies is an important medical and social issue, since children born with these defects have a high mortality rate, gross motor and tonic disorders, disorders of pelvic organs, severe pain. The diagnosis of rahishisis and myelo-encephalocele currently presents no special difficulties, but such anomalies as diastematomyelia or ‘‘threatened cord’’ can easily be missed by US only. The purpose of our study is to outline the advantages and to illustrate the original experience of prenatal MRI screening for spinal abnormalities that show the new abilities for more precise diagnoses of diastematomyelia, meningocele and ‘‘threatened cord’’ than those obtained with conventional US only. Materials & Methods: Two pregnant women, 22 and 24 years old underwent fetal US on VolusonÕ 730 Expert with surface abdominal sensor in 2D and 3D sectional planes and render imaging at 12 and 20 weeks of gestation. Chromosomal abnormalities markers and biochemical screening tests performed at 18 weeks were normal. Fetal MRI was performed at 20 weeks of gestation on a 1.5 Tesla Magnet (Achieva, Philips) using Torax-XL coil, SSh-T2-TSE (TE = 100 MC h 80 MC) weighted sequence in addition to sT1-TFE, MRCP and DYN-BFFE sequences. The MRI results were compared with previous US in details. Clinical Cases or Summary Results: In the first case US screening revealed the stable scoliosis in cervical-thorax level with wedge vertebra on the top and wide spinal canal in lumbar region. MRI visualized of the spinal cord duplication, merged with additional intradural lesion and mid located radicular structures distally, proved

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DOI: 10.3109/14767058.2014.924236

the density of intracanal midline structure. The pregnancy was terminated and the morbid anatomy of abortus fully confirmed radiologic prenatal diagnosis of lumbar diastematomielia with wedge vertebra cause cervical-thorax scoliosis. In the second case fetal MRI was done after supposed Spina bifida on US. On fetal MRI the spinal malformation was shown to be not only spine scoliosis and Spina bifida original on lumbar-coccygeal level, but as exposure of the spinal canal and neural elements into the open neural tube defect like multilobal thecal sac extending to the skin. We detected the low position of spinal cord that extends to above described meningocele sac consistent with tethered cord. Conclusions: In cases of fetal spinal structures disorders, results of MRI with additional Cine-technique provide the sufficient information supplement to US findings which may directly affect management or appropriate counseling if performed on the early age of fetal development. Described above cases demonstrate the lack of concordance between US and MRI that should stimulate the obstetricians to be more careful using US as the only one tool of spinal malformations prenatal diagnosis. It is strongly recommended to include fetal MR imaging as a standard tool to clarify the particular variant of spinal dysplasia and to reveal the associated movement disorders, anomalies of brain, genitourinary tract, maternal structures.

fetal moves and NST was pathological. Emergency cesarean section was performed and a female neonate was born at 35 weeks with birth weight 4.410gr, pH of umbilical artery 7.31 and Apgar score 0/(neonate was intubated at the 1st min). Neonate was extremely hydropic, with no vital signs. She underwent active resuscitation and peritoneal and pleural fluid drainage of 500ml. Angoron was administered immediately, propanolole was added on day 2 and on day 3 neonate was on sinus rhythm.He is currently 7 months old, free of symptoms with normal development. Treatment changed to flecainide and atenolole due to increased TSH and recurrent episodes of bronchospasm. Conclusions: Fetuses with arrhythmia should be closely monitored during pregnancy, since, in case of tachycardia, hydrops fetalis may develop in a few days, even late in pregnancy. Decision of when and how to end pregnancy should be taken on the basis of gestational age and the proportion of intervals of tachycardia to normal rhythm during 24hrs. Right timing is crucial given the fact that if neonate receives appropriate antiarrhythmic treatment and is not hydropic prognosis is extremely good. Keywords: fetal arrythmia, hydrops fetalis, fetal dysrythmia Presenter: Evangelinakis Nikolaos

Keywords: fetal MRI, spinal malformations Presenter: A. Korostyshevskaya

ID 903

ACUTE APPEARANCE OF HYDROPS FETALIS IN FETAL DYSRHYTHMIA: CASE REPORT E. Tsekoura1, N. Evangelinakis2, S. Siristatidis2, S. Loukopoulou3, E. Georgantza1, & C. Chrelias2 1 NICU, 3rd Department of Pediatrics Medical School National and Kapodistrian University of Athens, ‘‘Attikon’’ General University Hospital, Athens, and 23rd Department of Obstetrics and Gynecology, Medical School National and Kapodistrian University of Athens,

Brief Introduction: Fetal dysrhythmia complicates 1–2% of all pregnancies. We report a rare case of fetal arhythmia that led to hydrops fetalis late in pregnancy and in rather short interval. Materials & Methods: We present a female neonate born at 35 weeks GA, with severe hydrops fetalis with no vital signs. Clinical Cases or Summary Results: A gravita II woman presented to our Outpatient Department at 9th week of gestation in order to be monitored throughout her pregnancy. She underwent a first ultrasound examination, which detected intrauterine sac, heart beating and confirmed gestational age. Nuchal translucency, nasal bone and Doppler measurements of uterine arteries at 11th week of gestation did not reveal any apparent pathology. Nevertheless, second trimester ultrasound revealed significant dysrhythmia of the fetus (alternations between intense tachycardia and bradycardia). No apparent structural anomalies were detected, thus patient was appointed for a fetal echocardiography. Glucose tolerance test was pathological (183 at 60‘, 162 at 120‘). Fetal heart U/S revealed frequent premature atrial contractions all of which were followed by ventricular contractions. Heart rate was 161–300bpm followed periodically by a transient episode of bradycardia (96bpm). At intervals between episodes of dysrhythmia, fetus had sinus rhythm (146–154bpm) and there were no signs of valve insufficiency, pericardial effusion, ventricular septal defect or heart failure. Patient was appointed to weekly echocardiography to monitor fetal dysrhythmia. Nevertheless she returned 10 weeks later for the third trimester U/S which was normal with no signs of dysrhythmia or hydrops. Finally, patient presented to our casualty due to reduced

ID 403

CONGENITAL LEUKEMIA OF FETUS WITH ACQUIRED AML1 GENE DUPLICATION S.Y. Kang1, Y.J. Lee1, & S.Ch. Kim1 Department of Obstetrics and Gynecology, Pusan National University School of Medicine, Busan, Korea Brief Introduction: Congenital leukemia is very rare, and its prevalence according to recently published papers is from 1 to 5 per million live births. This can be often diagnosed in postpartum throughout bone marrow biopsy, showing abnormal proliferation of immature blasts and granulocytic precursors. Materials & Methods: Hepatosplenomegaly is the only feature, found during perinatal examinations, that diagnosing is difficult during perinatal period. Hepatosplenomegaly can occur not only in congenital leukemia but in many other cases such as infection which is the most common cause. In other words, hepatosplenomegaly is rarely caused from congenital leukemia. Clinical Cases or Summary Results: This case shows the fetus with the features of hepatosplenomegaly during perinatal period and being diagnosed as congenital leukemia associated with acquired AML1 gene duplication in postpartum through bone marrow biopsy. Conclusions: Due to its rare instance, we are to describe the case with a review of literatures. Keywords: Presenter: SCh Kim

ID 296

CASE REPORT: ULTRASOUND & MRI DIAGNOSIS OF JOUBERT SYNDROME R. Cassis-Martinez1, C. Noboa Bejarano2, C.R. Cassis-Phillips3 1

Departamento de Ginecologı´a y Obstetricia, Hospital Clinica Kennedy. Universidad de Guayaquil.Ecuador, 2Departamento de Neurologı´a. OMNIHOSPITAL. Guayaquil – Ecuador, and

108 3

Departamento de Ginecologı´a y Obstetricia, Hospital Clinica Kennedy. Unidad de D

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Brief Introduction: Joubert syndrome is a rare genetic disorder that affects the cerebellum and is characterized by hypotonia, abnormal ocular movement, hyperpnea, developmental delay, hypoplasia of the cerebellar vermis and brainstem mal- formation. Joubert syndrome is estimated to affect between 1 in 80,000 and 1 in 100,000 newborns. The hallmark feature of Joubert syndrome is the ‘‘molar tooth’’ sign, that was first described in 1997, consisting of a triad of malformations including a deepened interpeduncular fossa with narrow isthmus, thickened, elongated and horizontally oriented superior cerebellar peduncles as a result of the absence of normal decussation and a variable degree of vermian hypoplasia, creating an appearance of a molar tooth on ultrasound and axial MRI images. Materials & Methods: Fetal ultrasound and MRI images were used in the diagnosis of Joubert Syndrome.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Clinical Cases or Summary Results: A 28-year-old woman presented in her first pregnancy at 26 + 6 weeks for fetal sonographic assessment. Ultrasound examination showed enlargement of the cisterna magna, vermian hypoplasia and a midline cleft of the midbrain with prominence of the superior cerebellar peduncles, consistent with the ‘‘molar tooth" sign. MRI exams were performed to the newborn confirming the diagnosis of Joubert Syndrome. Conclusions: The prenatal diagnosis of Joubert syndrome using both ultrasound and fetal magnetic resonance imaging (MRI) are good tools to identify this rare disorder. Keywords: ultrasound, fetal, Joubert, syndrome, diagnosis, prenatal Presenter: C.R. Cassis-Phillips

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ID 332

ID 850

INDICATORS OF MICROVISCOSITY AND THE CONTENT OF REDUCED FORMS NADH2 IN THE NEWBORNS ERYTHROCYTE MEMBRANE DEPENDING ON STATUS AT BIRTH

STERNAL CLEFT: A RARE CONGENITAL MALFORMATION

M. Shubina1, S. Tereshchenko1, & V. Manchuk1 1

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Scientific research institute of medical problems of the North, RUSSIA Brief Introduction: At present many researchers are trying to find the connection of various biochemical and biophysical indicators, i.e. the quantitative characteristics of the newborn with his health. In this regard, it is urgent to study biological membranes, such as the primary target of the impact of many pathogenic factors. AIM: to determine the structural-functional features of erythrocyte membranes in newborns depending on their condition at birth. Materials & Methods: It was surveyed 181 newborn, including: 108 with well condition at birth; 73 - with moderate to severe condition. The evaluation of the condition severity was carried out on Apgar scale (8/9 points - well condition; 58/9 points - moderate to severe condition) with subsequent correction based on the monitoring of child during the first 4 days of the life. Biophysical characteristics of membranes was investigated by the fluorescence spectroscopy method on spectrofluorometer «Hitachi MPF-4» (Japan). Was determined by the following parameters of the membranes: 1) the fluidity in the deep layers of phospholipids relative to fluorescence eximer/monomers of pyrene - relative units (RU); 2) the content NAD H2 (units of the fluorescence (UF)). Statistical analysis of the results was implemented in a computer program STATISTIKA 6 using Mann-Whitney test. Quantitative features are presented in the form of medians, intervals from 25 to 75 centile are given in brackets. Clinical Cases or Summary Results: Distinctive feature of newborns with moderate to severe condition at birth were more low indicators of fluidity in the deep layers of phospholipids (0.716 (0.592–0.804) RU), than in newborns with a well condition (0.788 (0.665–0.844) RU, p = 0.004), that, apparently, is connected with change of fatty acid composition of lipids caused by insufficient to fetus polyunsaturated fatty acids in the pathology of pregnancy, as well as activation of lipid peroxidation in the conditions of perinatal hypoxia. In addition, newborns with moderate to severe condition at birth installed decline fluorescence NADH2 (9.0 (8.0–10.6) UF, at 10.1 (9.0–11.4) UF - in newborns with a well condition, p = 0.018), which leads to the reduction of energy processes in the cell. Probably, it is connected with reduction of NAD synthesis from nicotinic acid, the deficit of which is observed in complicated pregnancy, as well as their recyclenet at the «saturation» of double bonds in the fatty acids at conditions of long-term hypoxia. Conclusions: Thus, when assessing the severity of the newborns state as an additional objective criteria, you can use such structuralfunctional changes of erythrocyte membranes, as the increase the viscosity in lipid bilayer on a background of reduction the content of the recovered forms NADH2. Keywords: newborns, erythrocyte membranes, viscosity, NADH2, fluorescence spectroscopy, condition at birth Presenter: Margarita Shubina

J. Methlouthi, S. Nouri1, S. Meddeb2, M. Bellaleh1, H. Ayech1, C.H. Hachani1, A. Ennouri3, N. Mahdhaoui1, & H. Seboui1 1

Neonatology Department F Hached universitary Hospital, Susah, Tunisia, 2G Obstetrics Department F Hached universitary Hospital, Susah, Tunisia, 3Pediatric surgery Department F Bourguiba universitary Hospital, Monastir, Tunisia Brief Introduction: Total or partial cleft sternum is a rare congenital anomaly of the chest wall with a prevalence of 0.15%. It is due to a failure of fusion of the ventral hemi-Sterna normally completed during the third month of embryonic development. Its diagnosis is usually made at birth. Its treatment consists in surgical closure during the first weeks of life. Materials & Methods: Objectives: to describe the clinical features of this rare disease and emphasize the interest of achieving surgery in the neonatal period because of the low risk of compression of underlying organs thanks to chest flexilbility at this age. Clinical Cases or Summary Results: Case report: Newborn female, born to a healthy mother at 42 weeks GA. Antenatal ultrasound was unremarkable. The neonate was admitted at birth for management of incomplete sternal cleft. Clinical examination showed absence of lower part of sternum. Skin was very thin giving way to the perception of cardiac movements. CT scan confirmed the sternal fissure in its 2/3 lower part. Complementary exams included a normal abdominal ultrasound, a normal transfontanellar ultrasound and, a caryotype without anomalies (46 XX). Heart ultrasound showed 3 mm per membranous interventricular communication. The patient was operated on day 12 of life. The intervention consisted of sternal closure through 8 stitches which helped to bring the two sternal edges side by side. The outcome was favorable at age 2 months. Conclusions: Conclusion: Surgical closure of congenital sternal clefts should be undertaken during the first weeks of life in order to protect the heart and great vessels of trauma and to improve respiratory dynamics. Keywords: Presenter: J. Methlouthi

ID 615

PRENATAL SONOGRAPHIC APPEARANCE OF SIGMOID COLON DUPLICATION IN A FETUS AND THE PERINATAL RESULT: A CASE REPORT T. Tsokaki, V. Tsitsis, S. Galanopoulou, M. Tsiamantani, A. Bami, & G. Kousavelou Department of Obstetrics & Gynecology, General Hospital of Pirgos, Peloponnisos, Greece Brief Introduction: Gastrointestinal duplications are rare congenital anomalies of partial or complete parallel growth of a twin segment of intestine, that may be cystic or tubular in form. One of the most widely accepted theories is the abnormality of the embryonic gut, that results in the formation of a diverticulum, a cyst, or twinning of a bowel segment. Enteric duplications typically share a common wall and vascular supply and are either cystic or tubular structures. The wall of the duplication is usually composed of a smooth muscle layer

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covered by an epithelium, mostly of intestinal type. About one third of infants with enteric duplications have associated anomalies. Materials & Methods: A sonogram performed at 35 weeks of gestation at the fetus of a 33 - year old woman (gravida II, para I) revealed a simple spaced cyst 4cm in the abdomen of a female fetus. The cyst was located at the left of the stomach and extended to the pelvis. The cyst was thought to emerge from the left ovary, a theory that was also accepted by the university fetal-maternal ultrasound unit, to which the woman was referred for further evaluation. Clinical Cases or Summary Results: The pregnancy was otherwise uncomplicated and a 3674gr female was born vaginally at 39 weeks. The neonate underwent abdominal ultrasound, which failed to reach a definitive diagnosis. Exploratory laparotomy was performed at 6 days of life, where a duplication cyst in touch with the sigmoid colon was excised. The cyst communicated with the sigmoid colon through a vascular petiole, showing signs of chronic active inflammation, which was also resected and suture of the colon was subsequently performed at this point. A petiolate cystic duplication of sigmoid colon, twisted and necrotic, was considered as the most probable diagnosis after the histopathology. Given the fact that it failed to reveal any epithelium that covered the cystic formation, a more definitive diagnosis could not be established. The infant is today 15 months old and has perfect health. Conclusions: 40% of all enteric duplications are found in the ileum. Less commonly, they involve the colon or rectum (4–18%). For the differential diagnosis, cysts of the ovary, omentum and mesentery are to be considered. The thick muscular wall, present in enteric duplications, helps to distinguish bowel duplication from these other cysts. Surgical excision is almost always required for enteric duplications, not only to make a definitive diagnosis, but also to prevent complications, such as nausea, vomiting, bleeding, perforation, or obstruction. Even though a specific prenatal sonographic diagnosis of colonic duplication is very difficult to make, the prenatal findings can lead to prompt evaluation and early postnatal surgical treatment. Keywords: laparotomy

sonogram,

prenatal,

sigmoid,

duplication,

cyst,

Presenter: T. Tsokaki

ID 609

ENLARGING FETAL AXILLOTHORACIC LYMPHANGIOMA WITH POSTNATAL RESOLUTION S. Iglesias Faustino, M.A. Enrı´quez Grande, E. Cervin˜o Go´mez, & C. Lo´pez Ramo´n y Cajal Unit of Fetal Medicine, University Hospital Complex Vigo, Spain Brief Introduction: Cystic lymphangiomas are the most common forms of lymphangioma. Their incidence at birth has been reported to be 1:6000 and the increased use of prenatal sonography has led to greater prenatal diagnosis of this malformation. Typically, they are found on the neck and the axilla, being three times more frequent those located on the posterior neck. The prognosis of the axillary lesion appears to be less grave tan that located on the neck. Cystic lymphangiomas have been associated with chromosomal abnormalities, structural malformations and intrauterine fetal death. We present a case of a giant axillo-thoracic cystic lymphangioma diagnosed on prenatal sonography, that revealed intrauterine growth, and resulted in the spontaneous resolution of the lesion two months after delivery. Materials & Methods: One case of axillo-thoracic cystic lymphangioma was diagnosed in our Fetal Medicine Unit. All scans

were performed by experienced maternal-fetal medicine physician sonographers using Philips IU-22 ultrasound system (Philips Medical systems). Clinical Cases or Summary Results: A 35-year-old woman, gravida 2, para 0, without family history of congenital abnormalities and unremarkable previous medical history and prenatal course, was referred at 21 weeks to our Fetal Medicine Unit after the prenatal ultrasound showed a cystic mass on the right axillary region. Prenatal diagnosis was based on ultrasonographic imaging of an anechoic cystic mass, without Doppler flux, measuring 44  25 mm on the fetus’s right side involving the right axillary region and the lateral chest wall. No other anomalies were noted. Amniocentesis revealed a normal 46, XX karyotype. After she had been counseled on the possible outcomes and postnatal management, the patient decided to continue the pregnancy. Follow-up ultrasounds which revealed normal fetal growth and steady growing of the axillary cystic mass were done. At 35 weeks the ultrasound confirmed the presence of a large, now multilocular, septate cystic mass located on the right side of the fetal trunk and axilla, measuring 80  70  140mm. The patient was counseled for a cesarean section in view of the large fetal thoracic mass. A cesarean section was performed at 37 weeks, and a female neonate was delivered, weighing 3380g with normal Apgar score. Neonatal physical examination confirmed the presence of a mass (60mm), located on the right thoracic region, and discovered another smaller one (20mm) located on the posterior neck. An MRI was performed after delivery that showed a mixed lesion composed of a large hematoma (70  40mm) and a smaller lymphangioma (20  12mm) located on the right axillary region. Since the infant’s follow-up showed signs of a decreasing mass, a conservative management was advised. The control MRI, performed two months after delivery, confirmed the complete resolution of the lesion. Conclusions: Cystic lymphangiomas are congenital malformations of de lymphatic system resulted from an obstruction of lymphatic vessels leading to the jugular venous system. About 75% of the tumors occur in the neck with prediction for the left side, mainly in the posterior triangle, and about 20% occur on the axilla. Other rare locations include the mediastinum, retroperitoneal area, abdominal viscera, bones, pelvis, groin, scrotum and the chest wall. Postnatal outcome depends mainly on the size, location and, most importantly, on the connections of the lesion with surrounding organs. Lesions located on the posterior aspect of the fetal neck are associated with a higher risk of chromosomal abnormalities, such as trisomy 21 and Turner’s syndrome. Because only small numbers of fetal axillary cystic lymphangiomas have been reported so far, it is uncertain if they carry a marked risk of aneuploidy or poor pregnancy outcome. Traditionally, ultrasonography has been used as the primary screening method, as shows the present case. MRI may be useful in prenatal imaging depending on the location of the lesion, thus providing early comprehensive information about both the anatomy and the extension of the tumor which may be used to prepare for surgery if needed. Surgical excision is the treatment of choice for large lesions. The operation should be as conservative as possible, since these are benign tumors. Other types of treatment have been developed, such as injection of sclerosing agents, which is the one that was proposed at first to this patient as an effective method for treatment after delivery. Conservative management with observation has been recommended in asymptomatic patients, rarely evolving, as in this case, to the spontaneous resolution of the lesion. Keywords: Fetal Lymphangioma, Prenatal Diagnosis, Axillary, Ultrasonography Presenter: S. Iglesias Faustino

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DOI: 10.3109/14767058.2014.924236

ID 233

FETAL INTESTINAL VOLVULUS WITHOUT MALROTATION CURSING WITH ANEMIA AND FETAL DISTRESS DIAGNOSED ON THE 3RD TRIMESTER. A LIFESAVING ULTRASOUND APPROACH

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C. Coutinho1, A. Melo1, B. Nobrega1, L. Sbragia2, A. Berezowski1, & G. Duarte1 University General Hospital, Medical School of Ribeirao Preto University of Sao Paulo. Ribeirao Preto, Brazil 1Department of Gynecology and Obstetrics, and 2Department of Surgery and Anatomy of Medical School of Ribeirao Preto - University of Sao Paul Brief Introduction: Fetal intestinal volvulus is a rare condition that is commonly related with poor fetal prognosis, especially when the diagnosis occurs late in pregnancy or only post-partum. To our knowledge, only three cases previously reported had shown association between intestinal volvulus and fetal anemia, all of

them presenting with ascites, polyhydramnios or hydrops. This case report shows a 3rd trimester ultrasound diagnosis of a previously silent fetal jejunal volvulus complicated by anemia and fetal distress that resulted in a timely life-saving pregnancy resolution. Materials & Methods: Not required for case reports. Clinical Cases or Summary Results: A 33 year-old pregnant woman, G2P1A0, presenting at University General Hospital, Medical School of Ribeirao Preto of University of Sao Paulo with 34 weeks and 4 days. During her prenatal care there were no clinical abnormalities and her 4 previous ultrasounds were considered "normal". The purpose of this appointment was fetal movement decrease for the last 12 hours. The first non-stress test (NST) revealed fetal tachycardia, low variability and absence of fetal movements. Ultrasound scan showed a biophysical profile (BPP) of 4/8 (positive for fetal tonus and amniotic fluid only). Besides that, doppler findings were normal for umbilical (UA) and median cerebral artery (MCA) pulsatility, but MCA peak systolic velocity was on the superior reference of normality. This last finding lead to a complete ultrasound anatomical survey in order to search for causes of fetal anemia, which resulted in the observation of dilated fetal intestine with heterogeneous content and the coffeebean sign, indicative of midgut volvulus. There were no ascites, polyhydramnios or hydrops. A subsequent NST showed the same previous findings added by spontaneous deceleration. Cesarean section was indicated because of fetal distress and anemia secondary to complicated midgut volvulus. The female newborn weighted 2315 g and had APGAR scores of 9 and 10 at minutes 1 a 5, respectively. In the first hours of life the diagnosis of midgut volvulus was confirmed by clinical, radiology and ultrasound examination. Intrauterine anemia was also reassured by postpartum hematocrit of 27. The newborn was submitted to lapatomy with excision of 25 cm of necrotic jejunal segment and done an end-to-end anastomosis. This jejunal volvulus cause was an internal hernia (mesentery defect). No malrotation was observed and cystic fibrosis was ruled out after neonatal screening. After almost 18 months of life the infant is in good health and has no sequels. Conclusions: This case exemplifies the utmost importance of third trimester ultrasound anatomical screening, especially in cases where fetal distress or anemia are suspected. Ultrasound is a tool that, used by well-trained hands and performed in cases of fetal suspicion, can lead to the diagnosis of threatening but potentially treatable malformations, such as this previously silent intestinal volvulus, and indicate timely pregnancy resolution in order to perform life-saving neonatal surgical procedures sparing the lives of many previously undiagnosed children. Keywords: Fetus, midgut volvulus, anemia, fetal distress, prenatal diagnosis. Presenter: C. Coutinho

112

ID 733

HYDRAMNIOS AND PERINATAL OUTCOME J. Cominho, M. Mouraz, S. Saramago, M.I. Reis, S. Proenc¸a, L. Reis, R. Rodrigues, & F. Nunes

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All from HPP Hospital de Cascais Dr. Jose´ de Almeida, Cascais, Portugal Brief Introduction: Hydramnios is an important obstetric complication. This study was conducted in order to determine the causes and perinatal outcome in women whose pregnancy was complicated by hydramnios. Materials & Methods: A hospital based retrospective study was conducted between 1st April 2013 to 31st March 2014. History, clinical examination and relevant investigation were carried out. Clinical Cases or Summary Results: In our feto-maternal medicine unit, there were identified 33 cases of hydramnios. Age range was 17–39 years with average 30.3 years. There were 21 nulliparas (63.6%) and 12 multiparas (36.4%). The last amniotic fluid index evaluated previously of labor, was between 18–41 cm. Two of them (6.1%) had made Prostaglandin synthetase inhibitor (Indomethacin). In 23 cases no etiology could be identified (69.7%). In 5 patients gestational diabetes was present (15.2%). In 4 patients there were congenital abnormalities of the fetus (12.1%). There was one twin pregnancy (3%). 29 patients had labor 437 weeks (89%) with total birth weight between 1685 – 4365, average 3222g. In 3 cases were an apgar score 57 at 5 minute (9.1%). There were no neonatal deaths. Conclusions: In our study, hydramnios was more frequent in nuliparas with the majority of cases with an idiopathic etiology. The majority of cases had a term pregnancy and no neonatal deaths were register. So, despite hydramnios is an important complication, an adequate fetomaternal surveillance can made the prognosis better. Keywords: Hydramnios causes and prognosis Presenter: Joana Cominho

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Materials & Methods: We present a case of isolated pericardial effusion (PE) in the second trimester in a fetus with a subsequent diagnosis of X-linked adrenoleukodystrophy. Clinical Cases or Summary Results: A 26-year-old woman was referred at our ultrasound Department at 17 + 5 weeks of gestation with a diagnosis of pericardial effusion. Fetal echocardiography revealed a small PE of about 3 mm in end-diastole, normal fetal heart structure, rhythm and function. There was no evidence of other structural fetal anomalies or hydrops. Other common causes of pericardial effusion, such as infectious or autoimmune diseases, and chromosomal aneuploidies, were excluded. Further genetic evaluation revealed that the fetus inherited, from the carrier mother, the c.919 C4T mutation in the ABCD1 gene. Parents opted to continue the pregnancy, given the possibility of hematopoietic stem cell transplantation. Serial fetal echocardiography showed a persistent small PE not requiring pericardiocentesis. Conclusions: This is the first reported case of fetal pericardial effusion in association with hypocortisolism from a non-autoimmune cause. We suggest that the hyporcotisolism itself could be one of possible causes of isolated fetal PE. In our case an appropriate genetic counseling could achieve a correct diagnosis even in the absence of a specific ultrasound phenotype. Our observation also suggests that isolated pericardial effusion can constitute an indication to screen for severe metabolic disease. Keywords: prenatal diagnosis; fetal pericardial effusion; ultrasound; adrenoleukodystrophy Presenter: Viola Seravalli

ID 914

FETAL DIGESTIVE TRACT IMAGING A. Ben Salem1, F.Z. Chioukh2, A. Khalfalli1, K. Ben Ameur2, H. Elmhabrech1 K. Monastiri2, & C. Hafsa1 1 2

ID 727

ISOLATED PERICARDIAL EFFUSION IN THE SECOND TRIMESTER OF PREGNANCY AND PRENATAL DIAGNOSIS OF X-LINKED ADRENOLEUKODYSTROPHY V. Seravalli1, E. Andreucci2, S. Giglio2, R. Biagotti1, & E. Cariati1 1 Medical Surgical Fetal-Neonatal Department, ‘‘A. Meyer’’ University Children’s Hospital, Florence, Italy, 2Medical Genetics Unit, Meyer Children’s University Hospital; Florence, Italy

Brief Introduction: Adrenoleukodystrophy is a recessive genetic disorder caused by an abnormality in the ABCD1 gene on the X chromosome. It is characterized by elevated levels of very long chain fatty acids in the serum, brain, and adrenal glands leading to neurodevelopmental impairment and decreased adrenal function.

Radiology Dept, University Hospital of Monastir, Tunisia, and Neonatology Dept, University Hospital of Monastir, Tunisia

Brief Introduction: The exploration of the fetal digestive tract is not systematized and the ends (thoracic oesophagus and anorectal area) are often excluded from the examination excluded from screening. In this paper, we review the normal appearance of the fetal bowel on US and MRI as well as the typical presentations of bowel pathologies. Materials & Methods: study and litterature review of foetal digestive tract pathology. Ultrasonography and MRI were used to identify aethiology in antenatal and postnatal period. Clinical Cases or Summary Results: The most frequent digestive pathologies (oesophagus atresia, anorectal malformation) are still very often a neonatal discovery. the foetal digestive pathology of liquid expression (digestive obstruction, digestive duplication) is the most detected in prenatal period. With echography or MRI, the antenatal analysis of the digestive tract is optimized by the acquisition of coronal (thoracic oesophagus, small intestine, and colon) and sagittal median cuts (rectal reference mark, sacral concavity). MRI is most useful when US has detected or suspected anomalies, and more anomalies are detected when MRI and US findings are assessed together. Conclusions: Foetal anomalies of the digestive tract are numerous and dominated by malformations, the prognosis of which may be severe. Antenatal diagnosis of these anomalies allows a better management of neonates. Keywords: Prenatal diagnosis, Digestive tract anomalies; Fetal MRI; Ultrasound Presenter: FZ.Chioukh

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DOI: 10.3109/14767058.2014.924236

ID 927

CAUDAL REGRESSION SYNDROME: A CASE OF EARLY PRENATAL DIAGNOSIS WITHOUT MATERNAL DIABETES M. Mouraz1, J. Cominho1, S. Saramago1, M.I. Reis1, S. Proenc¸a1, J. Pauleta1, C. Gameiro1, S. Pedroso1, J. Colac¸o1, R. Rodrigues1, F. Nunes1, & I. Serrano2

The parents choose for the interruption of the pregnancy. Radiologic studies and autopsy findings of the fetus confirmed the diagnosis. Conclusions: The authors concluded that this syndrome can be diagnosis sooner than is described in the literature and may be seen without any risk factors. Diagnosis is usually made by visualizing a shortened spine with missing sacral and lower lumbar vertebrae. Early diagnosis gives parents time to make informed decisions. Keywords: caudal regression syndrome, prenatal ultrasound, early diagnosis Presenter: M. Mouraz

1

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Obstetrics and Gynecology Dept., Hospital Dr. Jose´ de Almeida, Cascais, Portugal, and 2Anatomic Pathology Dept., Hospital Dr. Jose´ de Almeida, Cascais, Portugal Brief Introduction: Caudal regression syndrome (CRS) is a rare and severe syndrome in which a segment of the lumbo sacral spine and spinal cord fails to develop. It results from a disturbance in the fetal mesoderm in early pregnancy - 54th week of gestation. CRS is generally diagnosed at prenatal assessment, generally in the second trimester. Maternal diabetes, genetic predisposition and vascular hypoperfusion have been suggested as possible causative factors. Materials & Methods:. Clinical Cases or Summary Results: We reported a case of CRS diagnosed at 16 weeks’ of gestation. There was no history of maternal diabetes. Prenatal ultrasound examination revealed a sudden interruption of the spine, hypoplasic and fixed lower limbs with club feet.

ID 928

A RARE CASE OF BODY STALK ANOMALY WITH ABDOMINAL AND FACIAL DEFECTS – NON SPECIFIC PHENOTYPE M. Mouraz1, S. Saramago1, J. Cominho1, S. Proenc¸a1, M.I. Reis1, G. Ladeira1, M. Antunes1, S. Pedroso1, J. Colac¸o1, R. Rodrigues1, F. Nunes1, & I. Serrano2 1 Obstetrics and Gynecology Dept., Hospital Dr. Jose´ de Almeida, Cascais, Portugal, and 2Anatomic Pathology Dept., Hospital Dr. Jose´ de Almeida, Cascais, Portugal

Brief Introduction: Body stalk anomaly is a sporadic developmental abnormality reported to have an incidence of 1 in 7500 fetuses at 10–14 weeks of gestation. Several authors have described two clearly distinguishable phenotypes as a consequence of different pathogenetic mechanisms: the ‘‘placento-cranial’’ phenotype, with craniofacial defects, amniotic bands and/or adhesions, which can be related to an early vascular disruption and the ‘‘placenta-abdominal’’ pheonotype, with no craniofacial defects but urogenital anomalies, anal atresia, abdominal placental attachment, together with persistence of the extra-embryonic celomic cavity probably attributable to an intrinsic defect in embryonic development. Materials & Methods:. Clinical Cases or Summary Results: We describe a case of body stalk anomaly diagnosed at 12 weeks of gestation. The fetus was visualized in a fixed position with a major anterior abdominal wall defect herniated viscera adherent with placenta into the extra-embryonic celomic cavity and severe kyphoscoliosis and rudimentary umbilical cord. The diagnosis was confirmed by pathological examination after termination of the pregnancy at 14 weeks of gestation. The autopsy found limb and facial abnormalities undetected by the ultrasound: club feet, cleft lip and retromicrognathia. Conclusions: The typical defects of body stalk anomaly can be detected by ultrasound in the first trimester, which is important in patient management, since body stalk anomaly is incompatible with life. Postmortem examinations of fetuses have interest to find other abnormalities and helped predicting the etiology. Keywords: Body stalk anomaly, first trimester diagnosis, fetal autopsy findings Presenter: M. Mouraz

ID 942

FETAL HYPERECHOGENIC KIDNEY F.Z. Chioukh1, A. Ben Salem1, O. Jbara2, A. Khalfalli2, H. Elmhabrech2, K. Monastiri2, & C. Hafsa2 1

Neonatology Dept, University hospital of Monastir, Tunisia, and 2Radiology Dept, University hospital of Monastir, Tunisia

114 Brief Introduction: To evaluate the prenatal diagnosis and the prognostic value of ultrasound in case of fetal hyperechogenic kidneys. Materials & Methods: Retrospective study of cases of hyperechogenic kidneys. The clinical and ultrasound data were compared to the postnatal follow-up and the long-term prognosis. Clinical Cases or Summary Results: The aetiologies are 04 cases of recessive polycystic kidney diseases, three case of dominant polycystic kidney, Meckel-Gruber syndrome in one case. No renal ultrasonographic criterion is specific of aetiology. three pregnancies were terminated, three were interrupted. Conclusions: The fetal kidneys characteristics on prenatal ultrasound fail to provide an accurate etiological diagnosis. Only congenital defects and family history adjust the aetiology. Amniotic fluid volume and fetal kidney size are the best prenatal predictors of outcome. Keywords:

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Presenter: F.Z. Chioukh

ID 339

A CASE OF PROTRUDING MASS IN PHILTRUM DIAGNOSED BY PRENATAL 3D ULTRASONOGRAPHY: BILATERAL CLEFT LIP & PALATE OF FETUS S. Hong1*, W. Park2*, J. Hwang3, H. Lee3, D. Lee3, S. Na3# 1

Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon 200-701, South Korea, 2Department of Physiology, School of Medicine, Kangwon National University, Chuncheon 200-701, South Korea, and 3Department of Obstetrics and Gynecology, Kangwon National University Hospital, School of Medicine, Kangwon National University, Chuncheon 200-701, South Korea

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Brief Introduction: Cleft lip and palate is the most common deformity of head and neck and is next common anomaly than talipes valus of fetus. About 50% of cleft lip and palate occur together in 20% of the cleft lip occurs alone, and 30% in cleft palate occurs alone. It is occurs at a higher in Asia and more frequently occur in boy. Unilateral cleft lip and palate is the most common and severe case, which shows a distinct difference in shape of the nose having prominent twisting and depression. In addition, it was projected forward in the soft tissue of the significant distorsion of all bilateral cleft maxillary protrusion. Nasopharyngeal teratoma (Epignathus) may be confused with it. Materials & Methods: We examined by ultrasonogrpahy. Clinical Cases or Summary Results: This case is pregnancy at 33 weeks woman was transferred from a private clinic. Fetus is examined by ultrasonography. Result of examination is mass protruding area around showing mixed shades and 2.05*1.47cm size. Color Doppler sonography showed no blood flow waveform. Continuous follow-up was performed and at 38 weeks 5 days of pregnancy, boy was delivered by spontaneous vaginal delivery. In plastic surgery, the baby is under observation after corrective surgery. Conclusions: We report bilateral cleft lip and palate that is a case of protruding mass in philtrum diagnosed by prenatal ultrasonography. After success delivery, baby is completely corrected. Keywords: cleft lip and palate, epignathus, 3D ultrasonography Presenter: S. Na *These authors contributed equally to this work #Corresponding author.

ID 225

TERATOGENIC RISK FACTORS AND PREGNANCY EVOLUTION E. Crauciuc1, D. Crauciuc1, M. Bratu2 1

’’Gr.T.Popa’’ University of Medicine and Pharmacy Ia¸si, ‘‘Elena Doamna’’ Clinical Hospital of Obstetrics-Gynecology Ia¸si, and 2 ’’Sf. Apostol Andrei’’Emergency Hospital Gala¸ti Brief Introduction: Among the toxins contained in tobacco, nicotine and carbon monoxide are the ones with negative effects on the body of the embryo or the fetus. They pass in the developing body of the baby thanks to placental circulation and causes unwanted effects. Alcohol is a physical and behavioral teratogen which is one of the main causes of mental retardation in the world. Human fetal exposure to alcohol during its embryonic and/or fetal period leads to the birth of a child with fetal alcohol syndrome, which includes: pre-and/or postnatal retard of global growth, characteristic facial dysmorphia, associated malformations, neurologic impairment with microcephaly. Materials & Methods: The research included 205 pregnant women who were hospitalized in ‘‘Elena Doamna’’ Clinical Hospital of ObstetricsGynecology Ia¸si, over a period of time of 5 years (2009–2013). During the research the following have been met: the ethical collaboration with other physicians involved in the management of these cases, a non discriminatory attitude, without unprofessional judgments, the confidentiality of medical documents and personal data, except the statistical data included in the study. The questionnaire filled by the patients aimed the identify the presence of some teratogenic risk factors for the evolution of pregnancy and for the new-born. The share of women who voluntary exposed themselves to a toxic teratogen during pregnancy showed: exposure to nicotine – 25.4%, alcohol – 9.8% and professional toxic – 5.4%. The epidemiological study was a prospective one, case-control type. The data was processed with SPSS 13.0 statistical techniques. Clinical Cases or Summary Results: Age distribution of pregnant women in the study group, shows a higher frequency of pregnant women aged 20–29 (52.2%), those living in towns (78%), married (93.2%). According to the cases studied, 55% of the pregnant smokers had premature labour, and the children born by smoking mothers had an APGAR score57 (26.9%) and also their weight under 2700 g

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(46.2%). 95% of the children with mother who drank alcohol during pregnancy, had their weight at birth under 2700 g, and 30% of them had an APGAR score57. Premature labour was identified for 36.4% of the patients exposed to toxic emissions. 27.3% of the children whose mothers were exposed to professional toxic substances during pregnancy were under 2700 g at birth and 9.1% of them had an APGAR score57. Conclusions: Complications during pregnancy (hypertension, gestational diabetes, complications), were significantly more in smoking patients (p50.05). The relative risk of premature birth was over two times higher for pregnant smokers (RR = 2.25). 25% of patients exposed to alcohol and all the patients exposed to occupational pollutants had complications in pregnancy. Keywords: Teratogenic risk factors

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Presenter: E. Crauciuc

ID 931

FETAL KIDNEY: NORMAL AND PATHOLOGICAL FEATURES A. Ben Salem1, F.Z. Chioukh2, K. Mraidha1, O. Bradii1, K. Ben Ameur2, H. Elmhabrech1, K. Monastiri1, & C. Hafsa1 1

Radiology Dept, University Hospital of Monastir, Tunisia, Neonatology Dept, University Hospital of Monastir, Tunisia

2

Brief Introduction: Development of the urogenital system in humans is a complex process; consequently, renal anomalies are among the most common congenital anomalies. The aim of this paper to study the complementary diagnostic value and role in the perinatal management of foetal MRI in the prenatal diagnosis of abnormalities of the urinary tract Materials & Methods: retrospective study and litterature review of cases of fetus with renal anomalies. ultrasound and MRI were used to identify aethiology in antenatal and postnatal period Clinical Cases or Summary Results: Approximately 50% of fetal abdominal masses originate in the urinary system and those recognizable ultrasonically include renal dysplasia, renal agenesis and obstruction of the lower excretory channels. Fetal renal anomalies may be discovered co-incidentally during the course of sonographic evaluation of uterine size-dates discrepancy, because they are commonly associated with fetal growth retardation and/or oligohydramnios, or during a planned sonographic follow-up of pregnancies in patients who are at risk of recurrence of such anomalies. The sonographic demonstration of renal anomalies under these circumstances may allow for elective termination of pregnancy, may modify the obstetric management and/or facilitate pediatric and surgical care of the newborn. Conclusions: fetal renal anomalies can be accurately diagnosed and classified in the antenatal period using ultrasonography imaging and MRI. Antenatal diagnosis is a helpful tool in planning immediate postnatal care and deciding the place for delivery Keywords: Presenter: F.Z. Chioukh

ID 806

ROBERTS SYNDROME. A CASE REPORT AND REVIEW OF LITERATURE Razvan Socolov1, Oana Neumann1 (P), Ana Haliciu2, Vlad Gorduza3, Florentin Dumitrache1, & Raluca Balan4

1

Department of Obstetrics Gynecology, University of Medicine and Pharmacy ’’Gr. T. Popa’’ Iasi, Romania, 2Hospital of Obstetrics Gynecology ‘‘Elena Doamna’’ Iasi, Romania, 3 Human Genetic Department, University of Medicine and Pharmacy ‘‘Gr. T. Popa’’ Iasi, Brief Introduction: Roberts syndrome is a rare disease, there are only around 150 cases described in literature. We present such a case. It is a 17 year old 1GIP presenting at 38 weeks with intrauterine fetal demise. The pregnancy was not followed due to socioeconomic and family situation, and no prenatal ultrasound was made. After a normal length labor she delivered a 2650 gr male deceased fetus, with several morphological abnormalities and tight double umbilical abdominal loop. The macroscopic evaluation showed: dolichocephaly, hypoplastic inferior maxilla with micrognathia, antimongoloid palpebral slant, pterygium colli, abnormal and lower implanted ears, superior limbs phocomelia, syndactyly at lower left limb and tetradactily in all limbs, bilateral cryptorchidism. Materials & Methods: Case report. Clinical, genetic and pathologic exams. Clinical Cases or Summary Results: Further investigations of the parents are in progress. Conclusions: We believe this case is an argument towards introducing ultrasound screening compulsory to all pregnancies. Keywords: Roberts abnormalities

syndrome,

prenatal

ultrasound,

genetic

Presenter: Oana Neumann

ID 349

FIRST TRIMESTER DIAGNOSIS OF CANTRELL PENTALOGY: A CASE REPORT E. Ozcimen1, A. Gurbuz2, & N. Ozcimen3 1

Perinatology Dept, University Hospital of Baskent University, Turkey, 2IVF Department, Nova Fertil, Turkey, and 3 IVF Department, Medicana Hospital, Turkey Brief Introduction: ABSTRACT: Pentalogy of Cantrell is a rare syndrome with a deficiency of anterior diaphragm, a midline supraumbilical abdominal wall defect, a defect in the diaphragmatic pericardium, various congenital intracardiac abnormalities and a defect of the lower sternum. Herein a fetus with Cantrell Pentalogy who was diagnosed in the first trimester was presented and discussed in the light of the literature. Materials & Methods: INTRODUCTION: Pentalogy of Cantrell was described in 1958 by Cantrell. It was named as pentalogy because of the presence of five major malformations, which include a midline, upper abdominal wall abnormality, lower sternal defect, anterior diaphragmatic defect, diaphragmatic pericardial defect and congenital heart abnormalities (1,2). By the time the classification of the syndrome was suggested as class 1, definite diagnosis with 5 defects; class2, diagnosis with 4 defects and class 3, incomplete expression (3). Clinical Cases or Summary Results: CASE REPORT: A-30-year-old woman, gravida 1, para 0, presented to our hospital’s perinatology unit for a routine obstetric scan in the 11th week of gestation. Of note, her history and prenatal course were unremarkable up to this point. On sonographic evaluation, the fetus had 7 mm nuchal translucancy, large supraumbilical omphalocele (3  5 cm approximately), ectopia cordis, diaphragmatic defects. (Figure). After chorion villus sampling (CVS) therapeutic abortion was performed.

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ID 224

THE SCREENING OF CONGENITAL HEART DEFECTS IN NEWBORNS E. Crauciuc1, A. Rugina2, & D. Crauciuc1

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

1 ’’Gr.T.Popa’’ University of Medicine and Pharmacy Ia¸si, ‘‘Elena Doamna’’ Clinical Hospital of Obstetrics-Gynecology Ia¸si, and 2’’Gr.T.Popa’’ University of Medicine and Pharmacy Ia¸si, ‘‘Cuza Voda’’ Clinical Hospital of ObstetricsGynecology Ia¸si

The fetus and placenta were submitted for postmortem examination. Autopsy revealed a male fetus with cardiac anomalies, including hypoplastic left ventricule, sternal defect, abdominal wall defect and cleft palate. CVS result was normal. Conclusions: DISCUSSION: The pentalogy of Cantrell (PC) is a rare syndrome with an estimated incidence of 5.5 per 1 million live births (2, 4). It is described as a deficiency of anterior diaphragm, a midline supraumbilical abdominal wall defect, a defect in the diaphragmatic pericardium, various congenital intracardiac abnormalities and a defect of the lower sternum. The pathogenesis of Cantrell is not known exactly. Cantrell et al suggested an embryologic developmental failure of a segment of the lateral mesoderm (5, 6). The etiology of PC is also not known. Most cases are sporadic and no recurrences have been reported. The is male dominance with a male to female ratio of 2.7/1. (7) Our case was male and sporadic similar to the literature. In our case all the five compenents of the syndrome were observed. Cleft palate would not be diagnosed by ultrasound antenatally because of the difficulties of the first trimester diagnosing of the cleft palate. In the literature not so many cases were reported in the first trimester by using two-dimensional-ultrasound. Peixoto-Filho et al reported two cases at 10th and 11th weeks of gestation in which the patients were preffered to terminate thier pregnancies just like in our case. (8) Most of the cases in the literature diagnosed in the second trimester (9,10). There are also cases which were diagnosed after birth in newborn period (11,12). Magadum S et al reported a case of 11-year-old with incomplete PC (13). In recent years 3D sonography is used widely also in diagnosing PC. It has been also suggested that magnetic resonance imaging (MRI) and prenatal fetal echocardiography provide optimal assessment of fetuses with this syndrome (10). However, in PC large defects are observed in cases so 2D sonography can be enough to diagnose the pentalogy just like in our case. In conclusion when a case with omphalocele and cardiac abnormalities are observed on ultrasound, pentalogy of Cantrell should be remembered. A 2D sonography with high resolution can be enough to diagnose the pentalogy in the first trimester. Keywords: Cantrell Pentalogy, Congenital cardiac abnormalities, Abdominal wall defect Presenter: Emel Ebru Ozcimen

Brief Introduction: Introduction. Congenital heart defects are the most frequent congenital pathology met in newborns. The perspective of the newborns with congenital heart defects (CHD) has significantly improved over the last 50 years. Presently, about 1 million infants with significant congenital heart defects survive till adulthood. CHD treatment implies medical treatment, which aims to prevent or treat the complications of CHD (heart failure, hypoxic crises, pulmonary hypertension - PH, infective endocarditis, arrhythmias, pharmacological manipulation of the arterial ducts) and palliative or corrective surgery. Materials & Methods: The study group was made of 127 newborns in ‘‘Cuza-Voda˘’’ Maternity in Ia¸si. Methods of inclusion in the study group: newborns with cyanotic CHD, those seem to have unsatisfactory post operator results. The screening aimed to identify extra cardiac diseases in term infants. They occur with decreasing SaO2 (pneumonia, sepsis, meconium aspiration syndrome, pneumothorax, and hemoglobinopathies). The study was retrospective, starting from the already established disease we pursue the clinical and evolutionary particularities based on the production mechanism, precocity of diagnosis and establishing the therapy depending on the influence of risk factors and the treatment received. Clinical Cases or Summary Results: When a potentially lethal CHD is suspected in the newborns with a critical condition, showing shock, pulmonary edema or cyanosis pediatric cardiology consultation should be carried out in emergency. Prenatal diagnosis was established for 8.7% of the subjects, without significant differences depending on the severity of CHD (p = 0.596). In severe cases of CHD, the disease onset was, mainly, in the first day, while in the less severe cases this onset happened in the fourth day (p = 0.001). The early symptoms, for the patients with severe CHD showed mainly a generalized cyanosis (64.9%) and/or heart murmur (40.5%), while the patients with less severe CHD show a significantly more increased heart murmur in the beginning (93.3%) (p = 0.001). The presence of edema was significantly increased in patients with severe CHD (p = 0.001), where the edema was manifested especially after the 5th day. Severe CHD cases also showed systolic blood pressure, peripheral circulatory disorders, hepatomegaly and feeding difficulties, overlapping an associated respiratory pathology. For the treatment of heart failure in children 3 classes of drugs have been used: inotropic agents, diuretics, drugs that reduce afterload. The prognosis was favorable for 83.5% in children between 0–1 years old. Conclusions: Fetal circulation allows the fetus with severe CHD to survive, the disease being well tolerated in the intrauterine life, but fatal after birth, because of the lack of a promptly applied therapy. 16.5% of the children with CHD died, the most frequent cause being the cardiac one (11%). Severe congenital heart diseases remain the first cause in neonatal mortality. Keywords: Congenital heart defects Presenter: E. Crauciuc

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ID 512

ANTENATAL FETAL DEATH: THE ROLE OF INFECTIONS A. Strizhakov, I. Ignatko, & J. Popova

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Obstetrics, Gynaecology and perinatology department, First Mosow Medical University I.M.Sechenov, Moscow, Russia Brief Introduction: At present, the antenatal fetal death (AFD) remains one of the global problem of practical obstetrics, socially relevant and understudied. AFD has got the diverse etiology, but often etiological factors have clinical manifestations prior to pregnancy. Despite the use of modern techniques in the estimation of fetal status and condition during pregnancy, identifying the underlying cause remains a challenge in 60% of stillbirths. Found that AGW is one of high risk factor for adverse outcomes in subsequent pregnancy, high neonatal and infant morbidity and mortality. In practice, there is no algorithm of complex obstetrics pregravidal survey of women with this problem to subsequent pregnancy. Materials & Methods: Clinical retrospective-prospective study was conducted in two stages. Stage I - a retrospective survey of 60 women with singleton pregnancies, ended AFD in time from 22 to 41 weeks, to identify high risk factors for antenatal losses, to estimate of the complications of pregnancy, which ended AFD, to estimate the results of the morphology of the placenta and autopsy stillborn. Stage II prospective pregravidal comprehensive laboratory and instrumental examination to detect the risk of recurrent reproductive losses in the prospective group, which comprised 45 women retrospective group who were planning a pregnancy and who have agreed to participate in the study. The control group consisted of 30 women without a history of somatic and obstetric- gynecological problems. At the stage of the surveys were conducted a retrospective study of women, the analysis of the stories of pregnancy and childbirth, discharge summaries, extracts from reports of autopsy and morphological study of the placenta. Investigation of infectious status included: microscopic examination of vaginal smears; bacteriological examination for flora content of the cervical canal; PCR diagnosis of cervical content to identify genomic fragments C. trachomatis, M. genitalium, M. hominis, U. urealiticum, HSV type I and II, CMV, HPV; study TORCH- infections. Clinical Cases or Summary Results: We could find the different factors influencing on the pregnancy when analyzing the pregnancy ended AFD: in 9.8% of pregnancies occurred as a result of ART, 13% identified defects antenatal care, 80% - completed an incomplete set of standard examinations during pregnancy. In 11.3% of pregnant women have suffered genital infections in 21% - viral respiratory infections. In 46.7% in terms of AFD occurred 29–37 weeks of gestation. Investigation of infectious status included: microscopic examination of vaginal smears; bacteriological examination of the flora content of the cervical canal; PCR diagnosis of cervical content to identify genomic fragments C. trachomatis, M. genitalium, M. hominis, U. urealiticum, HSV type I and II, CMV, HPV; study TORCH- infections. Autopsy of the stillborns and morphological studies confirm the high frequency of placental morphological signs of chronic placental insufficiency (92%), low level of compensatory-adaptive reactions in the placenta (9.7%). With increasing gestational age of fetal death incidence of inflammatory changes in the placenta was significantly reduced from 67% in the II trimester to 27% in III trimester, and the frequency of hypoplastic placenta increases from 22 to 37 weeks of gestation. Phase II was a comprehensive laboratory and instrumental examination in preparation for a subsequent pregnancy in women with previous antenatal losses (prospective group, n = 45) and identified risk factors for recurrent reproductive loss. At 64.4% in the prospective group identified genital infections that 16.3 times more likely than the control group. In the prospective group, 46.6% infringements microcenosis vagina submitted by excessive growth of opportunistic mycoplasmas M. hominis and Ureaplasma spp. (26.6%), non-specific vaginal microflora (facultative anaerobic gram-positive cocci and enterobacteria) (20%), accompanied by clinical and

laboratory signs of inflammation of the lower parts of the reproductive system. Bacterial vaginosis associated with Gardnerella vaginalis - 13.3%, viral genital infections, combined with the clinic exo/endocervicitis - 11%, chlamydial infection - 6.7%; vulvovaginal candidiasis - 13.3% were identified only in prospective group. Only in prospective group in 42.2% identified genital mixed infection. In the control group revealed a 10% carrier opportunistic mycoplasmas was regarded as a variant of vaginal normotsenoza. Also in the prospective group, 8.97 times more frequently found to have elevated titers of IgG antibodies to three or four infections TORCHcomplex. During pregnancy, 17% of pregnant women revealed repeated violations microcenosis vagina successfully treated before pregnancy. 100% of violations microcenosis manifested by excessive growth of nonspecific microflora, mainly detected in II trimester and accompanied by clinic of threatening abortion. Conclusions: Thus, pregravid training for women with fetal death should include complex therapeutic interventions: assessment of microcenosis birth canal and infection status of women, as well as the treatment of urogenital infections (eradication of pathogenic and conditionally pathogenic vaginal flora; restoration of normal vaginal biocenosis; immunotherapy). Keywords: antenatal fetal death, infections, preconceptional care Presenter: A. Strizhakov

ID 936

KYPHOMELIC DYSPLASIA: A RARE FORM OF SKELETAL DYSPLASIA S. Meddeb1, M.S. Rhim1, J. Mathlouthi2, S. Mili1, H. Saidi1, & H. Khairi1 1

Department of gynaecology obstetrics university hospital Farhat Hached Sousse Tunisia, and 2Department of neonatal medecine university hospital Farhat Hached Sousse Tunisia Brief Introduction: Kyphomelic dysplasia has been reported as rare form of generalized skeletal dysplasia bone dysplasia with few cases described in the literature. We present the clinical, radiological and pathological findings of an antenatally detected male affected with this disorder. Materials & Methods: We present the clinical, radiological and pathological findings of an antenatally detected male affected with this disorder. Clinical Cases or Summary Results: The fetus was delivered at 24 weeks’ gestation, with birth weight 468g.The fetus was observed to have flattened nose, severe micrognathia and small ears slightly low.The long bones were bowed and short, femora seem to be the most severely affected. Conclusions: The above findings based on morphology and radiography concurred with diagnosis of kyphomelic dysplasia. Keywords: Kyphomelic dysplasias; keletal dysplasia bone dysplasia; antenatal diplasia; Presenter: S. Meddeb

ID 787

FETAL VENTRICULOMEGALY REVIEW C. Alvarez, S. Soldevilla, & C. Vivas Gynecology and Obstetrics Dept., Hospital SAS Jerez, Ca´diz, Spain

118 Brief Introduction: Ventriculomegaly is the descriptive biometric term expressing enlargement of the lateral ventricles in the brain. Its incidence is uncertain, but it is estimated that around 0.3 and 1.5 of 1000 fetuses are affected. Materials & Methods: We present a review of clinical cases in which ventriculomegaly was detected on prenatal ultrasound and observation of postnatal evolution performed in our centre. Clinical Cases or Summary Results: Fetal ventriculomegaly is one of the most sensitive markers of developmental abnormality of the central nervous system, so that measurement of the lateral ventricles becomes part of prenatal ultrasound regardless of gestational age. Its onset can occur at any gestational age and can affect both or only one of the lateral ventricles. Conclusions: It is important to note that this is not just a diagnosis, but a common feature shared by diverse pathological conditions of the central nervous system.

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Keywords: Presenter: Carmen Alvarez

ID 786

ANTENATAL HYDRONEPHROSYS REVIEW C. Alvarez, S. Soldevilla, & M.M. Alcala Gynecology and Obstetrics Dept., Hospital SAS, Jerez, Ca´diz, Spain Brief Introduction: Dilation of the renal pelvis is the most commonly detected anomaly published in prenatal diagnosis. Materials & Methods: We present a review of clinical cases accounting for prenatal diagnosis of hydronephrosis that have been performed in our centre. Clinical Cases or Summary Results: On a practical level, we speak about ectasia when the renal pelvis is inferior to 10 mm its anterioposterior diameter and about hydronephrosis when it is superior to 10 mm. The aim of prenatal diagnosis is to define the criteria that best match the renal function in postnatal life or the need for surgery. In the case of hydronephrosis the renal calices may or may not be dilated. The typical sonographic appearance is that of several interconnecting cystic images, and the parenchyma may have a normal or abnormal appearance. Conclusions: The differential diagnosis is done primarily by using multicystic renal dysplasia, where cysts are not communicated, and with renal cysts and urinomas. Keywords: Presenter: Carmen Alvarez

FETAL GROWTH RESTRICTION ID 777

FETAL FAT INDEX (FFI) REFERENCE RANGES: A SIMPLE METHOD TO ASSESS LIMB FAT C. Knight1,2, S. Rueda2, M. Ahmed2, K. Edwards1, J. Noble2, & A. Papageorghiou1 1

Nuffield Department of Obstetrics & Gynaecology, University of Oxford, Oxford, United Kingdom, and 2Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Brief Introduction: Previous preliminary work showed the potential use of the Fetal Fat Index (FFI): a quick, simple, multiple-sample method of arm fat thickness which was more representative than singlesampling and correlated well with fetal arm fat area. We tested FFI in a larger cohort, and compared with 3D volumes. Our aims were to develop a simple technique to assess fetal limb fat, and produce reference ranges for future research. Materials & Methods: Axial mid-humeral volumes from 19–40 weeks’ gestation were acquired in optimally healthy pregnant women from Oxford, UK (INTERGROWTH-21st study). A specifically-designed MATLAB tool (based on Lee et al’s 50% fractional limb volume) enabled fat volume assessment. Lean volume (muscle and bone) was subtracted from limb volume to give fat volume. The central, perpendicular 2D slice was extracted and fat depth measured at 9, 12 and 3 o’clock positions (6 o’clock position was obscured by humeral acoustic shadow). The measurements were added to give the arm FFI value. Fat volume and FFI were compared using Pearson’s correlation coefficient. FFI 3rd, 50th and 97th centiles were calculated using polynomial regression. Clinical Cases or Summary Results: 504 scans were measured from 208 women. There was a positive correlation between fetal arm fat volume and FFI (r = 0.93; r2 = 0.86), suggesting FFI’s potential as a quicker, 2D-based surrogate for fat volume. The mean difference in fat depth was 2.6mm (range 0–16.6mm). FFI reference ranges were calculated: 50th centiles 2.6mm at 19 weeks to 20.4mm at 41 weeks. Conclusions: FFI is a quick, simple method of fetal arm fat assessment in the second and third trimesters and correlates well with 3D fetal arm fat volume measurements. Reference ranges have been calculated from a healthy population to aid future research with this technique. Keywords: fetal; fat; arm; 3D ultrasound; second trimester; third trimester Presenter: C. Knight

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ID 372

AMNIOTIC FLUID ERYHTROPOIETIN IN PREGNANCIES COMPLICATED BY INTRAUTERINE GROWTH RETRICTION: CASE SERIES FROM A TERTIARY TEACHING HOSPITAL L. Seikku, L. Rahkonen, M. Tikkanen, K. Teramo, V. Stefanovic, & J. Paavonen

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Department of Obstetrics and Gynecology, Helsinki University Central Hospital, Helsinki, Finland Brief Introduction: Intrauterine growth restriction (IUGR) affects up to 10% of pregnancies. IUGR is associated with stillbirth, prematurity, intrauterine hypoxia, meconium aspiration, and long-term adverse outcome such as cognitive dysfunction and cerebral palsy. Timing of delivery in preterm pregnancy with severe IUGR is challenging. Many methods are used in surveillance of IUGR fetus, including biophysical profile and doppler velocimetry. One of the biomarkers of chronic fetal hypoxemia is erythropoietin (EPO) in the amniotic fluid. EPO is the primary regulator of erythropoiesis, and hypoxia strongly stimulates EPO synthesis. Objective of the study was to evaluate amniotic fluid EPO (aEPO) concentrations in preterm IUGR pregnancies, and to evaluate whether aEPO predicts neonatal primary outcome. Materials & Methods: Amniocentesis was performed in 66 pregnancies with growth restricted fetus (-2 SD) between 24 and 34 weeks of gestation. Concentrations of aEPO were quantitated with immunochemiluminometric assay. Normal aEPO was defined 53 IU/ l, intermediate 3–27 IU/l, and abnormal 27 IU/l. Clinical Cases or Summary Results: Altogether, aEPO was normal in 3 (4.5%) cases, intermediate in 53 (80.3%) and abnormal in 10 cases (15.2%). Abnormal biophysical profile was associated with abnormal aEPO (p50.001). The aEPO concentrations did not differ by absent or reversed end-diastolic flow or by oligohydramnion (p = 0.482, p = 0.091 and p = 0.08, respectively). Umbilical artery pH and base excess were lower in pregnancies with abnormal aEPO (p = 0.027 and p = 0.007, respectively). The rate of composite adverse neonatal outcome (intraventricular hemorrhage, periventricular leukomalacia, cerebral infarction and/or necrotizing enterocolitis) was associated with abnormal aEPO (p50.001). Conclusions: Umbilical artery pH and base excess are lower in IUGR pregnancies with abnormal aEPO concentrations. High aEPO values are associated with adverse neonatal outcome. Determining aEPO can be a useful additional method in timing of delivery in preterm pregnancies complicated by IUGR.

Brief Introduction: previously has been showed that intrauterine growth restricted (IUGR) fetuses have a thicker aortic intima-media thickness (aIMT) and these infants followed-up at a median age of 18 months, showed persistently greater aIMT, an elevated arterial systolic blood pressure (SBP) and renal glomerular dysfunction (microalbuminuria and elevated natriuria). To determine in utero predictors for cardiovascular risk in infants that had IUGR. Materials & Methods: From August 2008 to June 2014 we considered 344 fetuses: 124 IUGR and 220 appropriate for gestational age (AGA). In each fetus routine third trimester ultrasonography and Doppler velocimetry was performed and aIMT measured using the computer aided detection and diagnosis (CADD) system at a mean gestational age of 32 weeks (range 28–34), and a blood sample from the umbilical vein was taken soon after birth to evaluate IL 16, HDL and cholesterol. Fifty IUGR and 70 AGA infants were followed-up at 18 months for aIMT, SBP, albuminuria and natriuria. The scale for cardiovascular risk was developed considering aIMT, fetal Doppler velocimetry, birth weight and HDL cholesterol by multivariate regression analysis. Clinical Cases or Summary Results: In 50 IUGR and 70 AGA fetuses the most relevant prenatal predictors for cardiovascular risk in infancy were fetal aIMT 40.8 mm, Umbelical Artery Pulsatility Index (UA PI)42 SD, birth weight 51800 gr and HDL cholesterol at birth 530 mg/dL. The fetuses with these prenatal predictors showed persistent aIMT, higher SBP and glomerular dysfunction (evidenced by microalbuminuria and high natriuria) at mean age of 18 months Conclusions: Prenatal scale of cardiovascular risk in IUGR fetuses might be used to identify those infants who should be followed-up for SBP and renal glomerular dysfunction Keywords: IUGR, Cardiovascular risk, prediction Presenter: E. Cosmi

ID 369

PERINATAL MORBIDITY AND MORTALITY OUTCOME IN PREGNANCIES AFFECTED BY FETAL GROWTH RESTRICTION – A MULTICENTRE PROSPECTIVE OBSERVATIONAL STUDY J. Unterscheider, K. O’Donoghue, S. Daly, M.P. Geary, M.M. Kennelly, F.M. McAuliffe, A. Hunter, J.J. Morrison, G. Burke, P. Dicker, E. Tully, & F.D. Malone Perinatal Ireland Research Consortium, Ireland

Keywords: Intrauterine growth restriction, erythropoietin, hypoxia Presenter: L. Seikku

ID 550

CAN WE PREDICT CARDIOVASCULAR RISK LATER IN LIFE IN INTRAUTERINE GROWTH RESTRICTED FETUS? E. Cosmi & S. Visentin Deparment of Woman and Child Health, University of Padua School of Medicine, Padua, Italy

Brief Introduction: Fetal growth restriction (FGR) affects up to 10% of pregnancies and confers an increased risk of perinatal morbidity and mortality. The aim of the Prospective Observational Trial to Optimise Paediatric Health in FGR (PORTO) Study was to evaluate the optimal management of fetuses with EFW 510th centile. This analysis describes the 57 perinatal morbidity cases which occurred in this cohort of non-anomalous infants with prenatally identified FGR. Materials & Methods: The cohort consisted of 1,200 prospectively recruited fetuses with EFW 510th centile between 24 + 0 and 36 + 6 weeks’ gestation. Details on sonographic parameters including multivessel Doppler assessment were recorded together with information on pregnancy details and perinatal outcome. Adverse perinatal outcome was defined as composite outcome of intraventricular haemorrhage (IVH), periventricular leucomalacia (PVL), hypoxic ischaemic encephalopathy (HIE), necrotising enterocolitis (NEC), bronchopulmonary dysplasia (BPD), sepsis or death. Clinical Cases or Summary Results: Of the 1,116 fetuses completing the study protocol, 312 (28%) were admitted to the neonatal intensive

120 care unit and 57 (5%) were affected by adverse perinatal outcome including 6 mortalities. As outlined in table 1, adverse perinatal outcome was significantly associated with advanced maternal age (p = 0.002), obesity (p50.001), co-existing hypertensive disease (p50.001) and abnormal UA Doppler waveforms (p50.001). Fiftyseven infants were affected by 72 individual morbidities (figure 1), with the most frequent one being sepsis (36 cases), followed by NEC (11 cases) and IVH (7 cases). Five infants had BPD, 4 had PVL and a further 3 were diagnosed with HIE. Some infants were affected by more than one morbidity, for example an infant delivered at 26 + 6 weeks gestation weighing 680 grams was concomitantly affected by IVH, PVL, NEC and sepsis. Conclusions: Adverse perinatal outcome in FGR infants is significantly associated with advanced maternal age, obesity and co-existing hypertensive disease. In addition, gestational age at delivery and abnormal UA Doppler contribute to morbidity outcomes.

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Keywords: Fetal growth restriction, adverse perinatal outcome Presenter: Dr Julia Unterscheider

ID 705

FETAL GROWTH RESTRICTION AND PLACENTAL GROWTH FACTOR L. Sichinava1 & N. Gugushvili1 1 Department of Obstetrics and Gynecology, Pirogov Russian National Research Medical University, Moscow, Russian Federation

Brief Introduction: Fetal growth restriction (FGR) is associated with increased risk of perinatal morbidity and mortality as well as severe health problems throughout life. FGR is often resulting from placental insufficiency but its pathomechanism is still undergoing investigation.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

The altered process of placental angiogenesis in which placental growth factor (PLGF) plays an important role is considered to be one of the most important causes of FGR. The aim of our study was a to analyze PLGF maternal plasma concentration among patients with normal pregnancies and those destined to deliver small for gestational age neonates. Materials & Methods: This prospective study included 102 women (82 patients with FGR and 20 patients with singleton uncomplicated pregnancies). Patients with FGR were divided to three groups depending on estimated by ultrasound examination fetal weight (below 10th, 5th or 3rd percentile resp.). Fetuses with chromosomal or structural anomalies were excluded from the study. Maternal venous blood samples were collected in third trimester, serum PLGF concentrations were assessed using ELISA assay. Clinical Cases or Summary Results: In all 102 patients we found positive correlation between weight of newborns and PLGF levels (Spearman’s rank correlation coefficient – 0.4). In the FGR group significantly lower levels of PLGF (200 ± 39pg/ml and 104 ± 28pg/ml) were found in pregnants with severe (below 5th and 3rd percentile) growth restricted fetuses (in control group 439 ± 85 pg/ml). We observed decreased concentration of PLGF in preeclamptic patients with FGR (141 ± 36pg/ml) comparing not only to control group, but also to normotensive patients with FGR (315 ± 47pg/ml). Changes in PLGF maternal plasma concentration were found as well in patients with abnormal doppler waveforms (58 ± 35pg/ml compered to 315 ± 42pg/ ml in patients with FGR and normal doppler waveforms in uterine arteries, umbilical and middle cerebral artery). The lowest levels of FGR were found in women with absent diastolic flow in umbilical artery and in two cases of antenatal death (29 ± 11pg/ml). Conclusions: Thus our findings confirm the involvement of PLGF in appropriate placentation and accordingly intrauterine fetal growth. Detection of its low concentration may be helpful for identification of those patients requiring thorough examination of fetal wellbeing and more active management, which may require preterm delivery. Keywords: fetal growth restriction, placental growth factor Presenter: N. Gugushvili

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ID 883

AORTIC WALL THICKNESS AND AMNIOTIC FLUID ALBUMINURIA IN GROWTH-RESTRICTED TWIN FETUSES S. Visentin, A. Galzignato, S. lazzarin, & E. Cosmi

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Deparment of Woman and Child Health, University of Padua, Italy Brief Introduction: Fetal abdominal aIMT and amniotic albumin/ creatinine ratio (ACR) were measured in 126 individual twin fetuses, recruited in the Maternal Fetal medicine Unit of University of Padua (Italy). The IUGR twin fetuses were classified into two groups: Group A were those fetuses whose estimated fetal weight (EFW) was 2 SD and Group B were those fetuses whose EFW was510th percentile and had no velocimetry abnormalities Materials & Methods: The median fetal aIMT was significantly different in the three groups (Group A = 0.9 mm; Group B = 0.7 mm; and appropriate for gestational age (AGA) = 0.5 mm; p50.0001). It was significantly higher in Group A than in the AGA group (p50.0001) and than in th e Group B fetuses (p = 0.003), respectively. In addition, ACR was different in the three groups (Group A = 183,500 mg/g; Group B = 6,4720 mg/g; and AGA = 8,2750 mg/g; p = 0.0002). It was significantly higher in Group A than in the AGA group (p = 0.03) and than in Group B (p = 0.02), respectively Clinical Cases or Summary Results: The median fetal aIMT was significantly different in the three groups (Group A = 0.9 mm; Group B = 0.7 mm; and appropriate for gestational age (AGA) = 0.5 mm; p50.0001). It was significantly higher in Group A than in the AGA group (p50.0001) and than in th e Group B fetuses (p = 0.003), respectively. In addition, ACR was different in the three groups (Group A = 183,500 mg/g; Group B = 6,4720 mg/g; and AGA = 8,2750 mg/g; p = 0.0002). It was significantly higher in Group A than in the AGA group (p = 0.03) and than in Group B (p = 0.02), respectively Conclusions: Growth-restricted twin fetuses with velocimetry abnormalities present are associated with aIMT and higher ACR levels in amniotic fluid, which could be possible markers in utero of preclinical atherosclerosis, and early glomerulosclerosis. Keywords: Presenter: Alice Galzignato

ID 682

SONOGRAPHIC MEASUREMENTS OF THE UMBILICAL CORD VESSELS AREAS IN NORMAL AND SMALL FOR DATE FETUSES E. Di Naro3, L. Raio1, F. Ghezzi2, M. Vicino3, L. M. Scho¨nauer3, E. Silvestris3 & G. Loverro3 1

Dept. of Obstetrics and Gynecology, University of BerneInselspital, Switzerland, 2Dept. of Obstetrics and Gynecology, University of Insubria-Ospedale di Circolo, Varese, Italy, and 3 Dept. of Obstetrics and Gynecology, University of Bari, Bari, Italy Brief Introduction: Objective: A reduction of the Wharton’s jelly, the total umbilical area and the lumen of the umbilical vein has been described in small for date fetuses in comparison to healthy fetuses. Moreover, a higher incidence of ’’lean’’ umbilical cord has been reported in the former than in the latter group. The objective of this

study was to assess whether there is a difference in the sonographic vessels areas between small and appropriate for gestational age fetuses. Materials & Methods: Consecutive pregnant women undergoing routine sonographic examinations at a gestational age greater than 30 weeks, with intact membranes, known gestational age, and singleton gestation were included. The umbilical cord cross-sectional area and the umbilical cord vessels areas were computed using the software of the ultrasound machine. The Wharton’s jelly area was calculated subtracting the total vessels area from the umbilical cord area. Clinical Cases or Summary Results: A total of 710 fetuses were included. Of these 43 were small for gestational age at birth (birth weight 55th centile). A significant correlation was found between the umbilical artery area and gestational age (r = 0.065, p50.05) and between the umbilical vein area and gestational age (r = 0.075, p50.05). In comparison to appropriate for gestational age fetuses, the medians (range) of the following parameters were lower in small for gestational age fetuses: umbilical cord area [143 mm2 (91–297) vs. 179 mm2 (89–302), p50.01], total vessels area [47.6 mm2 (28–105) vs. 65.7 mm2 (25–190), p50.01], umbilical vein area [34.2 mm2 (17.3– 84.9) vs. 47.8 mm2 (15.2–150), p50.01]. A significant correlation was present between either the umbilical vein area (r = 0.49, p50.001) and the total umbilical arteries area (r = 0.42, p50.001) and the sonographic estimated fetal weight. Conclusions: These findings demonstrate that the alterations in umbilical vessels and Wharton’s jelly areas which have been described before delivery begin in utero. A reduction in the umbilical lumen vein and arteries areas may be the consequence of a chronic reduction in placental blood flow. Keywords: Umbilical cord, umbilical artery, umbilical vein, Wharton’s jelly, SGA, ultrasound Presenter: E. Di Naro

ID 085

PLACENTAL GROWTH FACTOR (PLGF) AND ULTRASOUND PARAMETERS FOR PREDICTING THE SMALL FOR GESTATIONAL AGE INFANT (SGA) IN SUSPECTED SMALL FOR GESTATIONAL AGE: PELICAN FGR STUDY M. Griffin, P. Seed, L. Webster, H. Tarft, L. Chappell, A. Shennan, On behalf of the PELICAN FGR study consortium Women’s Health Academic Centre, King’s College London, London, United Kingdom Brief Introduction: Accurately identifying the SGA fetus is a challenge, but is important because of the increased risk of short and long-term health complications in the infant. One contributing factor in its pathogenesis is placental insufficiency and therefore biomarkers of placental function such as PlGF may aid prediction. We have shown that PlGF accurately predicts delivery of an SGA infant (sensitivity 0.93 (0.84–0.98), negative predictive value (NPV) 0.96 (0.90–0.99)) in women with suspected pre-eclampsia. This study aimed to assess the test performance of ultrasound parameters and PlGF to predict delivery of an SGA infant in women presenting with reduced symphysis fundal height (SFH) measurement. Materials & Methods: PELICAN FGR, was a large international multicentre, prospective observational study in women with reduced SFH, enrolling 592 women with singleton pregnancies and reduced SFH

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122 between 24 and 37 weeks’ gestation across 11 sites in UK and Canada. Plasma PlGF was measured at enrolment and ultrasound data recorded. Plasma PlGF concentration 55th centile, estimated fetal weight 95th centile and oligohydramnios were compared as predictors for delivery of an SGA infant 53rd and 510th customised birthweight centiles. Test performance statistics were calculated for all parameters in isolation and combination. Clinical Cases or Summary Results: Sensitivity and Negative Predictive Value (NPV) of estimated fetal weight 510th centile for prediction of delivery of an SGA infant53rd customised birthweight centile (n = 78) were 61% and 93% respectively and for delivery of an SGA infant 510th customised birthweight centile (n = 192), 49% and 77% respectively. PlGF had sensitivity of 37% and NPV of 90% for delivery of an SGA infant 53rd customised birthweight centile. In combination, PlGF and estimated fetal weight 510th centile had sensitivity of 69% and NPV of 93% for delivery of an SGA infant 53rd customised birthweight centile. Conclusions: In women presenting with reduced SFH, ultrasound parameters have modest test performance for prediction of a subsequent SGA infant. PlGF alone performed no better, and combining PlGF measurement and ultrasound provided only small improvements in test performance. Keywords: PlGF, small for gestational age, symphysis fundal height Presenter: Prof A Shennan

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

combination with AREDF. In stratified analyses these associations were only present when GA was 528 weeks. Conclusions: Conclusion AREDF was associated with increased morbidity in premature infants born SGA or after preeclampsia, but the risk related to AREDF was low. The findings underscore the importance of gathering more information on associations between fetal circulatory patterns and outcome, especially when elective delivery before 28 weeks’ GA is considered. Keywords: Premature infant, Fetal Doppler, Absent or reversed enddiastolic flow in the umbilical artery, Middle cerebral artery, Ductus venosus, Neonatal mortality and morbidity, Cerebral palsy. Presenter: Siw Helen Eger

ID 823

CUSTOMIZED BIRTHWEIGHT CENTILES IN APPLICATION TO POLISH DATA K. Szamotulska1, E. Mierzejewska1, T. Maciejewski2, & M. Troszynski3 1

ID 417

FETAL ARTERIAL AND VENOUS DOPPLER: A POPULATION BASED STUDY OF OUTCOME OF PREMATURELY BORN INFANTS BORN SMALL FOR GESTATIONAL AGE OR AFTER PREECLAMPSIA S.H. Eger1,2, J. Kessler1,3, T. Kiserud1,3, T. Markestad1,2, & K. Sommerfelt1,2 1

Department of Clinical Science, University of Bergen, Norway, Department of Pediatrics, Haukeland University Hospital, Norway, and 3Department of Obstetrics and Gynecology, Haukeland University Hospital, Norway 2

Brief Introduction: Objective to evaluate associations between prenatal Doppler assessments and neonatal mortality and morbidity and longterm neurological outcome among premature infants born small for gestational age (SGA) or after pregnancies with preeclampsia. Materials & Methods: Population based cohort study of all infants of 22 to 534 weeks’ gestational age (GA) with birth weight (BW) below the 10th percentile for GA and/or maternal preeclampsia born alive in Hordaland County, Norway, during 2003–2007. Fetal circulation was assessed by pulsed Doppler of the umbilical artery (UA), middle cerebral artery (MCA) and ductus venosus (DV). Circulatory compromise was defined in terms of absent or reversed end-diastolic velocity in the UA (AREDF), MCA pulsatility index (PI) 52.5 percentile for GA (brain sparing) and DV pulsatility index for veins (PIV) 497.5 percentile. Clinical Cases or Summary Results: Of 172 eligible infants, 15 were stillborn and two died immediately after birth. Of the remaining 155 infants, Doppler assessments in UA, MCA and DV were available in 127, 125 and 95, respectively. Thirty-six of 127 infants (28%) had AREDF which was associated with increased frequencies of neonatal sepsis and necrotizing enterocolitis (NEC) after adjusting for GA (p50.05), but not neonatal mortality. Brain sparing was not associated with adverse outcome. Abnormal DV PIV was associated with increased risk of neonatal sepsis (p50.05), but only in

Department of Epidemiology, National Research Institute of Mother and Child, Poland, 2Department of Obstetrics and Gynaecology, National Research Institute of Mother and Child, Poland, and 3Department of Reproductive Health, National Research Institute of M Brief Introduction: Poland does not have population growth charts for newborns based on Polish data. It constraints studying the processes and risk factors leading to Fetal Growth Restriction (FGR). Therefore estimation of customized birthweight centiles as proposed by Gardosi may be important for better understanding, prevention and treatment of FGR in the country. Materials & Methods: One thousand two hundred deliveries in 8 hospitals in south-eastern and central Poland were observed in 2013 (150 consecutive deliveries per hospital) based on medical records and interview with the mother after delivery. Estimation of regression equation for optimal weight of a baby was based on data available for maternal height, maternal weight before pregnancy, parity and sex of the child (n = 945). Gestational age was centered around mean of 275 days from first day of the last menstrual period, maternal height – around mean of 166 cm, maternal weight before pregnancy – around mean of 64 kg. Parity was categorized as 0,1,2+. The tenth percentile was set up at expected birthweight minus 14%. Clinical Cases or Summary Results: Mean estimated birth weight was 3883 ± 343 g and was equal to mean observed birth weight. Estimated parameters of the model were similar to parameters from other populations. Observed birthweight below the 10th percentile of expected birthweight was related to smoking before pregnancy and low socioeconomic status. In comparison to clinical diagnosis of fetal hypotrophy, customized birthweight 510 centile calculated according to Gardosi method was ascertained in 91.7% cases of fetal hypotrophy noticed in medical records and in 10.6% cases of fetal hypotrophy not noticed in medical records. The risk of NICU admission in children without clinical diagnosis of hypotrophy was three-fold higher in case of customized birthweight = 10 centile. Conclusions: Customized birthweight centiles are useful for estimation of fetal growth restriction in Polish population and enable prediction of negative newborn outcomes. Keywords: fetal growth restriction, estimation, birthweight Presenter: K. Szamotulska

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ID 383

ASSOCIATION OF SERUM PROGESTERONE IN EARLY PREGNANCY WITH LOW BIRTH WEIGHT AND OTHER ADVERSE PREGNANCY OUTCOMES S. He1, J. C. Allen2, R. Malhotra3, T. Østbye3, S. Siew1, & T. C. Tan1,4 Duke-NUS Graduate Medical School, Singapore, 2Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore, 3Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore; Duke Global Health Institute, Durham, North Carolina, USA, and 4Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, Singapore

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1

Brief Introduction: Birth weight is an important parameter in predicting short-term survival of newborns as well as long-term health outcomes. Recently, low maternal serum progesterone concentrations in the first trimester have been found to be associated with lower birth weight in girls but not in boys. Yet evidence for the association between progesterone and birth weight is limited. Materials & Methods: We conducted a cohort study of 298 women to investigate the association between serum progesterone in first trimester and low birth weight. We also studied the link between serum progesterone and other adverse pregnancy outcomes, including preterm delivery, premature rupture of membranes and hypertensive disorders of pregnancy. Spot serum progesterone concentrations were measured once between gestational weeks

Event Occurrence

Total Frequency

Percent

No Yes

113 12

90.4 9.6

Low birth weight

Table 4. Frequency table for adverse pregnancy outcomes Adverse Pregnancy Outcome Gestational HTN

Table 1. Frequency table for low birth weight (52500g) Outcome

4–12 in 298 women with singleton intrauterine pregnancies who presented to KK Women’s and Children’s Hospital Singapore from December 2011 to December 2013. These women were followed up to the end of pregnancy. Low birth weight and other adverse pregnancy outcomes were assessed from clinical records. Follow-up data were available for 125 women, who were included in the analysis. Univariate and multivariate regression were performed to assess potential maternal risk factors, among them progesterone, and their association with low birth weight and other adverse pregnancy outcomes. Clinical Cases or Summary Results: In the univariate logistic regression model for low birth weight, defined as birth weight 52500g, low serum progesterone concentration was significantly associated with an increased risk of LBW (p = 0.035, 95% CI: 0.93, 0.99). On further categorization of birth weight into very low birth weight (VLBW; birth weight 51500g), low birth weight (LBW; 1500 birth weight 52500g) and normal birth weight (2500g), serum progesterone levels were found to be significantly lower in the VLBW compared to the normal birth weight group (p = 0.031). Association between progesterone and other adverse pregnancy outcomes, including pre-term delivery, premature rupture of membranes and hypertensive disorders of pregnancy did not reach statistical significance. Conclusions: This study suggests that low serum progesterone in the first trimester is associated with an increased risk of low birth weight and very low birth weight. The results add to the knowledge of the use of serum progesterone in predicting birth weight, and thus may allow clinicians to provide anticipatory guidance. However, further studies with larger sample sizes are needed to confirm this association.

Premature Rupture of Membranes Preterm Delivery

Event Occurrence

Total Frequency

Percent

No Yes No Yes No Yes

120 5 113 12 109 16

96.0 4.0 90.4 9.6 87.2 12.8

Table 2. Univariate analysis of factors predicting risk of low birth weight (n = 125) Predictors

p Value

Progesterone (nmol/L) Maternal BMI Gestational week of progesterone measurement Maternal age (years) Gestational age of delivery Gender of baby (F vs M) Maternal progesterone treatment in first trimester Previous Successful pregnancies (Y vs N) Maternal Group B Streptococcus colonization status (Y vs N)

OR (95% CI)

0.035 0.084 0.773 0.844 0.002 0.604 0.536 0.247 0.987

0.96 1.12 1.05 0.99 0.52 1.38 1.46 2.04 1.01

(0.93, (0.98, (0.77, (0.85, (0.34, (0.41, (0.44, (0.61, (0.26,

AUC

0.99) 1.28) 1.42) 1,14) 0.78) 4.59) 4.80) 6.82) 4.00)

0.697 0.658 0.517 0.503 0.761 0.540 0.547 0.588 0.501

Table 3. Serum progesterone as a predictor of birth weight category Birth Weight Category VLBW LBW Normal

Progesterone (nmol/L) N

Mean

2 10 115

30.3 60.2 72.1

Pair-wise Comparisons P-value

95% CI 7.31 43.34 67.12

67.88 76.97 77.12

VLBW

LBW

Normal

– 0.154 0.031

0.154 – 0.179

0.031 0.179 –

VLBW – very low birth weight (51500g); LBW – Low birth weight (1500–2500g); Normal (2500g)

F-test p Value 0.045

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Table 5. Univariate analysis: adverse pregnancy outcomes

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Adverse pregnancy Predictors outcomes

Progesterone (nmol/L) Maternal BMI Gestational week of progesterone measurement Maternal age (years) Gestational age of delivery Gender of baby (F vs M) Maternal progesterone treatment in first trimester Previous Successful pregnancies (Y vs N) Maternal Group B Streptococcus colonization status (Y vs N) Maternal Ward Class at delivery Class A (reference) Class B1 Class B2 Class C

Gestational Hypertension

Premature Rupture of Membranes

Preterm Delivery

N

p Value

OR (95% CI)

p Value

OR (95% CI)

p Value

OR (95% CI)

125 123 125

0.315 0.058 0.965

0.98 (0.93, 1.02) 1.20 (0.99, 1.44) 1.01 (0.64, 1.60)

0.455 0.260 0.544

1.01 (0.99, 1.03) 0.91 (0.77, 1.08) 1.02 (0.75, 1.38)

0.380 0.340 0.583

0.99 (0.97, 1.01) 1.06 (0.94, 1.20) 0.93 (0.71, 1,21)

125 125 125 125

0.082 0.093 0.939 0.405

1.03 (0.82, 1.28) 0.77 (0.57, 1.04) – 2.17 (0.35, 13.5)

0.514 0.544 0.267 0.996

0.95 0.92 2.04 1.00

1.11) 1.22) 7.15) 3.35)

0.123 – 0.918 0.077

1.11 (0.97, 1.27) – 0.95 (0.33, 2.70) 2.66 (0.90, 7.85)

125

0.912

0.90 (0.15, 5.60)

0.507

0.65 (0.19, 2.30)

0.235

1.89 (0.66. 5.48)

125









0.984

1.01 (0.30, 3.40)

122 46 11 52 13

– – – – –

– – – – –

0.763 – 0.397 0.707 0.815

– – 0.54 (0.13, 2.27) 1.39 (0.25, 7.87) 0.77 (0.08, 7.09)

0.024 – 0.397 0.707 0.013

– – 0.54 (0.13, 2.27) 1.39 (0.25, 7.87) 6.40 (1.48, 27.5)

Keywords: progesterone; birth weight; pregnancy; Singapore Presenter: He Song

ID 767

OXIDATIVE STRESS IN SMALLFOR-GESTATIONAL AGE (SGA) TERM NEWBORNS S. Gveric Ahmetasevic1, S. Sunjic Borovic2, S. Skrablin3, & N. Zarkovic4 1

NICU, Dept Gyn&Obst, university Hospital Center Zagreb Croatia, 2,4Division for Oxidative stress, Institute ‘‘Rudjer Boskovic’’ Zagreb, Croatia, and 3Dept Gyn&Obst, university Hospital Center Zagreb Croatia Brief Introduction: Oxidative stress presents the imbalance between the production of reactive oxygen species (ROS) and the antioxidant body defense. The body uses low concentration of ROS for numerous physiological reactions. Opposite, much higher concentrations of ROS (and effusive oxidative stress) leads to biological macromolecules damages, with possibly long term consequences. The aim of this study was to investigate oxidative stres in the mothers blood during labor, cord blood, and mother’s and infant’s blood third day after the labor. Materials & Methods: This study used malondialdehyde (MDA) determination by HPLC and enzymatic assays for total serum peroxides and antioxidant capacity to evaluate oxidative stress in 47 healthy full-term small-for-gestational age (SGA) newborns vs 67 appropriate-for-gestational age (AGA) newborns. Blood samples were collected at delivery from umbilical cord artery and vein and from peripheral blood of the babies on the third day after birth. Blood samples of mothers were also collected and compared with blood of 29 normal non-pregnant women (NPW). Clinical Cases or Summary Results: Serum peroxide values were significantly higher in both groups of mothers than in NPW, decreasing towards the third day in AGA mothers, while persisting in SGA mothers. Antioxidant capacity of sera of both groups of mothers was lower than NPW. Both SGA mothers and babies had increased MDA at delivery, unlike AGA counterparts. MDA levels in umbilical vein were higher than in umbilical arteries.

(0.82, (0.69, (0.58, (0.30,

Conclusions: These results show that both mothers and babies are exposed to oxidative stress during and after delivery, which is more pronounced and persistent in the perinatal period of the SGA group. Keywords: Presenter: S. Gveric-Ahmetasevic

ID 873

MARKERS OF ADVERSE FETO-NEONATAL OUTCOMES IN LATE-IUGR L. Marchi, M. Pisani, S. Simeone, S. Serena, M.P. Rambaldi, L. Bruni, S. Biagioni, G. Mello, & F. Mecacci Department of Obstetrics and Gynecology, Careggi University Hospital, Florence, Italy Brief Introduction: IUGR-late is defined as AC below 10th percentile for GA after 34th weeks’ gestation diagnosed in a fetus with previous normal growth. IUGR- late is associated with IUD at term, perinatal morbidity and mortality and neurodevelopment impairment in childhood. How to identify women who could benefit from induction of labour in order to reduce perinatal morbidity and mortality in IUGR late has not yet been determined. The aim of our study was to evaluate potential markers to improve timing of delivery in these pregnancies. Materials & Methods: This is a retrospective cohort study. All the patients included in the study were affected by late-IUGR. 121 singleton pregnancies where included. These patients were managed expectantly. Deliver was indicated in case of UA PI 495th percentile, non-reactive cardiotocography, oligohydramnios, gestational age 440th weeks, maternal indications, growth arrest. Primary outcome measures were neonatal admission to NICU, umbilical arterial/venous pH below 7.10, 1st and 5th minute Apgar score below 7, IUD. Secondary outcome were mode of delivery and induction rate.

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DOI: 10.3109/14767058.2014.924236

The study aims to evaluate if adverse outcome can be related to fetal markers. The markers studied were UA-PI, MCA-PI, Celebro-Placental Ratio (ACM PI/UA PI) 51, AC measurement at last ultrasound performed. Clinical Cases or Summary Results: In our study neonatal adverse outcomes were uncommon: no IUD was registered and admission to NICU was 12.5%. CS rate in this group was similar to that reported in literature (38.84%), although induction were more frequent than in general population (46.28%). Hypertensive disorders of pregnancy affected 6% of this patients. MCA55th centile and CPR51 were associated with a higher risk of been admitted to NICU. In the logistic regression model one day of gestation added causes a reduction of the O.R. for the admission to NICU by a factor of 0.89 Conclusions: Our results suggest to postpone delivery until 37th weeks gestation in this population. MCA PI is an important marker in choosing the appropriate timing of delivery in late-FGR. Although the positive predictive value of this parameter is unsatisfactory (20%) we can safely manage expectantly these patients if the Doppler indices of this vessel are normal (negative predictive value 95%). Keywords: Late-IUGR, timing of delivery, MCA-PI Presenter: L. Marchi

ID 887

DEVELOPMENTAL PROGRAMMING OF CARDIOVASCULAR RISK IN INTRAUTERINE GROWTHRESTRICTED TWIN FETUSES ACCORDING TO AORTIC INTIMA THICKNESS S. Visentin, S. Lazzarin, A. Galzignato, A. Friziero, & E. Cosmi DevDepartment of Woman and Child Heath, University of Padua, Italy Brief Introduction: We aimed to test the hypothesis that aortic intima thickness is greater in intrauterine growth-restricted (IUGR) twin fetuses compared to normally developing twins, thus defining an increased cardiovascular risk that reflects genetic factors in fetuses sharing the same womb. Materials & Methods: We conducted a prospective study performed on twins from January 2009 to July 2011. Twins were classified into 3 groups: IUGR fetuses with an estimated fetal weight below the 10th percentile and an umbilical artery pulsatility index of greater than 2 SDs (group A), fetuses with an estimated fetal weight below the 10th percentile and normal Doppler findings (group B), and fetuses with an estimated fetal weight appropriate for gestational age (group C). Aortic intima thickness was measured at a median gestational age of 32 weeks. Values were compared among groups and between each twin and cotwin, also considering sex and chorionicity. Clinical Cases or Summary Results: Twenty-five fetuses were classified as group A, 36 as group B, and 95 as group C. The median aortic intima thickness values were 0.9 mm in group A, 0.7 mm in group B, and 0.6 mm in group C (p50.0001). There was a statistically significant difference between the aortic intima thickness of the twins and cotwins in groups A and B (p50.0001). Sex and chorionicity did not correlate with aortic intima thickness

Conclusions: In this study, IUGR fetuses with Doppler abnormalities had greater aortic intima thickness, and IUGR twins with normal Doppler findings had intermediate thickness, supporting a genetic predisposition to cardiovascular risk independent of sex and chorionicity. Keywords: Presenter: S. Visentin

ID 587

INFLUENCE OF MATERNAL HOMOCYSTEINE AND UTERINE AND UMBILICAL ARTERY DOPPLER WAVEFORMS ON INTRAUTERINE GROWTH RESTRICTION S. Bel-Querol1, M. Murphy2,3, M. Ballesteros4, C. Grifoll1, J. Pascual1, J. Ferna´ndez -Ballart2,3, & P. Cavalle´-Busquets1,2,3 1

Unit of Obstetrics and Gynaecology, Hospital Universitari Sant Joan de Reus, Reus, Spain, 2Area of Preventive Medicine and Public Health, Faculty of Medicine and Health Sciences, Reus, Spain, and 3Universitat Rovira i Virgili (URV), IISPV and CIBER Fisiopatologı´a de la Obesidad y Nutricio´n (CB06/03) Instituto Carlos III, Spain, 4Unit of Obstetrics and Gynaecology, Hospital Universitari Joan XXIII, Tarragona, Spain Brief Introduction: Elevated maternal fasting plasma total homocysteine concentracion (tHcy) during pregnancy has been associated with increased risk of intrauterine growth restriction (IUGR). However, not all studies have found this association and this has led to the questioning of its importance. Materials & Methods: A prospective, multicentric nested case-control study of pregnant women that received their prenatal care from early pregnancy (12 gestational weeks [GW]) in the University Hospitals Sant Joan, Reus and Joan XXIII, Tarragona, was carried out between January 2005 and December 2011. 43 cases were matched with 161 controls by age, parity, socioeconomic status and smoking habits. The association between early pregnancy tHcy or uterine and umbilical artery dopplers at 20 and 32 GW with birth weight was investigated. Clinical Cases or Summary Results: Early pregnancy tHcy 7.12 mmol/L (P90) was associated with an average reduction of 139.6 g in birth weight, pathological Doppler of the umbilical artery (Pulsatility Index41.33 [P95]) at 32 GW [OR (95%CI):3.1(1.0–9.2)] and increased risk of IUGR [OR (95% CI): 8.2 (1.1–11.58)] compared to normal maternal tHcy. A 1mmol/L increase in maternal tHcy was associated with an average increase of 0.059 in mean uterine artery PI at 32 GW. Pathological Doppler waveforms of the uterine arteries at 20 GW (Mean PI of right and left maternal arteries  1.54 [P95] and/or bilateral notch) increased the risk of IUGR [OR (95% CI):12.9 (3.0–55.1)]. Conclusions: Elevated tHcy during early pregnancy is associated with lower birth weight, higher uterine and umbilical artery pulsatiliy indices and increased risk of IUGR. Keywords: homocysteine, intrauterine growth restriction, doppler Presenter: Sabina Bel-Querol

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ID 832

Perinatal Ireland Research Consortium, Ireland

CORRELATION AMONG ECHOCARDIOGRAPHIC PARAMETERS, ENDOTHELIAL DAMAGE AND LIPID PROFILE IN TWIN PREGNANCIES COMPLICATED BY SELECTIVE INTRAUTERINE GROWTH RESTRICTION

Brief Introduction: Several publications suggest a male preponderance in a variety of pregnancy complications. The objective of this analysis was to investigate the influence of infant sex on perinatal outcome in the setting of fetal growth restriction (FGR). This is a secondary analysis of the Prospective Observational Trial to Optimise Paediatric Health in FGR (PORTO) Study. Materials & Methods: The cohort consisted of 1,200 prospectively recruited fetuses with EFW 510th centile between 24 + 0 and 36 + 6 weeks’ gestation. Details on sonographic parameters including multivessel Doppler assessment were recorded together with information on pregnancy details and perinatal outcome. Adverse perinatal outcome was defined as composite outcome of intraventricular haemorrhage (IVH), periventricular leucomalacia (PVL), hypoxic ischaemic encephalopathy (HIE), necrotising enterocolitis (NEC), bronchopulmonary dysplasia (BPD), sepsis or death. Statistical comparisons between male and female infants were made using Fisher’s exact test and logistic regression. A p-value50.05 was considered statistically significant. Clinical Cases or Summary Results: Of the 1,116 fetuses completing the study protocol, 684 (61%) were female and 432 (39%) were male. Male infants were more commonly affected by adverse perinatal outcome (8% vs 3%; p50.001). Both, male and female fetuses, showed similar longitudinal growth and Doppler patterns in utero (figure 1), therefore the increase in composite morbidity in boys could not be explained by decelerative growth or abnormal Doppler parameters. Interestingly, boys were delivered earlier than girls (37.2 vs 38.6 weeks; p50.001). This was due to the fact that gestational hypertension (16% vs 11%; 0.039) and pre-eclampsia (12% vs 7%; p = 0.014) was more frequently observed in mothers carrying male fetuses. While adverse perinatal outcomes were more common for males than females, the numbers of outcomes were no longer statistically significant after adjusting for gestational age at delivery (table 1). Conclusions: Data from this large prospective cohort of fetuses with EFW 510th centile could not contribute evidence to support the concept of male sex bias in adverse pregnancy outcome.

S. Gizzo1, S. Visentin1, C. Sarais2, G. Giunta1, M. Noventa1, S. Di Gangi1, D. Trevisanuto1, M. Rampon1, & E. Cosmi1 1

Department of Women’s and Children’s Health, University of Padua, Padua, Italy, and 2Department of Cardiology, Thoracic and Vascular Sciences, University of Padua, Padua, Italy Brief Introduction: Aim of the study was to evaluate intrauterine cardiovascular function of twin foetuses affected by intrauterine growth restriction (IUGR) compared to healthy twin foetuses. Materials & Methods: A perspective study on 20 twin foetuses after 32 gestational week were conducted. We compared 10 twin foetuses (cases) affected by IUGR (weight centile less than 10) and abnormal umbilical artery (UA) pulsatility index (PI) with 10 healthy twin ones (controls). In both groups foetal cardiovascular pattern was evaluated by echocardiography deceleration time. In particular we collected data about anterior mitral leaflet thickness and aorta intima media thickness (aIMT) detected at ultrasound investigation. At delivery, we collected also data about neonatal cord blood lipid profile. Clinical Cases or Summary Results: As expected, we found an increased globular hearts index in IUGR twins respect to the healthy ones. IUGR foetuses showed also an increased thickness of both anterior mitral leaflet and aIMT. A positive correlation was found between echocardiographic parameters (global longitudinal systolic strain, end diastolic and systolic left ventricular volumes), UA-PI and aIMT. Finally, total cholesterol was higher in IUGR than healthy twin newborns. Conclusions: Foetal cardiovascular programming occurs in IUGR twin foetuses. These findings open a new paradigm on different cardiac markers of endothelial dysfunction in cases of twins affected by IUGR and Doppler abnormalities. Keywords: IUGR, fetal endothelial damage, echocardiography, lipid profile, Doppler abnormalities, low weight newborns. Presenter: Salvatore Gizzo

ID 371

DOES INFANT SEX INFLUENCE THE RISK OF ADVERSE PERINATAL OUTCOME IN FETAL GROWTH RESTRICTION? – RESULTS FROM A MULTICENTRE PROSPECTIVE STUDY S. Corcoran, J. Unterscheider, K. O’Donoghue, S. Daly, M.P. Geary, M.M. Kennelly, F.M. McAuliffe, A. Hunter, J.J. Morrison, G. Burke, P. Dicker, E. Tully, & F.D. Malone

Keywords: Fetal growth restriction, adverse perinatal outcome, infant sex Presenter: Dr Siobhan Corcoran

ID 854

AMPLITUDE INTEGRATED ELECTROENCEPHALOGRAPHY ACTIVITY AND MIDDLE CEREBRAL ARTERY DOPPLER FLOW MEASUREMENTS IN PRETERM SMALL FOR GESTATIONAL AGE INFANTS L. Daban Kolsuz1, S. Topcuoglu1, T. Gursoy1, G. Karatekin1, & F. Ovali1 Neonatal Intensive Care Unit, Zeynep Kamil Maternity and Children’s Training and Research Hospital, Istanbul, Turkey Brief Introduction: Amplitude integrated encephalography (aEEG) is frequently used in neonatal intensive care units to monitor brain functions. Its bedside application and easy interpretation are the most important features. Brain development of small for gestational age (SGA) infants can be affected by intrauterine chronic hypoxia. The current study aimed to demonstrate cerebral functions of SGA infants by means of aEEG.

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Table 1. Quantitative aEEG, Burdjalov Score, and MCA Doppler values of SGA and AGA infants SGA (n = 22)

AGA (n = 27)

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Quiet sleep lower border 2.5 (1–3.25) 3 (2.75–4) 0.041 (mV) (IQR) Quiet sleep upper border 45 (30–50) 40 (30–45.5) 0.22 (mV) (IQR) Quiet sleep bandwidth 20 (17–27) 37.5 (27.75–42) 0.11 (mV) (IQR) Active sleep lower border 7 (6.75–8) 7 (6–8) 0.99 (mV) (IQR) Active sleep upper border 28.5 (24.5–35) 26 (22.25–30) 0.51 (mV) (IQR) Active sleep bandwidth 42 (28.5–48) 37.5 (27.75–42) 0.33 (mV) (IQR) Total Burdjalov score (IQR) 8 (6–10) 9 (9–11) 0.045 MV (cm/s) 21.09 ± 4.25 17.8 ± 4.07 0.028 SGA: Small for gestational age; AGA: Appropriate for gestational age; MV: Mean Velocity

Materials & Methods: Thirty to 34 week-old 22 SGA and 27 appropriate for gestational age (AGA) preterm infants were included in the study. The mode of delivery, gender, birth weight, and Apgar scores of the patients were recorded. Following middle cerebral artery (MCA) mean velocity (MV) measurement with cranial Doppler at the 24th hour of birth, an aEEG recording was performed on all infants, for a period of 4–24 hours. Clinical Cases or Summary Results: SGA infants had significantly higher MCA mean velocity than appropriate for gestational age (AGA) infants (Table 1). The aEEG recordings showed lower ‘‘lower border of quiet sleep’’ and total Burdjalov score in SGA infants when compared with AGA infants (Table 1). Conclusions: Increased MCA blood flow observed in SGA infants might be a marker of chronic intrauterine hypoxia that these infants were exposed. These infants demonstrated a more immature pattern of aEEG.

defined as a composite of intraventricular haemorrhage (IVH), periventricular leucomalacia (PVL), hypoxic ischaemic encephalopathy (HIE), necrotising enterocolitis (NEC), bronchopulmonary dysplasia (BPD), sepsis or death. A subgroup of pregnancies with EFW 95th centile, absent or reversed end diastolic flow) was divided into earlyand late-onset FGR, defined as 534 and 34 weeks respectively. Statistical comparisons between early-and late onset FGR were made using Fisher’s exact test and logistic regression. A p-value 50.05 was considered statistically significant. Clinical Cases or Summary Results: Of 1,116 pregnancies completing the study protocol, 512 met the inclusion criteria for this analysis. Early-and late-onset FGR accounted for 318 (62%) and 194 (38%) of cases respectively. Early-onset FGR was associated with lower birth weight at delivery, a higher neonatal intensive care admission and greater adverse composite perinatal outcome compared with lateonset FGR. Although adverse outcomes associated with early-onset FGR were associated with lower birth weight and earlier gestational age at delivery, these findings were not significant after adjusting for gestational age at delivery. Early-onset FGR was more commonly associated with gestational hypertension/preeclampsia (p = 0.13) and antihypertensive use (p = 0.019). To determine predictors of adverse perinatal outcome, a stepwise logistic regression analysis of all maternal demographic characteristics found that BMI 425kg/m2 (p = 0.002) in addition to (and independently of) advanced maternal age 435 years (p = 0.0489) were predictive of occurrence of FGR 534 weeks’ gestation (Table 1.) Conclusions: Early-onset FGR is associated with adverse perinatal outcome. Although there were no differences in composite adverse pregnancy outcomes after adjustment for gestational age for earlyversus late-onset FGR, perinatal mortality (1%) was reported in pregnancies 34 weeks’ gestation in our cohort. Risk factors for the development of early-onset FGR have been identified in this cohort as higher BMI and advanced maternal age. Results from this large prospective study further support the identification of maternal risk factors and intensive surveillance for FGR early in pregnancy. Keywords: fetal growth restricition, perinatal outcome Presenter: Dr Sieglinde Mu¨llers

Keywords: Amplitude integrated EEG, middle cerebral artery blood flow, small for gestational age infant, prematurity Presenter: F. Ovali

ID 488

EARLY- AND LATE-ONSET FETAL GROWTH RESTRICTION- A COMPARISON OF PERINATAL OUTCOMES S. Mu¨llers, J. Unterscheider, K. O’Donoghue, S. Daly, M.P. Geary, M.M. Kennelly, F.M. McAuliffe, A. Hunter, J.J. Morrison, G. Burke, P. Dicker, E. Tully, & F.D. Malone Perinatal Ireland Research Consortium, Ireland Brief Introduction: Fetal growth restriction (FGR) contributes significantly to adverse fetal and neonatal outcome. The objective of this analysis was to investigate the perinatal outcomes of pregnancies complicated by early- and late-onset FGR. This is a secondary analysis of the Prospective Observational Trial to Optimise Paediatric Health in IUGR (PORTO) study. Materials & Methods: A total of 1,200 fetuses with an EFW 510th centile between 24 + 0 and 36 + 6 weeks’ gestation were prospectively recruited. Sonographic parameters including multi-vessel Doppler assessment were recorded in addition to demographic, pregnancy and perinatal outcomes. Adverse pregnancy outcome was

ID 157

PROTEOMIC ANALYSIS OF AMNIOTIC FLUID IN IDENTIFICATION OF MARKERS OF FETAL GROWTH RESTRICTION V. Gunko, T. Pogorelova, & V. Linde Rostov Scientific-Research Institute of Obstetrics and Pediatrics, Rostov-on-Don, Russia Brief Introduction: An innovative way in the search of biomarkers of complicated pregnancy is the study of proteomic profile of amniotic fluid (AF), which largely reflects the fetus state, and it allows to evaluate the imbalance in the system mother-placenta-fetus to the full extent. The leading obstetric cause resulting in perinatal morbidity and mortality is the fetal growth restriction (FGR), the molecular mechanisms of formation and development of which remain so far insufficiently studied. Objective of this research is the study of proteomic spectrum of AF in physiological pregnancy and FGR Materials & Methods: The study included 64 women at the age of 23–33 took part in this study: 40 - with physiological pregnancy, 24 – with FGR. The material for the study was AF obtained in II trimester of gestation (23–24 weeks) be means of transabdominal amniocentesis and by rupture of amniotic fluid sac in I period of delivery (39–40 weeks). The pproteomic analysis of AF carried out using the twodimensional electrophoresis with the subsequent protein staining of

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silver ions and matrix-assisted laser desorption/ionization time-offlight mass spectrometry (MALDI-TOF-MS) of peptides extracted from gel. Proteins were identified using the Mascot program and SwissProt and NCBI data bases. Clinical Cases or Summary Results: Fifteen differently expressed proteins were identified using MALDI-TOF-MS (p50.05). In the proteomic spectrum of AF we detected 9 down-regulated proteins in FGR both in 23–24 and 39–40 weeks of gestation: epidermal fatty acid-binding protein, plasma retinol-binding protein, chorionic somatomammotropin hormone, haptoglobin, peroxiredoxin-2, insulin-like growth factorbinding protein-1 (IGFBP-1). By the end of III trimester of gestation complicated with FGR we detected in AF also down-regulated transthyretin, calgranulin A and B besides the above-stated proteins. In FGR there are 5 up-regulated proteins in AF regardless of the pregnancy term: zinc-a-2-glycoprotein, NKG2D ligand 2, fragment IGFBP-1, fibrinogen b chain, putative CDC37-like protein. Besides these proteins we detected and identified in AF two more upregulated proteins only in 23–24 weeks of gestation: hippocalcin-like protein 1 and a-1-microglobulin/bikunin precursor. In case of FGR they are absent in 39–40 weeks. Conclusions: 65% of the identified proteins are secreted proteins performing their functions in the extracellular space, other proteins are referred to cytoplasmic or nuclear proteins. In complicated pregnancy the change of level of proteins was registered in AF, these proteins participate in regulation of apoptosis, cell differentiation and proliferation, membrane transport, in support of pro- and antioxidative balance and other important biological processes. Summarising the received data it is possible to come to a conclusion that the modification of protein production in the fetoplacental system, which is reflected in the proteomic spectrum of AF, is one of initial disorders causing further metabolic and functional disorders in organisms of a mother and fetus and, as a consequence, it results in the development of FGR. Identified proteins of AF difference may be used as informative prognostic markers of this obstetric pathology.

Clinical Cases or Summary Results: 35% of our cases carried chromosomal abnormalities. Trisomy 18 and 21 were detected in 2 and 4 cases respectively. Trisomy 13, tripoloidy, monosomy X, supernumerary isochromosome 18p and supernumerary der(22), del (15)(q26.3), del (4)(p15.2), del (11)(q22q24) and dup (11)(p15) in Silver Russel Syndrome(SRS) were observed each in one case. Aneuploidies are the main causes of IUGR. They lead to some placental histological abnormalities that are responsible of its dysfunction. Furthermore, IUGR might also result of a dysregulation of the GH-IGF1 axis as seen in 15q26.3 deletion including IGF1R gene, coding for Insulin Like Growth Receptor which plays a key role in this pathway. Moreover, we suggest a dysregulation of chondrogenesis and ossification processes in 4p15 and 11q22 deletions cases related to the deletion of FGFRL1 and BARX2 genes respectively. In fact, these genes encode key proteins in cell growth, maturation and adhesion that are important components of these processes. On the other hand, IUGR seems to be associated to an epigenetic disorder in 11p15.5 region in the SRS and the triploidy cases. In fact, copy number gain of KCNQ1 et CDKN1C and H19 genes which expression is limited to the maternal chromosome 11, leads to a reduction of cells’ proliferation and to an apoptosis’ promotion in both fetal and placental sides. Conclusions: To conclude, our study confirms further the association of IUGR to genetic and epigenetic disorders. Molecular techniques are important to enravel new IUGR loci and fine map some others, and to improve our knowledge of the epigenetic regulation of fetal growth and development.

Keywords:

FETAL GROWTH RESTRICTION AND MAIN FETAL BRAIN ARTERIES: A COMPARISON BETWEEN DIFFERENT DOPPLER DETECTIONS.

Presenter: V. Linde

ID 629

INTRA UTERINE GROWTH RETARDATION AND GENETIC DISORDERS M. Kammoun1, H. Hannechi1, D. H’mida1, J. Mathlouthi2, H. Seboui2, H. Ben Hammouda3, A. Saad1, & S. Mougou-Zerelli1 1 Department of Cytogenetics and Reproductive Biology, Farhat Hached University Teatching Hospital, Sousse, Tunisia, 2 Department of Neonatology, Farhat Hached University Teatching Hospital, Sousse, Tunisia, and 3Department of Pediatrics, Tahar Sfar, University Teatching Hospital, Mahdia, Tunisia

Brief Introduction: Fetal growth involves a large number of maternal, placental and fetal factors of which 50% are genetic and epigenetic, leading to a systematic screening for Intra Uterine Growth Restriction (IUGR) genetic causes. We report the cytogenetic exploration results of 40 IUGR cases diagnosed in the pre and neonatal period. Materials & Methods: Maternal and placental causes were excluded for all our cases. R banding karyotyping was performed for all the fetuses and neonates. Based on the phenotype, array CGH and MS-MLPA were realized respectively for 4 and 6 cases with normal karyotyping.

Keywords: Fetal growth, chromosomal abnormalities, epigenetic regulation Presenter: S. Mougou-Zerelli

ID 572

P. Rosati, S. Buongiorno, P. Ciliberti1, I. Mappa, M. Tintoni, A. Ciardulli, M. Viggiano, AF. Cavaliere, & L. Guariglia Obstetrics and Gynecology Dept., Catholic University of the Sacred Heart, Rome, Italy Brief Introduction: The brain sparing effect, an essential adaptive response that preserves brain oxygen supply in chronic hypoxia, is defined by a reduction in the pulsatility index (PI) in the middle cerebral artery (MCA). It is supposed that similar changes occur in all cerebral arteries and have a relationship with fetal hemodynamic adaptation. The aim of our study is to evaluate differences and regional distribution of arterial brain Doppler parameters in relation to different stages of hemodynamic adaptation in fetuses small for gestational ages (SGA). Materials & Methods: 57 SGA fetus (estimated fetal weight-EFW 510 pc) were evaluated with Doppler; we divided them into three groups according to different umbilical artery (UA) and MCA Doppler indices: -Group A: fetuses without alteration at Doppler findings (n = 28); -Group B: fetuses with UA pulsatility index (PI) 42SD with a normal cerebroplacental ratio (MCA/UA PI 41 (n = 12); -Group C: fetuses with UA PI42SD with an abnormal cerebroplacental ratio (MCA/UA51) with a MCA PI52SD (n = 17)(‘‘brain sparing’’). Moreover, 29 normally growth fetuses (appropriate for gestational age-AGA) were studied for comparisons. Middle, anterior (ACA) and

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posterior (PCA) cerebral arteries Doppler were recorded. In addition, ACA and MCA were then recorded in two segments: ACA1- ACA2 and MCA1-MCA2. Clinical Cases or Summary Results: In this study, Group A had similar indices than control group. In Group B, ACA (both segments considered 1 and 2) showed a slight decrease of PI (1.44 ± 0.22; 1.34 ± 0.18) compared with control group (1.85 ± 0.38; 1.67 ± 0.41). In Group C, PI of all cerebral arteries evaluated were reduced. In all groups, differences were found between the two segments of MCA and ACA, while PCA PI did not change further. Conclusions: In fetuses with only EFW below 10 percentile, brain arteries PI is comparable with AGA controls as reported in literature. In IUGR fetuses with only abnormal UA there is an earlier decrease of resistances in ACA than MCA, suggesting an initial frontal cerebral adaptation to hypoxia. In IUGR fetuses with brain sparing, all arteries differ in Doppler parameters in relation to systemic hemodynamic adaptation, confirming literature results. Keywords: Fetal growth restriction; Doppler velocimetry; cerebroplacental ratio Presenter: P. Rosati

ID 969

APGAR SCORE OF INTRAUTERINE GROWTH RETARDED NEONATES ACCORDING MODE OF DELIVERY B. Frundeva, L. Vakrilova, V. Zlatkov, & A. Dimitrov Medical University of Sofia, Faculty of Medicine, Department of Obstetrics and Gynecology, University Obstetrics and Gynecology Hospital ‘‘Maichin Dom’’, Sofia Brief Introduction: Objective: To evaluate Apgar score at 1st and 5th minutes of eutrophic and hypotrophic neonates according mode of delivery – vaginal or Cesrian section. Design: Retrospective cohort study of prospectively collected maternal and neonatal data. Settings: University Hospital ‘‘Maichin dom’’, Sofia, Bulgaria. Materials & Methods: Population: Singleton pregnancies between 24 and 40 gw without any fetal malformations. In the study are enrolled 530 eutrophic and 329 intrauterine growth retarded neonates (IUGR). Methods: All cases are subdivided on four groups by gestational weeks – 24–27; 28–31; 32–35; 36–40 and each group again according mode of delivery – vaginal and CS. The neonates are classified as IUGR or AGA according intrauterine growth curves of Fenton TR (2003). IUGR neonates are defined as BW510th percentile. Main outcome of interest was 1/5 min Apgar scores according mode of delivery. Clinical Cases or Summary Results: The Apgar score at 1st minutes of AGA, born by CS at 24–27 gw, is 2.85 ± 1.62, for 28–31 is 4.42 ± 2.18, for 32–35 is 6.07 ± 1.40 and for 36–40 is 6.79 ± 1.22. The Apgar scores of AGA neonates, born vaginaly at the same gw periods are not statistically different from those of neonates born by CS. The 5th minutes Apgar scores are higher by 2 points from the 1t minutes score for the gw period 24–31 and with 1 points for 32–40gw. The difference between two modes of delivery is again not significant. At IUGR neonates the 1/5 min Apgar scores are significantly bather for the gw 24–31 than delivered by CS in comparison with vaginal one. The increase of Apgar score from 1st to 5th minutes is less than 1 point for IUGR neonates. There is significant difference in 1/5 min Apgar scores according mode of delivery for premature IUGR neonates. The term IUGR fetuses do not benefit from CS in comparison of vaginal delivery. Conclusions: The mode of delivery of AGA is not of significance, estimated by 1/5 min Apgar scores. For premature IUGR neonates CS give better Apgar score than vaginal delivery. Keywords: IUGR, Apgar score, mode of delivery Presenter: L. Vakrilova

ID 253

ADROPIN LEVELS IN INTRAUTERINE GROWTH RESTRICTED AND LARGE FOR GESTATIONAL AGE FULLTERM NEONATES T. Boutsikou1, S. Baka1, D.D. Briana1, D. Piatopoulou2, M. Boutsikou1, D. Hassiakos1, D. Gourgiotis2, & A. Malamitsi-Puchner1 1 Department of Neonatology, Athens University Medical School, Athens, Greece, and 2Laboratory of Clinical Biochemistry-Molecular Diagnostics, 2nd Department of Pediatrics, Athens University Medical School, Athens, Greece

Brief Introduction: Introduction/Background: Adropin is a peptide hormone, encoded by the Energy Homeostasis Associated (ENHO) gene. Low plasma adropin levels are associated with obesity, insulin resistance, aging, endothelial dysfunction and poor hepatic lipid homeostasis. We aimed to determine cord blood adropin levels in intrauterine-growth-restricted (IUGR), large-for-gestational-age, (both characterized by the above pathophysiological dysfunctions) and appropriate-for-gestational-age (AGA) pregnancies. Furthermore, to investigate possible correlations of adropin concentrations with several demographic parameters of infants at birth. Materials & Methods: Patients and Methods: Plasma adropin concentrations were determined by ELISA in 80 mixed arteriovenous cord blood (UC) samples from IUGR (n = 30), LGA (n = 30) and AGA (n = 20) singleton full-term infants and their mothers (MS). Clinical Cases or Summary Results: Results: No significant differences in adropin concentrations were observed between IUGR, LGA and AGA groups. In a combined group, MS adropin was significantly increased in female neonates (b = 0.977, 95%CI: 0.122- 1.832, p = 0.026), while MS adropin positively correlated with UC adropin (r = 0.282, p = 0.011). In the IUGR group MS adropin levels decreased with higher birth weight (b = -0.003, 95%CI: -0.006- 0.0, p = 0.043). Conclusions: Conclusions: Increased MS adropin levels in pregnancies with female offspring might indicate a synergistic protective role of adropin and estrogens in the regulation of hepatic lipid metabolism. The positive correlation between maternal and fetal adropin levels possibly reflects optimal energy homeostasis and thus, fetal growth, while increased adropin levels in severe IUGR might represent a regulatory feedback mechanism to counteract the endothelial dysfunction present in these cases. Keywords: adropin, AGA, LGA, IUGR, fetus Presenter: T. Boutsikou

ID 549

CARDIOVASCULAR CHANGES IN INTRAUTERINE GROWTH RESTRICTED FETUSES E. Cosmi, S. Visentin Department of Woman and Child Health, University of Pasua School of Medicine, Padua, Italy Brief Introduction: To compare the aortic intima-media thickness (aIMT) of the posterior wall of the abdominal aorta between IUGR and AGA. Evaluate cardiac function in the groups of fetuses. Assess the presence of a possible correlation between aIMT and fetal cardiac function in IUGR group

130 Materials & Methods: A case-control study in which 56 patients were enrolled, including 8 twins: 64 fetuses divided in 36 AGA and 28 IUGR. IUGR fetuses were those with an EFW 510th centile ans abnormal Doppler Velocimetry. fetal aIMT and aortic diameter were measured at a median gestational age of 30 weeks (range 28–32) and a complete echocardiographic functional examination has been performed Clinical Cases or Summary Results: The aIMT, aortic PI and ductus venosus PI of IUGR were higher than in AGA (p50.05). The S-wave lateral and Sino-tubula aortic diameter were lower in IUGR fetuses compared to AGA controls (p50.05). The AIMT in IUGR correlates positively with the left end-diastolic volume and the thickness of the flaps mitral, and negatively with the Global Longitudinal Peak Systolic Strain, the Deceleration Time, the wave A. Conclusions: The aIMT is increased in IUGR fetuses than in AGA. There were not statistically significant differences between cardiac parameters. This might be a correlation between vascular structures exposed to an increased stress pressure J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Keywords: IUGR, Cardiovascular Risk, Fetal programming Presenter: E. Cosmi

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multiparous women may reflect the documented positive association between parity and fat deposition. Finally, irisin upregulation in cases of maternal smoking may indicate the need for enhanced oxygen consumption to maintain energy production under conditions of hypoxia. Keywords: irisin, AGA, IUGR, LGA, fetus Presenter: T. Boutsikou

ID 752

RATES OF STILLBIRTH AND NEONATAL DEATH SECONDARY TO IUGR OVER A 10 YEAR PERIOD C. Nolan, E. Kent, & F. Malone RCSI Fetal Medicine Centre, The Rotunda Hospital, Dublin

ID 252

MATERNAL CIRCULATING IRISIN CONCENTRATIONS IN LARGE FOR GESTATIONAL AGE AND INTRAUTERINE GROWTH RESTRICTED PREGNANCIES D. D. Briana1, S. Baka1, T. Boutsikou1, A. Marmarinos2, M. Boutsikou1, D. Hassiakos1, D. Gourgiotis2, & A. Malamitsi-Puchner1 1 Department of Neonatology, Athens University Medical School, Athens, Greece, and 2Laboratory of Clinical Biochemistry-Molecular Diagnostics, 2nd Department of Pediatrics, Athens University Medical School, Athens, Greece

Brief Introduction: Introduction/Background: Human pregnancy is characterized by a progressive decrease in insulin sensitivity, which facilitates glucose diversion to the fetus. Normal gestational insulin resistance is further enhanced in pregnancy complications, such as those resulting in fetal macrosomia and growth restriction. Irisin has recently been introduced as a novel myokine with antiobesity properties, which promotes energy expenditure and improves glucose tolerance. We aimed to prospectively investigate maternal circulating irisin concentrations of in large-for-gestational-age-(LGA) and intrauterine-growth-restricted-(IUGR) versus appropriate-forgestational-age-(AGA) pregnancies. Materials & Methods: Patients and Methods: Plasma irisin concentrations were determined by ELISA in 80 maternal samples from LGA (n = 30), IUGR (n = 30) and AGA (n = 20) singleton full-term pregnancies. Clinical Cases or Summary Results: Results: Maternal irisin concentrations did not differ in LGA and IUGR cases, compared to AGA controls. In a combined group, maternal irisin concentrations significantly decreased with increasing gestational age [b = -0.193, 95% CI -0.321(-0.065), p = 0.004] and were lower in multi-, compared to nulliparous women [(b = -0.193, 95% CI -0.321- (-0.065), p = 0.004]. In the IUGR group, smokers presented with higher maternal irisin concentrations (b = 0.317, 95% CI 0.096- 0.537, p = 0.006). Conclusions: Conclusions: Myokine irisin may not be differentially regulated in insulin resistance-related pregnancy disorders resulting in fetal macrosomia and growth restriction. Maternal irisin downregulation with advancing gestation could possibly contribute to the observed maternal fat accumulation and progressive insulin resistance towards term. Similarly, lower maternal irisin concentrations in

Brief Introduction: Intrauterine growth restriction (IUGR) is the largest contributing factor to perinatal mortality in non-anomalous fetuses. The aim of the study was to evaluate changes in rates of stillbirth and neonatal death secondary to IUGR over a 10 year period. Materials & Methods: A retrospective cohort study was performed from 2003 to 2012 in a large tertiary referral hospital. Rates of stillbirth and neonatal death with IUGR as a causative factor were calculated. Comparison was made between the first 5 years and the second 5 years of the study period. Clinical Cases or Summary Results: A total of 253,061 births occurred in the period 2003 – 2012, 117,667 in the first 5 year period and 135,394 in the second 5 years. The overall rate of stillbirths decreased between the two time periods (0.47% vs 0.39%; p = 0.005), as did the rate of NND (0.28% vs 0.23%; 0 = 0.01). The proportion of stillbirths attributed to IUGR decreased from 7.4% to 4.1% (p = 0.002). However, the proportion of NND with IUGR as a factor increased (1.2% to 0.62%; p50.001). This resulted in no significant overall change in perinatal mortality rates attributable to IUGR (5.1% vs. 4.0%; p = 0.3) Conclusions: We have identified that the proportion of stillbirths and NND due to IUGR has not significantly changed over the study period. The proportion of stillbirths attributed to IUGR has decreased, reflecting the increased use of ultrasound surveillance, with both improved access to such imaging techniques and more personnel with expertise in performing antenatal ultrasound. However, the proportion of NND with IUGR as a factor has increased. This would suggest that we are identifying growth restricted babies and opting for timely delivery, but this is not necessarily translating into better outcomes overall for IUGR babies. Keywords: IUGR, growth restriction, stillbirth, neonatal death Presenter: Ciara Nolan

ID 624

HEPATIC ARTERY DOPPLER CHANGES IN FETUSES WITH INTRAUTERINE GROWTH RESTRICTION M. Bot¸, A. Petca, M. Zvanca, & D.C. Radu Elias University Hospital, Obstetrics and Gynecology Department, Bucharest, Romania Brief Introduction: Although the hepatic artery has a modest contribution to the blood supply of the liver, its most important role is to

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DOI: 10.3109/14767058.2014.924236

maintain hepatic perfusion in fetuses with intrauterine growth restriction (IUGR) by an adaptive mechanism referred as the hepatic artery buffer response. The purpose of this study is to determine the hepatic artery flow changes in IUGR fetuses during the second and third trimesters of pregnancy compared to normal-weight fetuses. Materials & Methods: We have created two study groups named A and B. In group A we included 302 pregnant women with normal weight fetuses without pregnancy associated pathology, while in group B we have included 38 pregnant women with fetuses with intrauterine growth restriction through placental insufficiency. We have conducted three different ultrasound examination at 21–23 weeks, 26–28 weeks and 31–33 weeks. We have performed measurements of the pulsatility index (PI) of the hepatic artery, umbilical artery (UA) and middle cerebral artery (MCA). Clinical Cases or Summary Results: By means of mathematical statistical analysis of group A PI values, we have obtained a nomogram of the fetal hepatic artery flow. We also analyzed the results obtained in group B and performed comparative analysis of the two groups. Concurrently with the degree of placental dysfunction and decreased umbilical flow evidenced by increased umbilical artery PI, we found decreased cerebral PI demonstrating the phenomenon of circulation centralization and redistribution with vasodilatation in the brain for protective purposes of this noble organ. In parallel with the decreased cerebral PI we found decreased hepatic artery PI compared to normal weight fetuses, that suggests the installing adaptive mechanism of circulatory redistribution and vasodilation for the hepatic artery too, in case of decreasing umbilical flow, thus demonstrating the crucial role of the liver. Conclusions: The present study attempts to illustrate the existence of the hepatic artery buffer system, which operates even in fetuses, in extreme conditions, with priority to maintaining homeostasis and liver perfusion. Keywords: intrauterine growth restriction, hepatic artery flow, umbilical artery Doppler, MCA Doppler

impact of additional to standard treatment administration of PTXF, DHA and ASA on IUGR pregnancies. Materials & Methods: 63 pregnant women with diagnosed IUGR were randomly allocated into four groups. In the Group A 35 patients were given PTXF (400mg orally twice a day; for 7 successive days). In the Group B 15 patients were given PTXF and DHA (DHA: 500mg orally twice a day) and in the Group C 6 patient were given PTXF and ASA (75mg once a day orally) as an adjunct to standard supportive therapy. In the Group D 7 patients did not receive PTXF, DHA or ASA and represented the placebo group. Main outcome measurements were PIUA in Doppler measurement, a change in EFBW (estimated fetal birth weight) after one week interval and a birth weight after delivery. No significant side effects related to PTXF, DHA or ASA treatment were observed. Clinical Cases or Summary Results: The mean birth weight at delivery was bigger in the Group A (1700g ± 563g) and in the Group C (1764g ± 558g) in contrast to the Group D (1498g ± 638g) with no statistical importance. Furthermore also the mean change in EFBW after one week supplementation was bigger in the Group A (126g ± 172g) and in the Group C (204g ± 301g) than in the Group D (41g ± 167g), but the difference did not reach the statistical importance. In our study the supplementation of PTXF, DHA and ASA did not influence the Doppler measurements of the umbilical artery. Conclusions: In conclusion, supplemental treatment with PTXF alone or with PTXF and DHA may have impact on birth weight and may decrease the incidence of hypotrophy, with no impact on the pulsatility index in the umbilical artery. Additional studies enrolling larger number of patients are required to determine the validity of the observed effects. Keywords: pentoxifylline, fetal growth restriction, docosahexaenoic acid Presenter: M. Radon´-Pokracka

Presenter: M.E. Zvanca

ID 728 ID 203

EFFECTS OF PENTOXIFYLLINE AND DOCOSAHEXAENOIC ACID SUPPLEMENTAL TREATMENT IN INTRAUTERINE GROWTH RESTRICTION H. Huras1, J. Kalinka2, M. Radon´-Pokracka1, K. Kus´mierskaUrban1, M. Kufelnicka-Babout3, M. Nowak1, K. Rytlewski1, P. Ossowski1, A. Wo´jtowicz -Grzyb1, & A. Reron´1 1

Obstetrics and Perinatology Dept., Collegium Medium Jagiellonian University of Krako´w, Krakow, Poland, 2 Perinatology Dept., Ist Chair of Gynecology and Obstetrics, Medical University of Lodz, Lodz, Poland, and 3Perinatology Dept., The M. Pirogow Regional Specialist Hospital in Lodz, Lodz, Poland Brief Introduction: The underlying mechanisms of intrauterine growth restriction (IUGR) remain poorly understood. It is known that pentoxifylline (PTXF) lowers blood viscosity, so it can improve microcirculation and tissue perfusion and as a result it may improve perfusion in the maternal – placental unit. Docosahexaenoic acid (DHA) is the most abundant omega-3 fatty acid in the brain and retina, so prenatal supplementation of DHA provides better developmental outcomes in children. Acetylsalicylic acid (ASA) in low doses inhibits platelet generation of thromboxane A2 with a result of an antithrombotic effect. The aim of the study was the evaluation of the

ULTRASOUND AND BIOCHEMICAL MARKERS OF THE FORMATION OF FETAL GROWTH RETARDATION A.N. Strizhakov, I.V. Ignatko, M.A. Kardanova, & M.M. Mirustchenko Department of the obstetrics, gynecology and perinatology, First Moscow State Medical University IM Sechenov, Moscow, Russia Brief Introduction: One of the most frequent perinatal complications in high-risk pregnancy is fetal growth retardation. And one of the most important issues is not only the identifi-cation of a syndrome, but the development of the criteria for its prediction. Materials & Methods: The aim of the study was the development of instrumental and laboratory criteria for the development of placental insufficiency and IUGR on a preconceptional stage and in the early stages of gestation. The study included patients belonging to the group of high perinatal risk both at the stage of preparation for pregnancy, and in terms of 5–12 weeks. Reasons for the formation of fetal growth retardation can be divided into «maternal» and «fetal». Clinical Cases or Summary Results: «Maternal» factors include: extragenital pathology - 38.3%; preeclampsia and other pregnancy complications - 37.9%; complicated obstetric and gynecological history - 9.8%; social and biological factors - 7.9%. «Fetal» factors include placental insufficiency - 87.6%; multiple pregnancy - 17.5%; intrauterine infection - 4%; fetal malformations and chromosomal abnormalities - 7.8%. In 23.2% of pregnant women there is a combination of two or more risk factors for IUGR. Survey methods for women of the preconceptional stage and later in the I trimester were include anamnestic follow-on, screening

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132 for genital infections, immunological studies, the study of hemostasis, sonography of the embryo/fetus and evaluation of extraembrional structures, placenta and amniotic water, Doppler blood flow in uteroplacental (spiral and uterine artery blood flow) vessels, fetalplacental (umbilical artery) and fetal vessels (arteries and veins), a study of extraembrional blood flow (blood flow in the duct and the yolk sac), the study of biochemical markers and growth factors (insulin-like growth factor, placenta growth factor), invasive diagnostics methods. Adverse echographic markers of severe stunting and death of the embryo/fetus in the I trimester were: CRL lag period of 410 days 22.9% (IUGR in 43%); bradycardia (less than 90 beats/min) (3.3%) - the death of the embryo in 90%, 10% observations severe IUGR; tachycardia (more than 170 beats/min) - 21.9% - stunting syndrome embryo/fetus is detected in 12.5%; markers of chromosomal abnormalities detected in 2.8%. Developmental disorders and involution of the yolk sac (increase in diameter, wall thickening) can be signs of early formation of placental insufficiency and IUGR and dysplastic form of fetal growth retardation and intrauterine infection. Conclusions: Prognostically significant signs were – disturbancies of the blood flow in the spiral and uterine arteries arteries, two-phase flow in the umbilical vein, a high index of pulsation in the umbilical artery. Registration venal spectrum or extremely low intervillous blood flow, detachment of the ovum (retrochorial hematoma). In addition to the ultrasonic Doppler and prognostic markers development FGR currently investigated biochemical markers. Thus, a high risk of developing the syndrome is defined, if during I -II trimesters is lower than normal placental growth factor level, plasma protein associated with pregnancy (PAPP-A), insulin-like growth factor, 13 plasma protein, vitamin D. And high lewel of soluble endoglobin and free fetal DNA in maternal blood. In the majority of cases, these same markers informative for predicting severe preeclampsia. Keywords: placental insufficiency, fetal growth retardation, ultrasound diagnostic Presenter: AN Strizhakov

ID 760

FETAL GROWTH RESTRICTION – PERINATAL OUTCOME J. Cominho, M. Mouraz, S. Saramago, M.I. Reis, S. Proenc¸a, L. Reis, R. Rodrigues, & F. Nunes All from HPP Hospital de Cascais Dr. Jose´ de Almeida, Cascais, Portugal Brief Introduction: Fetal growth restriction (FGR) is associated with stillbirth, neonatal death and perinatal morbidity as well as delayed effects including cerebral palsy and adult diseases. In most cases, FGR is due to placental insufficiency but may also be due to a number of other conditions. The main objective of this study is to compare some factors of antenatal and intrapartum management as well as perinatal outcome in fetal growth restriction. Materials & Methods: A hospital based retrospective study was conducted between 1st April 2013 to 31st March 2014. The study group included all fetuses with percentile 53 and/or alterations in umbilical/middle cerebral arteries in fluxometry. The control group included all fetuses with percentile between 3 and 10 and no alteration in fluxometry (small for gestational age – SGA). Clinical Cases or Summary Results: There was allocated 55 cases, 24 fetal growth restricted fetuses and 31 small for gestational age. In the study group, the average percentile was 2.7 and in the control group 6.6. There was no statistically difference between maternal age, parity or previous pathology between the two groups. There was no difference in relation to type of parturition but in the study group there were more cesareans related to suspected fetal distress, with statistically significance. In the study group, the gestational age at

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

birth was significantly younger than in control group. The average estimated weight in ultrasound in study group was 1925 grams and in control group 2297 grams. The average newborn weight in the study group was 2076 grams and in control group 2570 grams. There was no statistically difference relatively to Apgar score at 5th minute nor admissions in neonatal intensive care unit. Conclusions: Although in literature is refered a poorer neonatal outcome in fetal growth restriction, in our study this was not demonstrated. However this condition requires an individualized clinical assessment to ensure good management and timely delivery. Keywords: Fetal growth restriction, perinatal outcome Presenter: Joana Cominho

ID 622

IUGR – FINDING THE APPROPRIATE SURVEILLANCE METHOD A. Petca, M.E. Zvanca, M. Bot, & D.C. Radu Elias University Hospital, Obstetrics and Gynecology Clinic, Bucharest, Romania Brief Introduction: Our study focuses on finding the most accurate method to decide the wright time to terminate an IUGR pregnancy. It is still debatable, as long as TRUFFLE hasn’t published yet its conclusions, wether Doppler studies of umbilical and medium cerebral arteries or external cardiotocography, is the appropriate method for the assesment of risk and surveillance during pregnancy. Materials & Methods: This was a prospective study on 92 singleton pregnancies with growth restricted fetuses after 32 weeks of gestation. Pulsatility and resistivity indices of middle cerebral artery and umbilical artery as well as short-term variation of fetal heart rate were assesed for each patient. The study population was divided into two groups: Group 1 comprised pregnancies evaluated only with Doppler indices and Group 2 included pregnancies evaluated with external cardiotocography. Clinical Cases or Summary Results: Both groups comprised patients with similar age, parity, hypertensive disorders and history of prior placental insufficiency. Cesarian delivery was performed for every patient in both groups. 19,86 days was the medium pregnancy prolongation for group 1, and 19,28 days for group 2. The Apgar score, newborn weight, need for ventilation, neonatal complications were similar for both groups, as well as UTIN admission Conclusions: We didn’t find significant differences between two methods of fetal surveillance of IUGR pregnancies between 32 and 36 weeks gestation Keywords: intrauterine growth restriction, cardiotocography, umbilical artery Doppler, MCA Doppler Presenter: Mona Zvanca

ID 160

THE EFFECTS OF MOTHER’S ACTIVE SMOKING DURING PREGNANCY ON ANTHROPOMETRIC PARAMETERS OF NEWBORNS J. Cˇepin Bogovic´1, S. Anic´ Jurica2, S. Gveric´-Ahmetasˇevic´3, & I. Pavic´4

133

DOI: 10.3109/14767058.2014.924236 1

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Department of pulmonology, immunology, allergology and rheumatology, Children’s Hospital Zagreb, Croatia, 2 Neonatology Dept., University Hospital Centre Zagreb, Croatia, 3Neonatology Dept., University Hospital Centre Zagreb, Croatia, and 4Department of pulmonology, immunology, allergology and rheumatology, Children’s Hospital Zagreb, Croatia Brief Introduction: Many investigations have noted bad influence of smoking during pregnancy. In the present study, the influence of mothers smoking during pregnancy on the birth weight, birth length and body mass index (BMI) are examined. Materials & Methods: This retrospective research included 219 children. The questioned subjects were divided into two groups depending on mothers smoking during pregnancy: Group I: 156 newborns of mothers who didn’t smoke during pregnancy and Group II: 63 newborns of mothers who did smoke 10 or more cigarettes per day during pregnancy. In this study we included newborns of healthy mothers, who didn’t take any medications during pregnancy and with remarkable family and personal history. Children were conceived in natural way, with no problems during pregnancy and delivery, and all children were born on time. Anthropometric measurements were taken in the delivery room, just after the birth. Clinical Cases or Summary Results: Anthropometric parameters (birth length, birth weight and BMI) in newborns of non-smoker mothers were statistically higher (p50.05) than in newborns of smoker mothers. Newborns of smoker mothers had lower birth weight, shorter birth length and lower BMI then newborns of non-smoker mothers. On the basis of analysis of ROC curve, it could be presumed that newborns of smoker mothers would have birth length 50 cm, birth weight 3370 g and BMI 13.5 kg m2. Conclusions: According to the results of our study, every woman must be informed that by smoking during pregnancy she endangers not only her own health but also exposes her own child to great and unnecessary risk. Keywords: smoking during pregnancy, anthropometric parameters, newborns Presenter: Jasna Cˇepin Bogovic´

ID 106

LOW BIRTH WEIGHT, A SMOKE RELATED CONDITION AMONG THE ALBANIAN POPULATION IN R.MACEDONIA I. Kjaev, M. Hadzi-Lega, A. Bina, R. Spasova, & G. Kocoski University Clinic for Obstetrics and Gynecology -Skopje, R.Macedonia Brief Introduction: Smoking during pregnancy is estimated to account for 20 to 30 percent of low-birth weight babies, up to 14 percent of preterm deliveries, and about 10 percent of all infant deaths according to American Lung Association. Smoking during pregnancy is associated with 19, 17% among the pregnant Albanian population (significantly less than the Macedonian 28,19% and the Roma 35,24%). This is in touch with world statistics which account for between 12–20% of smokers during pregnancy. Materials & Methods: This retrospective study was done at the University Clinic of Obstetrics and Gynecology. Data was reviewed for the year 2012.Results showed that 26, 42% of the pregnant population in Macedonia smoke. Pregnant women were asked if they smoked more then 19 or less than 19 cigarettes.The biggest difference was among infant born among the Albanian population.

Clinical Cases or Summary Results: Average birth weight of the infants among patients who smoked less the 19 cigarettes was 3105 gram compared to those who smoked more then 19 cigarettes which was 2779 gram. The difference of 326 gram is significant and conclusive with worldwide statistics which show that the number of cigarettes smoked is in direct correlation with birth weight Conclusions: Low birth weight babies face an increased risk of serious health problems as newborns have chronic lifelong disabilities such as cerebral palsy, mental retardation and learning problems. Overall they also face an increased risk of death. Programs that involve smoking prevention is the only way to tackle this increasingly important issue. Keywords: smoking, low birth weight, disabilities Presenter: Ivo kjaev

ID 632

A NEONATAL CASE OF LENZMAJEWSKI SYNDROME S.A. Liguori1, M.C. Russo1, M. Cuozzo1, G. Caroni1, B. Ricci1, R. Cervini2, M. Baiona2, E. Belligni3, E. Biamino3, & P. Savant Levet1 1

Neonatal Intensive Care Unit, Maria Vittoria Hospital, Turin, Italy, 2Section of Child Neuropsychiatry, Maria Vittoria Hospital, Turin, Italy, and 3Pediatric Dept, University of Turin, Regina Margherita Children’s Hospital, Turin, Italy Brief Introduction: Lenz-Majewski syndrome (LMS) is a rare sclerosing bone dysplasia, characterized by craniofacial, cutaneous and distallimb anomalies, growth failure and mental retardation (1). To date only a few cases (eight typical cases) have been reported (2). Recently gain-of function mutations in the phosphatidylserine synthase 1 (PTDSS1) gene have been identified as causative of LMS (3). Here we report a case of LMS, suspected and promptly diagnosed in neonatal period. Materials & Methods: Case report Clinical Cases or Summary Results: Male, born at 41 + 5 weeks of gestation by vaginal delivery after an uneventful pregnancy. Neonatal resuscitation was needed for dystocic labor and perinatal asphyxia (Apgar score 0 and 4 at 1 and 5 minutes) with normal cerebral function monitoring. All birth measurements were 53rd centile. Physical examination at birth revealed craniofacial dysmorfisms, large anterior fontanelle, brachydactyly with proximal symphalangis, cutis laxa and reduction of subcutaneous fat. He presented respiratory distress syndrome, requiring mechanical ventilation for 24 hours, laryngomalacia and feeding difficulties, requiring tube-feeding for about 10 days. Skeletal radiographs revealed hyperostosis of diaphysis of long bones, clavicle and ribs. Brain echography showed corpus callosum abnormalities, confirmed also by brain magnetic resonance. Karyotipe was normal (46 XY). A new de novo heterozygous PTDSS mutation was identified, confirming the clinical suspicion of LMS. Conclusions: This case has been clinically suspected in the first days after birth because of typical phenotypic and radiological characteristics. Genetic analysis confirmed the syndrome, showing also a new mutation not previously described. LMS is a very rare condition, that could be suspected in harmonic small for gestational age newborns with cutaneous and skeletal abnormalities. Keywords: Lenz-Majewski syndrome, small for gestational age Presenter: S.A. Liguori

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ID 237

SERUM FREE FATTY ACIDS LEVEL AND ANTIOXIDANT ENZYMES ACTIVITY IN PREECLAMPSIA AND FETAL GROWTH RESTRICTION I. Baranov1, M. Vyssokikh2, & Y. Skripnichenko3

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Russian Federation, Moscow, Federal State Budget Institution ‘‘Research Center for Obstetrics, Gynecology and Perinatology named after academician V. I. Kulakov’’ Ministry of Healthcare of the Russian Federation Brief Introduction: The only way to prevent complications of pregnancy is timely diagnostics of pathological course of pregnancy.Controlled oxidation of organic macromolecules is the main mechanism for the maintenance of energy balance and functioning of aerobic organism’s cells. Successive oxidation of respiration substrates by oxygen continuously occurs in all organs and tissues and is not accompanied by theirs structure damage due to the coordinated work of antioxidant defense systems.Respiratory chain functioning disturbance leads to the accumulation of products of incomplete oxygen reduction and to the induction of free radical processes. Highly reactive products formation causes systemic damaging of the key macromolecules and leads to the dysfunction of cellular systems and tissue in pathology. Materials & Methods: Thus, the imbalance between lipid peroxidation kinetics and antioxidant activity is one of the leading factors in the pathogenesis of pregnancy complications. The aim of the study is to determine the level of free fatty acids and antioxidant enzymes activity in the serum of pregnant women of three groups: non-complicated pregnancy, preeclampsia and/or fetal growth restriction syndrome. Materials and methods: we plan to determine the level of free fatty acids and antioxidant enzymes content and activity in serum. Determination of free fatty acids level will be performed by high performance gas-liquid chromatography with mass detection. Clinical Cases or Summary Results: Results: the increase of the level and changes of free fatty acids composition in serum and the decrease of antioxidant enzymes activity contribute to the oxidative damage of placental mitochondria in women with preeclampsia. The increase of free fatty acids level in serum by the end of pregnancy is a compensatory mechanism which reduces free radicals rate under conditions of mitochondrial respiratory chain dysfunction in pathology. Conclusions: Study of the correlation between the level of oxidative stress markers (H2O2, ROO and secondary radicals) and antioxidant enzymes (glutathione peroxidase, catalase, superoxide dismutase I, II and III) in serum may have an implication for the development of predictors of pregnancy complications like preeclampsia, fetal growth restriction and other pathologies of gestation associated with mitochondrial dysfunction. Keywords: oxidative stress, antioxidant enzymes, pregnancy, perinatal pathology Presenter: I. Baranov

ID 051

MORBIDITY AND MORTALITY IN PRE-TERM FGR FETUSES: COHORT OUTCOMES IN 3.5 YEARS STUDY IN UNIVERSITY HOSPITAL ‘‘KOCO GLIOZHENI’’ TIRANA, ALBANIA

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

E. Prifti1, N. Manoku2, E. Roshi3, A. Hoxha4, A. Alikaj5, & E. Pupi6 1

High Risk Pregancy Unit Department, Faculty of Medicine, University Hospital of Obstetric and Gynecology ‘‘Koco Gliozheni’’, Tirana, Albania, 2Department of Obstetric and Gynecology, Faculty of Medicine, Tirana, Albania, and 3 Insitute of Public Health, Faculty Brief Introduction: To describe perinatal morbidity and mortality based on antenatal diagnosis, in FGR preterm fetuses, in our Institution. In relation to these data, we can consil the parents based on perinatal outcomes and delivery decision, according to gestational age and antenatal diagnosis parameters. Materials & Methods: We report data regarding a prospective study, between August 2010 and January 2014, in High Risk Pregnancy Unit and NICU, in University Hospital of Obstetrics and Gynecology ‘‘Koco Gliozheni’’, Tirana, Albania. Pregnant women, with single fetus, ultrasonography detailed normal anatomy, between 28 wGA and 37wGA, with EFW below 10th percentile, and at least one abnormal arterial Umbilical or cerebral Doppler parameter up to three days from delivery: DUPI 495th centile, AEDF, REDF, MCAPI5p.5th, CPI5percentile 5th. Main outcome was Adverse Perinatal Outcome which included a composite of: Perinatal Deaths and Severe Morbidity including: Interventricular Hemorrhage (HIV), Periventricular Leucomalacia (PVL), Hypoxic Ischemic Encephalopathy (HIE), necrotizing enterocolitis (NEC), BPD, sepsis. Clinical Cases or Summary Results: After fulfilling exact including criteria, study group included, 91 women with their fetuses. Mean Gestational Age +/- SD in moment of the study was 33wGA +/- 2.1; mean delivery weight was 1486.7 +/- 371.5. From 91 fetuses, 12 of them were perinatal deaths (6 Intrauterin Fetal Deaths and 6 neonatal deaths). All the neonatal deaths, were after severe morbidity. Deaths and severe morbidity resulted statistically related to Gestational Age, newborn weight, and absence of end diastolic velocity in Umbilical Artery. Conclusions: Adverse Perinatal Outcome was significantly related to gestational age and neonatal weight in the moment of delivery. Perinatal deaths were 11%, and 60% of neonates had no adverse perinatal outcome. In our Institution, we can offer better results regarding perinatal outcome beggining from 32 wGA. This prognosis is darker, below 30wGA. Keywords: FGR, preterm, adverse perinatal outcome Presenter: Enkeleda Prifti

ID 213

EARLY NEONATAL OUTCOME IN PATIENTS WITH INTRAUTERINE GROWTH RESTRICTION S. Polukarova, D. Kviluna, A. Miskova 1

Neonatology Clinic, Children’s Clinical University Hospital, Riga, Latvia, 2Neonatology Clinic, Children’s Clinical University Hospital, Riga, Latvia, and 3ObGyn Dept., Riga Stradins University, Riga Maternity Hospital, Riga, Latvia Brief Introduction: Intrauterine growth restriction (IUGR) is the fetal inability to reach genetic growth potential, so the newborn is small for gestational age (SGA). IUGR incidence is 4–10% in developed and reaches 30% in developing countries. IUGR is associated with increased perinatal, neonatal morbidity and mortality. Longterm outcome is associated with development of neurologic, cardiovascular and endocrinologic pathology. The aim of our study was to detect early neonatal outcome of SGA patients. Materials & Methods: Our descriptive prospective study recruited 31 SGA preterm neonates admitted to Neonalology Clinic of Children’s Clinical University Hospital. All patients had antenataly diagnosed

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IUGR by serial ultrasound studies. Control group of 31 preterm normal for gestational age (NGA) neonates was created. The data were analysed using Student t test. A p value 50.05 was considered to be statistically significant. Clinical Cases or Summary Results: Average gestational age of SGA patients was 34 weeks. Average birth weight 1561g. Maternal average age was 26 years, primipara 12 (39%) and multipara 23 (74%), all of them had antenatal care. IUGR pregnancies were complicated with any disease in 23 cases (74%), but in 7 cases (23%) by chronic disease diagnosed preconceptionaly. All mothers had normal body mass index, 5 of them (16%) smoked during pregnancy. Operative delivery was done in 28 cases (90%), vaginal delivery in 3 cases (10%). Respiratory distress developed in 14 newborns (45%). Hypoglycaemia was diagnosed in 15 (48%) on first day of life and persist on third day of life in 8 newborns. Hypoglycaemia was linked to gestational age. 5 newborns (16%) had trombocytopenia, 9 (29%) had anemia. Gastrointestinal pathology was diagnosed in 13 cases (42%), 4 of them (13%) developed necrotising enterocolitis. We detected statistically significant difference between patient’s and control group only for maternal disease complicated pregnancy (p50.05) and early neonatal hypoglycaemia (p50.05). Conclusions: IUGR preterm patients develop hypoglycaemia more common than preterm NGA neonates. IUGR pregnancy often is complicated by maternal disease. It is important to evaluate SGA newborns in early neonatal period to detect and threat pathologic conditions linked to IUGR.

Materials & Methods: The study was performed in two University Hospitals of northern Italy. We enrolled 76 pregnancies between 19 and 35 weeks: 51 pregnancies were at previous risk (PR) of developing PE, 9 were complicated by pregnancy induced hypertension and 16 at diagnosis of IUGR. PR pregnancies were identified by maternal characteristics, maternal diseases and/or previous obstetric complications. Maternal circulating PlGF levels were measured by the Triage PlGF Test (Alere). We considered fetal outcomes in relation to PlGF cut off values according to the manufacturer. Uterine Artery (UTA) PI (Pulsatility Index) was assessed by US in the same patients at the time of maternal sampling. Clinical Cases or Summary Results: Pregnancies at risk with PlGF levels5cut off had significantly lower GA and birthweight at delivery than patients with PlGF  cut off. The rate of emergency C-Section was significantly higher in the group with PlGF5cut off. IUGR pregnancies with PlGF5cut off delivered earlier, had significantly lower BW than patients with PlGF  cut off. In the IUGR group, altered UTA mean PI didn’t identify pregnancies that delivered earlier than IUGR with normal UTA mean PI. Conclusions: Our data suggest that PlGF may provide useful information to identify fetuses requiring urgent delivery and those at risk of adverse outcomes when evaluating pregnancies at risk of PE. Therefore, PlGF measured at the time of diagnosis of IUGR can predict adverse fetal outcomes that may be secondary to placental insufficiency; instead, UTA Doppler fails to identify the majority of these cases (supported by PRIN 2010 and ASM).

Keywords: IUGR, SGA

Keywords: PlGF; IUGR; PE; Uterine Artery Doppler

Presenter: Polukarova Svetlana

Presenter: I.CETIN

ID 706

ID 107

PLACENTAL GROWTH FACTOR FOR THE PREDICTION OF FETAL OUTCOMES IN PREGNANCIES AT RISK AND IN IUGR

PATTERN OF SMOKING AMONG THE PREGNANT POPULATION IN R.MACEDONIA

I. Cetin1, M. Mazzocco1, V. Giardini2, S. Calabrese1, P. Algeri2, A. Martinelli1, L. Todyrenchuk2, & P. Vergani2 1

Unit of Obs and Gyn, L.Sacco Hospital, Center for Fetal Research Giorgio Pardi, University of Milan, Italy, and 2 Unit of Obs and Gyn, S.Gerardo Hospital, University Bicocca, Monza, Italy. Brief Introduction: Placental growth factor (PlGF) is an angiogenic molecule produced by the placenta and implicated in the pathogenesis of preeclampsia (PE) and intrauterine growth restriction (IUGR). Both PE and IUGR are leading causes of maternal and neonatal morbidity and mortality. We have hypothesized that PlGF could be used as a marker to predict fetal outcomes in pregnancies at risk of PE or complicated by IUGR.

I. Kjaev, R. Spasova, G. Kocoski, J. Gjoreski, V. Tofiloska, & A. Sima University Clinic of Obstetrics and Gynecology - Skopje, R.Macedonia Brief Introduction: Smoking in pregnancy is related to many effects on health and reproduction. A number of studies have shown that tobacco use is a significant factor in abortions among the smoking population, and that it contributes to a number of other threats to the health of the fetus. A recent study has shown that more than 37% of the Macedonian populations are smokers which put the nation among the highest tobacco users in the world. The goal of this study was to establish the smoking trends among the pregnant population in Macedonia

Table. AT RISK

Maternal age(yrs) BMI(kg/m2) UTA, mean PI 495 (%) GA at delivery(wks) Emergency C-section(%) Spontaneous Vaginal Delivery(%) BW(gr) pH Umb Artery *p50.05; **p50.01

IUGR

PlGF5cut off (13)

PlGF  cut off (47)

PlGF5cut off (10)

PlGF  cut off (6)

UTA mean PI495 (12)

UTA mean PI normal (4)

34.5 ± 4.3 26.2 ± 5.6 61 * 35+4 ± 4+1** 31.5** 7*

32.3 ± 4.7 26.3 ± 6.5 12 38+6 ± 1+3 10.5 34

33.0 ± 6.0 23.3 ± 4.3 100** 33+6 ± 3* 70 10

30.5 ± 8.2 24.1 ± 3.5 33 38+3 ± 1+4 50 16.5

33.6 ± 6.0 23.7 ± 4.1 100 34+1 ± 3+6 75 8

27.2 ± 8.3 23.5 ± 3.8 0 37+6 ± 1 50 25

2516 ± 948** 7.29 ± 0.04

3274 ± 499 7.34 ± 0.3

1368 ± 338** 7.30 ± 0.08

2333 ± 335 7.35 ± 0.04

1582 ± 590 7.28 ± 0.08

2118 ± 167 7.38 ± 0.01

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Materials & Methods: The multiethnic society offers a chance to view patterns of smoking among the three biggest ethnicities (Macedonian, Albanian and Roma). This represents a retrospective study done at the University Clinic of Obstetrics and Gynecology –Skopje, R.Macedonia. Data was reviewed from January 2012 until January 2013. In this time period there were 5506 deliveries. Women were asked whether they smoked or not. The population of smokers was 1455 (26, 42%). Among ethnicities the trends are as followed: – Macedonians 28.19% – Albanians 19.17% – Roma 35.24% Clinical Cases or Summary Results: Unfortunately the results are similar as with the general population in R.Macedonia. Smoking represents a big problem during pregnancy. Women who smoke during pregnancy are about twice as likely to experience the following pregnancy complications: premature rupture of membranes, placental abruption and placenta previa Conclusions: Ideally, women should not smoke before, during or after pregnancy. One of the ways to reduce the number of smokers in pregnancy is through better education and public awareness programs.

syndrome, the prevalence being 1:316. The DR was 77.3% and FPR 4.9%. The number of invasive procedures needed to detect one case of Down’s syndrome was 15. During the latter half, years 2007 – 2011, 31 147 women participated in combined first trimester screening. The mean maternal age was 29.4 years and the proportion of women aged 35 years or older was 15.3%. There were 83 cases of Down’s syndrome, the prevalence being 1:375. 77.1% of the Down cases were detected for a FPR of 2.8%. The number of invasive pro-cedures needed to detect one case of Down’s syndrome was 11. Conclusions:. Assessing the screening performance in Down screening sensitivity and specificity are important. The most important issue is the number of invasive procedures needed to detect one case of Down’s syndrome and decrease the risk on unnecessary fetal loss. After the 5 year learning period the screening performance improved markedly in the latter 5 year period since the false positive rate lowered from 4.9% to 2.8% and the number of invasive procedures needed to detect one case of Down’s syndrome lowered from 15 to 11.

Keywords: pregnancy, smoking, ethnicities

ID 796

Presenter: Ivo Kjaev

EXPLAINING LARGE VARIATIONS IN DOWN’S SYNDROME SCREENING UPTAKE BETWEEN THE NETHERLANDS, ENGLAND AND DENMARK

FIRST TRIMESTER SCREENING AND PREVENTION STRATEGY ID 077

INVASIVE PROCEDURES IN FIRST TRIMESTER COMBINED SCREENING: EXPERIENCES OF THE FIRST TEN YEARS IN NORTHERN FINLAND M. Ryynanen1, T. Vaskivuo2, & J. Marttala1 1 Department of Obstetrics and Gynecology, Oulu University Hospital, Finland, and 2Laboratories, Oulu University Hospital, Finland

Brief Introduction: The main purpose of this study was to evaluate the clinical performance of first trimester combined screening for T21 in Northern Finland during its first ten years of practice. We divided the ten screening years into two periods of 2002 – 2006 and 2007 – 2011 and compared the performance of the test DRs, FPRs and the number of invasive procedures needed to detect one case of Down’s syndrome between those two time periods. The first five year period was perceived as a learning period.e. Materials & Methods: During the study period of 1.1.2002–31.12.2011 47896 women participated voluntarily to first trimester combined screening at an accredited laboratory of Oulu University Hospital in accordance with the regulations of the Finnish Ministry of Social Affairs and Health during gestational weeks 9–13. The risk cut-off was 1:250. The study period was divided into two time periods of 2002– 2006 and 2007–2011. Mean maternal age, proportion of women aged 35 years or more, detection rates (DRs), false positive rates (FPRs) and number of invasive procedures needed to detect one case of Down’s syndrome were compared between the groups. Clinical Cases or Summary Results: During the first part, years 2002 – 2006, 16 749 women participated in combined first trimester screening. Mean maternal age was 29.6 years and 17.4% of the women were 35 years of age. There were 53 cases of Down’s

Keywords: Down’s syndrome, first trimester, nuchal translucency, combined screening, singleton pregnancy Presenter: Markku Ryynanen

N. Crombag1, Y. Vellinga2, S. Kluijfhout2, L Bryant3, P. Ward4, R. Iedema-Kuiper1, P. Schielen5, J. Bensing6, G.H.A. Visser1, A. Tabor7, & J. Hirst8 1

University Medical Centre Utrecht, Department of Obstetrics, The Netherlands, 2Erasmus University Rotterdam, The Netherlands, 3Leeds Institute of Health sciences, Faculty of Medicine and Health, University of Leeds. United Kingdom, 4 NHS Fetal Anomaly Screening Programme, Innovation Centre, University of Exeter, United Kingdom, 5National Institute for Public Health and the Environment, Diagnostic Laboratory for Infectious Diseases and Perinatal Screening Bilthoven, The Netherlands, 6The Netherlands Institute for Health Services Research Utrecht, The Netherlands, 7Center for Fetal Medicine, Dept. of Obstetrics and Gynecology, Copenhagen University Hospital, Rigshospitalet, Denmark, and 8Leeds Institute of Health sciences, Faculty of Medicine and Health, University of Leeds. United Kingdom Brief Introduction: The offer of prenatal Down’s syndrome screening (DSS) is part of routine antenatal care in most of Europe; however screening uptake varies significantly across countries. Although a decision to accept or reject screening is a personal choice, it is unlikely that the widely differing uptake rates across countries can be explained by variation in individual values alone. The aim of this study was to compare DSS policies and programmes in the Netherlands, where uptake is low (530%) with England and Denmark where uptake is much higher (74 and490% respectively), in an attempt to explain the observed variation in national uptake rates. Materials & Methods: This study adopted a pragmatic qualitative approach to help describe and explain relationships. To answer the research questions we used a mixed methods approach with an embedded design: a) analysis of relevant documents to describe differences and similarities within established policies and programmes and b) to further explore this information we performed in depth interviews with relevant experts. First, we studied central statistical offices and legal documents to gain insight in demographic

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DOI: 10.3109/14767058.2014.924236

characteristics, cultural background, organization and structure of healthcare in each of the three countries. Second, we performed documentary analysis of primary and secondary sources on relevant documents on DSS policies and programme, and third, to enhance interpretation of these findings we performed in-depth interviews with relevant expert stakeholders in the participating countries to provide insight in initial intentions and formal rules of the national DSS policy and the impact on performance. For a subsequent qualitative analysis we performed 10 focus group interviews with Dutch pregnant women, both before and after consultation with a healthcare professional on factors influencing utilization of DSS. The groups were categorised towards their screening intention, women intending to accept screening or women intending to decline screening. Clinical Cases or Summary Results: There were many similarities in the demographics, healthcare systems, government abortion legislation

and DSS policy across the studied countries. However, the additional cost for Down’s syndrome screening over and above standard antenatal care in the Netherlands and an emphasis on the ‘right not to know’ about screening in this country were identified as potential explanations for the ‘low’ uptake rates of DSS in the Netherlands. The social context and positive framing of the offer at the service delivery level may play a role in the high uptake rates in Denmark. Pregnant women accepting DSS intended to opt for a termination of pregnancy (TOP) in case of a diagnosed Down’s syndrome, using arguments of ‘the right to make personal reproductive decisions’ and ‘optimising pregnancy outcomes’. A subgroup of these women expressed more ambivalence towards consequences in case of diagnosed Down’s syndrome; for most of them TOP was not a self evident act. Women declining the offer of DSS all expressed not to opt for TOP in case of diagnosed Down’s syndrome. But within this argument

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women expressed different types of arguments, from accepting a child with Down’s syndrome to only wanting to know the fetal chromosomes in case of high a priori risk (to prepare for a life with a handicapped child in case Down’s syndrome.) Conclusions: This research clearly shows how macro-level demographic, social and healthcare delivery factors may have an impact on national uptake rates for Down’s syndrome screening. A number of policy level and system characteristics may explain the relatively low uptake rates of Down’s syndrome screening in the Netherlands when compared to England and Denmark. The preliminary results from the focus group interviews indicate that some women, both within the ‘accept’ and’ decline’ subgroups express ambivalence within their arguments for utilization of screening. For these women, macro-level demographic, social and healthcare delivery factors may well play a role in their decision to accept or decline the offer of prenatal screening. Keywords: Down’s syndrome, Antenatal screening, Utilization of healthcare, Uptake, International comparison Presenter: N. Crombag

ID 415

ASSOCIATION OF FIRSTTRIMESTER PAPP-A WITH SMALLFOR-GESTATIONAL AGE INFANT AND OTHER ADVERSE PREGNANCY OUTCOMES Cervino Gomez E, Gonzalez Rodriguez L, Cernadas Pires S, Gonzalez Boubeta R, & Lopez Ramon y Cajal CN Unit of Fetal Medicine, University Hospital Complex Vigo, Spain (all authors) Brief Introduction: The PAPP-A is produced by the placental syncytiotrophoblasts and works as a protease for IGF binding protein 4. IGF plays a major role in the fetal growth, mediating in the trophoblastic invasion and the glucose and aminoacids transport across the placenta. Levels of PAPP-A 50.4 MoM in the first trimester screening, have been linked to an increasingly frequent adverse perinatal outcomes. The early identification of fetuses at risk of SGA may improve the gestational surveillance and optimize the moment of birth. The objective is ascertain the clinical usefulness of a low level of PAPP-A in the first trimester screening, as a SGA predictor at birth and if there are differences for other adverse perinatal outcomes. Materials & Methods: Type of study: cases and controls. Inclusion criteria: Spontaneous, single pregnancies, in 38 yearold women subjected to first trimester screening for aneuploidies between week 11 and 13 + 6 at University Hospital Complex Vigo, between January 2012 and June 2013. Exclusion criteria: twin pregnancy, maternal illness, in vitro fertilization, chromosomal aneuploidy or fetal malformation. The cut-off point for a low PAPP-A is set at MoM  0.4, in accordance with the 5st percentile of our center. Population: 4879 pregnant women subjected to first trimester screening over this period. Cases: 259 patients with low PAPP-A (0.40 MoM) in first trimester screening over the same period. Controls: 259 patients in the control group (PAPP-A  0.41 MoM) are selected on a pairing basis. Statistical analysis: Conducted with a SSPS 19 pack for Windows. A P value 50.05 was deemed to be statistically significant. Clinical Cases or Summary Results: 225 pregnant women were included in the cases group (34 of those 259 were excluded) and 228 in the control group (31 of those 259 were excluded). There were no differences of statistical relevance regarding the age, race, BMI or cigarette smokers.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

We found relevant differences as for the number of SGA and preterm delivery (p50.05). 30.9% of newborns with low PAPP-A were SGA (54.36% of those SGA featured a weight below 5st percentile), as opposed to 11% in the controls group. 73% of SGA born during our study featured a low PAPP-A, coming up to 80.4% in SGA below 5st percentile. The incidence of preterm birth was 9.5% in the cases group, compared to 3.6% in the controls group. We did not find differences with regard to adverse outcomes such as preeclampsia, gestational diabetes or intrauterine fetal birth. Perinatal outcomes were pretty similar concerning the type of birth, Apgar and pH. The number of admissions of newborns was higher in cases group, 13.6% compared to 2.7%. It was somewhat noticeable, though, that there were 3 fetal deaths before week 24 in the cases group as opposed to none in the control group. Conclusions: Low levels of maternal serum PAPP-A are associated with an increased risk of SGA (RR 4.2 for SGA below 5st percentile, RR 2 below10st percentile), preterm delivery (RR 2.6) and admission in neonatal care unit (RR 5). The association for SGA of PAPP-A levels below the 5st percentile suggests that patients within this group may benefit from increased surveillance for this condition. Keywords: adverse pregnancy outcome; PAPP-A; prenatal screening; preterm delivery; SGA Presenter: Cervino Gomez E

ID 653

DOES A PATIENT DECISION AID HELP WOMEN TO DECIDE ABOUT DIAGNOSTIC TESTING FOR DOWN’S SYNDROME? K. Best, C. Watson, S. Stroyan, A. Noble, & S. Macphail Fetal Medicine Unit, Department of Womens’ Services, Royal Victoria Infirmary, Newcastle upon Tyne, Tyne and Wear, NE1 4LP, England, U.K. Brief Introduction: The ‘‘Diagnostic testing for Down’s Syndrome’’ patient decision aid is an online tool designed to help parents who have received an at risk screening test result to make an informed decision about diagnostic testing. The decision aid provides evidence-based information about Down’s Syndrome and a comparison of the diagnostic tests available. The decision aid is intended to supplement patient counselling provided by clinical staff and to support patients in the process of shared decision making. Our aim was to evaluate whether the ‘‘Diagnostic testing for Down’s Syndrome’’ decision aid helped pregnant women who were identified as high risk for having a baby with Down’s Syndrome make an informed decision regarding diagnostic testing. Materials & Methods: Pregnant women identified as high risk for having a baby with Down’s Syndrome (combined screening test result 41 in 150) were signposted to the decision aid website via a telephone call from a screening midwife. Individuals who used the decision aid were invited to self-complete an anonymous questionnaire prior to their diagnostic test at the Fetal Medicine Unit. The questionnaire was composed of nine open and closed response questions, exploring patients’ views on how useful and accessible they found the decision aid. Clinical Cases or Summary Results: All women were notified of their screening test result within two weeks and had access to discuss their result with a trained professional within three working days, in accordance with the Newcastle upon Tyne Hospitals NHS Foundation

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Trust’s Antenatal Screening Working Standards for Down’s Syndrome Screening. The majority of women chose not to use the decision aid; reasons included feeling sufficiently informed, being too busy, anxious or concerned the tool would influence their initial decision. 100% of women who used the decision aid found it easy to use and 60% agreed it helped them to make a decision. The majority of women opted for chorionic villus sampling. Conclusions: The majority of women at high risk of having a baby with Down’s Syndrome did not use the ‘‘Diagnostic testing for Down’s Syndrome’’ decision aid, generally because of time restrictions and anxiety. The women who did engage in this shared decision making process found the tool to be helpful and user friendly. Parents who used the tool found it helped them to make an informed decision about diagnostic testing for Down’s Syndrome, in accordance with their personal attitudes and values in this difficult healthcare situation. Keywords: Patient decision aid; Shared decision making; Screening; Diagnostic test; Down’s Syndrome Presenter: Katie Best

ID 027

NONINVASIVE PRENATAL DIAGNOSIS OF FETAL AND NEONATAL THROMBOCYTOPENIA EARLY IN THE PREGNANCY E. Le Toriellec, C. Chenet, A. Denis, C. Casale, C. Kaplan, & R. Petermann Institut National de la Transfusion Sanguine (INTS), De´partement d’Immunologie Plaquettaire, F-75015 Paris, France Brief Introduction: Fetal and neonatal alloimmune thrombocytopenia is due to maternal immunization against fetal platelet antigens inherited from the father and that the mother lacks. Antenatal therapy at 20–22 weeks of gestation or before this term according to risk strategies evaluation has been developed to avoid intracranial haemorrhage, the most deleterious consequence of severe thrombocytopenia. Before therapy, fetal platelet genotyping is a prerequisite in case of paternal heterozygosity for the implicated antigen or when the paternity is unknown. To avoid invasive strategies for this determination, we developed assays based on circulating fetal DNA in the maternal blood. Our study focused on human platelet antigen (HPA)-1 and -5, the most frequently implicated antigens in this condition in Caucasians. Materials & Methods: Cell-free fetal DNA was extracted from maternal blood samples. Two different real-time polymerase chain reactions (QPCR) were developed for each antigen: an allele-specific QPCR (AS-QPCR) targeting the polymorphic sequence for HPA-1 or HPA-5, and variations studies in the high-resolution melting curve of amplicons containing the polymorphic region (PCR-HRM), with a modifying program promoting the formation of heteroduplexes and the amplification of the fetal allele. Clinical Cases or Summary Results: During validation, the results for HPA-1 fetal genotyping from the 49 samples were consistent with expectation: six women (3 HPA-1bb and 3 HPA-1aa) were compatible with their fetuses, 41 HPA-1bb women were incompatible with their fetuses, as 2 HPA-1aa (Le Toriellec et al, Transfusion, 2013). Since this report, 56 other samples were studied. With both techniques, testing were obtained with 95% sensitivity and 100% specificity. PCR-HRM for HPA-1 was then improved with cold-PCR. Till now, the specific allele of the fetus was detected from 5%. With cold-PCR, the detection is from 1 to 2% of the specific fetal allele. For HPA-5, the use of cold-PCR combined to PCR-HRM, and the AS-QPCR, discriminate 1 to 2% of the specific fetal allele.

Conclusions: Two fetal platelet genotyping assays on maternal blood samples were developed for HPA-1 and HPA-5, and are proved to be reliable as early as 13 weeks of gestation. It allows to avoid invasive techniques such as amniocentesis allowing decision for antenatal therapy in due time. However a number of testing is still necessary for HPA-5 to evaluate the sensitivity and specificity of the assays. Similar techniques are also under study for HPA-3 and give encouraging results. Keywords: Presenter: E. Le Toriellec

ID 322

PAAP-A RELATIONSHIP AND CHANGES IN METABOLISM OF CARBOHYDRATES IN PREGNANCY A. Mun˜oz Ledesma1, A. Rodrı´guez Bu´jez1, M. Garcı´a Yuste1, B. Gonza´lez Soto2, Y. Pascual Are´valo1, E. Manchado Heredero1, M. Navarro Monje1, C. Montoya Garcia1, & F. Va´zquez Camino 1

Department of Obstetrics, University Hospital Rio Hortega of Valladolid, Valladolid, Spain, and 2Department of clinical analysis, University Hospital Rio Hortega of Valladolid, Valladolid, Spain Brief Introduction: Values compare PAAP-A in pregnant women who developed gestational diabetes Determine if the values of the hormone in the first trimester may be decisive for developing gestational diabetes in the second quarter of gestation Materials & Methods: Retrospective cohort study from data routinely recorded at the time of three clinical tests performed as per protocol -triple screnning of first trimester, glucose screening test and glucose tolerance test- during the period of two years. All available women in the database were included, except those previously diagnosed with diabetes and those with incomplete or inaccurate data. The sample consisted of 2,750 pregnant women, among which 190 (6.9%), diagnostic 26–28 weeks. Women were also classified by gestational age, weight and age ranges at time of triple screening to assess differences based on such parameters. Hypothesis test was performed to determine any significant difference between both groups’ sampling distribution. Additionally, a simple bivariate analysis was performed and Odds Ratios (OR) were estimated in order to study the force association between PAPP-A and GD, specifically across ranges of gestational age, weight and age ranges at time of triple screening. Clinical Cases or Summary Results: Low PAPP-A levels correlated with a higher probability of GD: 5th Percentile-OR = 1.85 (p = 0.024); 10th Percentile-OR = 1.85 (p = 0.013); 20th Percentile-OR = 1.75 (p = 0.001). The study found that median PAPP-A was significantly lower when measured at week 13 (0.79 MoM), by comparison to measurement at week 11 (1.01 MoM) and week 12 (0.93 MoM), in women that developed GD. Low PAPP-A levels (at 20th and 50th percentile) significantly correlated with a higher probability of GD when measured at an advanced gestational age (week 13 of gestation), and such correlation was statistically stronger as compared to the whole sample. Median PAPP-A decreased in gestational diabetics as weight increased. Low PAPP-A levels (at 5th, 10th, 20th and 50th percentile) significantly correlated with a higher probability of GD when only women over 70 kg were consider, and such correlation was statistically stronger as compared to the whole sample. Conclusions: Low levels of maternal serum PAPP-A in the first trimester correlates positively with a higher risk of GD in the second trimester of pregnancy. Such correlation is stronger if weight is higher (for pregnant women over 70 kg), if mother’s age is under 35 years of age

140 2

or if PAPP-A is measured at a more advanced gestational age (week 13 of gestation).

Obstetrics and Gynecologic Dept., St. Paul Hospital of Catholic University, Seoul, Korea

Keywords: PAAP_A, gestational diabetes, first trimester

Brief Introduction: The objective of this study is to construct size charts of two-dimensional and three-dimensional ultrasonographic parameters in the first trimester of pregnancy.

Presenter: A. Mun˜oz Ledesma

ID 762

LIPOXINE A4 AS A POTENTIAL FIRST TRIMESTER BIOCHEMICAL MARKER OF THE FETAL GROWTH DISTURBANCES J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

D.A. Bomba-Opon, M. Lipa, R. Brawura-Biskupski-Samaha, P. Kosinski, & M. Wielgos 1st Department of Obstetrics and Gynecology of Medical University of Warsaw Brief Introduction: Physiological implantation of placenta is a complex phenomenon determining normal fetal development. The regulation of throphoblastic invasion into endometrial tissue involves both antiand inflammatory processes. Lipoxine A4 is an arachidonic acid metabolite with multidirectional immune-modulating and antiinflammatory activity. The aim of the study was to investigate maternal serum levels of lipoxine A4 in the first trimester as a potential biochemical marker of fetal intrauterine growth disturbances. Materials & Methods: Material and Methods: Maternal serum lipoxine A4 was measured at 11–13 weeks’ gestation in 105 singleton pregnancies. The medial lipoxine A4 level in the small for gestational age (SGA), average for gestational age (AGA) and large for gestational age (LGA) groups were compared. Clinical Cases or Summary Results: Results: Medial levels of lipoxine A4 in maternal blood among patients with SGA (n = 16), AGA (n = 66) and LGA (n = 23) were 74.8 ± 35.2; 95.5 ± 46; 64.5 ± 20.4 pg/ml respectively. There was nonlinear correlation between lipoxine A4 and birth weight percentile. Lower level of maternal lipoxine A4 serum concentration increased chance of either small or large neonatal birth weight. The difference between LGA group and AGA controls was significant (p = 0.003). Maternal serum lipoxin A4 concentration was not correlated with maternal age, body mass index, parity, gestational age at the day of ultrasound scan or crown-rump length. Conclusions: Conclusion: Lipoxine A4 may be considered as an early biochemical marker of the fetal growth disturbances.

Table 1. The regression equations for all biometric variables as a function of gestational age (GA) (days). A quadruple model : MGSD and YSD in relation to GA MGSD (cm) = 2.469 + 0.1035  GA YSD (cm) = 0.1837 – 0.0004  GA + 0.000048  GA2 A modified logarithmic transformation of GSV and YSV Log (GSV(cm3) – 0.4) = 4.5202 + 0.1592  GA – 0.001  GA2 Log (YSV (cm3) – 0.001) = 0.17063 + 0.00176  GA The best model for FHR in quadruple model. FHR (bpm) = 198.35 + 9.9769  GA – 0.0619  GA2 MGSD : modified GSD In regards of FHR, FHR increased rapidly according to GA, but after 9 weeks of GA, the rate plateaus at 176 ± 6 bpm. Until 8 weeks of GA, the best model for FHR was a quadruple model. Materials & Methods: A prospective, cross-sectional study was performed with 158 singleton pregnancies between 6 to 9 weeks of gestation. there were no miscarriages and no congenital abnormalities.The following ultrasonographic variables were measured: gestational sac volume (GSV), Yolk sac volume (YSV), gestational sac diameter (GSD), and Yolk sac diameter (YSD), fetal heart rate (FHR). For each measurement, regression models were fitted to estimate the mean and standard deviation at each gestational age. The 5th, 50th and 95th percentile were derived using a combination of these regression data. Clinical Cases or Summary Results: New charts for the Korean population were presented for all of ultrasonographic parameters in the first trimester of pregnancy. The centiles for GSD fitted a linear model and the centiles for YSD fitted a quadruple model. The best models for GSV and YSV were quadruple and linear model subsequently on the modified logarithmic transformed data. In regard of FHR, until 8 weeks of gestational age, the best model for FHR was a quadruple mode, and after 9 weeks of gestational age, the rate plateaus at 176 ± 6 bpm. Conclusions: We present reference intervals and centile charts for first-trimester GSV, YSV, GSD, YSD, and FHR according to gestational age (days). Keywords: ultrasonographic parameters, first trimester Presenter: IC Jeung

Keywords: lipoxine A4; pregnancy; fetal macrosomia Presenter: D.A. Bomba-Opon

ID 186

BIOMETRY OF THREEDIMENSIONAL AND TWODIMENSIONAL ULTRASONOGRAPHIC PARAMETERS IN THE FIRST TRIMESTER OF PREGNANCY I.C. Jeung1, & J.Y. Kwon2 1

Obstetrics and Gynecologic Dept., Dae-jeon St. Mary’s Hospital of Catholic University, Dae-jeon, Korea, and

ID 177

OXIDATIVE STRESS AND SPONTANEOUS ABORTIONS Z. Grujic1, I. Grujic2, & M. Bogavac1 1

Clinical Centre of Vojvodina, Department of Obstetrics and Gynecology, Faculty of Medicine, University of Novi Sad, Serbia, and 2Private Gynecological Hospital, Femina’’, Novi Sad; Serbia Brief Introduction: Aims: The goal of this research was to determine the intensity of pro-oxidative processes (LPx) and the content of GSH, as well as antioxidative enzymes (SOD, CAT, GSH, GSH-Px) and the total antioxidative status (TAS) in patients with spontaneous abortions. Materials & Methods: A total of 155 patients were involved in the research.The patients were divided into groups (gr):35 patients (pts) with threatening spontaneous abortion (ab) (gr I), 35 pts with

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incomplete and complete spontaneous ab (gr S), 35 pts with missed ab (gr M) and a control gr of 50 healthy pregnancies (gr N).The lipid peroxidation was determined with a thyobarbituric acid method.The GSH was determined based on the amount of non-protein sulfhydryl residues using the Ellman reagens.The antioxidative parameters were measured with:SOD method with xanthine oxidase-using RANSOD sets, CAT by Aebi, the enzyme activity was measured by monitoring the decomposition of H2O2 at 240 nm, the activity of GSH-Px was determined using hydrogen peroxide as a substrate.The TAS was determined using the FRAP method. Clinical Cases or Summary Results: The highest average value of lipid peroxidation was recorded in the spontaneous ab gr S-48,03 pmol/ mg Hgb and the lowest value was recorded in the control gr N-26,06 pmol/mg Hgb.A statistically significant (p50.05, r = 0.37) positive correlation between lipid peroxidation and catalase in the gr of patients with missed ab was also noted, as well as positive correlation (p50.001, r = 0.46) between lipid peroxidation and catalase in the gr of patients with threatening spontaneous ab (gr I).There is a statistically significant difference (p50.001) in SOD and in CAT content between the examined patients and the control gr.The highest average value of TAS was recorded in gr S-710,39 mmol/L, while the values in other examined gr were equal: gr I-378,16 mmol/L and gr M-277,66 mmol/L. The values of TAS in the control gr of healthy pregnant women were: gr N-452,12 mmol/L. Student’s t-test show a statistically significant difference in the values of TAS between the examined patients and the control group. Conclusions: Determination of the value of pro-oxidative and antioxidative parameters in patients with spontaneous abortion can be the inex of condition of fetoplacental unit and these analyses can be included in protocol of rutine perinatal diagnosis. Keywords: spontaneous abortions, oxidative stress Presenter: Z. Grujic

ID 551

MATERNAL CHARACTERISTICS AND ULTRASONOGRAPHIC MARKERS IN THIRD TRIMESTER MIGHT PREDICT LATE GESTATIONAL HYPERTENSION E. Cosmi, & S. Visentin Department of Woman and Child Health, University od Padua School of Medicine, Padua, Italy Brief Introduction: The aim of this study was to assess potential ultrasound markers during third trimester ultrasound growth scan measurements (29–32 weeks’ gestation) to predict late onset gestational hypertension. Materials & Methods: This was a case-control study. Singleton pregnancies affected by late onset gestational hypertension (after 34 weeks’ gestation) and normal pregnancies were considered. In all pregnancies were available ultrasound examination (fetal biometry, maternal-fetal Doppler, fetal aorta intima media thickness(aIMT), and fetal kidney volumes) as well clinical data (age, BMI, parity, and pregnancy outcomes). Data was analyzed using R software (version 2.15.2). Clinical Cases or Summary Results: Gestational age at delivery was 36.98 weeks (±1.41) in cases and 39.27 weeks (±1.5) in controls (p50.05). At the growth scan (29–32 weeks’ gestation) we found in late hypertension significantly higher fetal aIMT thickness, umbilical arteries pulsatility index (PI), mean uterine arteries PI or resistance index (RI) with persistent bilateral notch. In multivariate logistics regression analysis we found that aIMT, umbilical artery PI, woman age, and pre-gravidic BMI were the most predictive values and the AUC of the model was 85.4% (CI.95 75.4–95.4%)

Conclusions: This study showed that higher fetal aIMT thickness, umbilical arteries pulsatility index (PI), mean uterine arteries PI or resistance index (RI) with persistent bilateral notch might predict late hypertension in pregnancy, moreover the most predictive markers were aIMT, umbilical artery PI, woman age, and pregravidic BMI. Keywords: Prediction, Hypertension Presenter: E. Cosmi

ID 282

THE FIRST EARLY DIAGNOSIS OF AN ATRIOVENTRICULAR CANAL MADE IN EQUATORIAL GUINEA, AFRICA BY NUCHAL TRANSLUCENCY J.J. Jaramillo, J. Arias, A. Aldape, E. Paz, L. Pin˜in, D. Sima, & C. Kupfersztain Fetal Medicine Department, La Paz Malabo Medical Center, Malabo; Equatorial Guinea Brief Introduction: Objective: to evaluate the nuchal translucency (NT) examination in a developing country like Equatorial Guinea, for early diagnosis of cardiac anomalies. Materials & Methods: This was a retrospective study carried out in the only one fetal unit in Equatorial Guinea, during the first four operational months at our unit from December 2013 to March 2014. The study population included every woman who had, had a routine NT examination (11–13.6 weeks) in our center, as was the only screening option available in the first trimester in the country.

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When an NT increase was found, a fetal cardiac ultrasound was performed at 15 weeks. When a cardiac anomaly was found, parents were informed about the prognosis and non-availability of fetal karyotype analysis in the country. Furthermore, they were informed about the possibilities of pregnancy termination only in cases with non-prognosis. Clinical Cases or Summary Results: During the study period, we performed 42 NT examinations. We found only one case with an NT increase and we carried out one fetal cardiac ultrasound at 15 weeks, through which, we found a complete atrioventricular canal. The only one patient chose to do a pregnancy termination right after the diagnosis. Conclusions: Evaluation of NT has been proven to be of value in screening for cardiac defects and this is the only instrument that we could use for early diagnosis in developing countries like Equatorial Guinea.

ID 183

Keywords: Nuchal translucency, atrioventricular canal, cardiac defects.

Brief Introduction: Hormonal levels in early pregnancy may have predictive value in regard to outcome pregnancy. This study was conducted to investigate the effectiveness of serum levels of progesterone, beta human chorionic gonadotropin(b-hCG) and their combined use in the prediction of the outcome of first trimester threatened miscarriage. Materials & Methods: This retrospective study was conducted on 70 intrauterine pregnant women from January 2011 to December 2012. A total of 70 singleton pregnant women between 5 and 13 weeks’ gestational age were included as Group I (n = 32) who resulted in threatened miscarriage including missed abortion, incomplete abortion, complete abortion and inevitable abortion; Group II (n = 38) included normal, ongoing pregnancies. The serum concentrations of progesterone and b-hCG were measured by Microparticle enzyme immunoassay between the fifth and thirteenth gestational weeks at first diagnosis of pregnancy. The discrimination attained between the two study groups was evaluated by Student’s t-test, Mann Whitney U test and multivariate logistic regression analysis. Clinical Cases or Summary Results: The mean serum levels of progesterone (12.4 ± 5.52 ng/ml) and b-hCG (2874 ± 1923.0 mIU/ml) in patients with threatened miscarriages were significantly lower than these levels in ongoing pregnancies (24.43 ± 6.18 ng/ml, 7680 ± 1890.00 mIU/ml, respectively) (p50.01). Serum progesterone combined with b-hCG measurements with a positive predictive value(PPV) of 95%, negative predictive value(NPV) of 97% (sensitivity 93%, specificity 99%) had the best prognostic reliability and significant differences were found when this parameter was compared with the predictive value of a single progesterone using a progesterone of 15 ng/ml as a cut off point (sensitivity 91%, specificity 81%, PPV 57%, NPV 98%) or b-hCG using the free b-hCG level of 2,000 mIU/ml as cut off point(sensitivity 90%, specificity 84%, PPV 47%, NPV 98%) determinations. Conclusions: The single measurement of free b-hCG or progesterone levels can be useful in the prediction of first trimester threatened miscarriage., but using progesterone may be recommended since it has high availability and low cost. Progesterone combined with b-hCG measurements may be more useful for predicting the outcome of threatened miscarriage.

Presenter: J.J. Jaramillo

ID 623

FIRST TRIMESTER DETECTION OF STRUCTURAL ANOMALIES – SINGLE OPERATOR STATISTICS M.E. Zvanca, M. Bot, & A. Petca Elias University Hospital, Obstetrics and Gynecology Department, Bucharest, Romania Brief Introduction: Considering the advances in non-invasive diagnosis of fetal aneuploidies, the main challenge for the fetal medicine specialist remains the early detection of fetal structural anomalies. The purpose of this study is to investigate the technical possibilities of a single operator to detect fetal structural anomalies at 11 – 14 weeks, highlighting the pathologies that may benefit from early diagnosis Materials & Methods: The study included 1818 consecutive patients that were seen in the ultrasound clinic between January 2011 – January 2013. The examinations were standardly performed at 11 – 14 weeks, 20 – 24 weeks, 30 – 34 weeks. The number of examinations per patient varied according to the referral system and the fetal pathology. We have excluded from analysis all cases with chromosomal anomalies. Clinical Cases or Summary Results: Our study group included 41 cases (2.25%) with isolated or complex structural anomalies. Most of them were diagnosed during the second trimester (29 cases). The most common pathology were cardiac defects (15 cases), with the highest rate of first trimester detection (44.4%). This may be related to the increased measurements of nuchal translucency in these cases and to the fact that heart examination is included in the first trimester risk assessment for aneuploidies. The lowest detection rate was for renal and central nervous system pathologies. However, the main bias of the study was that only 19 of the 41 cases with structural defects had a 11 – 14 weeks scan. Conclusions: Early detection of fetal structural anomalies is limited, firstly, by the low addressability of the pregnant women for the first trimester detailed scan and, secondly, by the progressive character of some fetal pathologies. Keywords: fetal structural defects, first trimester screening Presenter: Mona Elena Zvanca

THE PREDICTIVE VALUE OF PROGESTERONE, BETA HUMAN CHORIONIC GONADOTROPIN IN THE OUTCOME OF THREATENED MISCARRIAGE Jong In Kim, M.D. PhD., Jun Chul, Park, M.D., PhD, & Sung Mee Kim, M.D Department of Obstetrics and Gynecology, School of Medicine, Keimyung University, Daegu, Korea

Keywords: Threatened miscarriage, Progesterone, b-hCG Presenter: Jong In Kim, M.D. PhD

ID 097

THE ROLE OF CATHEPSIN D IN PREGNANCY H.Y. Kim, & C. Moon Dept. of Obstetrics and Gynecology, KangDong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea

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DOI: 10.3109/14767058.2014.924236

Brief Introduction: The high invasiveness of first trimester cytotrophoblast depends on their secretion of proteolytic enzymes. Well known proteolytic enzymes are metalloproteinases and proteinases such as cathepsins. Cathepsin D is the most significant aspartic protease and was reported to be involved in implantation in previous in-vitro studies. This study was conducted to investigate the role of cathepsin D in pregnancy. Materials & Methods: Fourty three pregnant and 20 healthy nonpregnant patients were enrolled in this study. We obtained longitudinal cathepsin D levels in 43 healthy pregnant women in first and third trimesters and compared these levels to the 20 non-pregnant controls. Serum levels of soluble cathepsin D were measured with an enzyme-linked immunosorbent assay (ELISA) kit. Clinical Cases or Summary Results: A total of 76 cathepsin D values were obtained during pregnancy. The median (and range) cathepsin D level in the first and third trimesters was 89.7 (80.35–105.75) and 191.55 (139.8–241.5) ng/ml respectively. The median cathepsin D level in non-pregnant control was 115.6 (89.1–138) ng/ml. The cathepsin D levels in the third trimester and non-pregnant control were significantly higher than that in the first trimester. The cathepsin D level in the third trimester was significantly higher than that in nonpregnant control. We found no correlation between the cathepsin D levels in first trimester and the concentration of the serum pregnancyassociated plasma protein-A (MoM) and human chorionic gonadotropin (MoM). Conclusions: Our study is unique in evaluating longitudinal changes in cathepsin D levels in normal pregnancies in comparison with healthy nonpregnant controls. It demonstrates that cathepsin D levels are much lower in the first trimester of pregnancy than nonpregnant state and increases markedly late in pregnancy. These results contribute to the understanding of placentation and parturition.

Keywords: Down syndrome; Whole genome sequencing; Costeffectiveness Presenter: W.K. MING

Keywords: Cathepsin D, Pregnancy Presenter: HY Kim

ID 096 ID 501

COST-EFFECTIVENESS OF PRENATAL DOWN SYNDROME SCREENING STRATEGIES: SHOULD WHOLE GENOME SEQUENCING TO BE WIDELY USED? W.K. Ming, & X.M. Xiao Department of Gynecology and Obstetrics, The First Affiliated Hospital of Jinan University, China Brief Introduction: To determine whether whole genome sequencing is a cost-effective strategy compare to other prenatal Down syndrome screening. Materials & Methods: Decision-analysis modeling was used. We performed computer simulations to compare 3 screening options. Cumulative costs, effects and incremental cost-effectiveness ratio were calculated. Sensitivity analysis was performed using one-way, two-way and Monte Carlo simulation. Clinical Cases or Summary Results: The implementation of whole genome sequencing for prenatal Down syndrome screening will become cost-effective when the price of sequencing down to US$2884. Conclusions: Whole genome sequencing for prenatal Down syndrome screening will become cost effective when the price of sequencing down to US$2884. The clinical value of whole genome sequencing can be much higher as other genetics diseases also screened.

EARLY ULTASOUND SCREENING FOR FETAL MALFORMATIONS IN THE SECOND PREGNANCY AFTER COMBINED MODALITY TREATMENT FOR HODGKIN’S DISEASE: A CASE REPORT J. Ivanov1, G. Bushinoska-Ivanova2, & T. Sotirova3 1

Gynecology and Obstetrics Dept., Clinical Hospital Acibadem-Sistina Skopje, Macedonia, 2University Clinic of Gynecology and Obstetrics, Skopje, Macedonia, and 3 University Clinic of Hematology, Skopje, Macedonia Brief Introduction: Therapeutic progress in HD has led to a high rate of cure, but at the expense of some side effects. Abnormalities reported so far are: cardiac toxicity, pulmonary toxicity, endocrinal failure, second cancers and congenital malformations. Although several studies reported in the literature showed no or slightly increased risk of congenital abnormalities among newborns of women previously treated for Hodgkin’s disease compared with the general population, abnormalities do occur and sometimes they are very odd and difficult. Materials & Methods: Case Report We report a case of female patient, 25 years old, macedonian, presented with Hodgkin’s disease, subtype nodular sclerosis, stage IIIA. The patient received chemotherapy according to ABVD protocol – 6 cycles. Thereafter she received mantle field radiation with 3600 cGy. She was followed for the next 36 months and than she became pregnant. Clinical Cases or Summary Results: Ultrasound confirmed a normal fetus in first pregnancy during controls. A normal female baby was born with Caesarian section at term. Clinical assessment in the

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follow-up period showed normal development. Also the mother was assessed regularly and was free of disease. The next pregnancy occurred 87 months after completion of treatment. At 13th gestational week ultrasound assessment revealed malformations and induced abortion was suggested. A male fetus with malformations on the head such as proboscis, cyclopia and omphalocele on the front abdominal wall containing liver and small bowels was found. After induced abortion the autopsy report from the Institute of Pathology was: male fetus with malformations on the head such as proboscis and cyclopia (one eye beneath proboscis), and omphalocele on the frontal abdominal wall containing liver and small bowels. Other findings were normal. The patient has been followed-up regularly until now. She is disease free, with no more pregnancies. Conclusions: We consider this case important in bringing the potential late side-effect to the attention of both patients and doctors. They should be alert for the risk of congenital abnormalities in newborns of women previously treated for Hodgkin’s disease, especially with combined modality treatment, and should check for them during pregnancy, at birth, in early childhood, or in adulthood. Treatment with chemotherapy, radiation therapy or both may have adverse effects on germ cell survival, fertility and health of offspring. Congenital abnormalities occur in 3–5% of all live-births and the possibility of an increased risk of congenital abnormalities in newborns cannot be ignored.

Screening NC in early pregnancy could identify those obese women who are at a higher risk of a failed intubation.The measurement of NC is a simple non-expensive screening tool which should be evaluated further in a larger prospective study.

Keywords: Ultrasound Screening, Fetal Malformations, Hodgkin’s Disease

1

Presenter: Jordancho Ivanov

ID 744

MATERNAL OBESITY AND NECK CIRCUMFERENCE B. Anglim1, A. O’Higgins2, N. Daly3, M. Farren4, & M. Turner5 Coombe Women and Infant University Hospital, Dublin, Ireland Brief Introduction: Obese women are more likely to require general anaesthesia for an obstetric intervention than non-obese. Difficult tracheal intubation and oxygen desaturation is more common in pregnancy (Heidemann & McClure, 2003). Failed tracheal intubation has been associated with an increase in neck circumference (NC). We studied the relationship between maternal obesity and NC as pregnancy advanced in women attending a standard antenatal clinic. Materials & Methods: Women who were attending a standard antenatal clinic were recruited at their convenience. Women had their weight and height measured in the first trimester before calculating the BMI. Women with a multiple pregnancy, women 518 years old and women who were unable to give consent were excluded. Using a disposable tape measure, the sympysiofundal height was measured as part of standard antenatal care. A single researcher (BA) then measured the neck circumference at the level of the thyroid cartilage with the head erect. This was carried at 18–22 weeks gestation, and repeat in the same population of women at 36– 40 weeks gestation. The tape was held snug without compressing the skin. Clinical Cases or Summary Results: Of the 96 the mean age was 29.9 years. The mean BMI was 25.4 kg/m2 and 13.5% were obese based on a BMI 429.9 kg/m2. The mean NC was 36.8 cms (SD 1.9) in the obese women compared with 31.5 cm (SD 1.6) in women with a normal BMI (p39 cms in the obese women compared with 0% in the non-obese women (n = 83) (p50.001). Obese women had a greater NC than women with a normal BMI but the increase in NC as pregnancy advanced was similar. Conclusions: About one in six women booking for antenatal care in our Hospital is obese and they are a group who are at risk of an adverse outcome is increased if the patient requires intubation.

Keywords: Neck circumference, Anaesthetic difficulties, Difficult intubations, High risk pregnancy, Wound infection, Obesity in pregnancy Presenter: Breffini Anglim

ID 655

EVALUATION OF FIRST TRIMESTER MATERNAL SERUM ANALYTES FOR THE SCREENING OF DOWN SYNDROME IN OOCYTE DONATION PREGNANCIES V. Savasi1,2, L. Mandia1,2, A. Laoreti1,2, P. Duca3, L. Ghisoni1, & I. Cetin1,2 Unit of Obstetrics and Gynecology, Department of Biomedical and Clinical Sciences, Hospital ‘‘L. Sacco’’, University of Milan, Italy, 2Centre for Fetal Research Giorgio Pardi, University of Milan, Italy, and 3Statistical and Biometry Department, Department o Brief Introduction: Down syndrome screening at 11–13 + 6 weeks is routinely offered to pregnant women. While first trimester serum markers screening for aneuploidies is well established in spontaneous pregnancy, assisted reproduction techniques (ART) have shown to affect biochemical markers. The aim of our study was to compare nuchal translucency (NT), free b-hCG and pregnancy-associated plasma protein-A (PAPP-A) in spontaneous, in vitro fertilization (IVF) and oocyte donation pregnancies in order to evaluate for potential differences of Down syndrome screening. Materials & Methods: We retrospectively analyzed data of singleton pregnant women who underwent their first trimester screening for aneuploidies between January 2000 and June 2013 carried out in a single reference, quality controlled and accredited laboratory. Exclusion criteria were multiple gestations, structural fetal malformations and chromosomal abnormalities. We collected 13667 spontaneous pregnancies (Group A), 203 oocyte donation pregnancies (Group B), and 79 IVF pregnancies (Group C). Furthermore, we collected a cohort of 804 spontaneous ‘‘age-matched’’ pregnancies (Group D) in order to evaluate the contribution of elderly uterus to the changes in markers concentrations. We compared NT, the multiples of the median (MoM) of free b-hCG and PAPP-A. Clinical Cases or Summary Results: As expected, mean maternal age varied among groups (Group A: 30.4 ± 3.6 years; Group B, oocyte recipients: 41.9 ± 4.2 years; Group B, oocyte donors: 25.9 ± 3.7 years; Group C: 36.0 ± 4.8 years; Group D: 39.7 ± 1.5 years). Overall, significantly lower NT was detected in spontaneous pregnancies (1.41 ± 0.36 mm) compared to oocyte donation pregnancies (1.46 ± 0.44 mm; p50.05), IVF pregnancies (1.51 ± 0.34 mm; p50.05) and age-matched spontaneous pregnancies (1.45 ± 0.42 mm; p50.05). Free b-hCG levels were significantly higher both in oocyte donation pregnancies (1.44 ± 1.06 MoM) and IVF pregnancies (1.48 ± 1.02 MoM) compared to spontaneous pregnancies (1.15 ± 0.84 MoM; p50.05) and age-matched spontaneous pregnancies (1.18 ± 0.98 MoM; p50.05). Free b-hCG levels did not differ respectively between Group B and Group C and between Group A and Group D. PAPP-A levels did not significantly differ among the four groups.

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Conclusions: A marginal decrease in NT was observed in spontaneous pregnancies, however, this very small difference is not clinically relevant and it is likely due to the higher numerosity of this group, as well as operator effect, with ART pregnancies more likely to be scanned by a small subset of operators linked to ART clinics. Oocyte donation and IVF pregnancies have higher free b-hCG levels compared to spontaneously conceived pregnancies, probably a consequence of the hormonal treatment used to induce superovulation and to establish endometrial receptivity, or to the IVF procedure itself. Adjustment of first trimester serum marker levels in oocyte donation pregnancies may be considered in order to reduce the likelihood of receiving false-positive results and the rate of invasive diagnostic procedures. Keywords: oocyte donation, first trimester screening, PAPP-A, free b-hCG, NT

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Presenter: A. Laoreti

ID 500

FIRST TRIMESTER SCREENING IN MACEDONIA - CURRENT STATE OF PRACTICE P. Dimcev Clinical Hospital ACIBADEM-SISTINA, Skopje, Macedonia Brief Introduction: After introducing nuchal translucency as important screening marker for chromosomal abnormalities in early 90’s, First Trimester Ultrasound examination of the fetus in pass 20, but especially in last five years became one of the most important early examinations to determine fetal well being, Moreover, huge part of the anomaly scan in 20 weeks is moved at First Trimester. NT screening was introduced in Macedoinia in 2001 after author of this work was certified for NT screening by FMF, London. In last few years we are trying to incorporate in First Trimester ultrasound examination all recommendations published in ISUOG White Journal, Published in February 2013(ISUOG Practice Guidelines: performance of first-trimester fetal ultrasound scan). Materials & Methods: Our data is presenting period between November 2010 an March 2014.In this period in our hospital 1292 patients were examined. The average gestational age was 12.3(11.3– 13.6).Singleton pregnancies were 1132, twins 160. Average maternal age, 31.4, over 35 years of age 260 patient. Screen positive were 3.9%. Five chromosomal abnormalities were confirmed - Trisomy 21(2), Turner(2), Trisomy 18(1) According structural defects, we find these abnormalities: two AV heart defects (one of them Tr 21), choloprosencephaly (Tr 18), two megacystis (no chromosomal abnormality), one omphalocelae (no chrom.abnorm.) Clinical Cases or Summary Results: Despite modest number of patient, this data is trying to present current state of practice in Macedonia according First Trimester Screening(NTS) These should be first published work in Macedonia which are trying to meet modern principles of FTS(ISUOG Practice Guidelines: performance of first-trimester fetal ultrasound scan). Conclusions: Problem in Macedonia with First Trimester Screening is that there are great number of doctors performing Nuchal Translucency Screening(FTS) but the luck of proper training is evident. Just a a very few doctors are adequate trained concerning NTS. Anomaly scan in first trimester like ISUOG is guidelines is almost missing. Maybe the greatest problem is state policy for this issue, also no adequate protocol by health and professional authorities. Keywords: First Trimester Screening, ISUOG, Macedonia Presenter: Pavle Dimcev

INDUCTION OF LABOUR ID 654

COMPARISON OF INTRAVENOUS OXYTOCIN AND VAGINAL DINOPROSTONE FOR LABOR INDUCTION IN PATIENTS NON RESPONDERS TO A FIRST DOSE OF PROSTAGLANDINS: A RANDOMIZED PROSPECTIVE STUDY A. Laoreti1,2, P. Antonazzo1,2, C. Personeni1,2, E. Grossi1,2, A. Martinelli1,2, & I. Cetin1,2 1

Unit of Obstetrics and Gynecology, Department of Biomedical and Clinical Sciences, Hospital ‘‘L. Sacco’’, University of Milan, Italy, and 2Centre for Fetal Research Giorgio Pardi, University of Milan, Italy Brief Introduction: Bishop score 6 defines an unfavorable cervix. Each point of Bishop score affects the caesarean section’s risk. In the presence of an unfavorable cervix, cervical ripening using prostaglandins is indicated. However, no studies have been performed to assess the best practice after failure of a first dose of prostaglandins. The aim of this study was to evaluate the efficacy of two different regimens for labor induction in patients with unfavorable cervix not responsive to a first dose of dinoprostone vaginal insert. Materials & Methods: Singleton term pregnancies with a Bishop score 6 who underwent labor induction between November 2011 and December 2013 were eligible. After 24 hours, patients non-responders to a first dose of dinoprostone of vaginal insert (PropessÕ , Ferring) were randomized into two different regimens: intravenous oxytocin or repeated vaginal dinoprostone. Clinical Cases or Summary Results: 300 women were enrolled. 201 patients delivered or were in labor within 24 hours. Of the remaining 99 patients with persistent Bishop score 6, 91 accepted to be randomized. 45 women received a second administration of dinoprostone (Group A) and 46 women were treated with intravenous oxytocin (Group B). The two groups were similar for maternal age, parity, pregestational BMI, weight gain, Bishop score (Group A: 1.7 ± 1.1; Group B: 2.2 ± 1.5) and gestational age (Group A: 39.9 ± 1.5 weeks; Group B: 40.0 ± 1.4 weeks) at induction. Bishop score at randomization was significantly higher in the oxytocin group compared to dinoprostone group (Group A: 2.5 ± 1.2; Group B: 3.5 ± 1.9; p50.05). Vaginal deliveries were significantly higher (Group A: 25/45 (55.5%); Group B: 16/46 (34.8%), p50.05) and cesarean deliveries were significantly lower (Group A: 20/45 (44.5%); Group B: 30/46 (65.2%), p50.05) in patients who received a double dose of dinoprostone. The interval between induction and delivery was significantly shorter in Group B (Group A: 54.5 ± 15.2 hours; Group B: 33.5 ± 12.1 hours, p50.001). As regards to maternal and fetal complications, uterine tachysystole rate and meconium passage rate were similar in the two groups. Dinoprostone followed by i.v. Oxytocin was associated with significantly higher blood losses at delivery (Group A: 290.5 ± 178.5 ml; Group B: 404.5 ± 300.9 ml, p50.05). Neonatal outcomes were comparable between the groups. Conclusions: This is the first randomized trial finalized to evaluate different therapeutic options for the prosecution of labor induction in patients with persistent unfavorable cervix. Our data indicate that a second dinoprostone vaginal insert is an effective and safe choice for patients with unfavorable cervix not responsive to a first 24 hours

146 administration of dinoprostone for cervical ripening, and its use is associated with lower cesarean section rates. Keywords: labor induction, unfavorable cervix, oxytocin, dinoprostone, cesarean section Presenter: A. Laoreti

ID 029

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ELECTROHSYTEROGRAPHIC PARAMETERS CAN HELP TO PREDICT THE ONSET OF SPONTANEOUS LABOR AT TERM A. Perales1, J. Alberola-Rubio1, J. Valero1, D. Desantes1, J.O. Zamora1, G. Prats-Boluda2, Y. Ye-Lin2, & J. Garcia-Casado2 1

Hospital Universitari i Polite`cnic. La Fe, Dpt. Obstetrics, Valencia, Spain, and 2Universidad Polite´cnica de Valencia, Grupo de Bioelectro´nica (I3BH), Valencia, Spain Brief Introduction: The recording of the myolectrical activity of the uterus on maternal abdominal surface, is called electrohysterogram (EHG) and appears as an alternative to external tochography measurements (TOCO) for the non-invasive monitoring of uterine contractions. It is hypothesized that the EHG measurements can increase the information provided by conventional tochography. The objective of this work was to study if patients that will deliver spontaneously present differences in the evolution of EHG parameters from those that will require labor induction, and to check the feasibility of predicting between these two types of labor. Materials & Methods: 209 healthy pregnant women at term pregnancies were monitored. Patients were assigned to the spontaneous group (SPT), or to the cervical ripening/induction group (CRI). EHG and TOCO recordings were performed simultaneously. Uterine contractions were identified with TOCO recordings, and the corresponding EHG signal segments were characterized: mean frequency, peak frequency, energy in different bandwidths, etc. The evolution of EHG parameters as delivery approaches was studied. A decision support system (DSS) to predict the type of delivery based on EHG parameters and other biological and obstetric parameters (maternal age, BMI, gestations, parturition and gestational age) was designed with 80% of the patient’s database, and tested on the remaining 20%. Clinical Cases or Summary Results: The studied EHG parameters presented different trends for the SPT and CRI group. For example, the mean frequency of EHG presents an increasing trend as the delivery approaches for the SPT group whereas it tends to decrease for the CRI group. Regarding the DSS, a mean area under the ROC curve of 0.86 was obtained, with mean value of maximum accuracy of 95% of correctly predicting 95% the type of labor. Sensitivity and specificity value of predicting spontaneous birth was 0.97 and 0.94, respectively. The same kind of DSS without including EHG parameters provided accuracies lower than 60% in the test database. Conclusions: EHG measurements provide valuable information for discriminating those women that will spontaneously achieve active labor from those that would require cervical ripening/labor induction, what can be of paramount importance in clinical practice. Keywords: Uterine contractions, electrohysterpgraphy, labor induction, spontaneous labor Presenter: A. Perales

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

ID 262

THE ASSOCIATION BETWEEN ISOLATED OLIGOHYDRAMNIOS AT TERM AND PREGNANCY OUTCOME E. Ashwal, L. Hiersch, N. Melamed, A. Aviram, A. Wiznitzer, M. Hod, & Y. Yogev Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Brief Introduction: As conflicting data exist concerning the implications of isolated oligohydramnios on pregnancy outcome at term, we aimed to assess this association in low risk pregnancies. Materials & Methods: A retrospective cohort study of term pregnancies with sonographic finding of isolated oligohydramnios (amniotic fluid index (AFI)55cm) between 2007–2012. Outcome was compared to a control group of pregnancies with normal AFI (5–25cm). Pregnancies complicated by thrombophilia, hypertension, diabetes, deviant fetal growth or chromosomal/structural abnormalities were excluded. Composite adverse outcome included CS/operative delivery due to non-reassuring heart rate (NRFHR), low Apgar score, umbilical artery pH57.10, neonatal intensive care admission, meconium aspiration syndrome, intubation or hypoxic-ischemic-encephalopathy. Clinical Cases or Summary Results: Overall, 987 pregnancies complicated by isolated oligohydramnios were compared to 22,280 low risk pregnancies with normal AFI. Isolated oligohydramnios was associated with a higher rate of induction of labor (27.7%vs. 3.7%, p50.001), CS due to NRFHR (2.3%vs. 1.1%, p50.01) and composite adverse outcome (9.7%vs. 7.1%, p50.01). However, after adjusting for potential confounders as induction of labor and nulliparity using multivariable logistic regression analysis, isolated oligohydramnios was not found to be independently associated with increased risk for composite adverse outcome (OR1.01, 95%CI 0.80–1.27, p = 0.93). Conclusions: Isolated oligohydramnios at term by itself is not associated with increased obstetrical morbidity. Keywords: Cesarean section; Induction of labor; Isolated oligohydramnios; Pregnancy Presenter: Eran Ashwal

ID 638

CERVICAL AUGMENTATION AFTER CESAREAN SECTION P. Barbero, M.D. Montan˜ez, O. Villar, P. Vallejo, L. Force´n, & A. Garcı´a Burguillo Obstetrics and Gynecology Dept., University 12 de Octubre Hospital, Madrid, Spain Brief Introduction: Rate of cesarean section (CS) has significantly increased worldwide, which has led to an important fall in the maternal and perinatal mortality, but has also created a new morbidity. It’s a challenge for the current obstetrician to counsel the women with a prior CS about the suitability of having a vaginal birth (VBAC). Although a trial of labor after a CS (TOLAC) is widely accepted and VBAC has demonstrated to be safe for both mother and newborn, induction of labor after CS must be carefully assessed. Materials & Methods: We describe here the results of cervical ripening with PGE2 controlled-released vaginal insert, PropessÕ , in pregnant women with a previous CS during a 15 month period (from January 2013 to March 2014)

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DOI: 10.3109/14767058.2014.924236

We allow labor induction in women with a prior CS subject to certain conditions. Singleton pregnancies with one uncomplicated lower transverse caesarean section are suitable candidates for a TOLAC. Suspected fetal macrosomia (EFW44000g), lapse between the CS and the LMP 512months, previous uterine rupture, puerperal complications (especially when infectious) or other patient conditions which lead to suspect a low chance of success contraindicate the labor induction. When Bishop Score was 56, augmentation with Propess was indicated. Clinical Cases or Summary Results: 146 women with prior CS were admitted for labor induction, 59 required cervical ripening with Propess. 36 (61%) patients had a successful VBAC, 15 (41%) of them needed operative delivery (forceps, Thierry spatulas or vacuum-assist). 9 of the 23 CS performed were due to failed induction, which means that we were able to start labor in 85% of women who initiate induction with Propess. The main indication of CS was fetal suffering (11 cases). Only one of these newborns have an Apgar score under 5 at 1st minute and cord pH 57,10. Posterior evolution didn’t show any sequel. In one case, CS was performed on patient’s request. No major maternal complications were found. We didn’t report any case of uterine rupture or dehiscence in the CS performed. Uterine tachysystole without fetal repercussion and fever were the most common complications observed during labor. Two patients (1 CS and 1 operative delivery) were readmitted due to postpartum endometritis, successfully treated with antibiotics. Conclusions: Labor induction after a prior CS has to be carefully assessed due to the increased risk of complications (mainly uterine rupture and its consequences). However, when women are properly selected, it seems to be a safe procedure both for the mother and newborn. The use of Propess for augmentation in women with a Bishop score 56 offers a rate of successful VBAC rate around 60%, with a percentage of labor initiation greater than 80%. No major maternal or neonatal complications were showed. However women under labor induction with prior CS should be close controlled in a center prepared to perform an emergency CS. Keywords: Labor induction, augmentation, vaginal birth after cesarean, trial of labor after cesarean section Presenter: P. Barbero

ID 208

SAFETY AND EFFICACY OF SUBLINGUAL MISOPRSTOL FOR INDUCTION OF LABOUR AT TERM G. Brembilla, V. Brusati, L. Mastricci, F. Cirillo, E. M. Ferrazzi Dept. Woman, Mother and Neonate, Buzzi Children’s Hospital, Biological and Clinical School of Medicine, University of Milan, Italy Brief Introduction: Misoprostol is a synthetic prostaglandin E1 analog that can be administered off-label for labour induction. Based on moderate-quality evidence, taking safety as primary concern, WHO recommends a fixed dose of oral misoprostol in solution of 25 mcg every 2 hours for labour induction. Nevertheless, the efficacy of the recommended regimen has not been proved. The sublingual route of administration has the advantage of rapid onset of action similar to the oral one, prolonged activity and greatest bioavailability similar to the vaginal route. Safety and optimal dosage of sublingually administered misoprostol have not been established yet. The object of our study was to evaluate effectiveness and safety of 25 mcg misoprostol doses administered sublingually for labour induction.

Materials & Methods: A prospective observational study was conducted at Department of Woman, Mother and Neonate, Buzzi Children’s Hospital, Biological and Clinical School of Medicine, University of Milan, Italy, from May 2013 to February 2014. We enrolled pregnant women at gestational age 36 weeks, with medical or obstetric indication to induction of labour according to our clinical protocol, Bishop score equal or less than 5, alive fetus in cephalic presentation, and reassuring Fetal Heart Rate (FHR) for at least 20 minutes. Exclusion criteria were: intrauterine growth restriction, preeclampsia, previous cesarean section or miomectomy, any controindication to vaginal delivery. Capsules containing 25 mcg of misoprostol were prepared by the hospital pharmacist and administered sublingually every 3–4 hours until active labour was achieved, up to a maximum of 12 doses. Prolonged uterine contractions or tachysistole within 60 minutes from misoprostol administration were recorded as hyperstimulation. Primary outcomes were considered: mode of delivery, vaginal deliveries within 24 hours, cesarean section (CS) rate, hyperstimulation, blood loss at delivery 1000 ml, neonatal pH at birth 7.1 and Apgar score at 5 minutes less than 7. Secondary outcomes were considered: number of women receiving only one dose, number of women receiving more than six doses, use of oxyotcin rate, number of amiorexis perfomed at dilatation less than 3 cm, and number of women requiring analgesia in labour. Clinical Cases or Summary Results: We studied 441 inducted women, 321 nulliparous and 120 multiparous. Data are presented as mean ± standard deviation. Characteristics of the population were similar for nulliparous and multiparous women: age 33 ± 5 years, BMI at term 27 ± 4, gestational age 40 ± 1 weeks. Main indications for induction of labour were: post term (50.6%), premature rupture of membranes (29.0%), gestational diabetes (4.8%), fetal reasons (4.8%), oligohydramnios (4.3%), cholestasis (2.5%), gestational hypertension (1.6%), others (2.5%). Bishop score at the start of induction was 2 ± 2 (range 0–5) and 2 ± 1 (range 0–5) for nulliparous and multiparous women respectively. Primary and secondary outcomes are shown in table 1. Seventyseven percent of nulliparous and 93% of multiparous women delivered vaginally. Among these women, 67% and 81% delivered within 24 hours from first administration respectively. Median time to delivery was 20 hours (IR 13–28) for nulliparous and 14 hours (IR 9–19) for multiparous women. Median duration of active labour was 3 hours (IR 2–4) and 7 hours (IR 4–10) respectively. Cesarean section rate was 23.1% in nulliparous and 6.7% in multiparous women. Fetal distress was the most frequent cause of CS (55% of cases in nulliparous and 50% in multiparous). CS was performed for induction failure in 7 nulliparous cases and in no cases among multiparous women. No cases of tachysystolia or hypertonus were recordered in both groups. Blood loss 1000 ml was recordered in 8% of vaginal deliveries among nulliparous and 6% among multiparous, in 4% of CS among nulliparous, and no cases among multiparous. Umbilical arterial pH at birth was 57.1 in 11 cases (3.4%) in nulliparous group and 2 cases (1.7%) in multiparous group. No pH  7.0 and Apgar score at 5 minutes 57 were recorded. Conclusions: Sublingually administered misoprostol at the dose of 25 mcg every 3–4 hours is a safe method for induction of labour at term. In pluriparous women this regimen is also very effective. Nevertheless, our data suggest that in nulliparous women a more effective regimen should be considered. We suggest that doses could be increased to 50 mcg whether labour is not achieved with 3–6 doses. Further studies are needed to evaluate this hypothesis. Keywords: Induction of Labour, Misoprostol, Sublingual route Presenter: V. Brusati

148

ID 035

EFFICACY AND SAFETY OF INDUCTION ON THE UTERUS AFTER PREVIOUS CAESAREAN SECTION: COHORT STUDY AND LITERATURE REVIEW

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

N. Sanane`s, M. Rodriguez, C. Stora, G. Fritz, A. Gaudineau, G. Aı¨ssi, E. Boudier, B. Viville, R. Favre, I. Nisand, & B. Langer N. Sanane`s: University Hospital of Strasbourg, Strasbourg, France, M.Rodriguez:University Hospital of Strasbourg, Strasbourg, France, C. Stora: University Hospital of Strasbourg, Strasbourg, France, G. Fritz: University Hospital of Strasbourg, Strasbourg, Brief Introduction: Purpose: To evaluate the efficacy and safety of induction in women with a single uterine scar from a previous Caesarean section. Materials & Methods: Methods: this was a cohort study in which we included all singleton pregnancies in patients with a single uterine scar after previous Caesarean who delivered between 2007 and 2012. Methods of induction were oxytocic infusion plus amniotomy (if Bishop score 6) or insertion of a Foley catheter (Bishop 56). Clinical Cases or Summary Results: Results: Of the 2075 patients included, 806 (38.8%) had an elective repeat Caesarean, 1 045 (50.4%) went into spontaneous labour, 89 (4.3%) were induced by artificial rupture of the membranes and infusion of oxytocics and 135 (6.5%) were induced using a Foley catheter. Rates of vaginal delivery were 79.2, 79.8 and 43.7%, respectively. Six cases of uterine rupture were reported in the group of patients who went into spontaneous labour. There was no difference between groups with regard to neonatal morbidity. On multivariate analysis, risk factors for Caesarean delivery were macrosomia (OR 2.04, 95% CI 1.31–3.18) and induction by Foley catheter (OR 3.73, 95% CI 2.47–5.62); protective factors were previous vaginal delivery (OR 0.41, 95% CI 0.29–0.57) and cervical dilatation (OR 0.84, 95% CI 0.78–0.91). Conclusions: Conclusions: Induction on the uterus after previous Caesarean section with oxytocic infusion and amniotomy where the cervix is favourable does not appear entail any significant added risk in terms of maternal or foetal morbidity. Foley catheter induction is a reasonable option if the cervix is not ripe. Keywords:: Foley catheter, Induction of labour, Uterine rupture, Oxytocic, Caesarean section, Prostaglandins Presenter: Maylis Rodriguez

ID 154

PERINATAL OUTCOMES OF LABOR INDUCTION IN A OBESE POPULATION T. Ferraz1,2, C. Peixoto1, M. Rei1, G. Namora1, & N. Montenegro1,2 1

Obstetrics and Gynecology Dept., Sa˜o Joa˜o Hospital Center, Porto, Portugal, and 2Faculty of Medicine of University of Porto, Porto, Portugal Brief Introduction: To compare perinatal outcomes between obese pregnant women with spontaneous labor onset and those with labor induction. Materials & Methods: Retrospective cohort study of 637 obese pregnant women (body mass index (BMI)  30Kg/m2) between november 2011 and december 2013, in a University based Hospital.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Our exposure variable of interest was labor induction. Maternal outcomes considered were hypertensive gestational disease, birth trauma or cesarean section. Fetal or neonatal outcomes considered were preterm labor, large for gestational age (LGA) defined as birthweight (BW) 490th centile, small for gestational age (SGA) defined as BW 510th centile, neonatal hypoglycemia and neonatal respiratory distress syndrome. Clinical Cases or Summary Results: In our cohort, 37.2% of the women had their labor induced. Twent-nine percent delivered after 40 weeks. After multivariate adjustment, labor induction for motive other than preeclampsia remained significantly associated with increased risk of adverse composite neonatal outcome (aOR 2.72, 95%CI 1.06– 6.99). Additionally, an increased risk of cesarean section was found among women with labor induction (spontaneous onset labor 32.1% vs. 47%, aOR 1.73; 95%CI 1.22–2.45). No significant association between labor induction and birth trauma was seen in our cohort (aOR 2.13; 95%CI 0.57–8.0) after controlling for confounders. Conclusions: A higher risk of adverse neonatal outcomes and cesarean section after labor induction warrants the need for a high-risk management in obese pregnant women. Keywords: obesity, labor induction, neonatal outcomes Presenter: Ferraz, T.

ID 851

INDUCTION OF LABOUR WITH PROSTAGLANDIN E2 IN WOMEN WITH PREVIOUS CESAREAN SECTION: 2 YEARS EXPERIENCE C. Rodrigues, R. Caldas, P. Oliveira, C. Soares, A. Pinto, & T. Teles Centro Hospital Entre o Douro e Vouga, Santa Maria da Feria, Portugal Brief Introduction: In an attempt to reduce the rising cesarean section rate, many centers have recommended that women who have had a cesarean section be considered for subsequent vaginal delivery. This practice was associated with the concern of the safety of mother and fetus as many published studies showed its association with ruptured uterus during induction of labour. Recent recommendation of the Royal College of Obstetricians and Gynaecologists (RCOG) encourage the use of prostaglandins E2 (PGE2) in the trial of labour with prior cesarean section. Our objective is study the outcome of induction of labor with PGE2 vaginal delivery system in those with one previous cesarean section. Materials & Methods: Two years retrospective comparative study in a primary hospital, North of Portugal. The sample included 218 women with singleton gestation and a previous cesarean section, of whom 89 underwent induction of labour (study group) and 119 were admitted with spontaneous onset of labour (control group). In the study group we used vaginal PGE2 to induce labour. Mode of delivery, uterine rupture, admission to neonatal intensive care unit (NICU), indications for cesarean section and complications like infections morbidity were compared between the groups. Clinical Cases or Summary Results: There were no statistically significant differences between groups in maternal age, parity and gestational age at delivery or birth weight. Overall rate of vaginal delivery was 44.9% in study group and 64.7% in control group. There were 5 (5.6%) cases of NICU admission in the study group and 11 (9.2%) in the control group. Cesarean section was performed for nonreassuring fetal heart rate in 27% of the cases in study group and 21% in control group. There were no cases of uterine rupture in both study and control group.

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DOI: 10.3109/14767058.2014.924236

Conclusions: Induction of labour with PGE2 in women with one previous cesarean does not significantly increase the risk of new cesarean section or uterine rupture, and does not adversely affect immediate neonatal outcome. Keywords: Induction of labour; vaginal birth after cesarean section Presenter: Ca´tia Rodrigues

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ID 439

CLINICAL OUTCOMES OF THE USE OF SYNTHETIC OSMOTIC DILATOR DILAPAN-S FOR CERVICAL RIPENING PRIOR LABOR INDUCTION O. Simetka, I. Michalec, & P. Vasek Department of Obstetrics and Gynecology, University Hospital Ostrava, Czech Republic Brief Introduction: To analyze the effect of Dilapan SÕ (hygroscopic dilator) on pre-induction (cervical ripening prior induction) of delivery using standardized protocol. Materials & Methods: This is a prospective study. Women with singleton pregnancies and unfavorable cervix score (CS55) indicated for delivery at 24 weeks of gestation were included. The standardized protocol was overnight (9–15 hours) insertion of 2–4 pieces of Dilapan SÕ into the cervical canal. After extraction of Dilapan SÕ , the CS was re-evalauted. The results were analyzed using statistical methods. Clinical Cases or Summary Results: Dilapan-SÕ was used in 92 women. There was a significant increase in cervix score before and after insertion of Dilapan SÕ (2.8 (0–4); and 6.5 (3–10) respectively). After extraction of Dilapan-SÕ the CS in 55 women was above 5 and their delivery could be induced; in 31 women the CS remained under 5 and another method (dinoprostone vaginal suppository) of cervical ripening had to be used. Six women progressed to birth during insertion of Dilapan-SÕ . Dilapan SÕ is a hydrophilic dilator which increases its volume by absorbing fluids and gradually dilates the cervix. It also stimulates the release of endogenous prostaglandins which leads to degradation of collagen fibers. Due to this mechanism of action, the effect is gentle as well as predictable. The use of Dilapan SÕ is not associated with uterine hyperstimulation, infections or other complications. The dilation is accompanied by a minimum of pain and does not have any undesirable pharmacological effects. It is also well accepted by women. In another multicentre prospective study, which was performed in Czech Republic in women 36 weeks of pregnancy, mean CS of 5 points after extraction of Dilapan-SÕ was reached totally in 83 (86,46%) from 96 included patients. Our obstertric centre is specialized to manage more risky births. Therefore our inclusion criterion of delivery at 24 weeks of gestation could cause the different rate of women with CS above 5 after extraction of Dilapan-SÕ from population of women who gave birth at term. Conclusions: The insertion of Dilapan SÕ into the cervical canal is an effective method of cervix ripening prior induction of delivery. Keywords: labor, induction Presenter: O. Simetka

ID 113

ANALYSIS OF FACTORS INFLUENCING THE RATE OF CESAREAN DELIVERY AT TERM IN DIABETIC PATIENTS M. Mitani, Y. Makino, T. Sugiura, S. Hashimoto, J. Konno, M. Ogawa, & H. Matsui Department of Obstetrics and Gynecology, Tokyo Women’s Medical University, Tokyo, Japan Brief Introduction: The rate of Cesarean delivery is high among diabetic patients compared to that observed in non-diabetic patients. However, the factors influencing the rate of Cesarean section in patients with diabetes remain unknown. Moreover, it is unclear when pregnancy should be terminated in diabetic patients in order to decrease the rate of Cesarean section. In this study, we investigated the factors affecting the rate of Cesarean delivery and evaluated the appropriate week for inducing labor at term among diabetic patients. Materials & Methods: We retrospectively reviewed a cohort of 3,314 females with singleton pregnancies who delivered between January 2001 and December 2012 at our institution, excluding cases of anomalous babies, gestational diabetes mellitus, stillbirth, preterm birth, Cesarean section without labor and elective Cesarean section. Clinical Cases or Summary Results: With respect to the comparison between the diabetic patients and non-diabetic patients, the rate of Cesarean section was significantly higher in the former group (68/255 vs. 493/3,059, p50.0001). According to an analysis of the primiparas, the rate of Cesarean section associated with the arrest of labor was significantly high among the diabetic patients (47/255 vs. 282/3,059, p50.0001). However, the rate of Cesarean section associated with a non-reassuring fetal status was not significantly different between the two groups. Among the patients in whom pregnancy was terminated due to diabetes only, a comparison between those treated with Cesarean section with arrest of labor versus vaginal delivery showed that age, BMI and the frequency of type 2 diabetes were significantly higher in the Cesarean group. Among the patients in whom pregnancy was terminated due to diabetes only, the rate of Cesarean section at 38, 39 and 40 weeks of gestation was 35%, 27% and 23%, respectively. Conclusions: In diabetic patients, factors influencing the rate of Cesarean section include age, BMI and the induction of labor. Based on our results, the rate of Cesarean section can be decreased by decreasing the frequency of labor induction. Furthermore, it is necessary to consider the gestational age at termination in patients with diabetes. Keywords: diabetes mellitus, induction of labor Presenter: M. Mitani

ID 304

MATERNAL AND NEONATAL OUTCOMES BASED ON PRIMARY REASON FOR INDUCTION WITH RETRIEVABLE PROSTAGLANDIN VAGINAL INSERTS USING DATA FROM THE EXPEDITE TRIAL

150 K. F. Trofatter1, B. Powers2, D. A. Wing3, & O. Rugarn4 1

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Department of Obstetrics and Gynecology, Greenville Health Hospital System and University of South Carolina School of Medicine, Greenville, South Carolina, United States, and 2 Independent Consultant, Phoenixville, Pennsylvania, United States, and 3University Brief Introduction: Maternal and neonatal outcomes may differ depending on the indication for induction when using retrievable prostaglandins for induction of labour (IOL) or cervical ripening. Materials & Methods: This study assesses maternal and neonatal outcomes for non-elective and elective primary reasons for induction using post-hoc analysis of the Phase III trial, EXPEDITE, which compared retrievable misoprostol 200 mg with dinoprostone 10 mg vaginal inserts (MVI 200, DVI; clinical trial registration: NCT01127581) [1]. The study was not stratified by IOL indication. Clinical Cases or Summary Results: For MVI 200 and DVI, 596 (87.9%) and 597 (87.8%) women had non-elective inductions versus 82 (12.1%) and 83 (12.2%) with elective inductions. Non-elective primary reasons for induction were further grouped: post-date gestation (40 weeks), n = 210 and n = 227; maternal indications (hypertension, preeclampsia, diabetes), n = 198 and n = 188; fetal indications (olioghydramonios, intrauterine growth restriction, premature rupture of membranes), n = 118 and n = 120; and all other reasons, n = 70 and n = 62, respectively. The incidences of caesarean delivery (CD) for non-elective versus elective inductions for MVI 200 were 159/596 (26.7%) versus 17/82 (20.7%), respectively (p = 0.250). For DVI, these were 161/597 (27.0%) versus 23/83 (27.7%), respectively (p = 0.887). The rates of CD for nonelective subgroups (post-date gestations, maternal indications, fetal indications, and all other indications) for MVI 200 were 31.4%, 27.8%, 23.7% and 14.3%, and for DVI were 28.2%, 28.2%, 23.3% and 25.8%, respectively. The incidences of vaginal delivery (VD) within 24 hours for nonelective versus elective inductions for MVI 200 were 315/596 (52.9%) versus 55/82 (67.1%), respectively (p = 0.015). For DVI, these were 194/ 597 (32.5%) versus 37/83 (44.6%), respectively (p = 0.029). The rates of VD within 24 hours for non-elective subgroups for MVI 200 were 52.4%, 47.5%, 61.9% and 54.3%, and for DVI were 33.9%, 25.5%, 41.7% and 30.6%, respectively. The incidences of tachysystole with fetal heart rate (FHR) involvement (ACOG classification Category II/III) for non-elective versus elective inductions for MVI 200 were 60/596 (10.1%) versus 10/ 82 (12.2%) (p = 0.553). For DVI, these were 16/597 (2.7%) versus and 2/ 83 (2.4%) (p = 0.886). The rates of tachysystole with FHR involvement for non-elective subgroups for MVI 200 were 11.9%, 7.1%, 13.6% and 7.1%, and for DVI were 2.2%, 0.5%, 6.7% and 3.2%. For neonatal outcomes, the mean Apgar scores at 5 minutes for non-elective versus elective inductions for MVI 200 were 8.8 versus 8.9 (p = 0.095). For DVI, these were both 8.8 (p = 0.633). The mean Apgar scores for all non-elective subgroups for MVI 200 were 8.8, 8.7, 8.9 and 8.7, and for DVI were 8.9, 8.8, 8.9 and 8.8, respectively. The incidences of neonatal intensive care unit (NICU) admissions for non-elective versus elective inductions for MVI 200 were 60/596 (10.1%) versus 1/ 82 (1.2%) (p = 0.009). For DVI, NICU admissions were 65/597 (10.9%) versus 6/83 (7.2%), respectively (p = 0.307). NICU admissions for all non-elective subgroups for MVI were 8.1%, 10.6%, 8.5% and 17.1%, and for DVI were 11.5%, 10.1%, 12.5% and 8.1%, respectively. Conclusions: The incidences of vaginal delivery within 24 hours were higher for elective versus non-elective inductions for both MVI 200 and DVI whereas the incidences of NICU admission were lower for elective versus non-elective for MVI 200.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

ID 948

A COMPARISON BETWEEN TWO DIFFERENT DOSES OF VAGINAL ISOSORBIDE MONONITRATE VERSUS MISOPROSTOL IN PREINDUCTION CERVICAL RIPENING AT TERM: A RANDOMIZED CONTROLLED STUDY W.A. Sayed Ahmed, M.R. Ahmed, E.H. Madny, R.M. Mohamed, & A.M. Elshahat Suez Canal University Hospitals, Ismailia - Egypt Brief Introduction: The aim of the study is to evaluate the efficacy and safety of the vaginal Isosorbide Mononitrate (IMN) at two doses (40 and 60 mg) in comparison to vaginal misoprostol (50mg) in cervical ripening at term pregnancy. Materials & Methods: This single blind randomized controlled study was conducted at Suez Canal University Hospitals. 141 nulliparous women with singleton pregnancy and cephalic presentation, at 41+ weeks of gestation with Bishop Score 6, were randomly allocated into three equal groups (n = 47) by block randomization. Group (A) received 40 mg IMN, group (B) received 60 mg IMN while group (C) received 50 mg misoprostol every 6 hours for a maximum of three doses, all through the vaginal route in the posterior fornix. Assessment of Bishop Score was carried out every two hours. Cervical ripening and adverse effects were the primary outcomes. Progress and outcomes of labor were also assessed. Clinical Cases or Summary Results: There was no difference in the pretreatment median Bishop Scores among the three groups. However, with misoprostol treatment; Bishop Score was 6 or more in significantly less time as compared to the 40 mg and 60 mg IMN groups (8 hrs 45 min, 11 hrs 30 min and 9 hrs 45 min respectively). Also, the mean treatment - artificial rupture of membranes time was significantly lower in the misoprostol compared to the other 2 groups (10 hrs Vs. 14 hrs and 11 hrs respectively). Misoprostol-treated women reported significant side effects in the form of flushes and headaches as well as an increased need to use analgesics as compared to the other two groups. No significant difference was noted in the side effects reported in the IMN groups. Progress of labour was faster in the misoprostol group. No difference in CS rates was noted. Conclusions: Misoprostol results in quicker cervical ripening and progress of labour compared to IMN. However, IMN reported minimal side effects and better tolerability. The prospect of IMN use for cervical ripening on outpatient basis should be evaluated. Keywords: Isosorbide Mononitrate, Misoprostol, Cervical ripening Presenter: Waleed Ali Sayed Ahmed

ID 866

1. Wing DA et al. Obstet Gynecol. 2013;122:201–9.

DOES ROUTINE INDUCTION AT 41 WEEKS REALLY REDUCE CAESAREAN SECTION?

Keywords: Retrievable prostaglandin vaginal inserts; non-elective induction; elective induction; maternal and neonatal outcomes

I. Pozzi1, M. Incerti2, D. Bernasconi3, V. Ciscato4, V. Giardini5, L. Todyrenchuk6, & P. Vergani7

Presenter: Deborah A Wing

1

MD Dipartimento Materno Infantile, Ospedale Manzoni, Lecco, Italy, 2,4,5,6MD Dipartimento Materno Infantile, Ospedale San gerardo-Fondazione MBBM, Monza, Italy, 3PHD Dipartimento di Statistica, Universita` degli Studi di Milano-

151

DOI: 10.3109/14767058.2014.924236

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Bicocca, Milano, Italy, and 7Professore Associato in Ostetricia e Ginecologia Universita` degli Studi di Milano-Bicocca, MD Dipartimento Materno Infantile, Ospedale San GerardoFondazione MBBM, Monza, Italy Brief Introduction: The risk of prolonged pregnancy, defined as beyond 42 weeks, is well-known, therefore international consensus on routine induction of labor at 42 weeks is acknowledged. However, the debate on when it is better to conclude a pregnancy after 41 weeks is still open. We carried on a study to evaluate if the conservative management between 41.0 weeks and 42.0 weeks modifies the mode of delivery and the perinatal outcomes. Materials & Methods: We retrospectively analyzed a cohort of singleton, non complicated pregnancies at or beyond 41 weeks between January 2009 and June 2013 at S. Gerardo HospitalFondazione MBBM in Monza (Italy). The monitoring protocol was: amniotic fluid index evaluation and biophysical profile at 41.0 weeks and at 41.3 weeks, sweeping of membranes at 41.3 weeks and routine induction at 41.5 weeks. Induction method was based on Bishop score, using prostaglandins for Bishop score 57. FHR tracings were prospectively classified using ACOG classification. Primary outcomes were mode of delivery and neonatal morbidity, defined as the 5th minute Apgar score 5 and/or umbilical artery pH 7.10 and/or BE 12 and/or need for resuscitation and/or admission to NICU, and perinatal mortality. Statistical analysis included Fisher’s test and logistic regression to assess the independent effect of induction on primary outcomes in the cohort of women with post-term pregnancy. Clinical Cases or Summary Results: During the study period, the incidence of post term pregnancy was 17.2% (14.5% in 2009, 16.0% in 2010, 17.1% in 2011, 20.9% in 2012 and 18.9% in the first 6 moths of 2013), showing a rising trend due to the increase of maternal age and BMI. Among 2062 post term pregnant women we included for the analysis 33 cases of cesarean section (CS) for fetal distress before labor and we excluded 31 cases of elective CS. Sixty one percent (1241/2031) of pregnant women had a spontaneous onset of labor including the women with induction after 24 hours of pre-labour rupture of membranes (n = 49). The remaining 790 (39%) had induction of labor: 428 (54%) for prolonged pregnancy (41.5 weeks) and 362 (46%) for other reasons. Gas analysis was available in 91.4% cases, 5.6% of babies (115/ 2062) had a 5th minute Apgar score 5 and/or umbilical artery pH 7.10 and/or BE 12 and/or need for resuscitation and/or admission to NICU. The rate of CS was higher in the induction group than in the non-induction group (17.3% vs 9.0%, p50.001). Both CS for labor arrest and for emergency conditions were greater in the induction group compared to not inducted women [(17.3% vs 9%, p50.001) and (7.1% vs 3.2%, p50.001)]. A significant rise in abnormal FHR during 1st and 2nd stage of labour was observed in the induction group compare to spontaneous group [(8.3% vs 4.6%, p = 0.001) and (21.8% vs 15.4%, p50.001)]. Moreover, the induction group had a higher rate of neonatal morbidity and mortality (7.2% vs 4.7%, p = 0.018). We had one case of intrauterine fetal death in the not inducted group. Logistic regression analysis, adjusting for gestational age and parity, demonstrated that the induction of labor was an independent predictor of higher CS (OR 1.82; 95% CI, 1.34–2.45; p50.001) and abnormal FHR monitoring (OR 1.66; 95% CI, 1.10–2.50; p = 0.015). However, the induction of labor was not significantly associated with neonatal morbidity (OR 1.42; 95% CI, 0.94–2.16; p = 0. 1). Conclusions: In the ongoing debate on the better management in post term pregnancy, our data show that a conservative protocol allows spontaneous onset of labour for 60% of pregnant women beyond 41 weeks with a lower rate of CS. Furthermore, the induction of labor increases the incidence of CS without reducing the neonatal morbidity. Keywords: Induction of labour, post term pregnancy Presenter: I. Pozzi

ID 492

EFFECTIVENESS AND SAFETY OF THE OSMOTIC DILATOR DILAPANS FOR CERVICAL RIPENING IN FEMALES WITH/WITHOUT CAESAREAN SECTION IN MEDICAL HISTORY L. Hruban1, P. Janku˚1, O. Sˇimetka2, I. Michalec2, R. Vlk3, J. Za´humensky´4, A. Toman5, R. Doubek6, & K. Rousˇarova´6 1

Department of Obstetrics and Gynaecology, University Hospital of Masaryk University in Brno, Czech Republic, 2 Department of Obstetrics and Gynaecology, University Hospital in Ostrava, Czech republic, and 3Department of Obstetrics and Gynaecology, Universi Brief Introduction: Mechanical and medicamentous methods have been used for cervical ripening prior to labor induction. Mechanical methods were extensively replaced by pharmacological methods during the last decades. However recently there is a trend of reintroducing them for clinical use because of availability of sterile and efficious devices and various contraindications limiting medication with prostaglandins. Documented clinical efficacy and safety of Dilapan-S in females with/without caesarean section in medical history are lacking. The purpose of this study is to evaluate efficacy and safety of use of the synthetic osmotic dilator Dilapan-S for cervical ripening prior to labor induction according to defined criteria and to compare results in females with/without caesarean section in medical history. Materials & Methods: The study was designed as an observational, prospective, multicentre, data collection, performed between 15. May 2013 and 31. October 2013. The 96 female patients were included in the data analysis. 35 patients (36.5%) had a caesarean section reported in their medical history, while the group of patients without previous caesarean section involved 61 patients (63.5%). Assessment of the primary objective and success of cervical ripening procedure was based on the Bishop (cervical) score. Clinical Cases or Summary Results: The evaluation of efficacy of the medical device Dilapan-S in labor pre-induction showed that the application was effective in terms of the Bishop cervix score with improvement from a mean of 2,81 to 6,13, which was confirmed as statistically significant. In case of patients with caesarean section in medical history the cervix score improved from 2,83 to 5,5, while in subjects without previous SC the improvement was from 2,80 to 6,5. In both cases the improvement was confirmed as statistically significant. Comparison of both sub-groups showed that the mean achieved cervix score was statistically significantly higher in the subgroup of patients without SC in medical history. Safety data collection was focused on fetal hypoxia, uterine hypertonus, clinical signs of infection and other potential adverse effects related to the use of Dilapan-S. No complications related to the use of Dilapan-S could be identified. Conclusions: Dilapan-S administered for cervical ripening prior to labor induction was effective in terms of statistically significant improvement of the Bishop score in females regardless of caesarean section in their medical history. Use of Dilapan-S was not associated with occurrence of excessive uterine contractions or other complications in all 96 patients. Keywords: cervical ripening, Dilapan-S, labor induction Presenter: Luka´sˇ Hruban

152

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ID 452

DINOPROSTONE FOR CERVICAL RIPENING AS A SUCCESFULLY, SAFE AND EFFICIENT ALTERNATIVE REGARDING ELECTIVE CESAREAN IN WOMEN WITH PRIOR CESAREAN DELIVERY CS. Pin˜el Pe´rez, A. Castillo Martı´n, N. Izquierdo Me´ndez, N. Pe´rez Pe´rez, JE. Asenjo de la Fuente, M.A. Herra´iz Martı´nez

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Hospital Clı´nico San Carlos, Madrid, Spain Brief Introduction: The background of this study is to descript the success rate, neonatal outcomes, uterine rupture rate and efficiency of cervical ripening with dinoprostone in women with prior cesarean delivery and to establish a comparison between these results and those obtained in a group of elective cesarean. Materials & Methods: We have designed a prospective study with 120 patients distributed into two groups of 60 women each, recruited between 2012 and 2013. First group included women with prior cesarean section who need cervical ripening with dinoprostone. Second group included women whom were performed an elective cesarean. When analyzing efficiency of each intervention we have included the cost of personal, medicines, hospital stay, infrastructures, surgical material, etc. Statistical analysis was performed by using statistical software STATA 12.0. We have analyzed differences between two groups of patients with ji-squared for categorical variables and t de Student for quantitative variables. We have performed multiple regressions and chunk tests to study possible confusion factors and interactions between variables and normality tests to asses our sample is representative of global population. Clinical Cases or Summary Results: 120 patients have been included in the study and distributed into two groups: (dinoprostone group1, 60 patients) and elective cesarean (group 2; 60 patients). Both groups were similar in maternal age, previous parity and gestational age (Table 1). Cervical ripening indications in dinoprostone group were prolonged gestation (41.67%; 95%CI: 28.82%-54.51%, premature rupture of membranes (20%; 95%CI: 9.58%-30.42%), arterial hypertension (13.33%; 95%CI: 4.48%-22.19%), gestational diabetes (3.33%; 95%CI: 0%-8.01%), restricted intrauterine growing (5%; 95%CI: 0%-10.68%), maternal interest ((5%; 95%CI: 0%- 10.68%) and others (11,67%; 95%CI: 3.30%-20.03%). Vaginal delivery rate was 53.33% (95%CI: 40.34%-66.33%), versus cesarean delivery proportion of 46.67% (95%CI: 33.67%-59.66%). The main cesarean indication in this group was induction fail 58.62% (95%CI: 39.55%-77.69%). 24.14% of cesarean sections were performed for fetal welfare lost suspect (95%CI: 7.57%-40.70%), and the other indications were arrest of dilatation (3.45%), arrest of descent (10.34%) and other (3.48%). There were not uterine ruptures in any group. Neonatal outcomes had not clinically important differences, as it is showed in Table 2. Actually, statistical significant differences were a consequence of elevated N. However, global cost differences of both interventions were statistically significant and economically important, with a mean saving of 744.81E (95%CI: 551.89E-937.74E; p50.001). Furthermore, we have analyzed by a multiple regression curve and a chunk test (p = 0.6769) all possible confusing variables or interactions and we have not found any of them. Conclusions: - Use of dinoprostone for cervical ripening in women with prior cesarean delivery was a successfully alternative to elective cesarean, with a minimal success rate (vaginal delivery rate) of 40.34%, with 95% confidence.

- It was a safe alternative, without any uterine rupture in 60 patients and similar and acceptable neonatal outcomes. - Use of dinoprostone for cervical ripening in women with prior cesarean delivery was more efficient than performing an elective cesarean, with minimal saving of 551.89E per patient (with 95% confidence). Mean saving in our study was 744.81E per patient. Keywords: dinoprostone, cervical ripening, elective cesarean, labour induction Presenter: CS. Pin˜el Pe´rez

ID 181

PERINATAL OUTCOMES OF LABOR INDUCTION IN GESTATIONAL DIABETES T. Ferraz1,2, C. Peixoto1, M. Rei1, E. Lau2,3, J. Queiro´s3, A. Magalha˜es2,3, G. Namora1, & N. Montenegro1,2 1

Departament of Gynecology and Obstetrics from Sa˜o Joa˜o Hospital Center, Porto, 2Faculty of Medicine of University of Porto, and 3Departament of Endocrinology from Sa˜o Joa˜o Hospital Center, Porto Brief Introduction: To compare perinatal outcomes between women with gestational diabetes (GDM) with spontaneous labor onset and those with labor induction for GDM. Materials & Methods: Retrospective cohort study of 557 patients with managed between january 2011 and december 2013, in a University based Hospital. GDM was defined using IADPSG criteria. Our exposure variable of interest was labor induction for GDM. Maternal outcomes considered were hypertensive gestational disease, birth trauma or cesarean section. Fetal or neonatal outcomes considered were preterm labor, large for gestational age (LGA) defined as birthweight (BW) 490th centile, small for gestational age (SGA) defined as BW 510th centile, neonatal hypoglycemia and neonatal respiratory distress syndrome. Clinical Cases or Summary Results: GDM prevalence in our center was 7.5%; mean age was 32.8 years old (±5.4). Pharmacological therapy was used in 60.2% of cases. In our cohort, 40.8% had their labor induced because of GDM. After multivariate adjustment, no association was found between labor induction and cesarean delivery (aOR 0.65; 95%CI 0.38–1.10) or adverse neonatal composite outcome (aOR 0.87; 95%CI 0.56–1.34). No significant association between adverse composite outcome and birth after 40 weeks (aOR 1.22; IC95% 0.72–2.1) was found in this group of women.

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DOI: 10.3109/14767058.2014.924236

Conclusions: We found no association between adverse neonatal outcome and labor induction in GDM women. Additionally those women with birth 440 weeks had similar neonatal outcomes from those born between 37–39 weeks. These results endorse the need for individually assessment of labor induction in GDM. Keywords: Gestational diabetes; labor induction; neonatal outcomes Presenter: T. Ferraz

ID 730

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PREDICTORS OF FAILED INDUCTION J. Cominho, M. Mouraz, S. Saramago, M.I. Reis, S. Proenc¸a, L. Reis, R. Rodrigues, & F. Nunes All from HPP Hospital de Cascais Dr. Jose´ de Almeida, Cascais, Portugal Brief Introduction: Induction of labor is a commonly performed obstetric procedure. Most of studies show that there is a 2 fold increased risk of cesarean delivery with induction of labor compared with spontaneous labor. The main objective of this study is to identify clinical variables associated with unsuccessful labor induction. Materials & Methods: A hospital based retrospective study done over a year between 1st January 2013 to 31 st December 2013. Inclusion criteria: singleton pregnancies beyond 37 weeks with vertex presentation. Induction was considered failed if it ended up in cesarean section. Clinical Cases or Summary Results: Cesarean section in the study group was 26.55% and 15.32% in the group with spontaneous onset of labor. The main cause for cesarean section was suspected fetal distress for both groups (56.16% in induction of labor group and 52.94% in spontaneous onset of labor group). There was no statistically difference between maternal age in the two groups. In the induction of labor group, the gestational age where more cesareans were was above 41 weeks (67.12%). In the spontaneous onset of labor groups were more cesareans between 40 and 40 + 6 weeks (85.29%). In both groups the majority of cesareans were made in nulliparous (91.78% in induction of labor group and 85.29% in spontaneous onset of labor group). There was no statistically difference in birth weight and apgar score between the two groups. Conclusions: As mentioned in literature, in our group there were more cesareans in the induction of labor group and were more frequent in nulliparas with advanced gestational age. We must keep in mind that despite the benefit of induction of labor in some cases, it has an important impact in the rate of cesarean delivery. Keywords: Induction of labor, cesarean Presenter: Joana Cominho

ID 292

NEONATE AND INDUCTION OF LABOR COMPARED WITH EXPECTANT MANAGEMENT FOR PRELABOR RUPTURE OF THE MEMBRANES A. Nurc¸e1, E. Kamberi2, A. Hoxha3, Xh. Prendushi3, G. Koroveshi4, I. Kola1, & V. Shpata3

1

Department of Health Diagnostic and Rehabilitation, Medical Science Technical Faculty, University of Medicine, Tirana, Albania, 2Department of Obstetrics, University Obstetric-Gynecologic Hospital ‘‘Koc¸o Gliozheni’’, Tirana, Albania, 3Department of Clinic, Medical Science Technical Faculty, University of Medicine, Tirana, Albania, and 4 Department of Neonatology, University Hospital of Obstetric Gynecologic ‘‘Geraldine Queen’’, Tirana, Albania Brief Introduction: The optimal management of pregnancies complicated by premature rupture of membranes remains largely undefined and is an area of great controversy in obstetrics. Materials & Methods: It is a prospective descriptive study in University Hospital of Obstetric Gynecologic ‘‘Geraldine Queen’’ in Tirana Albania during a period 1 January 2009 to 31 December 2012. We study the outcome of neonate with history of premature rupture of membrane in two groups, induction of labor and expectant management at preterm neonate. Clinical Cases or Summary Results: 617 newborns were included. The labor was induction in 263(42.6%) case. Composite neonatal major morbidity was less in induction group than in the other group: OR = 0.442, 95% CI: 0.29–0. 66, p = 0.0001.Infants in the induction group had less infection, sepsis and mortality than in the expectant management group so respectively OR = 0.26, 95% CI: 0.1470.49, p50.0001; OR = 0.19, 95% CI: 0.09–0.41, p50.0001; OR = 0.44, 95% CI: 0.08–2.21, p = 0.2. Infants in the expectant management group were less likely to have asphyxia than in the induction group OR = 1.17, 95%CI: 0.74–1.84, p = 0.4. Administration of antibiotics was more commonly used in the expectant management group OR = 0.56; 95% CI: 0.38–0.82, p = 0.002. Duration of hospitalization of babies was longer in the expectant management group OR = 0.35, 95% CI: 0.07– 1.72, p = 0.16. Conclusions: Induction of labor is protective factor for neonatal infection, sepsis, mortality but not asphyxia. Keywords: neonate, management

preterm,

induction

of labor,

expectant

Presenter: Alma Nurc¸e

ID 680

FETAL CESAREAN DELIVERY FOLLOWING UTERINE DETORSION THROUGH EXTRAPERITONIZATION OF HUGE MYOMA IN A PREGNANT WOMAN S. Kim, C. Lee, & H. Park Departments of Obstetrics and Gynecology, Dongguk University Ilsan Hospital, Goyang, Korea Brief Introduction: Some degrees dextrorotation of the uterus is physiologic phenomenon in pregnant women. Beyond 45 degrees rotation of uterus on its long axis is defined as uterine torsion, commonly associated uterine myoma or congenital uterine anomaly. Torsion of pregnant uterus is a rare complication. We report a case of torsion of gravid uterus due to huge myoma, successful fetal delivery after detorsion through extraperitonization of huge myoma. Materials & Methods: case report Clinical Cases or Summary Results: A 36 year old nullipara was referred to our hospital to evaluate abdominal mass occupying whole abdominal cavity, at 16th weeks of gestation. We confirmed the mass was 30cm sized subserosal myoma without malignant potential by non-contrast magnetic resonance imaging. Untill near-term, she was asymptomatic except enormous abdomen, admitted at 37th weeks of gestation for labor induction. However, cesarean delivery was decided because of failure of cervical dilation despite uterine

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154

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Brief Introduction: Labor induction (LI) is the artificial start of the birth process through medical intervention or other methods. Prostaglandins analogues, such as misoprostol, are drugs commonly used in our clinical practice. Several studies revealed similar rates of instrumental vaginal deliveries (forceps-assisted and/or vacuumassisted vaginal deliveries) among women who were induced compared to expectant management. This study aims to compare the type of vaginal delivery (normal or dystocia) among a group of pregnant women undergoing LI with misoprostol and another group who started labor spontaneously. Materials & Methods: Retrospective study based on clinical records of 1031 pregnant women, whose birth occurred at the Hospital of Santa Maria between January 2012 and December 2013. Singleton pregnancies with gestational age 40 weeks were included. We excluded all pregnant women with maternal and/or fetal pathology, which could influence the type of delivery. The sample was divided in two groups according to the onset of labor (induction with misoprostol, n = 245 and spontaneous onset of labor, n = 786) comparing the type of delivery. The variables in study were: normal delivery and instrumental (forceps-assisted and/or vacuum-assisted) vaginal delivery. For the statistical analysis we used SPSS, Chi-Square test and Fisher test software, and considered statistically significant all p values 0,05. Clinical Cases or Summary Results: No significant differences were found between the two groups with regard to the type of vaginal delivery. Conclusions: LI should be reserved for cases in which maternal and fetal benefits outweigh the continuing of the pregnancy and its use is not associated with increased risk of instrumented vaginal delivery. These data are consistent with the literature. Keywords: Labor induction, misoprostol; dystocia, instrumental vaginal delivery Presenter: Joana Sousa

ID 161 contraction. Intraoperatively, 90 degrees dextrorotated, left deviated uterus due to mass effect was diagnosed. Successful fetal delivery at lower segment uterine incision following detorsion through extraperitonization of huge myoma, carried out. And also, cesarean myomectomy was performed. Conclusions: Rarity of torsion of uterus in pregnant woman with myoma makes the preoperative diagnosis difficult. Obstetricians should have this comlplication in mind when performing cesarean section with huge myoma, and may correct torsion of uterus by extraperionization of huge myoma. Keywords: Torsion, gravid uterus, complication, myoma Presenter: S Kim

ID 907

DOES THE LABOR INDUCTION WITH MISOPROSTOL INCREASE THE RISK OF DYSTOCIA? EXPERIENCE OF OUR DEPARTMENT J. Sousa, M. Centeno, & L. Mendes da Grac¸a Departamento de Obstetrı´cia, Ginecologia e Medicina da Reproduc¸a˜o, Hospital Universita´rio de Santa Maria- Centro Hospitalar Lisboa Norte, Lisboa, Portugal

RISK OF SEQUELAE AFTER VIRAL INFECTION DURING PREGNANCY V. Kuzmin Department Obstetrics and Gynecology, Moscow State University of medicine and dentistry, Moscow, Russia Brief Introduction: Study of features of current and outcomes at virus and bacterial infections at the women, development of rational tactics of running of pregnancy, delivery at the women and newborn. Materials & Methods: We have revealed 2900 pregnant women with virus and bacterial infections: virus hepatitis B and C, herpes, cytomegalovirus, parvovirus, HIV infection and followed them during pregnancy. The verification of the diagnosis was carried out in view of the data clinical and special methods of researches. The medical therapy directed on removal of symptoms most frequently to an observed pathology, with the account thus of a degree of weight and stage virus hepatitis, has allowed to keep pregnancy at all women Clinical Cases or Summary Results: To prevent development of virus hepatitis B all newborns were introduced vaccine and immunoglobulin during the first hours after delivery, and following vaccination of 1, 2 and 12 months of life. With the purpose of preventive maintenance virus hepatitis C applied immunoglobulin. At display of clinical symptoms of an infection to children carried out antivirus and symptom therapy, detailed virology research, with the subsequent supervision in dynamics. Chemoprophylaxis HIV infection at pregnant women descend frequency transmission HIV to newborn with 50% to

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5%. Realization hemostatic cesarean section permit descend frequency transmission HIV to newborn with 10% to 2%. Conclusions: Thus, the creation of women dispensary system and organisation of newborn help and the choice of optimum obstetrics tactics with the virus infections pregnant women are the necessary condition for the decrease of perinatal mortality and morbidity. Keywords: infection, pregnancy, complication, newborn Presenter: V.Kuzmin

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ID 973

INDUCTION TO DELIVERY INTERVALS: OPTIMISING RESOURCING DECISIONS REGARDING THE USE OF RETRIEVABLE PROSTAGLANDIN VAGINAL INSERTS

for nulliparae (32.2% [n = 145]; 95% CI: 27.9–36.7) and 12–24 hrs post insertion for multiparae (40.6% [n = 93]; 95% CI: 34.2–47.3), suggesting 7am and 7pm as induction start times for nulliparae and multiparae, respectively. Using these start times, the median time to onset of active labour would be 4:06am and 7:53am, and the median time of delivery would be 1:41pm and 12:09 pm, for nulliparae and multiparae, respectively Conclusions: When determining the time to initiate induction of labour to achieve daytime deliveries, our results suggest that different clinical strategies may be appropriate. As such, the type of retrievable prostaglandin vaginal insert and parity should be considered to optimise resource planning around expected active labour and delivery times. 1. Gijsen R et al. BMC Pregnancy Childbirth. 2012;12:92. 2. Wing DA et al. Obstet Gynecol. 2013;122:201–9. Keywords: Presenter: O. Rugarn

INFECTION & SURROUNDINGS ID 861

H. Miller1, L. Goetzl2, D. Wing3, B. Powers4, & O. Rugarn5 1 Watching Over Mothers & Babies Foundation, Tucson, Arizona, United States, 2Obstetrics, Gynecology and Reproductive Sciences, Temple University, Philadelphia, Pennsylvania, United States, and 3University of California, Irvine, Department of Obstetrics and

Brief Introduction: Retrievable misoprostol 200 mg or dinoprostone 10 mg vaginal inserts (MVI 200; DVI) are both approved products available for induction of labour (IOL) or cervical ripening. Nursestaffing decisions are most efficient and cost-effective when the time course of labour induction can be reasonably estimated. Furthermore, studies have shown that daytime deliveries improve safety outcomes [1]. The primary aim of this study is to determine an optimal induction start time to obtain the most daytime deliveries during a specific 12-hour (daytime) period for nulliparous and multiparous women. Materials & Methods: A post hoc analysis was performed using data from the Phase III trial, EXPEDITE (clinical trial registration: NCT01127581) [2]. A Cox regression analysis was conducted using time of day when IOL began and treatment as predictive variables for interval to delivery. Assuming theoretical IOL start times (7am, 7pm or 11pm), we calculated the proportion of either caesarean or vaginal deliveries during a 7am and 7pm period. Clinical Cases or Summary Results: A total of 678 women received MVI 200 (441 nulliparae; 237 multiparae) and 680 women received DVI (451 nulliparae; 237 multiparae). No relationship was identified between IOL start time and interval to delivery for either induction agent (p = 0.133), justifying the use of hypothetical start times to model expected delivery time. Using the pre-specified start times for MVI 200, the 12-hour interval with the largest proportion of any delivery mode (vaginal or caesarean) will occur 12–24 hrs post insertion for nulliparae (45.8% [n = 202]; 95% confidence interval [CI]: 41.1–50.6) and 8–20 hrs post insertion for multiparae (60.8% [n = 144]; 95% CI: 54.2–67.0). These data suggest that 7pm in nulliparae and 11pm in multiparae are optimal start times to achieve daytime delivery when using MVI 200. Applying these start times, the median time to onset of active labour would be around 9:00am for both parities and the median time of delivery would be 4:32pm and 11:55am for nulliparae and multiparae, respectively. Using the prespecified start times for DVI, the 12-hour interval with the largest proportion of any delivery mode will occur 24–36 hrs post insertion

NEONATAL SEPSIS OF VERTICAL TRANSMISSION CAUSED BY LISTERIA MONOCYTOGENES. AN EPIDEMIOLOGICAL STUDY FROM THE ‘‘GRUPO DE HOSPITALES CASTRILLO’’ B. Fernandez-Colomer, G.D. Coto-Cotallo, J. Lopez-Sastre and members of Grupo de Hospitales Castrillo Neonatology Service, University Hospital Central of Asturias, Oviedo, Asturias, Spain Brief Introduction: Listeria monocytogenes (LM) is a gram-positive bacillus, which causes infections almost exclusively in inmunocompromised hosts, including pregnant women and newborns. Neonatal listeriosis of vertical transmission occurs by transmission of LM from mother to fetus, either transplacentally from the maternal circulation, by inhalation of infected amniotic fluid or by ascending colonization from the vagina. Materials & Methods: Objective: to assess the epidemiology of neonatal vertical sepsis caused by LM in our country (Spain). Patients and methods: From 1996 the neonatal services of 37 acute-care teaching hospitals in Spain (‘‘Grupo de Hospitales Castrillo’’) carries out a prospective surveillance of the epidemiology of vertical neonatal sepsis. Clinical Cases or Summary Results: Among 1,542,770 live births (LBs) in the study period (1996–2012), 125 newborns developed neonatal vertical listeriosis (0.08/1,000 LBs). Most newborn with listeriosis were preterm (80.8%) and in 37 cases (29.6%) VLBW babies (babies birth weight lower than 1500 gr). The incidence of vertical listeriosis increased from 0.04 to 0.14/1,000 LBs between 1996 and 2012, being in 2012 the third cause of neonatal vertical sepsis after E. coli (0.42/ 1,000 LBs) and GBS (0.22/1,000 LBs). Corioamnionitis was present in 42.4% of cases (59.4% in VLBWB). Listeriosis was complicated with meningitis in 29% of cases. Global mortality rate was 14.4% (18/125) and 32.4% in VLBWB.

156 Conclusions: In Spain where national guidelines for prevention of perinatal GBS infections were issued in 1998, LM appears as the third most common organism isolated in neonatal vertical sepsis. Keywords: neonatal vertical sepsis, listeria monocytogenes, neonatal listeriosis Presenter: B. Fernandez-Colomer

ID 722

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IMMUNOGLOBULIN PREPARATION ENRICHED WITH IGM REDUCES THE ECONOMIC BURDEN OF NEONATAL SEPSIS FOR THE RUSSIAN FEDERATION I. Soldatova1, M. Avksentyeva2,3 1

Pirogov’s Russian National Research Medical University, Russian Academy of National Economy and Public Administration under the President of the Russian Federation, and 3Sechenov’s First Moscow State Medical University 2

Brief Introduction: The economic burden of severe neonatal sepsis is currently uncertain. In a period when hospital budgets become restrained, economic assessment is important for rational decision making. Aim. To evaluate economic burden of severe neonatal sepsis in the Russian Federation and assess clinical efficacy and costeffectiveness of a specific polyclonal intravenous immunoglobulin preparation enriched with IgM (IVIG IgM). Materials & Methods: Chosen methodology was based on the selection of medical records of neonatal intensive care units (NICUs). Neonates (n = 79) were classified according to gestational age (GA – 25–41 weeks) and IVIG IgM administration. Published cost data were applied to assess differences in treatment costs. Clinical Cases or Summary Results: Mean cost of hospitalization to NICU (direct costs) per infant with neonatal sepsis is estimated as E 9 092. Cost per infant is inversely related to gestational age (GA). Total costs associated with neonatal sepsis are estimated as E 176 067 per infant. Taking into account both direct and indirect costs and extrapolating these data to a target population of Moscow, we estimated total economic loss, resulting from neonatal sepsis, as E 60 919 123. IVIG IgM administration in cases of neonatal sepsis promoted reduction of direct costs per patient by 19% and leads to substantial cost savings (up to E 168 896 per patient). Conclusions: Improvement of treatment of neonatal sepsis plays the crucial socio-economic role since it could significantly reduce the economic burden of the disease for the Russian Federation. Keywords: neonatal sepsis, specific polyclonal intravenous immunoglobulin preparation enriched with IgM, economic burden Presenter: I. Soldatova

ID 480

VERTICAL TRANSMISSION OF T.CRUZI: OUR EXPERIENCE AT A SECONDARY HOSPITAL IN BARCELONA C. Mendoza1, S. Ruiz1, S. Maya1, M. del Rio2, & E. Rodrı´guez1 1 Neonatology Dept., Consorci Sanitari Integral/Hospital General Hospitalet, Hospitalet de Llobregat, Barcelona, Spain, and 2Obstetrics Dept., Consorci Sanitari Integral/Hospital General Hospitalet, Hospitalet de Llobregat, Barcelona, Spain

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Brief Introduction: Chagas’ disease has become a public health problem in non-endemic countries due to high rates of immigration. Our aim is to evaluate the rate of congenital transmission of Trypanosoma cruzi in our population. Materials & Methods: This is a descriptive study over a three-yearperiod (July 2010-December 2013). Latin American pregnant women were tested for Trypanosoma cruzi serology with ELISA technique in the first trimester of pregnancy. When the mother was positive, the neonates were studied with a microhematocrit and a Polymerase Chain Reaction (RT-PCR) test at birth and underwent a serological follow-up (recombinant Trypanosoma cruzi IgG antibody) at 9 months in order to confirm congenital infection. Epidemiological data were collected. Clinical Cases or Summary Results: A total of 1717 pregnant women were included in the screening program. Eighty one cases (96% from Bolivia) were seroreactive for Trypanosoma cruzi (18%; 81/1717) and five cases of congenital infection were identified. Congenital infection was confirmed by positive PCR at birth in one case and by serological test at the age of 9 months in four. All the neonates were asymptomatic. Seroprevalence for Trypanosoma cruzi infection in our sample of Bolivian women was 17.1%. Conclusions: Our prevalence of 30% of Latin American pregnant women with a mother-to-child transmission rate of 6% (5/81) highlights the importance of screening programs for vertical transmission of Chagas disease in non-endemic areas. Early detection in neonates affected allows early treatment and prevention of long term complications. Additionally, treatment of infected mothers may prevent progression of disease and future cases of multigenerational transmission. Keywords: Chagas; Infection; Congenital; Neonates Presenter: Carolina Mendoza Mayor

ID 477

ASSOCIATION OF INTERLEUKIN-1 AND INTERLEUKIN-6 GENES POLYMORPHISMS WITH CONGENITAL CYTOMEGALOVIRUS N. Rahimova Newborn’s Pathology Department, Scientific-Research Institute of Pediatrics, Baku, Azerbaijan Brief Introduction: Cytomegalovirus is the largest member of the herpes virus family. To evaluate whether genetic variability in the Interleukin-1 (IL-1) and Interleukin-6 (IL-6) genes is associated with congenital cytomegalovirus, six common polymorphisms in the IL-1 (-31, -511 and -889) and IL-6 (-174, -572 and -597) promoters in 50 congenital CMV patients and 76 healthy neonates were studied. Materials & Methods: Genomic DNA was extracted acturer’s protocol. The IL1 (-889) C/T, IL1 (-511) C/T and IL1 (-31) single nucleotide polymorphisms were genotyped by PCR assay. Post PCR, the amplified products were subjected to restriction enzyme (RE) digestion using NlaIII, MbI1 and FokI for IL-6 (–174) G/C, IL-6 (–572) G/C and IL-6 (–597) G/A SNPs. All genotype frequencies except IL-1 (-511) and IL-6 (-174) in both patient and control groups and IL-6 (-597) in the patient population were in Hardy-Weinberg equilibrium. Clinical Cases or Summary Results: The frequencies of the IL1 variants (-889) C/T as well as the polymorphisms within the IL1 gene [(-31)C/T] did not differ significantly between the patient group and the control population. Only the distribution of the IL1 gene polymorphism at position -511 differed significantly between patients and controls. The CC genotype was more frequent among patients (58%) than among

157

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DOI: 10.3109/14767058.2014.924236

the control population (26.3%).The frequency allele C was also significantly higher in the patient group.Although, the analysis of IL-6 (-572) allelic and genotypic frequencies revealed that the G allele and GG genotype were the most common allele observed in both patient and healthy control groups.The results of this study also showed that the genotype and allele frequencies of the IL-6 (-597) polymorphism in congenital CMV patients were not significantly different from those in the healthy controls.Studying four polymorphic sites in the IL-6 gene in two different cell lines (HeLa and ECV304), they observed that the polymorphisms could really influence IL-6 transcription and that this influence varied according to the studied cell type. Each cell type may express essential transcription factors differently or have underlying differences in transcriptional control that could lead to the differential expression of IL-6. So, while in some cell types the G allele/GG genotype promote the proinflammatory phenotype, in others the C allele/CC genotype are responsible for it. Single nucleotide polymorphism analysis showed no significant differences in the allelic and genotypic frequencies of -31C/T, -889C/T and-597G/ A between the congenital CMV patients and the healthy controls. Genotype frequencies between patients and the comparison group, however, differed significantly for the IL-1(-511), IL-6(-174) and IL-6(572) genomic regions. To the best of our knowledge, no study has been conducted on the polymorphisms of these genes and congenital CMV in other countries; therefore, we were not able to compare our results with other investigations. Further research in this field on other populations will be necessary. Conclusions: In conclusion, our results suggest that three common polymorphisms in the regulatory region of IL-1 and IL-6 are associated with congenital CMV. To the best of our knowledge, no study to date has been conducted on the polymorphisms of these genes and congenital CMV in other countries. Therefore, we were not able to compare our results with other investigations. Moreover, since the dual biological effects of these cytokines and the functional significance of their promoter polymorphisms in determining gene expression still need to be clarified, further investigations are required to explore the relationship of the polymorphisms of IL-1 and IL-6 promoter and the clinical outcome of congenital CMV. Keywords: Cytomegalovirus infection, Single nucleotide, polymorphism, Interleukin-1, Interleukin-6, Marker-assisted Presenter: Nailya Rahimova

examination in the second trimester, mild discordant growth was noted in one of the twins. At 16 weeks, the mother presented a febrile exanthema compatible with measles infection (IgM positive and IgG negative); the other serological determinations were negative and included CMV IgM and IgG antibodies. A caesarean section at 33 + 2 weeks of gestation was performed due to preterm labor and transverse position of the second twin. The first twin was a male, birth weight 2245 gr (percentile 50–75), head circumference 31.5 cm (percentile 10). The second twin was a female, birth weight 1800 gr (percentile 50), head circumference 28 cm (percentile 10). On the initial physical examination, the first born was found to be a normal infant; however the second born had central hypotonia. Additional tests were performed to find out the cause of the different weight between the two babies and the neurological findings of the second twin. Periventricular calcifications and ventriculomegaly were demonstrated by cranial CT scan and transfontanellar ultrasound. The head MRI showed polymicrogyria and ventriculomegaly. Otologic and ophthalmological examinations were performed with normal results. Urine culture and polymerase chain reaction (PCR) were positive for CMV, suggesting congenital infection. The studies in the other twin were negative for CMV. She received treatment with intravenous ganciclovir during 7 days and oral valganciclovir during 6 months, achieving negativization of urine cultures and serum PCR in the first month of treatment. Clinical follow-up has been made in the subsequent months. Polymicrogyria and ventriculomegaly persisted in subsequent MRI. Neurological exam shows adequate cognitive function, mild left hemipalsy with acceptable motor development at 24 months of age. Conclusions: The exact mechanism that mediates the congenital infection and severity of the disease in twin pregnancies is still unknown. We postulate that besides maternal factors, placental type and viral load there are other factors involved in the CMV transmission, therefore further studies are needed to elucidate the pathway that mediates congenital infections in twins. Negative initial screening for CMV during pregnancy should not rule out a late infection. The early diagnosis with novel molecular techniques as PCR allows a prompt treatment and therefore a better outcome. Our case shows that congenital infection involving dizygotic twins can result in totally different outcomes. Keywords: Cytomegalovirus, congenital infection, twins Presenter: P. Catalina Morales Betancourt

ID 377

DISCORDANT CYTOMEGALOVIRUS CONGENITAL INFECTION IN DICHORIONICDIAMNIOTIC TWINS

ID 139

P. Morales, A. Vidal, L. Brea, R. Perez, A. Alarabe, & L. Sa´nchez de Leo´n

VAGINAL GLUCOSE AND LACTATE DEHYDROGENASE LEVELS IN THE DIAGNOSIS OF CHORIONAMNIONITIS IN WOMEN WITH PPROM

Neonatology Department. University Hospital of Mo´stoles. Mo´stoles. Madrid. Spain

T. Myntti, L. Rahkonen, M. Tikkanen, V. Stefanovic, & J. Paavonen

Brief Introduction: The cytomegalovirus (CMV) infection is the most common cause of congenital infection. The factors related to the severity of CMV infection are unknown, although maternal and fetal immune statuses are considered to be determinants in the infection. When CMV affects a twin gestation, both of the twins usually have clinical or laboratory evidence of infection. The data in the literature of congenital CMV infection in twins are limited. We describe a unique case of congenital CMV infection in a dizygotic twin gestation, in which only one member of the twins was congenitally infected with CMV. Materials & Methods: case report. Clinical Cases or Summary Results: A 25 year old woman had a dichorionic-diamniotic twin pregnancy. During the ultrasound

Department of Obstetrics and Gynaecology, Helsinki University Central Hospital, Helsinki, Finland Brief Introduction: Preterm birth is often caused by infection or inflammation. Diagnosis of early intra-amniotic infection (IAI) is a challenge. High concentration of lactate dehydrogenase (LD) and low concentration of glucose in amniotic fluid are used to diagnose IAI by amniocentesis. We evaluated vaginal sampling of amniotic fluid to diagnose IAI. Materials & Methods: Vaginal sample of amniotic fluid was obtained from 38 patients with PPROM between 22–37 weeks of gestation. Glucose and LD concentrations were measured. Histopathologic specimens of placenta were routinely examined. Glucose

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concentration of 50,5 mmol/L and LD concentration of 1000 U/l were used as cut-offs. Delivery took place within 72 hours. Clinical Cases or Summary Results: 26 patients had histological diagnosis of chorionamnionitis. LD was increased in 15 (58%), and glucose was decreased in 16 (62%). Both values were abnormal in 12 cases (46%). LD concentration was significantly higher in those with chorionamnionitis than in those without (median 2908 vs 906), p = 0.023. Glucose concentrations did not differ (mean 0,6 vs 0,52), p = 0.676. Maternal highest CRP was 30 (range 0–96) among those with chorionamnionitis vs 12 (range 0–35) among those without, p = 0.256. Only three patients with proven chorionamnionitis (11.5%) had uterine tenderness on examination, p = 0.538. Conclusions: LD concentration in vaginal amniotic fluid sample can be used for the detection of IAI and chorionamnionitis in patients with PPROM.

Brief Introduction: Recent advances in neonatology have improved the survival of preterm infants with some inevitable risks.One of these risks is healthcare associated infections (HAI) in neonatal intensive care units (NICU).HAI’s increase neonatal mortality, morbidity, and health care cost. It is a serious problem in the developing countires.The characteristics of HAI’s vary considerably in the developed and developing countries, in different regions, over time and between hospitals. The availability of timely and accurate epidemiological information on healthcare associated pathogens is essential for infection control and the appropriate selection of empiric antibiotics.In this study, we aimed to analyze the characteristics of healthcare-associated infections in a tertiary referring center in Turkey. Materials & Methods: All newborns admitted to the NICU of Marmara University between 01/01/2011–10/31/2013 were included in this study.The diagnosis of HAI has been made according to the standards of Center for Disease of Control and Prevention. Samples of blood, urine and cerebrospinal fluid were collected from all of the patients with HAI.Total number of inpatients, number of days in the hospital for each patient, number of days on ventilator and number of catheter days were recorded. HAI rates were calculated using overall HAI infection rate, HAI incidence density, device-specific infection rates and device-days infection rates.The frequency and causes of HAI’s, antibiotic sensitivities and resistance patterns among the NICU patients have been reported. Clinical Cases or Summary Results: The total number of inpatients during the period between 01/01/2011–10/31/2013 was 1030. 29% of them have developed HAI. Patients were observed during 12463 hospital days. Of those days, 2901 days were catheter days and 2284 were ventilation treatment days. Overall rate and density of HAI were calculated 29.03% and 23.99%, respectively. 36.4% of HAI’s were bloodstream infections (with HAI rate of 10.58%). Pneumonia, was the second most frequent infection (22%). The most frequently isolated organisms were coagulase-negative staphylococci (CoNS) (25.64%), klebsiella pneumonia (19.66%), escherichia coli (6.84%), influenza virus (5.98%), and acinetobacter baumannii (4.2%). In our unite, overall meticiline resistance was 87%, ESBL rate was 79%, and VRE rate was 40%. Conclusions: This study determined that HAI presents a serious problem in NICU. The most frequent agents in our unit were coagulase-negative staphylococci followed by klebsiella. ESBL rate (79%) in our NICU is much higher than the rates observed in the developed countries. The availability of timely and accurate epidemiological information on healthcare associated pathogens is essential for infection control and the appropriate selection of empiric antibiotics. Antibiotic stewardship program is crucial to control the multiresistant species in NICU’s.

Keywords: chorionamnionitis LL glucose IAI

Keywords: Neonatal Intensive Care, Healthcare-associated infection

Presenter: Tarja Myntti

Presenter: Asli Memisoglu

ID 169

ID 381

CHARACTERISTICS OF HEALTHCARE ASSOCIATED INFECTIONS IN NEONATAL INTENSIVE CARE UNIT

AN 8-MONTH HISTORY OF MENINGITIS IN AN EXTREMELY LOW BIRTH WEIGHT INFANT? – CHRONIC INFECTION WITH UREAPLASMA PARVUM –

A. Memisoglu1, A. Yaman1, Y. Pekru2, A. Soysal3, H. S. Bilgen1, V. Korten4, & E. Ozek1

K. Glaser, M. Wohlleben, & C.P. Speer

1

Department of Pediatrics , Division of Neonatology, Marmara University, Istanbul / Turkey, 2Department of Pediatric Infectious Disease, Marmara University, Istanbul / Turkey, 3Hospital Infection Control Committe, Marmara University, Istanbul / Turkey, and 4Department of Infectious Diseases, Marmara University, Istanbul / Turkey

Children’s Hospital, University of Wuerzburg Brief Introduction: Introduction: Ureaplasma spp. has been implicated in the pathogenesis of both preterm labour and neonatal morbidity including pneumonia and sepsis and the development of chronic

159

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DOI: 10.3109/14767058.2014.924236

lung disease of prematurity. Data on Ureaplasma meningitis are limited and partly controversially discussed. Materials & Methods: Clinical Cases or Summary Results: Case report: We report the case of an 8-month-old infant with progressive internal hydrocephalus of unknown origin and developmental delay being referred to our hospital for ventrico-peritoneal shunt implantation. The female ELBW infant had been born at 26 + 3 weeks of gestation. Postnatal period had been reported uneventful with the exception of respiratory distress syndrome, but internal hydrocephalus had become manifest at 4 weeks of postnatal age. Intraventricular hemorrhage had been excluded by cranial ultrasound and magnetic resonance imaging. Cerebrospinal fluid (CSF) analysis had repetitively revealed pronounced inflammation reflected by CSF protein levels 600–1000 mg/ dL, CSF pleocytosis (50–86 leukocytes/mm3, 60% lymphocytes) and undetectable CSF glucose levels. Although suggesting bacterial meningitis, microbial diagnostics had not been indicative, and empiric antibiotics had not affected CSF findings. At admission, analysis still documented CSF protein levels4500 mg/dL, CSF pleocytosis with 125 leukocytes/mm3 and CSF glucose levels 52 mg/dL. Due to a prenatal history of cervical cerclage, microbial diagnostics on Ureaplasma and Mycoplasma spp. was initiated. Ureaplasma parvum was detected in CSF by culture and PCR, no other pathogens were isolated. On intravenous treatment with chloramphenicol, CSF profile continuously normalized, and cultures became negative. Treatment was continued for three weeks, and the infant was discharged after uncomplicated ventrico-peritoneal shunt placement. During a 6-month observation period she has shown remarkable recovery. Conclusions: Conclusion: In preterm infants, internal hydrocephalus of unknown origin and sustained CSF inflammation are highly suggestive of Ureaplasma meningitis. Our case highlights that infection may escape detection if not explicitly considered, since microbial diagnosis requires complex media and PCR. Keywords: Ureaplasma meningitis, internal hydrocephalus of unknown origin, CNS inflammation, preterm Presenter: Kirsten Glaser

ID 412

EFFECTIVENESS OF A MULTIMODAL INTERVENTION ON THE PREVENTION OF NOSOCOMIAL BLOODSTREAM

INFECTIONS IN A TERTIARY NEONATAL INTENSIVE CARE UNIT M. Gonza´lez, C. Go´mez, M.A. Rodrı´guez, MG. Espinosa, JE. Sa´nchez, T. Sa´nchez, E. Salguero Neonatology Dept., University Hospital of Ma´laga, Ma´laga. Spain Brief Introduction: Neonatal sepsis is a worldwide problem, further the health burden form infection in these fragile patients remains unacceptably high despite continuing efforts. Advances in diagnosis and management of sepsis can considerably decrease the sepsis complications and improve it’s outcomes.This study was conducted to investigate decreases in the incidence of nosocomial bloodstream infections (BSIs) in a tertiary Neonatal Intensive Care Unit (NICU) through an evidence-based multimodal intervention. Materials & Methods: This was a prospective interventional study of neonates with culture proven sepsis from our NICU database during 2011, 2012 and 2013, while at the same time implementing an information and prevention process specifically aimed at infection control, which included a data collection report providing information related to the number and characteristics of such infections, implementation of a procedure to central venous catheter hub care using 1% chlorhexidine and a guidelines for insertion and maintenance of the catheter, and education of medical staff and nurses about measures to decrease risk of contamination, particularly handwashing, proper disposal of infectious waste, and strict asepsis during procedures like the use of sterile gloves and sterile dressing pack, as well as prudent use of antibiotics. Bloodstream infections rates in the pre-intervention period (2011 and 2012) and postintervention period (2013) were compared. Clinical Cases or Summary Results: 367 cases of nosocomial sepsis and their characteristics were analyzed. A decrease in the specific incidence rate and density of BSIs was observed between the 2 periods. During 2011 and 2012, the overall incidence of BSI was 71.9% and 61.3% per 100 admissions respectively, with a incidence density of 40.7 and 29.2 per 1000 patient-days while in the second period there was a decrease in all these rates with an incidence of 21.3% and a density of 18.9 per thousand days of admission. Related to the etiology, the incidence of gram-negative septicemia also decreased, with no cases of candida species. Dominant etiologic factor of all infections were gram positive cocci specifically Staphylococcus epidermidis (Table 1)

2011 PATHOGEN GRAM + S.EPIDERMIDIS OTHER NCS ENTEROCOCCUS S.AUREUS OTHER GRAM KLEBSIELLA E.COLI ENTEROBACTER PSEUDOMONA CITROBACTER SERRATIA OTHERS CANDIDA

TOTAL (n = 156) 116 62 45 9 0 0 35 14 6 4 5 1 5 0 4

% 74.8 40 29.7 5 8 22.6 9 3.9 2.6 3.2 0.6 3.2 2.6

2012

51500 (n = 115) 91 44 39 8 0 0 21 6 1 4 4 1 5 0 3

% 79.1 38.2 33.9 6.9 18.3 5.2 0.9 3.5 3.5 0.9 4.3 2.6

TOTAL (n = 130) 99 61 22 16 1 0 29 14 3 5 0 0 4 3 2

% 76.2 46.9 16.9 12.3 0.8 22.3 10.7 2.3 3.8 3.1 2.3 1.5

2013 51500 (n = 65) 54 29 16 9 1 0 11 6 0 1 0 0 2 2 0

%

TOTAL (n = 96)

%

51500 (n = 73)

%

83 44.6 24.6 13.8 1.5

83 69 3 3 8

86.4 71.9 3.1 3.1 8.3

64 52 2 2 3

87.7 74 2.7 2.7 8.2

16.9 9.2

13 4 2 2 1

13.5 4.2 2.1 2.1 1

9 3 1 1 1

12.3 4.1 1.4 1.4 1.4

3 1

3.1 1 0

2 1

2.7 1.4 0

1.5 3.1 3.1 0

160 Conclusions: As it has been previously described in literature the present data suggests that prevention practices for central venous catheter insertion and maintenance are essential to reduce these infections, in addition to training and continuing education of the NICU staff. Keywords: Presenter: M. Gonza´lez

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

concentrations measured on admission to the NICU can be used as markers of severity of respiratory disease, constituting suitable parameters for the assessment of inflammatory and immune response in the RSV LRTI in the neonatal period. These observations may contribute to the design of new therapeutic strategies directed at immunomodulation of RSV disease. Keywords: respiratory syncytial virus, human metapneumovirus and pro and anti-inflammatory mediators

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Presenter: R. Vieira

ID 218

ID 939

COMPARISON OF CONCENTRATIONS OF PRO AND ANTI-INFLAMMATORY MEDIATORS IN THE NASOPHARYNGEAL SECRETION AND IN THE SERUM OF NEWBORNS WITH RESPIRATORY SYNCYTIAL VIRUS AND HUMAN METAPNEUMOVIRUS LOWER RESPIRATORY TRACT INFECTION

MOTHER-TO-CHILD HIV TRANSMISSION – EXPERIENCE OF A LEVEL II HOSPITAL

R. Vieira, E. Diniz, ME. Ceccon, W. Carvalho Neonatology Division, Pediatric Dept., Hospital das Clı´nicas da Faculdade de Medicina da Universidade de Sa˜o Paulo, Sa˜o Paulo, Brazil Brief Introduction: The lack of reports that compare the concentrations of pro and anti-inflammatory mediators in the respiratory epithelium and in the peripheral blood of newborns (NB) with respiratory syncytial virus (RSV) and human metapneumovirus (hMPV) lower respiratory tract infection (LRTI) justified this research. To compare the concentrations of pro and anti-inflammatory mediators (RANTES, soluble ICAM-1, TNF-a, IL-6 and IL-10) in the nasopharyngeal secretion (NPS) and in the serum of NB at the NICU admission, according to RSV and hMPV and to assess whether there is difference in RSV and hMPV respiratory disease severity. Materials & Methods: One hundred and fifty three NB with RSV and 45 patients with hMPV LRTI admitted to NICU were included in the crosssectional study, from July 2004 to July 2012. Specific tests for respiratory viruses were performed on NPS aspirates by real time RTPCR. The concentrations of pro and anti-inflammatory mediators were measured through the sandwich ELISA technique in the NPS and in the serum of all NB at the NICU admission. The following clinical markers were used in order to evaluate the severity of the respiratory disease: a clinical scoring system, adapted from De Boeck et al., duration of oxygen therapy and mechanical ventilation and length of NICU stay. Clinical Cases or Summary Results: RSV was found in 46% (153/333) of the samples collected from NB with LRTI and hMPV was identified in 13.5% (45/333) of them. The infants infected by RSV were the ones that evolved with moderate to severe LRTI (95%, p50.001) and a greater need of oxygen therapy (95%, p50.001) and mechanical ventilation (80%, p50.001). There were statistically significant differences between RSV and hMPV relative to the medians NPS RANTES (p = 0.047), serum IL-6 (p50.001), NPS and serum IL-10 (p50.001) and serum TNF-a (p50.001) concentrations, which were more elevated in NB infected by RSV. Conclusions: RSV and hMPV co-circulated during the period of the study, with RSV being predominant in these NB. The NB infected by RSV were the ones that evolved with a greater morbidity and greater NPS RANTES, serum IL-6, NPS and serum IL-10 and serum TNF-a concentrations at the NICU admission. This research indicates that the NPS RANTES, serum IL-6, NPS and serum IL-10 and serum TNF-a

I. Periquito1, R. Luz2, & L. Caturra1 1

Pediatric Department, Centro Hospitalar de Setu´bal, Portugal, and 2Obstetrics and Gynecology, Centro Hospitalar de Setu´bal, Portugal Brief Introduction: From 2001 to 2012, 22730 cases of HIV infection have been reported in Portugal, of these 156 (0.69%) were due to mother-to-child transmission (MCT), which still remains the primary cause for HIV infection in children. Most of these infections occur during pregnancy, labor or breastfeeding. Recommendations for the prevention of MCT rely on adequate surveillance, delivery method, mother and child antiretroviral treatment and avoidance of breastfeeding, with the goal of reducing MCT to less than 2%. Our objective is to report the experience of the surveillance and neonatal outcomes of children born of HIV positive mothers in a Level II Hospital in Portugal. Materials & Methods: Retrospective observational study including all neonates born from HIV-positive pregnant women in the maternity of Centro Hospitalar de Setu´bal, during a 12 year period (between January 2001 and December 2012). Epidemiologic data, clinical and laboratory findings, disease status and neonatal outcomes were assessed. Clinical Cases or Summary Results: During this 12 year period, 23836 neonates were born in the Hospital Maternity, of these 118 (0.49%) were born from HIV positive mothers (97% HIV 1 and 3% HIV 2). The origin of maternal infection was predominantly heterosexual (n = 70, 59%), followed by intravenous drug use (n = 37, 31%). Forty five (38%) mothers were co-infected, mostly by hepatitis C (n = 43, 34.4%) and syphilis (n = 8, 6.8%), and 17.8% had more than one coinfection. The majority of women had a prenatal diagnosis (n = 70, 59.3%), 42 (35.6%) cases were diagnosed during the gestation, and 6 (5.1%) were diagnosed during labor (the last case in 2009). The information of HIV viral load was available in 91 women and it was undetectable in 49%. The CD4+ count was 4500/mL in 49 (41.5%) women. Most deliveries were eutocic (n = 58, 49.2%), of these 5 cases were in women with an HIV viral load 41000/mL. The mean gestational age was 38.3 weeks with a standard deviation (SD) of 1.8, and the mean birth weight was 2887g (SD of 530). There was only one (0.85%) MCT case. Conclusions: A significant amount of HIV positive women are still diagnosed during pregnancy, which highlights the importance of screening all pregnant women for HIV and other sexually transmitted diseases. Our results are similar to what is recommended for HIV positive pregnant women and MTC transmission reflecting the effectiveness of a good multidisciplinary surveillance and treatment. Keywords: Mother-to-child HIV transmission Presenter: I Periquito

161

DOI: 10.3109/14767058.2014.924236

deteriorate, the respiratory failure worsened and on the second day of life (DOL) he died. Maternal IgG and IgM for CMV, performed after birth, were positive, with an IgG avidity 40.60%. Post-mortem examination identified CMV inclusions in central nervous system, lung, thymus (Hassall’s corpuscles), kidney (both in the glomeruli and in tubular epithelium), adrenal gland, pancreas, liver (both hepatocytes and bile ducts), spleen and testis (seminiferous tubules). Conclusions: In the presented case, the clinical picture compatible with disseminated intravascular coagulation, the extreme severity of the course rapidly evolving towards death and the post-mortem

ID 498

FULMINANT FATAL CONGENITAL CYTOMEGALOVIRUS INFECTION WITH MULTISYSTEM INVOLVEMENT IN A PRETERM NEWBORN A. Monzani1, M.R. Gallina2, G. Genoni1, S. Rizzollo1, S. De Franco2, G. Cosi2, I. Stasi2, C. Colli2, & F. Ferrero2

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

1

Division of Pediatrics, Department of Health Sciences, Universita` del Piemonte Orientale ‘‘Amedeo Avogadro’’, Novara, Italy, and 2Division of Neonatal Intensive Care Unit, Azienda Ospedaliero-Universitaria "Maggiore della Carita`", Novara, Italy Brief Introduction: Only few cases of multisystem fatal cytomegalovirus (CMV) infection have been reported, with death generally occurring in the first weeks of life. Severe manifestations of congenital CMV infection seem to occur more frequently in preterm than in full-term newborns. Materials & Methods: Clinical Cases or Summary Results: The patient was a male neonate born at 30 + 6 weeks gestation. The detection of cardiomegaly and pericardial effusion during a routine foetal ultrasonography led to emergent caesarean section. The Apgar scores were 5, 7 at 1 and 5 minutes, respectively. The physical examination showed a nondysmorphic newborn with severe general conditions, pale skin with many purpuric lesions on his face and ecchymosis on his trunk and limbs, hepatosplenomegaly, hyporeactivity and reduced muscle tone. Weight, length, and head circumference were small for gestational age. The baby developed a progressive respiratory distress syndrome in the first hour of life, leading to endo-tracheal intubation and conventional mechanical ventilation. Due to the detection of massive purpura and altered coagulation pattern, a plasma infusion was started. Platelets and red cells transfusions were also performed to treat thrombocytopenia and anemia. Echocardiography showed a moderate pericardial effusion, mild ventricular hypertrophy and reduced ventricular function. Cranial ultrasound examination revealed moderate ventricular dilatation, lenticulostriate vasculopathy and cerebellar hypoplasia. The newborn’s clinical condition worsened few hours after birth, with the progression of respiratory distress syndrome and the worsening of peripheral perfusion, requiring surfactant administration and inotropic support. Thrombocytopenia persisted, and was refractory to platelets transfusions. The newborn’s condition continued to

No of patients

Gestational age

Birth weight

Exitus at day of life

1

30 weeks

1080 g

2

central nervous system, lung, thymus, kidney, adrenal gland, pancreas, liver, spleen, testis

2

36 weeks

2411 g

1

Sampath (6), 2005

1

22 weeks 29 weeks

1360 g 695 g

15 25

Embil (7), 1969

2

Nagy (8), 2004 Boppana (9), 1992

1 13

35 weeks full-term 25 weeks n.s.

1560 g 2610 g 1150 g n.s.

Perlman (10), 1992

9

33 ± 3 weeks (mean ± SD)*

2350 ± 150 g (mean ± SD)*

30 38 9 during the first 6 weeks 18 ± 21 (mean ± SD)

central nervous system, parathyroid, pancreas, cervical lymph nodes, lung, liver, kidney central nervous system, liver lung, gastric mucosa, small bowel mucosa, thyroid, kidney, adrenal gland, myocardium lung, liver, kidney, ascitic fluid, heart blood, thymus lung, liver, kidney, thymus n.s. multiorgan involvement (sites not specified) in 7 out of 9 in which autopsy was performed central nervous system, kidney, lung, liver

Author (Ref), Year Elliott (5), 1962

Sites of CMV inclusions

162

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

histological findings suggest a multisystem involvement due to congenital CMV infection. To our knowledge, it is the case in which exitus occurred most rapidly, regardless therapeutic efforts. It was probably due to the massive CMV dissemination, even in never previously described sites, such as testis.

Presenter: G. Genoni

ID 952

IDENTIFICATION OF ETIOLOGICAL AGENTS OF NEONATAL SEPSIS BY PYROSEQUENCING HAS LESS SENSITIVITY THAN QPCR J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Presenter: Norma Galindo-Sevilla

ID 141

Keywords:

N. Galindo-Sevilla1, A. Ramı´rez-Ramı´rez2, R. Santilla´n, D. Morales3, E. Segura-Cervantes4, & J. Mancilla-Ramı´rez5 1

Department of Infectious Diseases, Instituto Nacional de Perinatologia Isidro Espinosa de los Reyes, Mexico, City, Mexico, 2Department of Infectious Diseases, Instituto Nacional de Perinatologia Isidro Espinosa de los Reyes, Mexico, City, Mexico, 3Department of Infectious Diseases, Instituto Nacional de Perinatologia Isidro Espinosa de los Reyes, Mexico, City, Mexico, 4Department of Infectious Diseases, Instituto Nacional de Perinatologia Isidro Espinosa de los Reyes, Mexico, City, Mexico, and 5Instituto Nacional de Perinatologia Isidro Espinosa de los Reyes, Mexico, City, Mexico Brief Introduction: Sepsis detection in neonates has difficulties such as the small size of the blood sample that can be drawn from the patients. Molecular methods are nowadays better options to search for sepsis because need less amount of sample to make the detection. Several molecular tools for diagnosis are now in search for the use in sepsis detection. Materials & Methods: With the aim to improve sepsis diagnosis in neonatal patients, a transverse study was achieved at the Instituto Nacional de Perinatologı´a, Mexico, City in child with risk factors for sepsis whose parents gave the informed consent. A blood sample of 0.5 mL was drown from them, divided in two samples, one for DNA extraction and bacterial detection through bacterial 16 S amplification by real time PCR. In the other sample of 0.2 mL clotting formation was allowed and serum was removed to do PCR, qPCR and Pyrosequencing. Clinical Cases or Summary Results: 98 samples were studied. 39 from new born with sepsis, and 59 as control.

Sensitivity Specificity PPV NPV LR+ LR-

Keywords:

qPCR

PCR

Pyrosequencing

Hemoculture

0.744 0.661 0.592 0.796 2.194 0.388

0.205 0.966 0.800 0.648 6.051 0.823

0.077 0.966 0.600 0.613 2.269 0.955

0.436 0.898 0.739 0.707 4.286 0.628

Pyrosequencing was positive for five samples, whereas S. epidermidis was identified in 4 samples and K. Pneumoniea in on case. Hemoculture was positive in 17/39 cases. More frequent microorganism were: Staphylococcus epidermidis, Klebsiella pnenumoniae, Escherichia coli and Staphylococcus coagulasa negatives and less frequent S. aureus y Enterobacter sp. qPCR identifyed 29/39 sepsis cases, but was less specific. Conclusions: Pyrosequencing had low sensitivity to detect etiologic microorganisms form newborn with sepsis. qPCR had good sensitivity with low specificity.

INTESTINAL NEMATODE INFECTION AND PROTEIN DEFICIENCY IN PREGNANT MICE IMPACT FETAL MASS AND CROWN-RUMP LENGTH THROUGH DISTINCT MECHANISMS L. Starr1, K. Koski2, M. Scott1 1

Institute of Parasitology, McGill University, Montreal, Canada, and 2School of Dietetics and Human Nutrition, McGill University, Montreal, Canada Brief Introduction: Protein deficiency (PD) and gastrointestinal (GI) nematode infection commonly co-occur during pregnancy and have negative outcomes for offspring. PD has been shown to induce stress hormones and reduce growth factor concentrations and fetal body mass. Human helminth infections have been linked to stunting in children and worm burdens of the murine nematode Heligmosomoides bakeri have been shown to be negatively correlated with fetal crown-rump length. Furthermore, combined PD and GI nematode infection during late pregnancy and lactation have been shown to reduce linear growth of mouse pups with concomitant increases in stress hormones and inflammatory cytokines. Our objective was to explore the combined effects of PD and nematode infection during pregnancy on markers linked to fetal growth. Materials & Methods: Using a 2  2 factorial design and beginning on d 5 of pregnancy, CD-1 mice were fed protein sufficient (PS; 24% protein) or protein deficient (PD; 6% protein) isoenergetic diets and were infected every 5 days with either 0 (sham) or 100 H. bakeri larvae (n = 7–8 dams per group). Fetuses were removed by C-section on d 18 of pregnancy and maternal serum, fetal serum and amniotic fluid were collected. Stress hormone, growth factor and cytokine concentrations in the three compartments (maternal serum, fetal serum and amniotic fluid) were determined using Luminex. Data were analyzed using a 2-way ANOVA with litter size as a covariate. Clinical Cases or Summary Results: PD and infection exerted only independent effects. Whereas fetal mass was reduced by maternal PD, fetal crown-rump length was reduced by maternal infection. Our biomarker data indicated that these insults affected fetal growth through distinct mechanisms. Maternal responses to PD were reflected in the fetus and amniotic fluid, presumably signaling low protein availability to the fetus. These responses included elevated corticosterone, reduced IGF-1 and reduced leptin in all compartments. Inflammatory, anti-inflammatory and regulatory cytokines were not altered in the dam but were elevated in the fetus. In contrast, maternal infection did not induce stress hormones but resulted in lower concentrations of prolactin and leptin and higher FGF-2 and eotaxin in maternal serum. In fetal serum, maternal infection reduced prolactin, a growth factor associated with bone growth, which could account for the impaired linear growth in response to maternal infection. However, no other fetal or amniotic fluid biomarkers were affected. Conclusions: Together, these results support the hypothesis that fetal mass and crown-rump length are regulated by different mechanisms. We suggest that weight gain and linear growth should be treated separately when considering fetal growth restriction. In addition, our data suggest that a mechanism exists to shield the fetus from maternal responses to GI nematode infection but not PD and this could be manipulated to protect the fetus from other insults.

163

DOI: 10.3109/14767058.2014.924236

Keywords: Protein deficiency, Heligmosomoides bakeri, nematode, pregnancy, fetal growth, stress hormones, growth factors, cytokines, mouse model Presenter: Lisa M. Starr

ID 573

PERINATAL TUBERCULOSIS IN PREMATURE NEWBORN: A CASE REPORT F. Maschio1, N. Mainini2 F. Lucca1, S. Spadini1, E. Donadel1, S. Visentin2, & L. Da Dalt1 J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

1

Paediatrics, Ca Foncello Hospital, Treviso, Italy, and Neonatal intensive care, Ca Foncello Hospital, Treviso, Italy.

2

Brief Introduction: TB infection is estimated to involve 1/3 of the world population. The incidence in pregnancy in industrialized countries is about 4.2/100000; perinatal TB is associated with high mortality rate, and can be misdiagnosed because of non-specific signs and symptoms. Materials & Methods: We report a case of perinatal tuberculosis in premature infant, born from mother emigrated few years before from India, a high TB incidence country. Clinical Cases or Summary Results: CASE REPORT The baby (BW 2030g- Apgar score 9/10)was born by caesarean section at gestational week 32 due to premature labour and breech presentation in a pregnant woman with recent onset of fever. The post-natal period was regular until day16 when he presented lethargy, poor feeding and respiratory distress. Meanwhile the mother was transferred to Infectious Disease Department for persistent unexplained fever. Chest x-Ray of the infant showed bilateral infiltrates. Gastric aspirate examination by combined smear for Acid Fast Bacilli and Polymerases Chain Reaction was positive and culture confirmed Mycobacterium Tuberculosis Complex. Blood, CSF, and urine culture were negative. The baby was treated in NICU. Complete recovery was achieved through a 9-month course combination of oral Isoniazid-Rifampicin– Pyrazinamide and intravenous aminoglycosides for the first month. A close followup is being performed. Conclusions: Neonatal TB can mimic bacterial sepsis and it’s fatal in half the cases especially if untreated. TB suspicion is important in performing proper investigation and initiation of treatment. Sensitization of neonatologists and obstetricians in order to perform attentive anamnesis and screening for TB in women with high risk provenance, are necessary to prevent perinatal TB. Keywords: Tubercolosis, premature infant, sepsis Presenter: N. Mainini

ID 712

USE OF CYTOMEGALOVIRUS HYPERIMMUNOGLOBULIN FOR PREVENTION OF CONGENITAL CYTOMEGALOVIRUS DISEASE M. De la Calle1, F. Magdaleno1, M. Sancha1, S. Lopez1, R. Rodriguez1, F. Baquero2, & JL Bartha

1

Obstetrics Dept., University Hospital of La Paz, Madrid, Spain, and 2Paediatric Dept., University Hospital of La Paz, Madrid, Spain. Brief Introduction: Congenital cytomegalovirus (CMV) infection is the most common cause of congenital disabilities and can cause auditory, cognitive and neurological impairment in infants. Administration of CMV hyperinmmunoglobulin (CMV-HIG) therapy to pregnant women who have a primary CMV infection has been reported to project their unborn children against symtomatic CMV infections. We studied fetal and neonatal outcomes with or without treatment with CMV-HIG after intrauterine CMV infection. Materials & Methods: We studied 35 cases of maternal CMV infection. Diagnosis was established by the presence of maternal IgG and IgM positive. The mean gestational age at diagnosis was 18.43 ± 5.2 weeks. The avidity was low in 29 cases (82%) and intermediate in 6 cases (18%). Amniocentesis was performed in 94.2% of cases (all but two), with polymerase chain reaction positive amniotic fluid in 20 of them (60.6%). They decided abortion in 5 cases (25%). CMV-HIG (200 UI per kilogram of maternal weight in a single intravenous administration) was applied in 10 cases (50%). In the remaining 5 (25%) cases therapy was not applied. Serial ultrasound scan were performed in all cases. MRI was performed in 10 cases (50%).Outcome of infants was evaluated at the age of 1 year. Clinical Cases or Summary Results: The percentage of fetuses with ultrasound abnormalities was similar in both groups (33.3%; 5/15 vs 30%; 3/10). During the pregnancy, two cases of fetal hyperecogenic bowel disappeared after CMV-HIG and one case of bilateral mild ventriculomegaly did not progressed after the therapy. There was no difference in gestational age at birth or birth weight of infants in both groups. At the 1 -year evaluation, the cases of total deafness and neurological poor prognosis were 100% (5/5) in the untreated group and 10% (1/10) in the treatment group CMV-HIG (p = 0.04). In the treated group, there was a case of total deafness without neurological disabilities a 1-year evaluation. There was one early neonatal death in the untreated group. Conclusions: The percentage of fetal infection by PCR amniotic fluid defined in cases of maternal infection is 60%. CMV-HIG was well tolerated. This preliminary study suggests an important role of CMVHIG therapy for improving neonatal prognosis of fetuses from women who had primary infection during the gestation. Also this study supports the efficacy of CMV-HIG therapy decreasing the severity of ultrasonographic fetal lesions. More patients are needed to draw firm conclusions. Keywords: congenital CMV disease, primary CMV in pregnancy, CMV hyperinmmunoglobulin therapy, prenatal diagnosis, children disabilities Presenter: M. De la Calle

ID 698

HIGH PREVALENCE OF CONGENITAL CYTOMEGALOVIRUS INFECTION IN INFANTS WITH ATOPIC DERMATITIS: A CASECONTROL STUDY I. Capretti, A. Mareri, M. Maresca, S. Lasorella, C. Fabiano, G. Nigro Pediatric Unit, San Salvatore Hospital, University of L’Aquila, Italy Brief Introduction: Atopic dermatitis (AD) is an itchy, chronically relapsing skin disease, with a typical morphology and skin localization, which occurs in 15–20% of the infants. The crucial immunologic

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point is an imbalance between Th1-mediated and Th2-mediated immune response, while the causes are generally unknown. Since cytomegalovirus (CMV) induces an immune modulation determining cross-protection to other infections and favoring a Th2-mediated allergic response, we searched for a possible association between DA and congenital CMV infection. Materials & Methods: The study included three groups of patients. (1) CMV+/therapy- group: 145 infants with congenital CMV infection, as shown by CMV DNA detection in the urine, and/or saliva and blood; (2) CMV+/therapy+ group: 51 infants with congenital CMV infection, who were treated within 1 month of life with ganciclovir for 6 weeks or valganciclovir for 6 to 18 months; 3) CMV-negative group: 145 infants without congenital CMV infection. The diagnosis of AD based on the Hanifin and Rajka major diagnostic criteria. Clinical Cases or Summary Results: The infants with congenital CMV showed a highly significant risk of developing AD, as compared to prevalence of AD in the infants without infection (43.4% vs. 16.6%; p50.0001). The significant association of AD to congenital CMV was confirmed by the decrease of the rate of infants with AD in the group of infants treated with ganciclovir or valganciclovir as compared to that of untreated infants (17.6% vs. 43.4%; p = 0.001). Conclusions: The favoring role of congenital CMV infection towards the development of AD has been shown not only by the highly increased prevalence of AD in congenitally infected infants but also by the significant decrease of AD in infected but treated infants. This clearly indicates that CMV replication induces an immune stimulation switching towards a Th2-mediated allergic response, which is absent in treated infants following CMV inhibition by the antiviral drug. Keywords: Presenter: I. Capretti

ID 401

COMPARISON OF CLINICAL EFFICACY OF INTERMITTENT VERSUS CONTINUOUS VANCOMYCIN INFUSION FOR THE TREATMENT OF LATE-ONSET SEPSIS IN PRETERM INFANTS 1

1

1

2

B. Demirel , E. Yalın Imamog˘lu , T. Gursoy , U. Demirel , S. Topcuoglu1, G. Karatekin1, & F. Ovalı1 1

Neonatology Dept., Zeynep Kamil Maternity and Children’s _ Hospital, Istanbul, Turkey, and 2Paediatric Dept., Yakacık State Hospital, Istanbul, Turkey. Brief Introduction: Vancomycin is the first drug of choice in the treatment of late-onset neonatal sepsis, that is a major cause of mortality and morbidity in preterm infants, Vancomycin is infused either intermittently or continuously, however, there is no consensus on the optimal dosing regimen. Aim: To compare intermittent infusion of vancomycin (IIV) to continuos infusion (CIV) with respect to microbiological outcomes, clinical response and adverse events. Materials & Methods: We conducted the study in Neonatal Intensive Care Unit of Zeynep Kamil Maternity and Children’s Hospital (Istanbul) between July 2013 and December 2013. The files of preterm infants (534 weeks), whose attending physicians had decided to give vancomycin for either a suspected or a well-established late-onset sepsis, were investigated retrospectively. Clinical (e.g. serum vancomycin levels, microbiological culture results, To¨llner scores) and demographic features were recorded. Infants received either intermittent (group I, n = 41) or continuous (group II, n = 36) vancomycin infusion. Vancomycin dose and dosing interval was determined

refering the book Neofax. SPSS 17.0 was used for statistical analysis. Ethical approval was obtained from local ethics committee. Clinical Cases or Summary Results: Clinical improvement rates, To¨llner scores and microbiological outcomes did not differ significantly between groups. At the 48th hour of vancomycin infusion, 52.8% of infants achieved therapeutic levels of vancomycin concentration in group II compared to 34.1% of patients in group I (p = 0.002). Thirtynine percent of infants in group I had supratherapeutic levels of vancomycin concentrations at the 48th hour compared to 5.6% in group II (p = 0.002). Dose adjustment rate was higher in group I but this difference lacked statistical sig nificance. (65.9% vs. 52.8%, p = 0.3). Supratherapeutic levels, dose miscalculations and errors of dosing interval were more common in infants with a gestational age 529 weeks for whom intermittent infusion with 18 hours interval was recommended in the book Neofax. Conclusions: In preterm infants, CIV and IIV have similar clinical efficacies. However, CIV is safer, well-tolerated and require less blood sampling compared to IIV. Keywords: vancomycin, sepsis, preterm Presenter: T. Gursoy

ID 718

COST-EFFECTIVENESS OF PALIVIZUMAB FOR RSV PREVENTION IN HIGH-RISK INFANTS FOR THE 2012/2013 EPIDEMIC SEASON IN MOSCOW V. Ignatyeva1,2, M. Avksentyeva1,2, O. Rebrova3,4, K. Gerasimova2, I. Soldatova4, G. Asmolova4,5, L. Pankratyeva5,6, E. Degtyareva7, D. Ovsyannikov8 1

Russian Academy of National Economy and Public Administration under the President of the Russian Federation, 2 Sechenov’s First Moscow State Medical University, 3National Center for Health Technology Assessment, and 4Pirogov’s Russian National Research Medi Brief Introduction: Respiratory syncytial virus (RSV) is one of the leading causes of lower respiratory tract infection in early childhood. Extremely-low-birth-weight (ELBW) neonates, infants with bronchopulmonary dysplasia (BPD) and congenital heart disease (CHD) are of particular risk. Palivizumab has been shown to reduce the risk of hospitalization caused by RSV in pediatric patients at high risk of RSV disease. Aim. To review the effectiveness and cost-effectiveness of palivizumab for the prevention of RSV in infants as part of immunization programme implemented in Moscow for the 2012/ 2013 epidemic season. Materials & Methods: The trial was conducted during a single RSV season and studied a total of 189 children less than or equal to 24 months of age with BPD or infants with premature birth (less than or equal to 35 weeks gestation) who were less than or equal to 6 months of age at study entry. Costs per health outcome are presented. Clinical Cases or Summary Results: Palivizumab is effective in decreasing hospitalizations due to RSV and admission to intensive care units. The incremental cost-effectiveness ratio was estimated at 9 607 Euro per life-year gained, which is only slightly higher than GDP per capita in 2012 in the Russian Federation (9 114 Euro) and significantly lower than 3 times GDP per capita (27 000 Euro), recommended by WHO as a threshold of economic feasibility of technologies for health preservation. Prevented economic loss due to one infant life preservation is estimated at 620 000 Euro. Conclusions: Use of palivizumab for the prevention of RSV infection should be considered clinically and economically effective.

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DOI: 10.3109/14767058.2014.924236

Keywords: Palivizumab, RSV infection, prematurity Presenter: I. Soldatova

ID 456

NEONATAL SEPSIS IN NICU RELATEDTO BREAST MILK L. Baglatzi1, M.E. Bompou, E. Stratiki1, E. Prifti2, S. Sevastiadou1, E. Papathoma1, & G. Baroutis1

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1 NICU, Alexandra Hospital, Athens, Greece, and 2Department of Microbiology, Alexandra Hospital, Athens, Greece

Brief Introduction: Breast milk is the optional nutrition of premature and sick newborns. Staphylococcus is the commonest bacteria isolated from breast milk, causing also neonatal septicemias that remains a severe problem in NICUs. Materials & Methods: We examined retrospectively 15 premature babies with sepsis from January 2013 till June 2013 in our NICU. Positive blood cultures and its antibiograms were compared with breast milk cultures obtained before the onset of neonatal sepsis.The aim of this study is the correlation between the results of positive blood cultures and breast milk cultures in premature breastfeeding babies with sepsis. Clinical Cases or Summary Results: Gram (+) bacteria were the most common isolated in blood cultures (93.4%). Bacterial species were: Staphylococcus epidermidis 40%, Staphylococcus hominis 13.3%, Staphylococcus haemoliticus 6.6%, Bacillus spp 6.6%. Gram (-) septicemia (E.coli) was found in a (1) newborn baby (6.6%). All breast milk cultures were positive for Staphylococcus epidermidis. 40% of neonates had Staphylococcus epidermidis in both milk and blood cultures, but the antibiograms revealed different sensitivity. Conclusions: Staphylococcus is the commonest bacteria causing sepsis in NICUs and also isolated from breast milk. According to antibiograms, strains of Staphylococcus isolated from breast milk are different from those isolated in blood cultures in this study.

Clinical Cases or Summary Results: two premature babies of 29 and 30 weeks of gestation developed this uncommon complication on five and third day of life respectively. Both of them initiated as unique and slight skin lesion. The first boy developed a small blister with epidermal peeling on the tip of the nose; an isolated similar lesion was observed in the trunk of the second infant. Both cases underwent rapidly expansion with blistering and epidermal peeling over next hours. Both of them developed erythroderma and Nikolski’s sign was positive. Laboratory data revealed a decrease in the total amount of neutrophils, normal platelet count and an increase in phase acute reactants. Culture of a blister and swabs of the nose and nasopharynx were positive for Staphylococcal aureus. Blood culture from the first neonate was sterile however In the second case Staphylococcal aureus was isolated again. A combination therapy of intravenous cloxacillin and local administration of muporicin and potassium permanganate 1/10.000 were completed. Fentanyl infusion was administered as supportive treatment to avoid pain. Sterile cloths, isolation in an incubator with high air humidity and minimal handling were promptly initiated to prevent the spread of the infection. Subsequent clinical course was uneventful in both infants Staff members, all neonates hospitalized and family members were screened for carriage by nasal swabs. Five from the 87 healthworkers were carriers (colonization rate of 5.7%). Molecular typing was carried out. Phages of S. aureus isolated in healthcare workers samples did not coincide with isolated in affected newborns. Ten Staphylococcus aureus isolates, five tested positive for exfoliative toxin A. None were methicillin resistant. Infection control measures were taken. All carriers received topical treatment until nasal swabs screening were negative. Conclusions: Results of staff screening underlines the need for vigilance and compliance in hand disinfection strategies. Effective case containment measures are highly important. In case of an outbreak epidemiological investigation should be initiated as soon as posible. Keywords: preterm infant; Staphylococcal scalded skin syndrome; nosocomial spread. Presenter: MG. Espinosa

Keywords: breast milk, neonatal sepsis Presenter: Sevastiadou S.

ID 400

TWO CASES OF STAPHYLOCCOCAL SCALDED SKIN SYNDROME IN PREMATURE INFANTS: EPIDEMIOLOGICAL INVESTIGATION AND CONTROL M.G. Espinosa, M.A. Rodriguez, M. Gonza´lez, C. Go´mez, M. Chaffanel, S. On˜a, & E. Salguero 1

Neonatology Dept., University Hospital of Ma´laga, Ma´laga, Spain, and 2Preventive Dept., University Hospital of Ma´laga, Ma´laga, Spain

Brief Introduction: Staphylococcal scalded skin syndrome (SSS) is a life threatening condition, rarely reported in prematures. Early diagnosis is important to avoid the risk of nosocomial spread. We describe two cases of preterm neonates who developed SSS and an approach to discuss the measures undertaken to bring the possible spread under control. Materials & Methods: Retrospective reviewed of the two cases of SSS diagnosed in our Neonatal Intensive Care Unit.

ID 972

SERUM C REACTIVE PROTEIN VALUES IN HEALTHY NEWBORNS DEPENDING ON DELIVERY TYPE C.V. Bellieni, L. P. Liuzzo, S. Giomi, M. Tei, G. Stazzoni, S. Bertrando, S. Cornacchione, F. Braconi, L. Zurli, & G. Buonocore Department of Pediatrics, Obstetrics and Reproductive Medicine, University of Siena, Siena, Italy Brief Introduction: C reactive protein (CRP) is an acutephase protein synthesized by the liver in reponse to inflammation. We want to assess the trend of CRP values in healthy full term newborns and how these values change depending on delivery type. Materials & Methods: 1012 neonates born in Siena since January 2010 to December 2011 were included. They were divided into three groups: vaginal delivery (VD), elective caesarian section (eCS) and emergency caesarian section (ECS). CRP serum values were assessed at 12–24–48–72 and 96 h in each group. Clinical Cases or Summary Results: CRP values were expressed as mg/dl (median and IC 97%). We observed: 0,05 (0,01–0,46), 0,17 (0,03–1,54), 0,32 (0,04–1,77), 0,42 (0,05–1,31) and 0,40 (0,04–1,13) at 12, 24, 48, 72 and 96 h respectively. Medin values in babies born after caesarian section, and higher in ECS than in eCS. Conclusions: This study described normal CRP serum levels in a wide population of healthy term neonates and the influence of the type of delivery on CRP rise as the expression of ‘‘perinatal stress’’.

166 Keywords: CRP, markers, perinatal stress Presenter: Carlo Valerio Bellieni

ID 848

EFFICACY OF PROLONGED THERAPY WITH VALGANCICLOVIR IN INFANTS WITH CONGENITAL CYTOMEGALOVIRUS INFECTION AND LOSS OF HEARING. J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

S. Lasorella, G. Iapadre, M. Maresca, A. Maresca, & G. Nigro Pediatric Unit, San Salvatore Hospital, University of L’Aquila, Italy. Brief Introduction: Background: Hearing reduction or loss is the most common sequela of congenital cytomegalovirus (CMV) infection, occurring in 10%-15% of all infected children. The virus remain latently in the epithelial and neural cells and viral replication induces a cytopathic/lytic process with cell dysfunction/destruction. Valganciclovir (VGC) has been suggested to inhibit virus replication stopping hearing deterioration. Objective: Aim of our study was to compared the efficacy of a prolonged treatment with VGC (6 months) compared to a 6 week treatment. Materials & Methods: Methods: Our open randomized study included 32 infants affected by unilateral or bilateral hearing loss associated with congenital CMV infection to. All of them presented encephalopathy (in particular leukoencephalophaty, hydrocephalus or calcifications). Group 1 included 16 infants receiving VGC for 6 months and group 2 included 16 infants treated for 6 weeks. 5 of group 1 (31.2%) and 6 of group 2 (37.5%) had also ocular abnormalities. Hearing evaluation was performed by BSER after birth and every 3–6 months. Clinical Cases or Summary Results: Results: 9 infants of group 1 (56%) showed improved or not worsened hearing threshold (4 had normal hearing), contrary to two of group 2 (12.5%), (p = 0.0092). Conclusions: Conclusion: Prolonged treatment with VGC has been significantly associated with improved hearing outcome in infants with congenital CMV. Persistent inhibition of CMV replication, and prevention of viral reactivation following short-term therapy, is the most likely pathogenetic explanation. Keywords: Presenter: S. Lasorella

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Brief Introduction: In cases of confirmed cytomegalovirus (CMV) infection, certain biological parameters in fetal blood have correlated with neonatal outcome. Materials & Methods: Seven-year cross sectional study (2006 – 2013). In fetuses with abnormal US/MRI findings and confirmed CMV infection in amniotic fluid, a fetal blood sampling was performed for evaluation of platelet count, Beta-2 microglobulin, presence or absence of IgM antibody, and DNAaemia. Blood parameter results were compared in severely affected fetuses (severe cerebral abnormalities or fetal hydrops) and mild-moderately affected ones (isolated extra-cerebral or mild cerebral abnormalities) diagnosed at sonographic examination, and confirmed at postmortem or postnatal evaluation Clinical Cases or Summary Results: Fetal blood sampling was obtained in 16 cases: 11 severely and 5 moderately damaged fetuses. The cordocentesis was performed at a mean gestational age of 26.3 weeks (range 20.4–35.5) with no difference in gestational age between both groups. Among the severely damaged fetuses there were 10 TOP and one fetal demise. Among the mild-moderately damaged ones there were 3 TOP and 2 alive newborns, one with unilateral hearing loss and one asymptomatic at 3 months of age. A low platelet count (5100 000) was significantly observed more frequently in severely damaged fetuses (80%) than in mild-moderately affected ones (20%) (p = 0.025). In contrast, high levels of Beta-2 microglobulin (411.5 mg/l), and DNAaemia (410 000 copies/ml) were found at similar proportions in both severely and mild-moderately damaged groups (44% and 50% p = 0.85, and 70% and 100% p = 0.07, respectively). In addition, in both groups IgM positivity was low (33% in severely affected and 25% in mild-moderately p = 0.76). Conclusions: In agreement with previous reports, thrombocytopenia was significantly associated with a worse outcome in CMV infected fetuses. In contrast, no differences were observed in the other biological parameters with respect to the degree of fetal damage Keywords: Congenital cytomegalovirus, fetal blood parameters Presenter: Anna Gonce´

ID 827

THE VALUE OF PRENATAL BRAIN MRI AND ULTRASOUND IN THE MANAGEMENT OF CONGENITAL CYTOMEGALOVIRUS INFECTION M. De la Calle1, F. Magdaleno1, R. Rodriguez1, A. Ferna´ndez2, F. Omen˜aca3, & JL Bartha1 1

ID 568

BLOOD PHENOTYPE IN SEVERELY AND MILD-MODERATELY AFFECTED FETUSES INFECTED WITH CYTOMEGALOVIRUS A. Gonce´1, F. Figueras1, A. Nadal2, M.A. Marcos3, M.D. Salvia4, M. Lopez1, B. Puerto1, & E. Grataco´s1 1

Maternal and Fetal Medicine Dept, Institut Clı´nic de Ginecologia, Obstetrı´cia i Neonatologia. Hospital Clı´nicIDIBAPS, Universitat de Barcelona, Barcelona, Spain, and 2 Pathology Dept. Biomedical Diagnosis Centre. Hospital Clı´nic-IDIBAPS, Universitat de Barc

Obstetrics Dept., University La Paz Hospital of Madrid, Madrid, Spain, 2Radiology Dept., University La Paz Hospital of Madrid, Madrid, Spain, and 3Pediatrci Dept., University La Paz Hospital of Madrid, Madrid, Spain Brief Introduction: Congenital cytomegalovirus (CMV) infection is the most common cause of congenital viral infection in the Western world and can lead to severe neurological sequelae. Once fetal infection is confirmed, presence of central nervous system (CNS) damage needs to be assessed to tailor appropriate management and counseling. The goal of this study was to evaluate the potential to predict the risk of symptomatic neonatal infection of fetal brain magnetic resonance imaging (MRI) in comparison to prenatal dedicated neuro-ultrasound (US). Our secondary goal was to compare the prenatal findings and the neurological symptoms at 18 months of age. Materials & Methods: We reviewed the abnormal findings in prenatal brain MRI and US in 10 cases of congenital CMV infection (confirmed positive polymerase chain reaction in amniotic fluid) referred to our institution in the years 2011 to 2013. Both imaging techniques were performed between gestational weeks 24 and 32; mean gestational

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DOI: 10.3109/14767058.2014.924236

age at time of MRI was 29 weeks. Fetal brain MRI examinations were performed in a General Electric, 1,5 Tesla, Signa MRI suite. US examinations were performed with a General Electric Voluson system equiped with 3D software. The prenatal findings were compared with findings from postnatal transfontanellar US examination and clinical follow-up at 18 months. Clinical Cases or Summary Results: US showed CNS abnormalities in 3 (30%) cases: cerebellar hypoplasia (1), ventriculomegaly (2), microcephaly (2), periventricular calcifications (2), enlarged cisterna magna (1) and ventricular sinechiae (1); 6 cases had a normal US. Five (50%) fetuses exhibited CNS abnormalities on fetal MRI: cerebellar hypoplasia (4), ventriculomegaly (3), altered neuronal migration (3), enlarged cisterna magna (3), microcephaly (2), periventricular calcifications (2), cortical anomalies (3), white matter anomalies (4), temporal lobe lesions (2) and ventricular sinechiae (1), and 5 had no anomalies. In 2 (20%) of the cases with normal US, MRI found (unilateral ventriculomegaly and cerebellar hypoplasia, proven at postnatal MRI). US and MRI were normal in 4 (40%) of cases. Of the 5 fetuses with findings in prenatal MR, 1 died in the neonatal period, 1 had severe neurological symptoms, 2 had mild neurological symptoms and 1 was asymptomatic at 18 months follow-up. Conclusions: 1. Prenatal MRI provides additional information to that obtained with US, such as cerebellar hypoplasia, neuronal migration delay and gyration anomalies. Both techniques should be offered in congenital CMV cases to guide clinicians and assist in counseling patients. Although the small size of our series does not allow us to draw statistically significant conclusions, our study suggests that fetal brain MRI increases the positive predictive value of US in the diagnosis of symptomatic neonatal infection. Keywords: brain lesion, CMV congenital infection, MRI, Ultrasound, Prenatal prognosis Presenter: Maria De la Calle

ID 574

MATERNAL FETAL HEPATITIS C TRANSMISSION, FROM MOTHERS WITH AND WITHOUT HIV. V. Maiques, V.J. Diago, V. Alberola, A. Perales-Puchalt, A. Garcı´a Tejedor, & A. Perales Obstetrical and Gynecological Departament La Fe Hospital, Valencia, Spain Brief Introduction: To analyze the difference in maternal-fetal prognosis and vertical transmission risk between Hepatitis C virus (HCV) pregnancies with and without concomitant Human immunodeficiency virus (HIV) infection. Materials & Methods: Retrospective study of 693 HCV pregnant women at our hospital between 1993–2011. These patients were divided in 2 groups: Group A (HCV-HIV, 194 pregnancies with 190 newborns) and Group B (HCV, 499 pregnancies with 506 newborns). We analyze the outcome of the pregnancy and the vertical HCV transmission. Vertical HCV transmission was excluded when the antibodies were twice times negatives. Clinical Cases or Summary Results: We have had 19 infants of vertical HCV transmission, 8 (5.6%) G-A and 11 (1.6%) G-B (OR 1.9 IC95%: 0.75–4.81). In all cases mothers have been RNA positive. Premature delivery was more prevalent in the HCV-HIV group (p50.001), 59 (30.4%) G-A and 72 (14.4%) G-B. Intrauterine growth restriction was no different among the two groups, 28 (14.4%) G-A and 59 (11.8%) G-B. RNA was done in 485 patients (70%), positive in 307 (63.3%). We studied 514 mothers with their infants (179 no analyzed). Genotypes became positive in 158 cases (22.2%), the most frequent was 1-b, 75 cases (54.7%)

Conclusions: The Vertical HCV transmission although is more prevalent in the HCV-HIV group, do not reach statistical significance. This group is more associated to prematurity. Keywords: Hepatitis C, HIV, pregnancy, vertical transmission Presenter: A. Perales

ID 902

PLACENTA INFLAMMATION OF INFECTIOUS VERSUS UNKNOWN ETIOLOGY IN AUTOPSY MATERIAL A. Konstantinidou1, M. Zafirelli1, N. Spanakis2, N. Papantoniou3, N. Tsakris2, A. Pontikaki4, & S. Sifakis4 1

1st Department of Pathology, University of Athens Medical School, Athens, Greece, 2Department of Microbiology, University of Athens Medical School, Athens, Greece, and 3 1st Department of Obstetrics and Gynecology, University of Athens, Alexandra Hospital, Brief Introduction: This study aimed a) to investigate the infectious versus unknown etiology of chronic villitis in placentas obtained at fetal autopsy and b) to assess the role of immunohistochemical inflammatory markers in the discrimination between chronic villitis of infectious versus unknown etiology. Materials & Methods: We studied 72 placentas histologically diagnosed with chronic villitis. All placentas were obtained at autopsy in cases of intrauterine fetal death (IUFD), abortion/premature labour or termination of pregnancy. The investigation for a possible infectious etiology was based on PCR testing for viruses in placental and fetal tissues, histological or immunohistochemical findings of specific infections, and clinical information on maternal serology or bacterial cultures. The immunohistochemical typing of the villous inflammatory infiltrates included 5 markers, CD45, CD3, CD4, CD8, and UCHL1. Clinical Cases or Summary Results: We found evidence of infectious chronic villitis in 77.8% of the examined placentas versus 22.2% of cases termed as villitis of unknown etiology (VUE). Viruses were the most common infectious agents (73.2%) versus bacterial/parasitic agents (26.8%). Adenoviral genome was the more common among viruses, followed by cytomegalovirus, enteroviruses, parvovirus and herpes simplex virus. Immunohistochemical typing of the inflammatory infiltrates failed to reveal any statistically significant differences between infectious villitis and VUE. Conclusions: Detailed search for infectious agents in autopsy placentas provides evidence that chronic villitis can be more often attributed to histologically nonspecific viral infection. Keywords: placental inflammation; infection; pregnancy; chronic villitis; autopsy Presenter: A. Pontikaki

ID 566

NEONATAL HERPES SIMPLEX VIRUS TYPE-1 INFECTION: A CASE REPORT R.L. Vidal1, F. Rodrigues1, J. Pires2, R. Zenha1, & A. Bicho1 1

Paediatric Department, Centro Hospitalar Baixo Vouga, Aveiro, Portugal, and 2Ophthalmology Department, Centro Hospitalar Baixo Vouga, Aveiro, Portugal

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Brief Introduction: Introduction: Although genital herpes infections in adults are very common, Herpes simplex virus (HSV) infection in the neonate is a rare manifestation, occurring in 1 out of every 3200 to 10 000 live births. The majority (85%) of neonatal HSV infection is acquired perinatally and it can be transmitted in uterus, intra partum or post partum. Most neonates with HSV disease are born from mothers without any known history of HSV infection. The disease in the newborn can be presented as a disseminated, isolated meningoencephalitis or as an infection limited to the skin, eyes, and/or mucous membranes. Materials & Methods: Clinical Cases or Summary Results: Case report: We present a 17-dayold boy newborn that was born from healthy mother. Delivery was uneventful at 40 weeks gestational age. The membranes ruptured spontaneously 12 hours before vaginal delivery, and Apgar score was 10 at first and fifth minutes. Birth weight was 3250 grams. The mother denied any history of sexually transmitted infections, particularly genital lesions or known exposure to herpes. On the 8th day of life, periorbital skin vesicles with erythematous base, conjunctival erythema and stromal keratitis were observed on the right eye of the newborn. The laboratory studies revealed a positive HSV-1 by DNA-PCR on the ocular exudates sample of the newborn and on the genital sample of the mother. Maternal lgG antibody for HSV was positive. Lumbar puncture of the newborn was negative for HSV and he completed 14 days of intravenous acyclovir. There was a cutaneous recurrence on the 57th day of life, with a good clinical evolution under oral acyclovir. Conclusions: Conclusions: Through this clinical report the authors would like to show the importance of considering HSV infection in the newborn with conjunctivitis, even when genital lesions are not present in the mother. Women with recurrent HSV infection present a very low risk of vertical transmission to the newborn, less than 2%, and there are rare case reports without any genital lesion during pregnancy or labour, so doctors must maintain a high level of clinical suspicion. According to the global increase of HSV-1 genital infection, one should expect that neonatal HSV disease is also likely to expand, which should alert gynaecologists to the prevention of vertical transmission and the pediatricians to an early diagnosis of neonatal HSV infections, allowing timely institution of appropriate therapy and preventing long-term sequelae and death.

fatigue and malaise. We evaluated the possible role of congenital CMV infection as enhancing factor of persistence of EBV-DNA detection and mononucleosis-like manifestations after EBV primary infection. Materials & Methods: Children with primary EBV infection, proved by the detection of serum VCA-IgM, were enrolled in our case-control study. Case group included children with congenital CMV infection while control group seronegative CMV children. All were examined for antibodies and specific DNA detection in saliva, blood and/or urine on admission and every 3 months. The presence of symptoms and signs as fever, pharyngo-tonsillitis, cervical lymphadenopathy, hepatomegaly and splenomegaly was evaluated every 3 months. Children were followed up for 1 to 10 years (mean: 4.2). Clinical Cases or Summary Results: Thirteen patients (11 males) aged 1.2 to 7.1 years (mean: 3.2) with congenital CMV infection and 13 seronegative CMV children, matched for gender and age, were included. EBV-DNA persistence in patients with congenital CMV infection was significantly longer than in children without CMV infection [mean: 51.3 vs 8.4 months (p50.0001)]. The analysis of clinical features showed that the number of febrile pharyngotonsillitis episodes per year was higher in children with congenital CMV infection compared with control group [mean: 8.3 vs 2.3 (p50.0001)]. Persistence of cervical lymphadenopathy and splenomegaly was longer in congenitally CMV children than in those without [mean: 17.4 vs 2.9 months (p50.001), 21.2 vs 3.1 months (p50.01) and 18.4 vs 3.6 months (p50.05) respectively]. Conclusions: Our study showed that congenital CMV infection in children with IM lead to persistence of EBV-DNA detection and mononucleosis-like manifestations significantly longer than in children without CMV infection. Therefore it is presumable that prenatal CMV infection decreases the capacity of their immune system to clear up EBV DNA after a primary infection, and the persistence of replicating EBV in the saliva enhances the implementation of a chronically evolving mononucleosis.

Keywords: Herpes simplex virus, conjunctivitis, acyclovir

IMPACT OF LOCAL VERSUS NICE GUIDELINES ON MANAGEMENT OF NEONATAL EARLY ONSET SEPSIS (EOS)

Presenter: Rita Lacerda Vidal

ID 855

ROLE OF CONGENITAL CYTOMEGALOVIRUS INFECTION IN THE PERSISTENCE OF INFECTIOUS MONONUCLEOSIS IN CHILDREN I. Mattei, R. Tambucci, G. Panzarino, M. Maresca, I. Capretti, G. Bottone, & G. Nigro Pediatric Unit, University of L’Aquila, L’Aquila, Italy Brief Introduction: Cytomegalovirus (CMV) infection is the most common cause of congenital infection in the developed world, occurring in 1% of all liveborns. Symptomatic disease occurs in 10% of all congenitally infected infants, resulting in a spectrum of clinical manifestations that include microcephaly, chorioretinitis, hepatosplenomegaly and sensorineural hearing loss. Infectious mononucleosis (IM) is a clinical syndrome caused by primary infection with Epstein– Barr virus (EBV). It is characterized by fever, sore throat, cervical lymphadenopathy, hepatosplenomegaly, and somatic complaints of

Keywords: Presenter: I. Mattei

ID 567

S. Chuang, J. L. Vieira, N. Gambhir, R. Dias, & E. Ogundipe Department of Neonatology, Chelsea and Westminster NHS Foundation Trust, London, United Kingdom. Brief Introduction: EOS is a major cause of neonatal morbidity and mortality that can progress rapidly with minimal clinical and laboratory signs. Early identification of at risk newborns and prompt antibiotic treatment is therefore crucial. In 2012, the National Institute for Health and Care Excellence (NICE) guidelines for EOS were published. Our local guideline includes fetal distress (abnormal cardiotocography) and meconium stained liquor as risk factors. We compare the outcomes with NICE and local guidelines. Materials & Methods: Retrospective analysis of infants 35 weeks gestation admitted to a level-3 NICU over 4 months with suspected sepsis classified to have presumed (PS) or confirmed sepsis (CS). Clinical Cases or Summary Results: Of 81 cases identified, 44(54.3%) had PS and 37(45.7%) CS. 23(28.4%) babies in poor condition at birth received antibiotics on clinical grounds. Of remaining 58 cases, 36(62.1%) had PS and 22(37.9%) CS. Using local guideline in PS, 9(25%) required antibiotics, 13(36.1%) observed and 14(38.9%) were low risk. With NICE guideline, 5(13.9%) received antibiotics, 8(22.2%) observed and 23(63.9%) low risk. Using

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local guideline in CS, 10(45.5%) required antibiotics, 4(18.2%) observed and 8(36.3%) low risk but with NICE guideline, 3(13.6%) received antibiotics, 8(36.3%) observed and 11(50%) low risk did not require antibiotics or observations. Meconium was more common in CS (12/37; 32.4%) versus PS (6/44; 13.6%). Abnormal cardiotocography was noted in 40.5% CS cases versus 25% in PS. Conclusions: Local guidelines with fetal distress as a risk factor may enable earlier identification of EOS risk. Larger study may enable better evaluation of our antibiotic therapy and resource implications. Keywords: Neonatal early onset sepsis, fetal distress Presenter: Shu-Ling Chuang

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ID 884

ENHANCING ROLE OF COINFECTION BY EPSTEIN-BARR VIRUS IN MATERNAL-FETAL TRANSMISSION AND PRENATAL PATHOGENICITY OF CYTOMEGALOVIRUS INFECTION 1

1

1

ALT levels was shown in the patients with fetal CMV transmission, compared to women without transmission. Immunological examinations were performed in 76 (80.8%) pregnant women, 39 (51.3%) transmitted CMV showing a statistically significant increased percentage of CD8+(p = 0.04) and HLA-DR+ cells (p = 0.04), decreased percentage (p = 0.02) and number (p = 0.03) of CD19+ cells, compared to the same immunological markers in 37 non-transmitters. There was also statistically significant increase of HLA-DR+ percentage (p = 0.03) and number (p = 0.05) in transmitter mothers with symptomatic fetuses/infants, compared to transmitters with asymptomatic fetuses/ infants. Conclusions: Our study showed a statistically significant role in the maternal-fetal CMV transmission for the following factors: EBV coinfection, flu-like syndrome, hypertransaminasemia, increased percentage of CD8+ and HLA-DR+ cells, decreased percentage and number of CD19+ cells. Fetal CMV pathogenicity appeared to be associated with EBV coinfection, increased percentage and number of HLA-DR+ cells. Keywords: Presenter: C. Di Paolantonio

ID 810 1

C. Di Paolantonio , A. Mareri , R. Tambucci , S. Lasorella , G. Carta2, & G. Nigro1 1

Pediatric Unit, Maternal-Infant Department, San Salvatore Hospital, University of L’Aquila, L’Aquila, Italy, and 2Obstetric and Gynecology Unit, Maternal-Infant Department, San Salvatore Hospital, University of L’Aquila, L’Aquila, Italy. Brief Introduction: Primary maternal cytomegalovirus (CMV) infection is the most frequent perinatal infection causing congenital disabilities. However, the mechanisms of maternal-fetal transmission and fetal pathogenicity is unknown.Objective: To investigate on the possible factors favoring the maternal-fetal CMV transmission, including (1) coinfection by Epstein-Barr virus (EBV) and herpes simplex virus (HSV); (2) clinical manifestations and laboratory abnormalities; (3) immunoglobulin and immune cell values. Materials & Methods: Patients: 94 pregnant with primary CMV infection were prospectively investigated for CMV seroconversion and DNA in AF, clinical manifestations, laboratory abnormalities, IgM and IgG anti-EBV/HSV, immunity, ultrasonography and MRI. The infants were followed up  for 2 years. Methods: viral CMV DNA was detected in amniotic fluid, serum, urine and salive by RT-PCR. Virusspecific IgG and IgM, and CMV-IgG avidity were detected by immuneenzymatic systems. Immunological investigations included T/B cell subpopulations, cytotoxic NK activity, and non-specific immunoglobulins. Clinical Cases or Summary Results: IgM anti-EBV/HSV were detected in 40 patients (42.5%), 28 (70%) of whom transmitted CMV infection to fetus, contrary to 20 of 54 women without coinfection (37%) (p = 0.005). Of 40 coinfected women, 24 (60%) had EBV infection: 17 (70.8%) transmitted CMV contrary to 20 of 54 (37%) women without EBV infection (p = 0.007). Coinfection by EBV increased the CMV transmission risk by 5.9 times (odds ratio 5.9). Of 17 women with EBV coinfection and CMV transmission, 9 (53%) had symptomatic fetuses and/or infants, contrary to 3 of 20 (15%) women without EBV coinfection and CMV transmission (p = 0.05). Of 94 women, 53 (56.3%) had clinical manifestations and/or laboratory abnormalities. Of 40 coinfected women, 21 (52.5%) had symptoms during pregnancy: 16 (76.1%) transmitted CMV contrary 8 (42%) to 19 (47.5%) women without symptoms (p = 0.028). No statistically significant correlation was found between maternal symptomatology and CMV pathogenicity (p = 0.38). No statistically significant results were obtained in the evaluation of coinfection with HSV infection and CMV transmission or pathogenicity. A statistically significant (p = 0.01) increase of AST and

CYTOMEGALOVIRUS INFECTION AND PREGNANCY A. Migliucci, A. Giudicepietro, C. Vassallo, M. Sansone, G. Saccone, G. Mallia Milanes, L.L. Mazzarelli, F. Quaglia, V. Donadono, R. Saviano, P. Martinelli Department of Neurosciences, Reproductive and Dentistry Sciences - High Risk Pregnancy Unit, Naples, Italy Brief Introduction: Human Cytomegalovirus (CMV) infection during pregnancy is the most frequent viral cause of intrauterine infection in developed countries. The infection occurs in approximately 1% of all live births (from about 0.3% to 2.4%). Mother-child transmission is mainly the result of primary maternal infection, which carries a risk of transmission varying from 14.2% to 52.4% in function of gestational age. The risk of fetal injury is greatest when maternal infection develops in the first trimester or in the early second trimester. The most frequent manifestations of congenital infection are related with defects in brain development, included cerebral palsy, mental retardation, sensorineural hearing loss, seizures, and visual impairments. Materials & Methods: From 2000 to 2013 years 473 women presented to our center with suspicious infection of CMV in pregnancy, related with positive IgM at laboratory test. Based on clinical, sierological and anamnestic dates, we divided the patients in 5 groups of diagnosis: early sieroconversion (520th gestational age), late sieroconversion (420th gestational age), reinfection, periconceptional infection (from 3 weeks before to 3 weeks after last menstruation), excluded infection in pregnancy (previous and/or susceptibility to infection). In cases of infection in pregnancy, we performed periodic fetal ultrasound controls and prenatal diagnosis by amniocentesis at 20–22 weeks. Neonatal outcome was collected by telephonic interviews one year after birth. Clinical Cases or Summary Results: Out of 473 patients, 230 (48.6%) were infection before pregnancy, 9 (1.9%) were susceptible to infection, 114 (24.1%) were early sieroconversion, 26 (5%) late sieroconversion, 62 (13.1%) periconceptional infection and 28 (5.9%) cases were reinfection. The mean age was 28 years. 105 (22%) patients were lost at follow-up. In 4 (0.84%) cases wasn’t possible to confirm or exclude infection in pregnancy for insufficient data. Our study included sieroconversion, reinfection and periconceptional infection cases; of these 230 women, 98 (42.6%) accepted prenatal diagnosis. In 82 (83.6%) cases the amniocentesis didn’t show infection and resulted negative; in any case 13 (15.8%) babies were infected at the birth. All babies born to mother with positive amniocentesis were

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170 infected. The sensibility and specificity were 76% and 100% respectively. Out of 344 (72.7%) live births, 282 (82%) were healthy babies, 17 (4.9%) were lost at follow-up and 45 (13%) were born infected by the CMV. In particular, 13 (29%) children presented manifestations of congenital infection, as deafness in 4 (30.7%) cases. Conclusions: Cytomegalovirus remains the main infectious cause of congenital abnormalities in the central nervous system caused by intrauterine infection in humans. Although the diagnosis of congenital CMV infection is still complex, major goals have been achieved in recent years including: more reliable IgM tests for screening pregnant women whose pre-pregnancy serological status for CMV is unknown; tests to determine the avidity index of anti-CMV IgG, allowing the diagnosis of a primary CMV infection; and innovative virological tests to detect the virus in amniotic fluid. As most maternal infections are asymptomatic, the only way to disclose primary infection is to implement specific serological testing as early as possible in pregnancy (before 12–16 weeks of gestation). Given the high risk of mother–fetus transmission and fetal damage, prenatal diagnosis is recommended to women with primary CMV infection contracted in the first half of pregnancy and in case of fetal abnormalities suggestive of infection. Congenital CMV infection is the leading non-genetic cause of deafness in children. It was recently demonstrated that a correct interpretation of serological and virological tests followed by appropriate counselling by an expert physician is an effective tool in reducing the number of unnecessary pregnancy terminations by over 70%. Keywords: Presenter: A. Migliucci

ID 270

ANALYSIS OF CONGENITAL INFECTIONS INFLUENCE ON THE INFANTS’ MORBIDITY AND MORTALITY S.T. Kizatova1, M.M. Tusupbekova2, G.T. Myrzabekova3, S.B. Dyusenova4, & S.S. Zhakupova5 1,2,4,5

Karaganda State Medical University, Karaganda, Kazakhstan, and 3Almaty State University of Doctors Improvement, Almaty, Kazakhstan Brief Introduction: The infectious pathology of neonatal period is an actual problem of modern medicine. One of the perinatal losses reasons in structure of neonatal mortality in period 2008 to 2012 years are congenital infections. Antenatal infections in children of the first year of life are observed often than they are diagnosed. The aim of investigation: was analysis of infants’ disease and mortality from congenital infections, including children with low and extra low body mass. Materials & Methods: Materials and methods: The work was made on the base of early age neurology department of Regional Clinical Children’s Hospital (RCCH) from 2010 to 2012 years. From 34 patients with congenital infections 265 were born as full-term with body mass in birth more 2500 gram; 74% children were born from preterm deliveries. The clinical investigation with estimation of disease data, morphological signs, general blood analysis, coagulogramm, polymerase-chain reaction for congenital infections, computed tomography of brain, roentgenological and ultrasonic investigations of internal organs was carried out. Clinical Cases or Summary Results: Results and discussion: The analysis of infants disease and mortality from congenital infections for 2010– 2012 years who were at the treatment in early age neurology

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

department of RCCH showed increase of frequency from 24.2% to 36.5%. Cytomegalovirus infection (CMVI) in the structure of infections pathology made up 44.2%, the second place took chlamidiosis 23.6%, further the herpes simplex virus made up 20.5%, toxoplasmosis made up 5.9%, 2.9% diagnosted ureoplasmosis and listeriosis. On results of our investigation the localized forms of congenital infections were revealed in79% cases. Generalized forms of congenital infectious pathology are established in 21% from general quantity of observations. CMVI was diagnosed in pregnant women of our region in 49.3%, but the acute course was revealed from 31.3% patients. The congenital CMVI in infants in 75% cases had chronic course with formation of dysembiogenesis stigmas, congenital anomalies. In 25% cases congenital CMVI took place as acute infectious process with signs of inflammation in different organs. CMVI was clinically characterized by lesion of central nervous system in the form of micro and macrocephalia, meningoencephalitis, lesion of brain ventricles, calcificates in brain tissue that found its reflection from light cerebral changes to serious convulsive hypertension-hydrocephalic syndrome. CMVI was developed also by hepatosplenomegaly, prolonged jaundice in 32% cases, intersticial pneumonia was established in 10% observations. The state of hemostasis system was characterized by hypocoagulational orientation in 51% infants, clinically was developed by disseminated intravascular coagulation syndrome. Trombocitopenia was mainly revealed in generalized forms in 23% infants. Conclusions: In analysis of structural changes character in the brain which were received according to data of instrumental methods of investigation the intracranial bleedings with leading position of intraventricle bleedings in 57% patients with congenital infections prevailed. Subarachnoidal bleedings were rare, the frequency of their registration didn’t depend on gestational age. In the same time the multiple pseudocysts and periventricular leukomalacias often met in premature children. The angiopathy of retina vessels on eyegrounds in 70% infants and typical changes for CMVI in the form of retinitis, partial atrophy of optic nerve in 8% cases were defined. Herpes-infection mainly was developed by encephalitis, chlamidiosis in 88% was accompanied by conjunctivitis and 12% pneumonias, toxoplasmosis was developed by meningoencephalitis and congenital hydrocephalus. The lethality from sepsis made up 20.5%. Thus, the congenital infections are the reason of infants’ infectious diseases, congenital anomalies, prematurity and lethality. The congenital infections demand use of screening tests with high sensibility and specificity with aim of early diagnostics and timely therapy pathology in pregnant woman. Keywords: congenital infections, infants, newborns Presenter: S.T. Kizatova

ID 732

RELATIONSHIP BETWEEN REDUCED FECUNDITY AND MISSED ABORTION V. Lazurenko1, I. Muryzina2, O. Chernyak3, & N. Kurichova4 1,2,4

Department of Obstetrics and Gynaecology, Kharkov National Medical University, Kharkov, Ukraine, and 3Health Department of Kharkov, Kharkov, Ukraine Brief Introduction: Missed abortion (MA) should be paid a lot of followup attention by gynaecologist because this clinical entity often entails significant reduction of fecundability including both natural cycle fecundity and assisted reproductive technology cycle efficiency. Suggested causative factors are still controversial and there is no

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DOI: 10.3109/14767058.2014.924236

Keywords: missed abortion, reduced fecundity

Materials & Methods: Maternal anamnestic data were collected and general and gynaecological examination has been made. At baseline and during the follow-up serological and instrumental tests were performed as shown below. Clinical Cases or Summary Results: A 35-y-old previous healthy became gravida of a twin dichorionic, diamniotic pregnancy following assisted reproductive technology because of previous spontaneous abortions (on 28th and 18th gestation weeks). She was admitted to hospital in the 16th gestational week, after2-week history of fever, malaise, myalgia and anorexia. Primary HSV-1 infection was demonstrated by positive HSV IgM detection and subsequent seroconversion. No history of recurrent genital or oral herpes was reported and previous mother serology for HSV infection was negative. No other infections (rubella, CMV, toxoplasmosis, or syphilis) were documented during the pregnancy. On clinical examination, she was afebrile and slightly fatigued. The rest of her examination was normal with no cervical lesions and on speculum examination. HSV DNA was detected by PCR from cervix but acyclovir treatment (400 mg twice/day) was started only 12 days before vaginal delivery, which occurred at 36 weeks following rupture of membranes 20 hours before normal delivery. One twin was normal and not infected, while the other female twin weighing 2.310 g. displayed diffuse multiform rush characterized by several vesicles both clear and hemorrhagic (2 mm); moreover several scabbed lesions scattered on upper trunk and extremities were observed and hypopigmented area suggestive of resolved skin lesions was detected over the upper abdomen. Full neurological assessment was normal as well as the rest of her examination. Initial white and red blood cells counts were normal, while platelet count showed severe thrombocytopenia (90000/mmc). There were no other hematologic or electrolyte significant abnormalities. On 1st day of life the infant received intravenous acyclovir therapy (180 mg/day). HSV DNA was positive in skin lesion while it was negative in blood and CSF. Head ultrasound performed on 2nd day of life showed 9 mm cystic/hypoechoic area seen adjacent to the right lateral ventricle. The MRI revealed significant asymmetry of cerebral hemispheres with malformation on the right: cystic areas medial temporal lobe and adjacent to the right lateral ventricle, cleft medial superior right frontal region, hemorrhage or calcification right basal ganglia. Ophthalmologic examination revealed retinal scarring bilaterally (left side worse than right). At the age of 18 months oral acyiclovir is still given since interruption was immediately followed by reappearance of cutaneous vescicles. Conclusions: This case indicates that pregnant women who are seronegative to HSV should be screened monthly and treated with acyclovir when maternal symptomatology or seroconversion occur.

Presenter: V. Lazurenko

Keywords:

incontestable evidence to attribute any of them such a peculiar mechanism of early pregnancy loss. That is why our study was aimed at elucidating mechanisms of MA deplorable sequels and suggesting pathways for solution of this problem. Materials & Methods: There were 124 women under surveillance. The main group (I) comprised 64 women with definitive diagnosis of MA. The group for comparison (II) included 30 women admitted for termination of the pregnancy according to their will. Following-up these women’ reproductive function, 30 healthy women contemplating prospect of pregnancy were picked out as a control group (III) in order to ascertain the more favourable background for conception. Subsequently the main group was divided into two subgroups according to their management: Ia (31 patients) – monophasic combined oral contraceptive pills, Ib (33) – additional administrational of cryopreserved placental extract (CPE) intramuscularly 1,8 ml at 10, 12, 14, 16, 18 days of menstrual cycle. Clinical state was assessed by means of routine and hormonal methods, histological, immunological features and functional capacity of the endometrium obtained by pipelle-curette at 19–21 day of cycle were determined, IL-1b, IL-6, IL10, TNF-a, glycodelin values in the washings from the uterine cavity were assessed by immunenzyme method. Clinical Cases or Summary Results: The study elicited significant disturbances of endometrial histological structure looking like chronic inflammation, recognized distortion in the local cytokine balance and endometrial steroid receptors susceptibility in the case of experienced MA. Inherent to healthy woman of her reproductive ages Th2cytokine balance is superseded by Th1-cytokine preponderance with increased values of IL-1b, IL-6 and TNF-a in the endometrium. Although IL-10 is anti-inflammatory cytokine, its level was higher than in other groups that could explain the dormant mechanism of switching on the uterine contractility for expulsion of non-viable concept. Delayed and incomplete endometrial maturation, subsided endometrial oestrogen and progesterone receptors susceptibility in case of MA suggest of luteum corpus failure entailing a significant reduction of glycodelin production which is the prerequisite for local Th2-microenvironment. CPE proved to have benevolent influence on luteum corpus function, endometrial maturation and glycodelin production, steroid endometrial receptors susceptibility and drift of endometrial microenvironment towards Th2-cytokine predominance. Conclusions: Proposed treatment facilitates recovery of reproductive function and increases the likelihood of successful conception and uneventful course of pregnancy.

Presenter: G. Panzarino

ID 881

CONGENITAL SYSTEMIC INFECTION FOLLOWING LATE ACYCLOVIR-TREATED HERPES SIMPLEX TYPE 1 G. Panzarino1, R. Tambucci1, I. Mattei1, A. Megalooikonomou1, C. Di Paolantonio1, G. Carta2, & G. Nigro1 1

Pediatric Unit, Maternat Infant Department, San Salvatore Hospital, University of L’Aquila, Italy, and 2Obstetrics and Gynecology Unit, Maternat Infant Department, San Salvatore Hospital, University of L’Aquila, Italy. Brief Introduction: Although specifically included in the acronymus TORCH, congenital herpes simplex infection (HSV) occurs rarely. We report a case of congenital systemic HSV infection following a primary maternal infection at 16 weeks’gestation, which was treated with acyclovir only 12 days before pregnancy.

ID 487

CONGENITAL PARVOVIRUS B19 INFECTION: ATYPICAL IMPLICATION FOR CHILDHOOD OUTCOMES K. Leonava1, M. Artsiusheuskaya1, M. Yermalovich2, E. Samoilovich2, & H. Shyshko1 1

Department of Neonatology and Medical Genetics, Belarusian Medical Academy of Post-graduate Education, Minsk, Republic of Belarus, and 2Laboratory of vaccine preventable diseases, Republican Research and Practical Center for Epidemiology and Microbiology Brief Introduction: Parvovirus B19 at transplacental transmission may lead to congenital anemia, hydrops fetalis, fetal death. We report a case of nonimmun hydrops fetalis due to parvovirus B19 resulted in

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172 ascites, hydropericardium, hydrothorax, pneumonia, anemia, thrombocytopenia as well as normal neurodevelopmental long-term outcome and hypoplasia of tooth enamel. Materials & Methods: Parvovirus B19 DNA was detected using PCR in serum samples of both mother and newborn. According to the sequensing result of NS1/VP1u fragment (994 nt) the viruses belonged to genotype 1 and on a phylogenetic tree clustered together with the parvoviruses B19 isolated at the same territory of the country from exanthematous patients that confirmed indigenous infection. Clinical Cases or Summary Results: A 29-year-old woman, gravida 1, para 0, screening’s results were normal. At the 25th weeks of gestation the mother had flu-like symptoms with arthralgia. At fetal ultrasound at 28 weeks of gestation showed ascites, hydropericardium, hydrothorax, tissue edema, single umbilical artery, umbilical cord cyst. At 31 weeks, a female infant was delivered by cesarean section. Birth weight was 1460 g (10rd to 50th centile), length 42 cm (50rd to 90th centile) and head circumference 29 cm (50th to 90th centile). Apgar scores were 5 and 7 at 1 and 5 minute respectively. At birth the infant was hydropic and suffered from asphyxia, respiratory distress syndrome, pneumonia. The infant needed intubation, a single dose of poractant alpha was introduced endotracheally. Following transference her ventilatory requirements slowly improved and on day 10 she was successfully extubated to continuous positive airway pressure (CPAP) support. She received CPAP for 2 days and low-flow oxygen for a further 5 days. Laboratory analysis revealed anemia (hemoglobin level of 12.8 g/dL), thrombocytopenia (platelet count 63,000/mm3). The infant was treated with transfusion of packed red blood cells. Ultrasound showed pleural effusion, ascites and hepatomegaly. A placental biopsy was performed because of fetal growth restriction during pregnancy. Histological examination revealed moderately delayed villous maturation. Further laboratory evaluations for TORCH (toxoplasma, rubella, cytomegalovirus, and herpes simplex) were negative. The infant was discharged from the hospital at 63th day of life. Hypoplasia of tooth enamel was found in the age of 8 months of the infant. At 2 years old the neurological development of the child was within the normal range. Conclusions: We observed a case of laboratory confirmed congenital parvovirus B19 infection with severe clinical presentations at birth time and normal neurodevelopmental long-term outcome at 2 years old except the hypoplasia of tooth enamel. Keywords: parvovirus B19, outcome, hydrops fetalis Presenter: K. Leonava

ID 056

INCIDENCE OF INVASIVE CNS DISEASE WITH UREAPLASMA – WHERE ARE WE NOW? O. O’Connor1, H. Ibrahim2, T. Neal3, & C. Corless4 1

Clinical Research Facility, Alder Hey Children’s Hospital, Liverpool, UK, 2Neonatal Intensive Care Unit, Liverpool Women’s Hospital, Liverpool, UK, 3Department of Microbiology, Royal Liverpool University Hospital, Liverpool, UK, and 4Department of Microbiology, Royal Liverpool University Hospital, Liverpool, UK Brief Introduction: We know that Ureaplasma spp. are the most common bacteria implicated in human urogenital infections including complications of pregnancy in women. Infection and colonization of newborns with Ureaplasma spp. has been associated with adverse neonatal outcomes, however little is known about the incidence of Ureaplasma meningitis in neonates. In the UK there are only two published studies on the subject, conducted in the eighties and early nineties and they estimated that the prevalence of CNS infection with Ureaplasma spp. was 8% and

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0.7% respectively20 3. These studies included premature and term infants and organism detection relied on culture-based methods. Materials & Methods: Since those studies were conducted new molecular methods of detection of microorganisms have been developed. We conducted a study to estimate the incidence of invasive CNS disease with Ureaplasma spp. in a prospective cohort of very low birth weight preterm infants using molecular methods. All consented infants with birth weight 51500 g admitted to the Neonatal Intensive Care Unit at the Liverpool Women’s Hospital, who underwent lumbar puncture (LP) as part of septic screen during the first 14 days of life were included in the study. Cerebrospinal fluid (CSF) samples were tested for Ureaplasma species (U. parvum and U. urealyticum) using specific real time PCR. Clinical Cases or Summary Results: During the period August 2012 to November 2013 four hundred and thirty (430) infants had LP performed as part of the septic screen; 77 (18%) were identified to be eligible for the study based on the inclusion criteria and 50 (65%) were recruited to take part in the study. Reasons for non-recruitment included death, transfer to another hospital or discharge prior to consent being obtained. All CSF samples were cultured and 3 (6%) were positive for coagulase-negative staphylococcus. We performed real time PCR for U. parvum, U. urealyticum4 and pan-bacterial confirmatory PCR on all included samples and did not detect any positive CFS samples. Conclusions: There is little evidence available regarding the incidence of CNS disease with Ureaplasma spp. in very low birth weight preterm infants and there have been no recently published studies conducted in the UK. Our results represent the largest reported cohort in the UK so far and we were unable to identify any positive samples, suggesting an incidence in this cohort of 52%. Our results are consistent with previously published UK results showing very low incidence of invasive Ureaplasma CNS disease, but differ from the results reported in the US studies1. Keywords: Ureaplasma, CNS infection, prematurity Presenter: Dr Olya O’Connor

ID 333

IDENTIFICATION OF BACTERIAL PATHOGENS AND THEIR ANTIMICROBIAL SUSCEPTIBILITY OF EARLY ONSET NEONATAL SEPSIS. A. Bystricka1, J. Khan2, & J. Abu Asbeh3 NICU, Al Rahba Hospital, Abu Dhabi, United Arab Emirates Brief Introduction: Neonatal sepsis is a major cause of mortality and morbidity. The aim of the study was assess the incidence of causative bacterial pathogens of early onset neonatal sepsis and its antibiotic susceptibility to commonly used antibiotics. Materials & Methods: This study was conducted at NICU of Al Rahba hospital in UAE, from Jan 2011 to Jun 2013.The result of blood cultures and antimicrobial susceptibility were observed. A total 175 cases of suspected sepsis were enrolled in this study. The result of blood cultures and antimicrobial susceptibility were observed. Clinical Cases or Summary Results: A total of 29% (51 out of 175) highrisk newborns had culture proven sepsis with an incidence of 13.7 per 1,000 live-births. The mean age of neonates at time of presentation was 2.3 ± 4.0 days and mean age at admission was 0 – 2 days. We defined EOS as a positive blood culture during the first 7 days. 70% of infants presented within the first 48 hours of life. Out of 175 presumed sepsis cases 51 (29%) patients had culture proven sepsis. The most common organism isolated was Streptococcus agalactiae, (68%) followed by Escherichia coli (17%), CONS (9%) and others (6%)

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(such as Klebsiella etc). Most of the organisms were sensitive to ampicillin, gentamicin. No neonatal death due to sepsis was reported in this study. 40 (23%) newborns had lumbar puncture. Only 3 (2%) had a pathogen isolated from CSF (E.coli, Klebsiella and Pseudomonas). The same organisms were isolated both from the blood and CSF culture. The most common clinical presentation in the cases was respiratory distress which was presented in 110 (63%) patients followed by poor feeding in 80 (46%), lethargy in 55 (31%), apnea in 43 (25%), hypothermia in 32 (18%), jaundice in 26 (15%), and shock in 5 (3%) patients. Conclusions: The organisms isolated are the same as expected. The organisms are sensitive to commonly used antibiotics. Empirically started antibiotics which are ampicillin and gentamicin cover those bacteria very well. Periodic evaluation helps in implementation of a rational empirical treatment strategy and limit antibiotics resistance. Keywords: newborn; early onset sepsis; antimicrobial sensitivity. J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Presenter: A. Bystricka

ID 892

HEPATITIS B INFECTION AND PREGNANCY. EXPERIENCE FROM A REFERENCE HOSPITAL IN BARCELONA I. Garcia Ruiz, A. Suy Franch, A. Gascon Portales, E. Llurba Olive´, & E. Carreras Moratonas Obstetrics and Gynaecological Department. Vall d’Hebron University Hospital. Barcelona, Spain Brief Introduction: Hepatitis B is one of the most common viral chronic infections. Uncontroled patients are at risk of vertical transmission. This paper revise and analyze the cohort of Hepatitis B infected pregnant women. Materials & Methods: Retrospective observational study. 126 women were identified from the High Obstetric Risk Unit between 2007 and 2014. We analyzed the following variables: demographic characteristics, past medical history, infection status, and obstetric and post delivery outcomes. Clinical Cases or Summary Results: The incidence of pregnant women with HBsAg was 0.5%. 33.3% were Asiatic, and 31.7% Caucasians, out of them 37.5% came from Romania. 3.9% were HIV/HBV coinfected (all of them with HAART). Only 5 women required ARV treatment for HBV during pregnancy. In 4 cases indication was high viral load (4107). The other one had treatment due to repeated amniotic fluid drainages in a case of idiopatic polyhydramnios. There were no cases of flaring up liver enzymes elevation and no clinical worsening. Tenofovir was the drug used. No maternal or fetal complications. 61.1% were eutocyc, 21.4% caesareans and 9.5% instrumental deliveries. 63% had maternal feeding. 113 (89.7%) new born received prophylaxis with gammaglobulin plus vaccine in the first 12 hours. 106 (84.1%) had a second dose, an 83 (65.9%) the third one. Just in 65 new born the serological screening was done, and in all cases was negative. There was no case of vertical transmission. Conclusions: Most of the pregnant women hepatitis B infected have an inactive status and they do not usually require any treatment during the pregnancy. Neonatal prophylaxis and antiviral treatment in selected cases are useful and safe tools to prevent vertical transmission. Keywords: Hepatitis B infecion; Vertical transmission; Hepatitis treatment Presenter: I. Garcia Ruiz

ID 505

COGNITION PROPERTIES OF SENSORINEURAL HEARING-LOSS CHILDREN WITHOUT AND WITH COCHLEAR IMPLANTATION DURING CYTOMEGALOVIRUS INFECTION T. Devdariani1, & Z. Kevanishvili2 1 Tbilisi State Medical University, and 2National Centre of Audiology, Tbilisi.

Brief Introduction: Applying Raven"s procedure of determination of colored progressive matrices, cognition properties have been estimated in sensorineural hearing-loss children. Materials & Methods: Group 1 included hearing-loss children with cytomegalovirus, CMV, bearing.Group 2 covered hearing-loss children without CMV bearing.Group 3 comprised hearing-loss children subjected to cochlear implantation.Raven"s properties were inspected for a reference in normal-hearing group.The age of children in all test groups fell within 3–7 years. Clinical Cases or Summary Results: Raven"s values in sensporineural hearing loss children of either groups 1 and 2 lagged behind those in normal-hearing group.On the other hand, no difference was revealed between children with and without CMV bearing. Conclusions: The conclusion has been reached consequently that the hearing-loss cause has no principal significance for intelligence qualities of impaired subjects.Cognition level of children with cochlear implants significantly exceeded those without.Moreover, after 6–12 months from implantation Raven"s indices in implanted children did not differ significantly from those in normal-hearing individuals. Keywords: cmv infection, hearing loss, Raven"s colored matrices, cochlear implantation. Presenter: Teona Devdariani

ID 581

DIAGNOSTIC ROLE OF PCT AND CRP IN EARLY NEONATAL SEPSIS IN INFANTS WITH VLBW AND ELBW O. Milaya1, A. Levadnaya2, O. Ionov3, A. Degtyareva4, & D. Degtyarev5 Federal State Budget Institution "Research Center for Obstetrics, Gynecology and Perinatology" Ministry of Healthcare, Russian Federation Brief Introduction: One of the methods used for the diagnosis of early neonatal sepsis in infants with very low birthweight (VLBW) (51500g.) is to detect the concentrations of markers: C-reactive protein (CRP) and procalcitonin (PCT). The aim of our study was to clarify the clinical relevance of CRP and PCT for newborns with VLBW. Materials & Methods: During the period 2012–2013 in the neonatal intensive care unit (NICU) of Federal State Budget Institution "Research Center for Obstetrics, Gynecology and Perinatology" Ministry of Healthcare of the Russian Federation was conducted a cohort prospective study of 129 children with VLBW. Based on the criteria for the diagnosis of early neonatal sepsis neonates were divided in two groups: 51 newborns (39.5%) with signs of early

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174 neonatal sepsis (of which 25 newborns (19.3%) with multiple organ dysfunction (MODS)), and 78 newborns of control group without signs of early neonatal sepsis. Clinical and laboratory criteria for early neonatal sepsis were MODS (involvement of 3 organ systems), X-ray signs of inflammation in lungs such as focal and infiltrative shadows, positive blood culture results and inflammatory changes in blood test. CRP and PCT were measured in the range of 48–72 hours of life in order to evaluate their role as diagnostic markers of systemic inflammation they. Clinical Cases or Summary Results: Among neonates with early neonatal sepsis the level of PCT (4.0 [2, 10] ng/ml and 2.0 [0.5, 3.52] ng/ml, respectively, p = 0. 00002) and CRP (3.8 [0.87, 12.9] mg/l and 0.95 [0.47, 3.03] mg/l, respectively, p = 0.0003) was increased compared with newborns in the control group. PCT had a higher sensitivity (Se = 76.5%, Sp = 57.7%), for CRP was characterized by a high specificity (Se = 41.2%, Sp = 88.5%). Neonates with early neonatal sepsis who had MODS had higher sensitivity of PCT (Se = 84%) and CRP (Se = 52%) than newborns with early neonatal sepsis but without MODS.In case of simultaneous use of CRP and PCT maximum sensitivity and specificity was shown: Se = 81%, Sp = 100%. Conclusions: In the group of newborns with early neonatal sepsis level of PCT and CRP is higher. Sensitivity for PCT and CRP increases in presence of MODS among children with early neonatal sepsis. Maximum diagnostic accuracy of CRP or PCT as the markers for early neonatal sepsis can be reached in case of simultaneous use of CRP and PCT together. Keywords: preterm infants, infection, C-reactive proten, procalcitonin Presenter: O. Milaya

ID 757

PROCALCITONIN GUIDED DECISION-MAKING IN SUSPECTED NEONATAL EARLY-ONSET SEPSIS M. Lithoxopoulou, P. Karagianni, E. Hatziioannidis, G. Mitsiakos, C. Tsakalidis, & N. Nikolaidis 2nd NICU and Neonatology Department of Aristotle University of Thessaloniki, General Papageorgiou Hospital, Greece Brief Introduction: The early-onset sepsis in newborns in Neonatal Intensive Care Unit is difficult to be diagnosed because the clinical symptoms and signs and the laboratory tests are non-specific. On the other hand antibiotic therapy is necessary for the treatment of possible early- onset sepsis. We evaluated procalcitonin (PCT) for guided decision-making in suspected neonatal early-onset sepsis and we decided the length of duration of antibiotic therapy. Materials & Methods: In a tertiary neonatal intensive care unit, we prospectively randomized the study between January 2010 and December 2012. Participant neonates were term and late preterm infants (gestational age 34 weeks) with suspected early-onset sepsis. We randomized two groups: the PCT-guided group and the control group. The control group had been evaluated with usual laboratory parameters. This group had duration of antibiotic therapy 72 h, but the PCT group stopped antibiotic therapy when two serial PCT values were below the cut-off values and when the assessment of the attending physician was completed. Clinical Cases or Summary Results: We randomized two groups of 150 newborns control group (n = 71) and the PCT group (n = 79). Two groups were similar for baseline demographics, risk factors (intrapartum maternal fever 438  C, clinical chorioamnionitis), for earlyonset sepsis, and they had clinical signs of infection as assessed by

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

the neonatologist. Control group was based on conventional laboratory findings. Duration of therapy Control group PCT group

472 hours 54 (76%) 41 (52%)

48–72 hours 17 (24%) 38 (48%)

The difference in the proportion of newborns treated with antibiotics for more than 72 hours between the control and the PCT group was significant (p50.01) (ARR 32%; odds ratio 0.24 (95% CI 0.13–0.68). In the PCT group, if early sepsis was considered to be unlikely, antibiotic therapy is discontinued when two PCT values (within 8 hours difference) were in the normal range. No adverse events were referred. Conclusions: PCT group resulted in shortened duration of therapy in term and late-preterm newborns. Long-term outcomes in newborns and their families because of the minimization of hospitalization were possible in the PCT group. Benefit of the study was the possible limitation of unnecessary use of antibiotics. Long-term use of antibiotics is a serious concern because it can promote the development of multi-resistant bacteria. Larger cohort studies are recommended. Keywords: early- sepsis, neonatal, PCT, antibiotics Presenter: M. Lithoxopoulou

ID 607

PRENATAL ISOLATED MILD VENTRICULOMEGALY: ASSOCIATION WITH FETAL INFECTIONS G. Masini1, L. Pasquini1, C. Franchi1, C. Gaini1, M. Di Tommaso1, C. Dani1, & M. Trotta2 1

Department of Science for Woman and Child Health, University of Florence, Florence, Italy, and 2Department of Critical Care Medicine and Surgery, Infectious Diseases Unit, University of Florence, Florence, Italy Brief Introduction: Ventriculomegaly (VM) is the most frequent fetal brain abnormality detected during routine ultrasound scan. It is known that VM can be associated with fetal infections, however only a few studies report systematically on this association in particular when mild VM (mVM) is isolated. Our study wants to assess the utility of infection screening in isolated mild VM (imVM) Materials & Methods: We retrospectively reviewed 141 consecutive cases of imVM. Screening for infections including TORCH, parvovirus B19 and syphilis was requested in all cases. Follow up US, fetal karyotype and fetal magnetic resonance imaging (MRI) were offered. Postnatal follow-up was obtained from paediatricians, medical records and directly from patients after birth, and from postmortem reports in cases of termination of pregnancy or intrauterine fetal death. Clinical Cases or Summary Results: Among the 141 studied fetuses, 70 (49.6%) had bilateral imVM and 71 fetuses (50.4%) unilateral imVM. It remained stable in 46 cases (32.6%), regressed in 94 (66.6%), worsened in 1. Follow-up US observed associated anomalies in 15 cases and in 7 cases MRI added relevant informations. Fetal karyotype was abnormal in 1 of the 39 tested fetuses (47, XXY). All patients resulted negative for toxoplasma, rubella, HSV1/2 and syphilis. Maternal IgM for parvovirus B19 resulted positive in 6 cases. Recent CMV infection was documented in 6 women (4.2%). The infection was transmitted to 1 fetus and after 3 years the baby has a good neuromotor development but severe hearing impairment. Conclusions: When a diagnosis of imVM occurs, a CMV test should be performed, whereas a complete TORCH screening is probably not

175

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necessary. In our population we confirm that imVM is a benign sign without pathological significance in the majority of cases. Keywords: Mild ventriculomegaly, fetal infections, TORCH, cytomegalovirus, ultrasound Presenter: Giulia Masini

ID 792

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COLONIC STENOSIS POST NECROTIZING ENTEROCOLITIS IN TERM NEWBORN WITH ACQUIRED CYTOMEGALOVIRUS INFECTION L. Marseglia, S. Manti, G. D’Angelo, E. Gitto, & I. Barberi Neonatal Intensive Care Unit, Department of Pediatrics, University of Messina, Italy Brief Introduction: Necrotizing enterocolitis (NEC) is a gastrointestinal emergency typical of premature infants that very rarely occurs in term neonates. Intestinal strictures infrequently complicate medical or surgical treatment of NEC. Postnatal cytomegalovirus (CMV) infection with gastrointestinal involvement is extremely rare in immunocompetent term newborns, and has been occasionally described in subjects with NEC. Materials & Methods: case report Clinical Cases or Summary Results: We report the case of a full term infant presenting NEC at 8 days of life not requiring surgical treatment; after 15 days an acquired CMV infection with gastrointestinal involvement was diagnosed and treated with a course of ganciclovir. For the persistent abdominal distension, a barium enema study was performed 6 weeks after the episode of NEC, confirming marked colonic dilatation (transverse colon45 cm), and showing the presence of colonic strictures of 1.2 cm from descending to sigmoid colon with severe degree of upstream bowel dilation. Hirschsprung Disease was excluded by negative rectal biopsies. Therefore, a post-NEC colonic stricture was diagnosed and the patient underwent surgery with resection of a sigmoid stricture and primary anastomosis, followed by complete recovery. Conclusions: We underline the role of bacterial and viral infections in the pathogenesis of post NEC-stenosis, either as directly responsible for the enterocolitis or as a secondary colonization after the initial acute phase. Keywords: Necrotizing enterocolitis, cytomegalovirus infection, colonic stenosis Presenter: I. Barberi

ID 338

A NEW RISK FACTOR FOR NEONATAL VANCOMYCIN RESISTANT ENTEROCOCCUS COLONISATION: BACTERIAL PROBIOTICS S. Topcuoglu, T. Gursoy, F. Ovali, O. Serce, G. Karatekin Neonatal Intensive Care Unit, Zeynep Kamil Maternity and Children’s Training and Research Hospital, Istanbul, Turkey

Brief Introduction: Recently, commensal bacteria are accused to play a role in the transfer of antibiotic resistance genes to pathogenic or opportunistic bacterial population. Vancomycin resistant Enterococcus (VRE) colonisation in intensive care units can be controlled with strict adherence to infection control measures. We describe a resilient VRE outbreak coincident with bacterial probiotic trial. Relationship between probiotic and VRE colonisation, and other possible risk factors were investigated. Materials & Methods: Two hundred ten patients with gestational age less than 33 weeks had been randomised for a probiotic trial after ethical approval and informed consent of parents. However, following the detection of three VRE colonised cases with active surveillance cultures during this period, we investigated whether there was a relationship between probiotics and VRE colonisation Clinical Cases or Summary Results: The outbreak could be eradicated in 18 months. Begining and end of the outbreak were coincident with the begining and the end of the probiotic trial. There was no difference between VRE colonised and noncolonised patients in terms of demographic and clinical features except for vancomycin and probiotic use. Conclusions: Probiotic and vancomycin exposure, especially when administered together, were significant risk factors for VRE colonisation. The results of this paper imply that the acquisition and transfer of the antibiotic resistance genes may be mediated by probiotics. Therefore, the safety issue of probiotics is a serious concern and should be investigated further. Keywords: Newborn, prebiotics, Vancomycin Resistant Enterococcus Presenter: T. Gursoy

ID 853

HEMORRHAGIC GASTROENTERITIS CAUSED BY PERINATAL CYTOMEGALOVIRUS INFECTION SUCCESSFULLY TREATED WITH VALGANCICLOVIR R. Tambucci, I. Mattei, G. Panzarino, G. Iapadre, I. Capretti, & G. Nigro Pediatric Unit, University of L’Aquila, L’Aquila, Italy Brief Introduction: Clinical manifestations of congenital cytomegalovirus (CMV) may range from severe multiorgan involvement with thrombocytopenic purpura, pneumonia, hepatitis, and encephalitis. Gastrointestinal involvement is reported very infrequently. We report one infant with extremely severe hemorrhagic gastroenteritis due to congenital CMV infection with no other organ involvement. Materials & Methods: Following laboratory tests has been performed: complete blood count, immunological investigation, microbiology stool tests, specific CMV antibodies (IgG and IgM), CMV DNA detection in blood, gastric aspirate and urine. As far as concern the instrumental assessment, abdominal ultrasonography and upper endoscopy with esophageal, gastric and duodenal byopsies for histological evaluation were performed. Clinical Cases or Summary Results: A male infant weighing 3350 gr was delivered by cesarian section at 38 weeks of gestation, and breastfed. Pregnancy was uneventful apart from dilation of the great cistern. On day 43 of life he had profuse bloody diarrhea, vomiting and fever. Leukocyte count was 15.17 K/ul, hemoglobin value was 8 g/dL, erythrocyte and platelet counts were normal. Immunological investigations were normal and microbiology stool tests were negative. Abdominal ultrasonography showed a hypoechoic bowel. In spite of administration of amino acid-based formula, the severe intestinal symptoms persisted. On day 47 blood transfusion was given because of severe anemia (Hb value 6.6 g/dL). Upper endoscopy showed macroscopically erythematous duodenitis, while the

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176 histological examination showed duodenal and jejuna lymphoplasmacellular infiltration and villous atrophy. Moreover CMV inclusion bodies were found in the endothelial cells. Active CMV infection was proved by the detection of CMV-DNA in the blood (91017 genome copies/ml), urine (5612 copies/ml), and gastric aspirate samples. Congenital CMV infection was supported by high CMV IgG levels and avidity associated with low IgM antibodies. Oral therapy with valganciclovir (30 mg/kg/day) was followed by gradual resolution of symptoms.Two months later, endoscopy showed an improvement of macroscopic findings, and histopathological examination revealed partial resolution of inflammatory infiltrate, reduction in the degree of villous atrophy, while CMV inclusion bodies were not observed. CMVDNA detection in blood and urine was negative. Valganciclovir dosage was gradually reduced until 8 mg/kg, and stopped after six months following persistent negative CMV DNA detection in any sample concomitantly with normal gastrointestinal, sensorial and psychomotor functions. Conclusions: CMV related enteropathy has been observed in preterm and immunodepressed infants. Congenital severe gastrointestinal CMV infection has never been reported in a full term immunocompetent infant while being breast fed, and successfully treated with valganciclovir. Our case may suggest to look for CMV infection as a possible cause of severe and persistent gastroenteritis not only in immunodepressed but also in immunocompetent infants. Protracted administration of valganciclovir should be considered for therapy, being effective in disease resolution without side effects. Keywords: Presenter: R. Tambucci

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Table 1. Predictors of septicaemia during hospitalization Risk factors

Apgar score56 Mechanical respiratory support Respiratory Distress Syndrome Patent ductus arteriosus Thoracic catheter-chest drain Central vascular catheters Administration of parenteral nutrition Intraventricular hemorrhage

VLBW infants with infection%

aOR VLBW infants without infection%

95% CI

p Value

58.8 75

38.8 68.1

1.302 0.448–3.782 0.712 0.206–2.460

0.628 0.591

94.1

73.6

5.736 0.711–46.242

0,101

35.3 3.7

19.4 5.5

2.260 0.713–7.160 1.062 0.111–1.061

0.166 0.958

82.4

55.5

3.949 1.044–14.935

0.043

100

98.6

0

5.6





0.492 0.057–4.226

– 0.518

Seventy five percent of the VLBW new-borns with sepsis were ventilated during their hospitalization in the NICU while in 82.4% had inserted central venous vascular catheters The mean duration of hospitalization in septic infants was 74.8 days. Conclusions: Conclusions: In this study the prevalence of sepsis in the VLBW neonates admitted in a NICU in Cyprus was very low, as septicemia occurred in 19% of the infants. Major risk factors were the chorioamnionitis and the presence of central vascular catheters. The main pathogen of neonatal sepsis in the unit was the staphylococcus coagulase-negative. Keywords: Neonatal Sepsis, Very Low Birth Weight Infants

ID 606

Presenter: Th. Papadouri

RISK FACTORS ASSOCIATED WITH THE ONSET OF SEPSIS IN INFANTS OF VERY LOW BIRTH WEIGHT IN A NEONATAL INTENSIVE CARE UNIT IN CYPRUS

ID 686

Th. Papadouri1, St. Nicolaou1, Ch. Karaoli1, & V. Raftopoulos2

S. Hitrova-Nikolova1, B. Slancheva1, A. Nikolov1, R. Russeva1, E. Shopova1, N. Yarakova1, L. Vakrilova1, T. Pramatarova1, D. Ivanova2, K. Milenkova3 & A. Decheva4

1

Neonatal Intensive Care Unit, Archbishop Makarios III Hospital, Cyprus, and 2Cyprus University of Technology, Nursing Department Brief Introduction: Introduction: Neonatal septicemia is one of the major causes of morbidity and mortality in very low birth weight (VLBW) infants. Aim: To explore the incidence, and risk factors of septicemia in a neonatal intensive care unit (NICU) in Cyprus in a cohort of very low birth weight infants. Materials & Methods: Methods: A retrospective study of all infants with birth weight of 1.500gr admitted in a neonatal intensive care unit in Cyprus between June 2011-June 2012 was conducted. A standardized survey record form has been used, according to the Healthcare Associated Infections definitions provided by the CDC’s NHSN. The form included data on the maternal prenatal history, delivery and neonatal course, including detailed information on episodes of septicemia. In all the cases, standard laboratory methods were used to identify microorganisms. Clinical Cases or Summary Results: Results: Of the 89 infants of VLBW, who were hospitalized in the NICU during that period 21 septicemia episodes occurred in 17 infants (19%). Staphylococcus coagulase negative was the main pathogen (76.1%) isolated from the positive blood cultures. According to logistic regression the main predictor of septicemia was chorioamnionitis during the pregnancy (OR 6,600, 95CI 1,236–35,234). According to the Table 1 the main predictor of septicaemia onset during hospitalization was central venus catheters

CLINICAL STUDY ON GROUP B STREPTOCOCCAL (GBS) NEONATAL INFECTION IN BULGARIA 2009–2013

1

Medical University of Sofia, Bulgaria Faculcy of Medicine, Chair of Obstetrics and Gynecology ,University Hospital of Obstetrics and Gynecology ‘‘Maichin dom‘‘, 2Second Multiprofile Active Treatment Hospital, Sofia, Bulgaria, 3 Second Municipal hospital for Obstetrics and Gynecology ‘‘Sheynovo‘‘ Sofia, Bulgaria, and 4National Center of Infectious and Parasitic Diseases, Sofia, Bulgaria Brief Introduction: Objective: To perform a clinical trial on pregnant women and newborns with neonatal streptococcal group B infection in order to estimate the necessity of intrapartum antibiotic prophylaxis in Bulgaria. Materials & Methods: Materials and methods: One hundred and seventy-six pregnant women (130 GBS positive for rectovaginal carriage, 46 GBS negative controls) and 38 newborns with early-onset GBS neonatal infection were included. The relation between GBS carriage of pregnant women and the risk to develop neonatal infection was analysed. Dominating serotypes of the GBS isolates were determined by Strep B Latex agglutination kit (Statens Serum Institut). Antibiotic susceptibility was tested by disk diffusion method of Bauer-Kirby. Clinical Cases or Summary Results: Results: Sixty-eight percent of the GBS positive women had no risk factors during delivery and gave birth to healthy children although only one-third received antibiotic prophylaxis. However 9% of the GBS positive women without risk

177

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DOI: 10.3109/14767058.2014.924236

factors delivered children with neonatal infection. They all received antibiotics for caesarean section prevention immediately before operation. Nineteen percent of the GBS positive women had also clinical risk at delivery. All their children developed neonatal infection although half of the mothers received intrapartum antibiotic prophylaxis. The explanation could be that most of them delivered by immergency caesarean section with the antibiotic given immediately before; the majority of the children were born immature – 29–31 gestation week; the infection could have appeared in utero – some of the newborns had APGAR 1 and 3. Five percent of the GBS positive women with risk factors received proper antibiotic prophylaxis for neonatal infection and delivered healthy newborns. All the children with neonatal infection and all the healthy but colonized newborns were treated with beta-lactams and were dismissed from the hospitals as healthy. The dominating serotypes in Bulgaria are III, II, Ia, Ib and IX. All the GBS isolates were susceptible to penicillins, cephalosporins and vancomycin. The resistance to erythromycin and clindamycin was 13.85%, the all ghe strains being from the MLSB type. Conclusions: Conclusions: We consider that all GBS positive women, no matter if there is risk factor at delivery or not, no matter if the woman is planned for cesarean section, should receive proper intrapartum antibiotic prophylaxis for neonatal infection following schemes proposed by CDC, USA. Antibiotic prophylaxis for cesarean section cannot replace IAP for neonatal infection. A future polysaccharide vaccine will most probably not cover infections caused by type IX. Macrolides can still be used but after testing for susceptibility. Keywords: GBS infection, IAP, newborn Presenter: Stanislava Hitrova-Nikolova

ID 575

CONGENITAL CYTOMEGALOVIRUS INFECTION: A CASE SERIES L. Castells1, N. Joaqui2, E. Guirado1, N. Pumares1, M. Miranda1, & F. Mun˜iz1 1

Neonatal Intensive Care Unit, IDC Hospital General de Catalunya, Sant Cugat del Valle´s, Barcelona, Spain, and 2 Paediatric Infectious Disease Dept., IDC Hospital General de Catalunya, Sant Cugat del Valle´s, Barcelona, Spain. Brief Introduction: Congenital Cytomegalovirus (CMV) infection affects 0,3 to 0.6% of all alive births in Europe. Primary CMV infection, reinfection or virus reactivation could occur during pregnancy. Almost 90% of intrauterine CMV infections result in assymptomatic babies at birth, but can develop long-term sequelae such as hearing loss and mental retardation. An accurate diagnosis of primary maternal and fetal infection should be made for a correct treatment and follow up. Materials & Methods: Ten newborns with Congenital CMV (cCMV) infection between January 2011 and December 2013 were included in the study. Detailed clinical reviews were performed in a Spanish tertiary paediatric hospital. Clinical Cases or Summary Results: There were 10 infants with cCMV identified. Three of them were studied due to primary maternal infection, one due to seroconversion during pregnancy and the rest because of clinical findings such as microcephaly, ventriculomegalia, prematurity, and intracranial or intrahepatic calcifications. In all cases, diagnosis was done by detection of the virus in urine within the first two weeks of life by PCR. In one pacient, CMV was detected in cerebrospinal fluid (CSF) by PCR and, in another pacient, CSF pleocytosis without CMV isolation. Antiviral treatment with Ganciclovir and finally with Valganciclovir was given in these two pacients. During pediatric follow-up any neurological and hearing sequelae were. Conclusions: Congenital CMV diagnosis should be done during pregnancy specially if a mononucleosic syndrome occurs in pregnant

women or CMV risk conditions exist. CMV PCR urine testing must be done in all newborns with microcephaly, intrauterine growth retardation, ventriculomegalia, intracranial or intrahepatic calcifications, and probably in preterm infants born before 32 gestacional weeks. Keywords: Congenital Infection, Cytomegalovirus Presenter: Laura Castells Vilella

ID 095

THE PRESENCE OF STAPHILOCOCCUS AUREUS IN SMIRCHES FROM MOTHERS WITH MECONIAL AMNION FLUID J. Ivanov1, & G. Bushinoska-Ivanova2 1

Gynecology and Obsterics Department, Clincal Hospital Acibadem-Sistina Skopje, Macedonia, and 2University Clinic of Gynecology and Obstetrics Skopje, Macedonia Brief Introduction: The aim of this study is to show the percentage of Staphilococcus aureus in smirches of newborns, from mothers with meconial amnion fluid after 48 hours of delivery. Materials & Methods: Newborns from mothers with meconial amnion fluid in 2010 year were analysed. Microbyologic findings from ear, pharynx and nose were analysed, taken randomly at our Department of Neonathology. They were processed at the Institute of Virusology and Microbyology in Skopje. Clinical Cases or Summary Results: In the course of 2010 year, 3290 newborns born live were analised. 530 (16.1%) of them were born from mothers with meconial amnion fluid. Bacterial flora were analysed in 273 (51.5%) of newborns with meconial amnion fluid. 216 (79,12%) of them were sterile and 57 (20,87%) were positive. Staphilococcus aureus was isolated in 24 (42.1%), Streptococcus beta haemoliticus in 4 (7,01%), Klebsiella aerogenes in 4 (7,01%), Acinetobacter species 6 (10,52%), Enterococcus in 3 (5.3%), E.coli in 13 (22.8%), Streptococcus pneumoniae in 2 (3,07%) and Pseudomonas aeruginosa in 1 (1,75%). Conclusions: The analysis showed that the most frequent bacterial flora in newborns from mothers with meconial amnion fluid, after 48 hours of delivery is Staphilococcus aureus, followed by E.coli and Streptococcus species. Keywords: Staphilococcus aureus, Newborns, Meconial Amnion Fluid Presenter: Jordancho Ivanov

ID 710

ANTIBIOTIC THERAPY IN NEONATAL PERIOD M. Dima1, D. Iacob1, N. Ionita2, & A. Manea1 1 University of Medicine and Pharmacy "Victor Babes" Timisoara, Romania, and 2Clinical Emergency Hospital- Bega University Clinic, Timisoara, Romania

Brief Introduction: Introduction: The neonate has many structural and functional features, a stereotype to react to different causes of disease. So that diseases with different etiologies have common or similar symptoms. Objectives: This paper aims to identify clinical forms of infection posed by newborn at the beginning of hospitalization, antibiotic treatment received and other factors influencing disease progression.

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178 Materials & Methods: Materials and methods: The study is based on retrospective analysis of cases of newborns with infectious pathology, at Bega maternity Emergency County Hospital Timisoara, during 2012–2013. Data needed to produce the study were drawn from clinical observation sheets and bacteriological analysis bulletins. Clinical Cases or Summary Results: Results and discussions: In the mentioned period were hospitalised in the clinic 284 neonates with infectious pathology. Distribution acording to sex and origin indicates insignificant differences. Clinical and paraclinical 58 cases were diagnosed with neonatal sepsis, the remaining 226 cases presents clinical forms of localized infections: respiratory tract infection 93, 15 digestive infections, 21 urinary infections, 12 skin infections, conjunctivitis 74. The remaining 11 cases were associated with two or more locations listed above. Initiation of antibiotic therapy was done with Ampicillin ± aminoglycoside in most cases and with thirdgeneration cephalosporins to neonates with neonatal sepsis and high risk category. In cases that had conjunctivitis, skin infections, was made local topical treatment. Evolution under treatment was favorable in most cases, maintaining the same antibiotic during the whole therapy period. 63 infants had a slowly favorable evolution, requiring the change of antibiotic. They had low birth weight or more associated risk factors. Unfavorable outcome, to death, was registered in 7 cases with complec pathology, 4 cases having severe congenital malformations. Conclusions: 1. In the group of infants studied were predominantly respiratory tract infections and conjunctivitis, followed by urinary tract infections. 2. Ampicillin ± aminoglycoside antibiotic treatment in the initial phase of treatment of neonatal infections continue to be the most used, because antimicrobial spectrum indicate them to be effective. 3. The choice and use of antibiotics to neonates requires: strictly necessary indications (correlated with bacteriological analysis), less toxic antibiotics, adequate doses, shorter treatment. Keywords: newborn, antibiotics Presenter: M. Dima

ID 014

INTRAPARTUM GROUP B STREPTOCOCCUS INFECTION: A REPORT OF THREE CASES IN THE PHILIPPINE SETTING

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

via urine culture and sensitivity. Neonatal outcomes for the three cases were unremarkable. Conclusions: In the Philippine setting, to address the threat posed by the continuing lead of GBS as a cause of worldwide neonatal morbidity and mortlity, it is recommended to screen all pregnant women with GBS colonization via GBS rectovaginal culture in order to detect patients qualified for administration of intrapartum antibiotic prophylaxis (IAP). Keywords: Presenter: C. Camanong

ID 336

FUNGAL INFECTION AMONG LOW BIRTH WEIGHT INFANTS M. Grasselly, O. Szaka´ll, & G. Oroszla´n Perinatal Intensive Care Unit, Markusovszky University Hospital, Szombathely, Hungary Brief Introduction: Sepsis is one of the most serious disorders in the neonatal period. The infection is caused by viruses, bacteria or fungi. 75% of the fungal infections is caused by Candida strains. Fungal infections are more common on the last years. Materials & Methods: Rewiev of the history of low birth weight patients with fungal sepsis. Clinical Cases or Summary Results: In the last years we treated 11 premature babies with fungal infection in our Neonatal Intensive Care Unit. The mean gestational age was 27.18 week (24–30 week) All patients were treated with broad spectrum antibiotics. Antifungal prophylaxis was introduced in 5 cases. In 5 cases Candida albicans, in 3 cases Candida parapsiolosis strains were isolated from the blood. The mortality rate was as high as 54% (6/11). The cause of the death was fungal sepsis in 3 cases. All the patients with profilactic antifungal treatment survived. Conclusions: Low birth weight premature babies treated with board spectrum antibiotics are very susceptible for fungal infection. In these cases prophylactic antifungal treatment is indicated. Keywords: low birth weight infants, fungal sepsis Presenter: G. Oroszla´n

C. Camanong St. Luke’s Medical Center, Quezon City, Philippines Brief Introduction: Group B Streptococcus (GBS) is a gram-positive bacterium that is commonly seen in the gastrointestinal tract. In pregnant women, GBS colonization in the vaginal tract is an intrapartum cause of concern due to the high probability of vertical transmission of GBS to the infant during passage upon delivery. Transmission of the bacteria to the infant may also happen intrauterine via ascending infection even with intact membranes. The burden of the disease concerns GBS being the leading cause of worldwide neonatal morbidity and mortality. In the Philippines, the true incidence of GBS disease among pregnant women is generally unknown since GBS screening is not a routine procedure that is being done intrapartum. Materials & Methods: In this paper, three cases are presented which are assessed via risk-based approach in identifying patients needing intrapartum antibiotic prophylaxis (IAP). Literature search was done using PubMed and Herdin using the keywords group B streptococcus, GBS intrapartum infection. Clinical Cases or Summary Results: All three cases reported were given IAP. Two presented with watery vaginal discharge, one at term and the other at preterm. The other one had GBS colonization confirmed

ID 069

DO WE NEED TO SCREEN PREGNANT WOMEN FOR MRSA? NOT YET! A. Page1, G. Page2, & I. Dehaene3 1 2

Obstetric Dept., Jan Yperman Hospital, Ypres, Belgium, and Obstetric Dept. University Hospital Ghent, Ghent, Belgium

Brief Introduction: The detection and eradication of MRSA (MethicillinResistant Staphylococcus Aureus) in hospitalized patients is a key health priority for many countries.Therefore, the Committee for Hospital Hygiene of the Jan Yperman Hospital, Belgium, started an universal screening. Any individual admitted to the hospital is screened by a nasal swab. If positive, isolation and decolonization is performed. The aim of this strategy is to limit nosocomial spread of MRSA. A second aim could be the prevention of maternal and neonatal infections. Screening in an obstetric population can be universal or targeted.

179

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DOI: 10.3109/14767058.2014.924236

We question both screeningmethod-approaches for a pregnant population of which there are no data on prevalence for neither HAMRSA (hospital-acquired MRSA) nor CA-MRSA (community-acquired MRSA). Materials & Methods: A literature search (PubMed, Cochrane Database, Embase) with keywords MRSA, Staphylococcus Aureus, screening, pregnancy, hospitalization, neonatal was performed. No metaanalyses or ran-domized controlled trials were found. Reviews and guidelines were examined and further evidence was searched by snowballing references of these papers. Our clinical question was if universal MRSA screening in an obstetric population meets the re-quirements of a functioning screening program. Second question was the value of a targeted screening of obstetric patients with an augmented risk for MRSA. Clinical Cases or Summary Results: In a pregnant population, prevalence ranges from 0.5- 3.5% (most CA-MRSA).There seems to be no correlation between nasal and genital carrier ship.There is a poor correlation between known risk factors and carrier ship (only 58% of carriers had risk factors).The risk of vertical transmission is very low.Maternal complications are rare and mild.No increase was documented in early-onset neonatal MRSA infections of babies of colonized women. MRSA is a rather particular threat to babies in neonatal units.Test accuracy depends on both sampling and testing proceduresThe gold standard test for MRSA detection is enrichment culture of swabs with a results-time of at least three days, which is too long for non-elective screening.Cost-effectiveness A number of studies have questioned the cost-effectiveness of MRSA screening in different patient populations, including obstetric patients. To our knowledge, no such studies have been undertaken in Belgium (nor for universal or targeted screening). Conclusions: Summarising the current best evidence, we propose a progressive analysis of the local situation, before a strategy of screening of the obstetrical population is implemented in our hospital. First, we propose to determine the local prevalence of MRSA(HA and CA) by universal screening at 37weeks(by the same swab as for GBS screening) by PCR., followed by subsequently screen-ing of all neonates by nasal swabs. Second, we argue for a need for a systematic registration of all maternal and neonatal MRSA-induced infections.Third, more information needs to be obtained onclinical effects and cost-effectiveness of decolonisation procedures. For this, large multicentre studies are recommended.

Clinical Cases or Summary Results: A male term newborn was admitted to the neonatal unit presenting bloody stools and early-onset neonatal sepsis suspicion. Maternal urine culture was positive for SGB; otherwise it was an uncomplicated pregnancy with normal prenatal laboratory tests. Apgar scores were 9/10. Growth parameters: weight 4.1 kg; length 50 cm and head circumference 35 cm. Artificial feeding. At 40 hours of live, the newborn presents bloody stools and hypoactivity. Physical examination revealed hypotonia, pallor and facial petechiae, without abdominal distension. The blood analysis only revealed leukopenia without neutropenia and a maximum value of reactive C protein of 1.7 mg/dl. Because early onset neonatal sepsis was suspected, stool, blood and CFS culture were obtained, and treatment with intravenous ampicillin and gentamicin was begun.12 hours after treatment had started the baby experienced clinical improvement and there weren’t no new bloody stools. Blood and CFS cultures were negative but stool culture was positive for Campylobacter sp. Thus, he remained with antibiotic treatment with gentamicin for 5 days. The patient had a good clinical course. Conclusions: Digestive tract of domestic and free animals and birds are the reservoir of the infection, while transmission is associated with the ingestion of contaminated aliments, or direct contact with the stools of contaminated persons or animals. In neonatal period, transmission can occur by direct contact with infected mothers, who sometimes are asymptomatic, as well as during vaginal birth. C fetu usually produces systemic illness (such as sepsis or meningitis) in newborns. Clinical manifestations in the newborn infected by C jejuni and coli are self-limited bloody stools, without fever or dehidratation signs, and with good appearance. These infections can occur as isolated cases or nosocomial infections in Neonatal Units. Bacteremia and other complications (meningitis) are exceptional. Maintaining a good hidratation is essential while treating this infants, while antibiotherapy is controversial. When administrated, erythromycin and azithromycin during 5–7 days can reduce the duration of the illness and prevent its relapse. Our conclusions are that we must think of Campylobacter while treating newborns with clinical manifestations like bloody stools, sepsis or meningitis, and that hand-cleaning is the best way to prevent its transmission Keywords: Presenter: Victor Sanmartin

Keywords: MRSA, pregnancy, screening Presenter: Ann-Sophie Page

INTRAPARTUM SURVEILLANCE ID 585

ACUTE ENTERITIS IN A 3-DAY-OLD NEWBORN BY CAMPYLOBACTER 1

2

3

4

V. Sanmartin , E. Lobera , J. Barberan , S. Amoretti , I. Collazo5, C. Hornos6, & R. Diez7 1

Paedriatic Dept. Hospital Mataro´, Mataro´, Spain, 2 Neonatology Dept. Hospital Mataro´, Mataro´, Spain, 3 Neonatology Dept. Hospital Mataro´, Mataro´, Spain, 4 Paediatric Dept. Hospital Mataro´, Mataro´, Spain, 5Paediatric Dept. Hospital Mataro´, Mataro´, Spain, 6Paedriatic Dept. Hospital Mataro´, Mataro´, Spain, and 7Neonatology Dept. Hospital Mataro´, Mataro´, Spain Brief Introduction: Campylobacter species are constituted by negativestained bacils, mobiles, that usually produce gastroenteritis. The most common isolated species in the stools of patients are C jejuni and C coli, being C jejuni one of the most common ethiologic agents that produce bacterial diarrheas in developed countries. Infants less than one year old are the most affected group, while in newborn period the incidence is minimal. Materials & Methods: Case Report

ID 754

THE DYSFUNCTIONAL LABOR STUDY E. Wiberg-Itzel1, A. Pembe2, M. Norman1, A-C. Wihlba¨ck3, I. Hoesli4, E. Azria5, & H. Akerud6 Karolinska Institute, Stockholm, Sweden, 2Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, 3Umea University, Sweden, 4University of Basel, Switzerland, 5Bichat, University of Paris, France, and 6KBH, Uppsala University, Swed 1

Brief Introduction: Oxytocin is a commonly used drug in obstetrical care worldwide. In previous studies we have shown that measurement of the AFL value (amniotic fluid lactate) may give important information of the metabolic status of the uterus, and the test may be useful when augmentation with oxytocin is needed. An AFL-value 410.1mmol/l has in earlier studies been considered as high, and a high AFL-value has been shown to have a strong association to operative intervention and/or complications for the mother and the fetus. The aim of the present study was to analyze if quantitative

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180 measurement of the AFL among healthy primiparas could be a new and helpful instrument when oxytocin is needed for augmentation of contractions during labor. Materials & Methods: In this multicenter trial, 2298 healthy primiparas from four delivery wards in Sweden, two delivery wards in Switzerland, one in France and one in Tanzania was included between April 2010 and December 2012. All women had a normal pregnancy with a spontaneous onset of labor. A sample of amniotic fluid was collected by the midwife in charge; (1) at the first vaginal examination after the membranes where broken, 2) If augmentation with oxytocin was needed due to arrested labor progress and (3) at delivery of the fetus. The AFLvalue was analyzed blinded immediately at the bedside, and the value was hidden to the midwife/obstetrician/women in labor. Data from delivery was collected from the medical files. Clinical Cases or Summary Results: Oxytocin was used in 1515/2298 (66%) of all included deliveries. In 87% of the augmented deliveries the AFL value was = 10.1 mmol/L when augmentation started. In this group only 61.1% had a vaginal delivery and 38.9% were delivered by cesarean. (p50.001) Conclusions: Normal levels of AFL in arrested labors correlate to a successful vaginal delivery after the use of oxytocin according to guidelines. High levels of AFL correlate to an increased risk of a complicated delivery followed by an operative intervention even if oxytocin is used according to guidelines We speculate that AFL-test can be a very useful decision tool in clinical management of a dystocic delivery when oxytocin is used. Keywords: Presenter: Eva Wiberg-Itzel

ID 155

LABOR MANAGEMENT BASED ON CLINICAL GUIDELINES: A SIXTEENYEARS ANALYSIS OF A MANAGEMENT MODEL. R. Latorre1,2, J. Carrillo1,2, F. Avila1,2, A. Valenzuela1,2, C. Carrillo1,2, R. Gomez2,3, A. Insunza1,2, & E. Paiva1,2 1

Unidad de Gestio´n Clı´nica de la Mujer y el Recie´n Nacido, Hospital Padre Hurtado, 2Facultad de Medicina, Clı´nica Alemana de Santiago-Universidad del Desarrollo, and 3Centro de Diagno´stico e Investigaciones Perinatales - Hospital Padre Hurtado (CEDIP), Santiago, Chile Brief Introduction: Hospital Padre Hurtado in Santiago, Chile started as a clinical facility in November 1998. In January 2002, two important targets were proposed in Obstetrics: to maintain a cesarean section rate below 25% and to reduce the rate of labor-related newborn hypoxic-ischemic encephalopathy (HIE). To accomplish these goals, we developed institutional clinical guidelines to standardize labor management (definitions and duration of labor phases, training for fetal heart rate monitoring and daily audits for cesarean sections and newborns with an Apgar score57 at 5 minutes). The aim of our study is to share the impact on the cesarean section rate and neonatal outcomes when appropriate clinical guidelines are used for labor management. Materials & Methods: Descriptive retrospective study. The hospital database was reviewed from November 1998 through December 2012, evaluating cesarean section, forceps and spontaneous delivery rates as well as neonatal outcomes, mainly the frequency of hypoxic-

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

ischemic encephalopathy. Statistical analysis was performed with Chisquare test for trends, with a p value set at 50.05. Clinical Cases or Summary Results: There were 88,347 deliveries between 1998 and 2012. HIE had an overall incidence of 2,47/1,000 newborns, with a progressive reduction that varied from 5,76/1,000 newborns in 1998 to 0,7/1,000 newborns in 2012. After Chi-square analysis for trends was performed, two inflection points were identified: one in 2002 and another one in 2008. Using these references, we segmented the study population into three periods, namely 1: 1998–2001, 2: 2002–2007 and 3: 2008–2012 (see graph). HIE rates (per 1,000 newborns) were 4,72 (Odds Ratio 1), 2,02 (OR 0,43) and 1,16 (OR 0,25) for periods 1, 2 and 3, respectively. This represents a 57% reduction in HIE rate between period 1 and 2 and an overall 75% reduction from period 1 through period 3 (Chi square linear tendency 54.5 [p0.05 between the periods 1 and 2) Conclusions: The use of detailed and monitored clinical guidelines for labor management had a significant impact on the HIE rate. The reduction observed on this neonatal outcome is not attributable to an increase in the cesarean section rate. Our rate of HIE is the lowest in our country and compares favorably with those published in the international literature. Keywords: hypoxic-ischemic encephalopathy, labor management Presenter: Rodrigo Latorre

ID 486

FETAL MONITORING WITH COMPUTERIZED ST ANALYSIS DURING LABOR VERSUS CARDIOTOCOGRAPHY. WHAT IS BETTER IN SUSPICIOUS CASES? O.V. Eremina, O.A. Kozlova, & O.R. Baev Maternity department of Federal Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia

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DOI: 10.3109/14767058.2014.924236

Brief Introduction: Objectives: The aim of the study was to compare sensitivity and specificity of cardiotocography complemented with ST analysis of fetal electrocardiography (FECG) versus cardiotocography (CTG) alone in term deliveries when a decision has been made to use fetal monitoring. Materials & Methods: Materials and Methods: 215 women in labour were included in the prospective study. According to CTG type (FIGO) all patients were divided into three groups: normal (138), suspicious (n = 42) and pathological (n = 35) CTG. FECG was performed both in 1 and 2 periods of labor with the use of single spiral scalp electrode connected to the STAN S31 monitor. The detailed analysis of ECG and CTG was performed. Inclusive criteria to the study group were:

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Sensitivity and specificity of CTG and CTG + ECG in second stage of labor

Sensitivity and specificity of CTG + ECG (%) Sensitivity and specificity of CTG (%)

1 group (n = 140)

2 group (n = 42)

3 group (n = 35)

66.7/100

100/100

100/92

66.7/100

80/67.5

80/57.6

singleton pregnancy at term, cephalic presentation, absence of fetal abnormalities or any signs of hypoxia (before including in study). Neonatal outcome parameters included Apgar scores at 1st and 5th minute after birth, cord artery acid-base assessment and lactate concentrations analysis. Clinical Cases or Summary Results: Results: We found a strong correlation between fetal status at birth, pH and lactate concentration in cord blood. In majority of cases of fetal hypoxia (88%) the lactate concentration was higher, than 5,2 mmol/L. This level was defined as «cut-off» for verification of fetal hypoxia. The sensitivity and specificity were higher for FECG than for CTG (86.6% and 98% Vs 78.5% and 81.5%). The most notable differences were found in second stage of labor in cases with suspicious and pathological patterns of CTG. The sensitivity and specificity for FECG in second stage of labor were 100% and 100% for suspicious CTG, 100% and 92% for pathological CTG. Whereas the sensitivity and specificity for CTG alone were 80% and 67.5%; 80% and 57.6%, respectively Conclusions: Conclusion: The high sensitivity and specificity are proof that FECG serves as a reliable method for electronic fetal intrapartum monitoring, including second stage of labour. Keywords: Hypoxia, ST-analysis, fetal ECG, CTG, lactate Presenter: Olga Eremina

Sensitivity and specificity of CTG and CTG + ECG during 1 and 2 stage of labor 1 group (n = 140)

2 group (n = 42)

3 group (n = 35)

All

Sensitivity and specificity 66.7/98.5 100/97.5 88.9/88.4 88.6/98 of CTG + ECG (%) Sensitivity and specificity 66.7/92 75/52.5 77.7/73.1 78.5/81.5 of CTG (%)

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ID 763

OUTPATIENT MANAGEMENT IN PREGNANT WOMEN WITH PREMATURE RUPTURE OF MEMBRANES (PROM) AT TERM: MATERNAL AND PERINATAL OUTCOME A.M. Knipprath-Me´sza´ros1, I. Ho¨sli1, A. Niklaus1, N. Kalberer1, & G. Vetter1

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Department of Obstetrics, University Hospital Basel, Basel, Switzerland Brief Introduction: PROM occurs in 8% of all pregnancies after 37 weeks of gestation. In more than 60% of cases spontaneous labor begins within 24 hours when it is managed expectative. There is a controversial discussion how patients with PROM should be managed: inpatient or outpatient management. To date there is insufficient data in the current literature. Materials & Methods: We retrospectively analyzed 189 patients (outpatient n = 37 (group A), inpatient n = 152 (group B)) between 06/2010 and 09/2013. The inclusion criteria for outpatient management in the low risk collective were: singleton pregnancy, ultrasound without abnormal findings, normal fetal heart rate, no laboratory findings of infection (White Blood Count512 g/L, C Reactive Protein 510mg/l), Group B Streptococcus negative, temperature 537.6  C, lack of contractions and clear amniotic fluid. In case of absence of spontaneous labor, the labour was induced within 24 hours after PROM. We compared maternal (induction of labour, mode of delivery, need of antibiotics) and fetal outcome (pH, 5min APGAR, transfer to the neonatological intensive care unit (NICU)) as well as the length of hospitalization. Clinical Cases or Summary Results: Group A/B consists of 31/105 primiparae and 6/47 multiparae. Maternal characteristics are summarized in Table 1. In group A 16 (43.2%) women were induced vs. 55 (36.2%) in group B. 73% of women in group A delivered spontaneously vs. 59.9% in group B, 16.2% had a vaginal operative delivery vs. 25.7% in group B and 10.8% had a caesarean vs. 14.5% in the outpatient population. In group A, 16% had signs of a chorioamnionitis during labour vs. 13% in group B. Three women (8.11%) in group A received an antibiotic vs. 19 (12.5%) in group B. Except for length of stay, which was shorter in group A (26 vs. 18

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

hours, p = 0.003), there was no significant difference between the two groups. Also the neonatal outcome in both groups was equally. Conclusions: Outpatient management of PROM was associated with a significantly shorter length of stay in hospital. The maternal or fetal outcome was comparable. An outpatient management of PROM in selected cases seems to be a reasonable option especially in times of increasing cost pressures. Prospective Data are required. Keywords: premature, rupture, membrane, outpatient Presenter: A.M. Knipprath-Me´sza´ros

ID 723

REAL-TIME ELECTROHYSTEROGRAPHY TO MONITOR CONTRACTIONS IN OBESE WOMEN M.W.C. Vlemminx1, H. de Lau1, R. Vullings2,3,4, C.H.L. Peters4,5, & S.G. Oei1,2 1

Department of Obstetrics and Gynaecology, Ma´xima Medical Centre, Veldhoven, the Netherlands, 2Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands, 3Nemo Healthcare BV, Eindhoven, the Netherlands, 4Medical Physics, Ma´xima Medical Centre, Veldhoven, the Netherlands, and 5Medical Physics, Jeroen Bosch hospital, ‘s Hertogenbosch, the Netherlands Brief Introduction: Monitoring uterine contractions is an essential part of cardiotocography during high-risk pregnancies. Non-invasive monitoring of contractions using external tocodynamometry can be difficult or even impossible in the increasing population of obese pregnant women. The only alternative is an intrauterine pressure catheter (IUPC). However, IUPC is invasive and can only be used during labour after rupture of membranes. A non-invasive technique based on real-time electrohysterography (EHG) has become available (PUREtrace, Nemo Healthcare, Eindhoven, the Netherlands). The electrical signals of the uterine muscle are less sensitive to fat tissue and may thus provide adequate monitoring in obese women. Materials & Methods: The EHG was tested in obese patients with failing external tocodynamometer. A single patch containing five electrodes (Tocopatch) was positioned at the maternal abdomen just below the umbilicus to record the electrical currents (see Figure 1). Consecutively, PUREtrace entails a combination of spatial and temporal filtering to retrieve the electrohysterogram, and suppress other bioelectrical signals and artefacts. The Tocopatch can directly be connected to a Philips Avalon FM30 fetal monitor (Philips, Eindhoven, The Netherlands). This allows real-time interpretation of the contractions. Clinical Cases or Summary Results: Three obese patients were included during the first stage of labour in which the external tocodynamometer failed to register uterine contractions despite repositioning and recalibrating of the transducer. BMI of the patients was 39.6 kg/ m2 (range 30–50) and all women received oxytocin for augmentation of labour. The real-time electrohysterogram showed in all cases a regular and well recognisable pattern of contractions. Conclusions: Real-time electrohysterography is a promising alternative to monitor contractions in obese women during labour. This new non-invasive technique may reduce the need for invasive intrauterine pressure catheters. Keywords: Electrohysterography, obesity, cardiotocogram, uterine activity, contractions, external tocodynamometry Presenter: Marion Vlemminx

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DOI: 10.3109/14767058.2014.924236

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ID 220

DO WE REALLY NEED A NORMAL CTG TRACE PRIOR TO COMMENCEMENT OF FETAL ECG (STAN)? M. Preti1, E. Chandraharan1, A. Archer1, V. Lowe1, & S. Arulkumaran2 1

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Women’s Directorate, St George’s Healthcare NHS Trust, London, United Kingdom, and 2St George’s University of London, London, United Kingdom Brief Introduction: BACKGROUND: Fetal ECG (ST-Analyser or STAN) is an additional test of fetal wellbeing to reduce the false positive rate of CTG. Some obstetricians currently perform a fetal blood sampling (FBS) prior to commencement of STAN, if the CTG trace prior to commencement of STAN is not normal. At George’s Maternity Unit, ST-Analyser is commenced if there is a stable baseline fetal heart rate and reassuring variability (i.e. evidence of good oxygenation of central organs) even if atypical variable or late decelerations are present on the CTG Trace prior to commencement of STAN. OBJECTIVE: To determine whether commencing fetal ECG monitoring (STAN) in a suspicious/pathological CTG trace is associated with poor perinatal outcomes Materials & Methods: Retrospective analysis of 202 CTG traces prior to commencement of STAN monitoring were included in the study after obtaining approval from our local Research Office. Perinatal outcomes (APGAR score 57 at 5 minutes, and umbilical cord arterial pH 57.05) were analysed. SETTING: Labour Ward, St George’s Hospital, London. Clinical Cases or Summary Results: 73 CTG s were normal, 37 were suspicious, and 92 were pathological prior to commencement of STAN monitoring. All the 202 traces showed normal variability (5– 25bpm) and stable baseline at commencement. 1.4% of fetuses in whom the ST-Analyser was commenced on a normal CTG had an Apgar Score of 57 at 5 minutes and none of the fetuses with suspicious or pathological CTG at commencement of STAN monitoring had an Apgar Score of57 at 5 minutes. None of the fetuses in any of these groups had a cord artery pH57.05, when STAN Guidelines were followed during labour. Conclusions: Our study shows that as long as the oxygenation to fetal central organs is maintained (i.e. stable baseline fetal heart rate and reassuring baseline variability) commencement of Fetal ECG (STAnalyser or STAN) on a suspicious or a pathological CTG Trace (i.e. in the presence of atypical or late decelerations) is not associated with poor perinatal outcomes, provided continuous Fetal ECG Signals are obtained throughout labour and STAN Guidelines are followed. Keywords: CTG, cardiotocography, STAN, ST-analyser, fetal monitoring, labour, intrapartum surveillance Presenter: Marianna Preti

ID 315

COMPARISON OF TWO CLASSIFICATION SYSTEMS OF FETAL CARDIOTOCOGRAPHY DURING LABOR IN INTERPRETING FETAL DISTRESS E. Grossi, MD1, G. Rossi, MD2, P. Antonazzo, MD1, C. Personeni, MD1, A. Laoreti, MD1, & I. Cetin, MD

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437 1

Unit of Obstetrics and Gynecology, University of Milan, Hospital Luigi Sacco, Milan, Italy, and 2Unit of Obstetrics and Gynecology, G. Fornaroli Hospital, Magenta, Italy Brief Introduction: Electronic fetal heart monitoring (EFM) represents the preferred modality of fetal surveillance during labor worldwide. In the past forty years the obstetric community has been unable to reach a broad consensus on a standardized approach to FHR (fetal heart rate) monitoring patterns. Inter- and intra observer reliability of analysis of FHR records shows high variability and inconsistence. The Royal College of Obstetricians and Gynecologists (RCOG) has classified patterns as normal, suspicious or pathological. Recently, the American College of Obstetricians and Gynecologists (ACOG) proposed a three-tiered model. The aim of this study was to evaluate inter-operator concordance and sensibility in the assessment of the FHR tracings according to these two major classifications. Materials & Methods: A retrospective analysis was performed on 150 intrapartum cardiotocography (CTG) tracings of single term women submitted to cesarean section during labor. Patients were divided in two groups according to indications to cesarean delivery: Group A (n = 75) due to suspected fetal distress and Group B (n = 75) carried out for dystocia of labor. All CTG tracings were independently evaluated by two obstetrics consultants, blinded to patient identity, mode of delivery and neonatal outcomes. Operators, defined as junior with experience 55 years and as senior with experience 45 years, classified FHR tracings according to RCOG and to ACOG criteria. Moreover, clinicians estimated umbilical artery pH using an algorithm proposed by Ross and Gala. Agreement between the two consultants and the two classifications was calculated with the Cohen’s kappa test. Clinical Cases or Summary Results: The two groups were similar for maternal age, pre-gestational Body Mass Index, parity and gestational age at delivery. Table 1 presents data about interpretation of FHR tracings by senior and junior operators and related sensitivity, specificity, positive and negative predictive values calculated considering pH 7 as cut-off. Agreement between the two consultants was better in group A (suspected fetal distress) than in group B for both classifications. (Weighted k values control group RCOG 0.44/ACOG 0.52; control group Weighted k value RCOG 0.24/ ACOG 0.30). The ACOG classification had a slighter better accuracy for both group A and group B. Major experience of senior consultant showed better results for the estimation of pH at birth (cases: 60% vs 57.3%; controls: 76% vs 65.3%). Conclusions: Correctly diagnosing fetal hypoxia and acidosis during labour is still a challenge in obstetrics. The commonly available methods of fetal surveillance are not specific and have high false positive rates. In our study we retrospectively reanalyzed FHR tracings, suggesting the two classifications used to evaluate fetal health in labor have a good sensitivity in predicting fetal distress in spite of the low prevalence of the target condition. On the contrary, inter-operator disagreement and clinical experience seem to be important limiting factors in the estimation of umbilical artery pH. Keywords: Cardiotocography tracings, fetal distress. Presenter: E. Grossi

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DOI: 10.3109/14767058.2014.924236

ID 521

HYPOXIA-INDUCIBLE FACTOR (HIF) IN HUMAN UMBILICAL ARTERY V. Vanzo1, R. Cardin2, M. Piciocchi2, A. Politi1, A. Zambon1, D. Grisafi1, L. Chiandetti1, & P. Zaramella1 1

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Department of Women’s and Children’s Health, University Hospital of Padova, Padova, Italy, 2Department of Surgery, Oncology and Gastroenterology, Section of Gastroenterology, University Hospital of Padova, Padova, Italy, and 3 Gynecologic and Obstetric Cl Brief Introduction: HIF is a heterodimeric transcription factor composed of a and b subunits inducible by hypoxia. It is the main regulator of many homeostatic mechanisms that are activated in response to the tissue hypoxia. Moreover, during prenatal development, HIF participates to several processes that take place in a condition of so-called physiological hypoxia. An increase in HIF-1a levels was found in neonatal pulmonary hypertension (Wang L, et al. 2011; Zhou Y, et al. 2011). Presently our main concern is towards the blood measure of the HIF-1a, due to it is an intracellular transcription factor. Our secondary aim is to study HIF-1a in hypoxic-ischemic

perinatal conditions. To date no data are available in the Literature on normal blood cord values of HIF. Materials & Methods: Samples were collected in the delivery room at the time of birth from 10 full-term infants (37 wk) withdrawing 2 mL of blood by puncture of umbilical artery. Simultaneously a blood gas analysis was performed. To assess HIF-1a concentrations we used ELISA kits by immunometric assay on microplate (USCN Life Science Inc., Wuhan, China). Clinical Cases or Summary Results: Median HIF-1a plasma concentration is 0.592 ng/ml, the lowest value detected is 0.188 ng/ml, the highest one is 0,988 ng/mL. Data analysis from our sample did not show a correlation between HIF-1a and the blood gas parameters such as pH, pCO2, pO2, HCO3-, BE. A relation was found between HTC and Hb with HIF-1a (R = 0.7). Conclusions: For the first time, we detected HIF-1a levels in umbilical artery. Our sample of patients did not show any correlation between HIF-1a and blood gas parameters. The relation with HTC and Hb may be justified from an upregulation in erythropoietin synthesis by mean of the HIF-1a. Keywords: HIF-1a, newborn, umbilical artery Presenter: Angela Politi

ID 726

THE SUCCESS OF CARDIOTOCOGRAPHY IN PREDICTING FETAL DISTRESS A. Codorniz1, V. Almeida2, F. Fernandes1, L. Almeida2, S. Mineiro1, T. Esteves1, J. Carvalho1 1

Gynecology and Obstetrics Department, Hospital do Espı´rito Santo, E´vora, Portugal, and 2Pediatric Department, Hospital do Espı´rito Santo, E´vora, Portugal Brief Introduction: Portugal has one of the highest cesarean (CS) rate in Europe. One of the main reasons for emergente CS is the suspicion of fetal distress based on fetal monitoring, for exemple, by cardiotocography (CTG). However, CTG interpretation is open to criticism as a method of monitoring fetal wellbeing, leading to unnecessary cesareans. Materials & Methods: Retrospective analysis of all cesareans performed in our department between 1 January and 31 December 2013 due to suspicion of fetal distress based on CTG interpretation and comparision with perinatal outcomes, using files and the delivery book. Clinical Cases or Summary Results: There were 1300 births in our department during the study period. 71 women underwent CS due to fetal distress suspected only by CTG abnormalities detected during the pre or intrapartum period. 7 newborns had low Apgar score (AS 57 at 1 minute), 13 newborns were admitted to neonatal intensivecare unit (NICU) with an average of 21 days of hospitalization for respiratory distress syndrome (2), hypoglycemia (4), sepsis (6) and one case of hypoxic ischemic encephalopathy. The remaining admissions were due to prematurity and low birthweight. Conclusions: Despite the high number of CS for suspected fetal distress, neonatal complications in these newborns were low. This may represent a large number of unnecessary cesareans. These data show the low specificity of CTG to analyze fetal oxygenation deterioration and our need for other methods of fetal wellbeing evaluation. Keywords: fetal monitoring, cardiotocography, cesarean, fetal distress Presenter: Ana Codorniz

186

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ID 378

ROLE OF FETAL PHYSIOLOGICAL SCORE (FPS) IN PREDICTING NEONATAL OUTCOMES IN THE PRESENCE OF ’PATHOLOGICAL DECELERATIONS’ K. Vigneswaran, E. Chandraharan, A. Archer, V. Lowe, & S. Arulkumaran

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Department of Obstetrics & Gynaecology, St George’s Hospital NHS Trust, London, United Kingdom Brief Introduction: BACKGROUND: A Fetal Physiological Score (FPS) has been advocated in 2012 (Table 1) to determine fetal physiological response to hypoxic stress, when recurrent atypical or late decelerations are observed on a CTG Trace. It consists of a scoring system for rise in baseline fetal heart rate from its previous baseline (adrenergic response), changes in baseline variability (oxygenation of autonomic nervous system), sum of inter-deceleration and inter-contraction intervals (time available for fetal gaseous exchange) over a 30 minute period. OBJECTIVE: To establish the validity of the Fetal Physiological Score (FPS) in a larger sample, following an initial pilot study involving 50 cases which showed that an FPS Score of 7 or higher (out of 10) was associated with excellent neonatal outcomes. Materials & Methods: METHODS: A retrospective analysis of 505 consecutive CTG traces with pathological decelerations present during the last 30 minutes of labour were analysed. A FPS score was determined for each of these traces and then correlated to APGAR Score and umbilical cord arterial pH. Clinical Cases or Summary Results: RESULTS: In total, 468/505 (92.7%) of CTGs with ‘pathological’ decelerations (late or atypical variable) during the last 30 minutes of labour had a Fetal Physiological Score of 7 or higher. When the FPS was 7 or higher, 94% of neonates had an APGAR Score 7 or more, with 96% of neonates having a Cord Arterial pH47.05. Conversely, a poor FPS score (57) was associated with APGAR scores 57 and umbilical cord gases of 57.05 in 16 out of 37 cases (43%). Conclusions: CONCLUSION: The fetal physiological score (FPS) appears to be a useful adjunctive tool to assist midwives and obstetricians in differentiating fetuses that are compensating to ongoing hypoxic stress (FPS 7 or higher) from those who require intrauterine Table 1. Fetal Physiological Score (FPS) Features of CTG with pathological decelerations during the last 30 minutes % Increase in Baseline Heart Rate from the initial baseline at the onset of monitoring Baseline Variability 55 bpm Total duration of Saltatory Pattern (425bpm) at baseline Total time spent at baseline (Sum of ‘inter–deceleration interval’) Total time in-between uterine contraction (Sum of ‘inter-contraction interval’)

0

1

2

420

10–19

510

420 minutes

10–19 minutes 510 minutes

420 minutes

10–19 minutes 510 minutes

510 minutes

10–19 minutes 420 minutes

510 minutes

10–19 minutes 420 minutes

resuscitation or delivery (FPS57). Therefore, determination of the FPS when pathological decelerations are encountered on the CTG Trace may help avoid unnecessary interventions during labour. Keywords: Presenter: Kugajeevan Vigneswaran

ID 962

PERINATAL RESULTS OF DELIVERIES WITH FETUSES IN BREECH PRESENTATION U. Tabuika1, L. Stavinskaya2, I. Sagaidac3, O. Cernetkaya4, & G. Paladi5 Department of Obstetrics and Gynecology, State University of Medicine and Pharmacy "N. Testemiteanu", Chisinau, Republic of Moldova Brief Introduction: Despite numerous studies and publications that address the management of pregnancy and delivery in women with fetuses in breech presentation (BP), the modern obstetrics has no single opinion yet on this issue. Breech presentation by itself is not an indication for caesarean section, however, combined with various complicating factors, and may impose the doctor to decide in favor of a surgical delivery. Objective of the study was to determine whether extended indications for cesarean section in case of breech presentation, are needed and to what extent it affects the improvement of perinatal indicators. Materials & Methods: A comparative analysis of major obstetrics and perinatal indicators at delivery in breech presentation of the fetus was undertaken for two time periods: 1994–2000 and 2005–2011 years. The core group consisted of 1409 births with BP registered between 2005–2011 at the Municipal level II Perinatal Center in Chisinau, Moldova; and a comparison group - 783 deliveries in BP during 1994– 2000. Clinical Cases or Summary Results: The results of the study showed that the incidence of BP, increased modestly in the main group, reaching 3.88 ± 0.07%, and 2.85 ± 0.11% in the comparison group. Analysis of the category of BP in both groups showed that in 4.40 ± 1.12% cases there was a complete beech presentation, in 84.33 ± 0.08% – frank breech presentation and in 11.26 ± 1.24% footling breech, somewhat contrary to the data presented in the literature. The need of caesarean sections has grown from 37.3 ± 1.25% in 1994 - 2000 to 76.2 ± 1.08% in 2005–2011. The proportion of urgent surgery remained at 42–45%. Analyzing the birth weight depending on the mode of delivery, it was found that more than half of the children (59.6 ± 0.78%) had a body mass between 2600 and 3500g, while 75% of them were born by caesarean section. In our view, children of this group, in the absence of other complications could be born vaginally. At the same time, in the group of newborns weighing 1600–2500g, vaginal labor occurred in 63.6 ± 1.45%, it is important to stress that the highest rate of fetal loss is registered in this group. Children weighting more than 3600 g were delivered by cesarean section in 86.6 ± 0.87% vs. 68.5 ± 1.54% of cases. At the same time there has been a significant improvement in the rate of perinatal mortality, which decreased from 49.8% to 25.5% (in the core group), particularly among full-term infants from 50.6% in the comparison group to 1.7% in the core group. A significant reduction of intra-and neonatal mortality from 19.2% to 12% in the main group was observed. The same indicator after caesarean section consisted of 2.98 %, and after giving birth vaginally - 34.9%. In 85% of cases of intra and neonatal mortality at the term of 28 -30 weeks the babies were delivered vaginally, which means that csection is a more gentle method of delivery in preterm labor in breech presentation.

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Conclusions: Increased rates of caesarean section in recent years has led to the improvement of perinatal indicators, particularly among full-term infants. At the same time, a negative dynamics was established among preterm infants due to the choice of giving birth vaginally in the group. Presented data confirm the need of expanding the indications for operative delivery in preterm labor of fetuses in breech presentation.

ID 149

Keywords: breech presentation, management of delivery, cesarean section, perinatal mortality

S.K. Choi, H.S. Ko, I.Y. Park, S.J. Kim, & J.C. Shin

Presenter: U.Tabuika

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ID 407

FETAL HEART RATE ‘CYCLING’ DURING LABOUR: DOES IT REALLY MATTER? M. Preti1, E. Chandraharan1, A. Archer1, V. Lowe1, & S. Arulkumaran2 1

Women’s Directorate, St George’s Healthcare NHS Trust, London, United Kingdom, and 2St George’s University of London, London, United Kingdom Brief Introduction: Background: Fetal heart rate cycling refers to alternate periods of activity (segments of normal variability, with or without accelerations) and quiescence (segments with apparent reduced variability with absence of accelerations). Cycling of fetal heart rate is a function of the central nervous system (CNS) and is believed to reflect fetal Rapid Eye Movement (REM) and non-REM sleep. Therefore, absence of ‘cycling’ of fetal heart rate observed on the Cardiotocograph (CTG) during labour may indicate ongoing depression of central nervous system. Objective: To determine the effect of the absence of cycling on perinatal outcomes. Materials & Methods: A retrospective analysis of 202 CTG consecutive traces was performed at St.George’s Hospital, London. Presence of cycling at the beginning of the CTG trace and at the end of the traces was analysed. Normal sleep/activity cycle was considered to be up to 50 minutes. Fetal outcomes (APGAR score 57 at 5 min and umbilical cord arterial and venous pH57.05) were determined in all cases. Clinical Cases or Summary Results: 73 CTGs were normal, 37 were suspicious, and 92 (45.5%) were pathological. All normal and suspicious traces showed evidence of cycling at the beginning of the trace.Whereas, 3.2% (n = 3) of pathological CTG traces showed no demonstrable cycling at the beginning of the CTG trace. Metabolic acidosis rate (umbilical arterial pH57.05 + BE4-12.0) in our sample of 202 cases was 2.4% (n = 5).Metabolic acidosis wasassociated with fetuses with absent cycling at the end of the CTG trace in 4 (80%) of those 5 traces.One of those 4 traces with metabolic acidosis did not show cycling at the beginning and also at the end of the trace. Overall, 2.4% (n = 5) of cases had an APGAR score 7.05 and APGAR score 47 at 5 min) Conclusions: Absence of fetal heart rate cycling at the onset of CTG recording was associated with 80% of cases with metabolic acidosis in our study. However, absence of cycling at the end of the trace is not consistently associated with poor neonatal outcome. The use of ‘cycling’ whilst interpreting the CTG traces can be useful to determine the functioning of the central nervous system. Absence of cycling of fetal heart rate at the onset of CTG recording may serve as an additional parameter to help clinicians determine fetal wellbeing in labour. Keywords: Cycling, CTG, cardiotocography, fetal monitoring, intrapartum monitoring, fetal wellbeing, fetal metabolic acidosis, fetal outcome Presenter: Marianna Preti

INVESTIGATION OF FETAL HEAD POSITION DURING LABOR BY INTRAPARTUM SONOGRAPHY Department of Obstetrics and Gynecology, College of Medicine, Catholic University of Korea Brief Introduction: The aim of this study was to was to perform an investigation of the position of the fetal head measured during the first & second stages of labor by intrapartum ultrasound. Materials & Methods: This was a prospective, cohort study involving transabdominal sonography in 290 singleton pregnancies with cephalic presentation in active labor at 37–42 weeks of gestation. Fetal head position during the first and second stages of labor were examined. Clinical Cases or Summary Results: Approximately one thirds of all vertex presentations are in the left occiput position, and 20% in the right. The occiput was posterior in 30.3%(88/290) and 10.2%(27/264) of fetuses at the first and second stages. The occiput was anterior in 13.8% (40/290) and 49.2% (130/264) of fetuses, in transverse in 55.8% (162/2900 and 40.6% (107/264) at the first and second stages, relatively. In 21.6% (19/88) of occiput posterior position during first stage of labor, there was persistence from this position the second stage of labor. Conclusions: The majority of occiput posterior positions during the first stage of labor rotate to the anterior or transverse position at the second stage of labor. Moreover, the vast majority of occiput posterior position at the second stage of labor are a consequence of persistence of this position rather than malrotation. Keywords: Ultrasound, fetal head position, intrapartum sonography Presenter: Sae Kyung Choi

ID 668

PRELABOR UTERINE RUPTURE: CLINICAL ASPECTS AND RECENT CHANGES IN RISK FACTORS S. Kim1, S Lee2,3, H Park1, J Lee3, C Park3, J Park3, J Jun3 1

Departments of Obstetrics and Gynecology, Dongguk University Ilsan Hospital, Goyang, Korea, 2Department of Obstetrics and Gynecology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea, and 3Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea Brief Introduction: To evaluate uterine rupture in antenatal period and latent phase of labor compared to that of phase of active phase of labor, with risk factors and clinical features for diagnosis. Materials & Methods: Eight cases of uterine rupture in pregnant women were identified between January 2000 and December 2011. Cases were divided into either ‘‘labor’’ group or ‘‘prelabor’’ group according to occurrence of time of uterine rupture. Prelabor group were defined as those with uterine rupture in antepartum period and during latent phase of labor, and labor group were defined during active phase of labor. And case reports forms were analyzed risk factors, clinical features, initial diagnosis and management, maternal and fetal morbidity and mortality. Clinical Cases or Summary Results: The incidence of uterine rupture is 0.05% during the 11-year study period. Maternal mortality was 0%, and perinatal mortality was 37.5% (3/8) in cases with uterine rupture in pregnant women. All fetal death occurred in prelabor group which

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Table 1. Clinical characteristics of the eight patients and first impression and management

No

Age

Parity

Risk factor

Labor

GA

Symptoms

1

36

2-0-2-2

Active phase

39 + 3

2

31

1-0-1-1

External version IVP VBAC

Active phase

39 + 6

3

34

2-0-3-2

Active phase

40 + 6

4

36

0-0-0-0

Multiparity Induction with PG/IVP Myolysis

Deceleration Arrest of descent Internal pressure not checked bradycardia Postpartum bleeding Hemoperitoneum

Latent phase

41 + 1

5 6

33 32

1-0-0-1 0-0-0-0

Prev C/S Myomectomy

Latent phase Antepartum

38 + 5 30 + 1

7

31

0-0-0-0

Myolysis

Antepartum

22 + 0

8

33

0-0-1-0

Myomectomy Placenta percreta

Antepartum

34 + 3

Initial diagnosis

L/P with vague abdominal pain Fetal tachycardia Labor pain PTL with vague Adominal pain Abdominal pain Syncope, dyspnea Abdominal pain Late deceleration

Initial management

FTP R/O fetal distress

Em C/S

R/O placental abruption R/O uterine rupture R/O uterine rupture

Em C/S Peripartum hysterectomy

Labor process

observation

Prev C/S with Labor R/O PTL

Em C/S Tocolytics

R/O medical problem

Contact other team Em C/S

R/O fetal distress

Table 2. Results of mother and fetus in uterine rupture cases

No 1 2 3 4 5 6 7 8

Rupture site Right wall (Vertical) Lower uterine seg Left lat (vertical) Ant wall (vertical) Lower uterine segment Fundus Post wall (vertical) Post wall (vertical)

Operative management 0

1 repair 10 repair Hysterectomy 10 repair 10 repair 10 repair 10 repair 10 repair

Transfusion RBC17, FFP10 PC 24 (-) RBC 22 FFP 17 PC 12 RBC 3 (–) RBC 6 FFP 3 RBC 5 RBC 5 FFP 3

patients occurred uterine rupture in antenatal period and latent phase of labor. Conclusions: The poor perinatal survival in prelabor group compared than labor group, reflecting of difficulties of diagnosis and decision of Cesarean surgery in preterm period with only suspicion. Nevertheless, keeping in mind recent highlighted risk factor including past risk factors, imply early detection of uterine rupture along with early management. Keywords: Uterine rupture, Obstetric labor complication, Perinatal mortality, Maternal mortality Presenter: S. Kim

ID 701

THE INITIAL EXPERIENCE WITH GBS INTRAPARTUM TESTING MANAGEMENT D. Ramasauskaite1, S. Kiveryte2, G. Opolskiene1, D. Lauzikiene1, G. Drasutiene1, & Z. Kucinskiene2 1

Center of Obstetrics and Gynaecology of Vilnius University, Vilnius, Lithuania, and 2Department of physiology, biochemistry, microbiology and laboratory medicine, Medicine faculty of Vilnius University, Vilnius, Lithuania Brief Introduction: About 15.3% of pregnant women are GBS carriers in Lithuania; 6.4% of newborns become colonized during labor and

Hospital day

AS 1/AS5

Cord pH

Survival

14 5 11 5 6 11 11 7

8/9 6/8 4/9 0/0 9/9 0/0 0/0 2/7

7.115 7.197 7.167 NA 7.250 NA NA 7.072

Y Y Y N Y N N Y

0,36% of them will develop severe systemic disease. The aim of antenatal screening is to identify GBS colonized mothers suitable for treatment with intrapartum antibiotic prophylaxis (IAP). GBS colonization is not stable until the time of delivery and between 30–40% of positive screening tests at 35–37 weeks’ gestation are negative at labor while 5–12% of negative tests will become positive, resulting in inappropriate antibiotic treatment or lack of treatment. Rapid polymerase chain reaction (PCR) assays have been suggested as an effective tool in testing women in labour for GBS and are believed to have a higher sensitivity for low levels of GBS colonization. Materials & Methods: During a period of 4 moths (July 2013 – October 2013) all women who were not screened for GBS colonization or culture for GBS was taken more than 4 weeks ago with singleton pregnancy at beginning of labor were enrolled. Exclusion criteria: planned cesarean section, recent use of systemic or topical antibiotics. 2 vaginal-rectal swabs were collected from each patient – one for culture and another for analysis by GeneXpertÕ System. The XpertÕ GBS assay uses real-time polymerase chain reaction (rtPCR) to directly detect the GBS genome cfb gene sequence in vaginal/rectal specimens. Clinical Cases or Summary Results: 55 women were enrolled during study period – 11 (20%) women were not screened for GBS during pregnancy and 44 (80%) were screened earlier than 4 weeks before delivery. 9 women were GBS positive (16.4%) – rtPCR was positive in all cases and culture was positive in 9 cases too, but 3 cases after additional tests for interpreting doubtful results. The results were obtained from 40 to 60 minutes for rtPCR and in 24–72 hours for culture. GBS colonization was not stable – 4 (9.1%) women from 44 had the different results from the the results obtained during screening for GBS (earlier than 4 weeks before labour). 1 woman was no longer carrier at labour and 3 patients had become carriers at labour and get IAP.

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Conclusions: Real time PCR assay is a rapid and highly accurate method of identifying GBS infection compared to culture based screening. It could enhance the accurate identification of candidates for IAP, including women with no prenatal screening (preterm rupture of membranes or preterm labor) or screened earlier than 4 weeks before labour. Keywords: GBS colonization, PCR method, culture Presenter: D. Ramasauskaite

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ID 541

ABNORMAL FETAL QRS WAVEFORMS DURING LABOUR AND IMPLICATIONS FOR ST INTERVAL ANALYSIS J. Sletten1, & J. Kessler2 1

Department of Clinical Science, University of Bergen, Bergen, Norway, and 2Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway Brief Introduction: Abnormalities of the QRS complex of the fetal ECG in intrapartum monitoring have been described previously, but their significance for the ST interval analysis is uncertain. The aim of the present study was to describe the QRS complex of the fetal ECG in relation to fetal presentation and explore the effect of an abnormal QRS complex on automated ST interval analysis. Materials & Methods: Case-control study on high-risk singleton deliveries with gestational age of 435 + 6 weeks, monitored CTG and ST analysis of the fetal ECG. Recordings of fetuses in breech presentation (n = 433) were matched with fetuses in cephalic presentation in a 1:1 fashion. Outcome measures: Frequency of QRS complex abnormalities (Deep Q or S, Split Q, R or S, widened QRS), ECG tracing abnormalities and ST signal quality. Clinical Cases or Summary Results: An abnormal QRS complex was found in 15.2% of the recordings without variation according to

presentation (breech vs. cephalic: 13.9 vs. 16.2%, p = 0.3). Split R (8.4%) and deep S (8.2%) were the most common abnormalities. Their occurrence was not dependent on fetal presentation. Deep Q (4.4% vs. 0.7%, p = 0.001) and split Q (1.8% vs. 0, p = 0.005) were more common in breech presentation. The abnormal QRS impacted on the automated ECG tracing in 114/866 (13.2%) of the total population, unrelated to fetal presentation. The most common finding was a varying placement of R and S in cases of a split vector (n = 112) (Fig. 1). Deviance of the ECG baseline above null was less frequent (n = 33, 3.8%), but occurred more often in breech presentation (5.3 vs. 2.3%, p = 0.02) (Fig. 1). ST events due to an erroneous identification of the ECG vectors or misplacement of the ECG baseline were found in n = 16 (3.7%) fetuses in breech presentation compared to n = 10 (2.3%) in cephalic presentation (p = 0.3). During the first stage of labor, the ST signal was more often impaired in cases of abnormal compared to normal QRS (15.2% vs. 7.4%, p = 0.006). Conclusions: The appearance of the QRS complex of the fetal ECG is dependent on fetal presentation. QRS abnormalities have an impact on the automated ECG tracing and subsequent ST analysis. Although infrequent, clinicians should be aware of this phenomenon, which can be depicted on the monitor by scrutinizing the shape and appearance of the averaged ECG complexes. Keywords: Fetal ECG, intrapartum monitoring, ST analyis, fetal presentation Presenter: Julie Sletten

ID 899

THE FREQUENCY OF STAN EVENTS SUBTYPES AND ASSOCIATIONS WITH HYPOXIC ISCHAEMIC ENCEPHALOPATHY A. Ugwumadu1, G. Lowe2, L. Lo Bello3, A. Archer4, E. Chandraharan5, & S. Arulkumaran6 1

Obstetrics and Gynaecology Dept., St. George’s Hospital, London, United Kingdom, 2Obstetrics and Gynaecology Dept., St. George’s Hospital, London, United Kingdom, 3Obstetrics and Gynaecology Dept., IRCCS materno infantile Burlo Garofolo, Trieste, Italy, 4Obstetrics and Gynaecology Dept., St. George’s Hospital, London, United Kingdom, 5Obstetrics and Gynaecology Dept., St. George’s Hospital, London, United Kingdom, and 6Obstetrics and Gynaecology Dept., St. George’s Hospital, London, United Kingdom Brief Introduction: Analysis of the ST-segment of the fetal electrocardiogram was introduced to support the CTG, detect intrapartum fetal myocardial stress, and reduce the frequency of metabolic acidosis and operative delivery for fetal compromise. Three categories of ECG changes are related to myocardial stress namely episodic T/ QRS ratio, baseline T/QRS ratio, and biphasic ST segment. Whilst T/ QRS ratio changes reflect cathecolamine drive of myocardial glycogenolysis, the biphasic ST segment changes reflect hypoxia and a range of other abnormalities of ventricular repolarisation and impaired myocardial cell performance. The aim of the study was to determine the distribution of the three types of abnormal intrapartum fetal ECG changes and their association with hypoxic ischaemic encephalopathy (HIE). Materials & Methods: Retrospective analysis of 6,205 term, singleton, cephalic fetuses monitored with STAN at St. George’s Hospital, London January 2007 - June 2013. STAN clinical guidelines were used for monitoring and interpretation. Metabolic acidosis was assessed in cord arterial and venous blood at delivery. Obstetric and neonatal data were retrieved from computerised records. The prevalence of the three types of STAN events and their associations with HIE were calculated.

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Clinical Cases or Summary Results: A total 6205 babies were monitored with STAN during the period of study. In 4,560 cases (73.4%) the STAN events did not prompt operative delivery. Baseline T/QRS rise was the commonest event prompting operative delivery (19.3%), followed by episodic T/QRS rise (4.7%) and then biphasic events (2.5%). There were 30 cases of HIE amongst babies monitored with STAN of whom baseline T/QRS rise was present in 14/30, episodic rise was present in 4/30, and biphasic events were present in 2/30. In 10 cases of HIE the STAN events were judged to be insufficient to prompt intervention for normal CTG (3/30), fetal sepsis (3/30), traumatic delivery (4/30). Conclusions: Of the tree subtypes of STAN events, baseline T/QRS rise appears to be the more frequent abnormality. Approximately 6% of STAN events were biphasics. A third of cases of HIE were not detected by STAN because of non-adherence to guidelines, undiagnosed fetal infection, fetal trauma. Keywords: STAN events, hypoxic ischaemic encephalopathy

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Presenter: Leila Lo Bello

ID 494

IS VALID STREPTOCOCCUS AGALACTIE CULTURE? A. Carballo Garcı´a1, J. Hijona Elo´segui1, & M. Artiles Morales2 1 Servicio de Ginecologı´a y Obstetricia; Complejo Hospitalario de Jae´n, Jae´n, Spain, and 2Servicio de Ginecologı´a y Obstetricia Hospital San Agustı´n, Linares; Spain

Brief Introduction: The group B streptococcus (GBS) is a gram positive organism that frequently colonizes the lower genital tract of women. Usually it is a non-pathogenic microorganism, but in some situations their presence in the vagina or rectum may be able to produce chorioamnionitis, preterm delivery and neonatal infection. Materials & Methods: We performed a prospective longitudinal study in which the aim was to establish what percentage of patients there is a discrepancy between the result of antepartum exudate, performed at week 35–37 and made at the time of delivery; and if there is a related factor. Clinical Cases or Summary Results: The sample was 104 patients. In the first exudate obtained a total of 24 positive results (21.15%) and 82 (78.85%), we were negative and the second discharge positive results obtained 24 (23.07%) and 80 (76.93%) Negative. The rate of discordance by negative (positive patients having the first discharge and the second discharge negative) was 7.6% and the rate of discordance by positivity (patients were negative first and positive second swab exudate) was 9.5%. Conclusions: The main reflection that can be drawn from our work is that there is an acceptable agreement between the result of the discharge of 35–37 weeks and performed at the time of delivery; however, we found a disturbing rate mismatch. Up to 26 days there is a good correlation in the negative; these last days, this correlation ceases to exist. Although we found no relationship between various factors and disagreements between exudates, it seems to disappear when analyzing how factors influenced each other; except that between the days between the two exudates and exudate positivization second. Probably an increase in sample size results in a statistically significant relationship. Keywords: Group B streptococcus; delivery, culture Presenter: A. Carballo

ID 469

NEUROLOGIC LONG-TERM OUTCOME AFTER INTRAPARTUM MONITORING WITH CARDIOTOCOGRAPHY AND ST ANALYSIS OF THE FETAL ELECTROCARDIOGRAM – AN OBSERVATIONAL STUDY J. Kessler1,3, D. Moster2,3,4, & S. Albrechtsen1,3 1

Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway, 2Department of Pediatrics, Haukeland University Hospital, Bergen, Norway,

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Department of Clinical Science, University of Bergen, Norway, and 4Norwegian Institute of Public Health, Bergen, Norway Brief Introduction: Previous research on the outcome of deliveries monitored with cardiotocography and ST analysis of the fetal electrocardiogram (STAN) has focused on short-term morbidity like neonatal encephalopathy and cord acidosis at delivery. The aim of the present study was to find the prevalence of cerebral palsy (CP) in STAN monitored high-risk deliveries and describe the clinical performance of intrapartum monitoring in those cases. Materials & Methods: The study population were all children born as singleton between 01.01.2004 and 31.12.2008 with a gestational age at delivery of435 + 6 weeks at Haukeland University Hospital, Bergen, Norway. All cases born during the study period with a diagnosis of CP (ICD 10 diagnoses G 80–83) were retrieved from the hospital system of patient administration at age 4.7 through 9.7 years. The diagnosis and type of CP was linked to an existing database on intrapartum monitoring, maternal and neonatal outcome of the study population. STAN monitoring was reserved to high-risk deliveries (n = 6010), while those with low-risk were monitored with cardiotocography or auscultation (n = 17193). Clinical Cases or Summary Results: A total of 34 cases out of 23203 children (0.15%, 95%CI 0.10–0.20) had a diagnosis of CP. Eleven cases were monitored with STAN, while the remaining 23 cases had cardiotocography or intermittent auscultation. This corresponds to a prevalence of CP of 0.18% (95%CI 0.10–0.33) and 0.13% (95%CI 0.09– 0.20) respectively, not significantly different from each other (p = 0.4). The frequency of moderate or severe encephalopathy (NE) among cases with CP was 36.4% after STAN monitoring, compared to 17.4% after monitoring with CTG or auscultation (p = 0.4). Among the STAN-monitored cases, n = 2 had spastic quadriplegic CP, and n = 3 had each of the dyskinetic, spastic diplegic and hemiplegic types. The four CP cases with NE were characterised by: (1) abnormal CTG, no ST signal available 2.5 hours prior to delivery, cord metabolic acidemia; (2) intrapartum fever, ST event and preterminal CTG, normal venous acid base; (3) severe shoulder dystocia, normal CTG and ST, no acid base data; (4) suspicious CTG, normal ST, moderate cord acidemia In 5 of 11 CP cases (45%) STAN clinical guidelines indicated intrapartum hypoxia, with the intervention being delayed beyond 20 minutes in 3 cases. Conclusions: The prevalence of cerebral palsy did not differ in relation to the type of intrapartum monitoring and the presumed risk of hypoxia during delivery. Non-adherence to the STAN clinical guidelines was evident in the majority of the CP cases where STANsurveillance had indicated intrapartum hypoxia. Keywords: fetal ECG, ST analysis, cerebral palsy, long-term outcome Presenter: Joerg Kessler

ID 329

FETAL ELECTROCARDIOGRAM ANALYSIS IN POSTPARTUM PREGNANCIES G. Caracostea, F. Stamatian Obstetric & Gynecology Clinic I, University of Medicine and Pharmacy ‘‘Iuliu Hatieganu’’, Cluj-Napoca, Romania Brief Introduction: Fetoplacental insufficiency and intrapartum hypoxic events are important determinants of perinatal outcome in postterm pregnancies. The fetal capacity to respond to hypoxic episodes depends on their severity, duration and recurrence. Fetal electrocardiogram analysis brings valuable information regarding the progressive adaptive mechanisms employed by the fetal heart in a hypoxic environement. Our paper aimed to assess these ST changes of intrapartum fetal electrocardiogram in postterm pregnancies.

Materials & Methods: A prospective observational study including singleton pregnancies over 41 completed weeks of gestation. The STAN S31 was used to monitor fetuses during labor. Umbilical cord blood analysis, Apgar score at 5 minutes, monitoring in neonatal intensive care unit (NICU) and neonatal outcomes were evaluated. Clinical Cases or Summary Results: Out of 49 patients, ST analysis identified 17 with ST changes during labor (34.69%). 12 traces recorded ST events, 3 cases had episodic rise of T/QRS value and 2 cases had biphasic ST grade 1. A significant correlation was found between ST events and severe neonatal acidotic status (pH57.00 and base excess 5-12mmol/l; RR = 15.95, 95% CI 1.93–116.45) (p = 0.0007). There was one case with a mild form of hypoxic-ischemic encephalopathy in the ST events group. 3 newborns with intrapartum ST events were monitored in NICU (RR = 2.00, 95% CI 0.66–6.03) (p = 0.24). Apgar score57 at 5 minutes was recorded in 3 cases with ST events (RR = 2.50, 95% CI 0.76–8.19) (p = 0.14). Conclusions: In our study conducted on postterm pregnancies, results showed a significant correlation between fetal adaptive mechanism during hypoxic events manifested as ST intrapartum changes and neonatal acidotic status. Keywords: fetal, electrocardiogram, postterm, acidosis Presenter: Gabriela Caracostea

ID 765

HOW TO IMPROVE ST-ANALYSIS IN FETAL MONITORING: RELATIVE VERSUS ABSOLUTE T/QRS RATIO RISES A.D.J. Hulsenboom1, R. Vullings2, J.O.E.H. van Laar1, M.B. van der Hout-van der Jagt2, S.G. Oei1,2 1

Department of Obstetrics and Gynaecology, Ma´xima Medical Centre, Veldhoven the Netherlands, and 2Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands Brief Introduction: ST-analysis is a promising method to detect intrapartum fetal metabolic acidosis (FMA). However, many false positives lower its specificity, leading to avoidable interventions and neonatal morbidity. Reducing false positives is preferable to current strict STAN guidelines. Present ST-analysis compares absolute T/QRS ratio rises to its baseline. As fetal heart axis orientation varies, fetal vector ECG parameters vary, resulting in interpatient T/QRS baseline differences. We hypothesize that patients with a higher T/QRS baseline are more prone to exceed absolute thresholds. We suggest analyzing relative rather than absolute T/QRS ratio rises would improve diagnostic accuracy. This study explores whether relative ST-analysis has distinctive value in detecting FMA and compares both methods. Materials & Methods: A retrospective case-control study was performed in a tertiary care teaching hospital with twenty healthy human fetuses during labour at term, of which 10 had an umbilical artery pH 57.05 (cases) and 10 had an arterial pH 47.20 (controls) after birth. Fetal electrocardiogram was recorded with single helix scalp electrode (Goldtraceä), a maternal skin electrode and a STAN S31Õ monitor (Neoventa Medical, Mo¨lndal, Sweden). Relative T/QRS values were calculated based on stored data from these registrations. Absolute ST-events were obtained from Event Log of STANviewer (Neoventa Medical). Absolute ST-events were defined as occurrence of either baseline or episodic ST-events. A receiver operator curve (ROC) of relative ST-analysis was constructed using SPSS Statistics 22. A cut-off value was determined at optimal specificity, which was used to calculate other test characteristics. Sensitivity, specificity, positive likelihood ratio (LR+), negative likelihood ratio (LR-) and diagnostic odds ratio (OR) were calculated for both relative and absolute ST analysis.

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192 Primary outcome measures were area under the curve of the ROC curve of relative T/QRS ratio and test characteristics of both relative and absolute ST analysis. Clinical Cases or Summary Results: Relative ST-analysis showed an area under the curve of 0.990 (95% CI 0.958–1.000). The optimal cut-off value of T/QRS ratio rise was determined at 70%. Relative vs. absolute ST-analysis showed specificity of 100% vs. 40% (p = 0.031); sensitivity of 90% vs. 90%; LR+ of infinity vs. 1.5; LR- of 0.1 vs. 0.25; OR of infinity vs. 6, respectively. Conclusions: Relative ST-analysis shows excellent distinctive value in this population. Specificity of this method is better than in absolute STanalysis (without CTG) at comparable sensitivity. However, this study only included patients with extreme pH values at birth; no patients with umbilical artery pH between 7.05 and 7.20 were included. Besides, the occurrence of biphasic events and CTG interpretation were not considered in this study, as we aimed to improve T/QRS baseline dependent aspects of ST-analysis. Nevertheless, relative ST-analysis seems to be a promising method for detection of metabolic acidosis during labour, as its specificity, LR- and OR are better than in absolute ST-analysis. Further research is required to determine whether our cutoff value is also appropriate in a large population that includes the complete clinical range of pH values; followed by external validation. Once validated, this method may improve detection of compromised fetuses during labour, decreasing unnecessary artificial deliveries and improving neonatal outcome. Keywords: Fetal electrocardiography, fetal monitoring, ST-event, metabolic acidosis, T/QRS, sensitivity and specificity, diagnostic accuracy Presenter: A. D. J. Hulsenboom

ID 865

INFLUENCE OF BREECH DELIVERY ON NEONATAL PROGNOSIS: A RETROSPECTIVE STUDY OF 896 SINGLETON PREGNANCIES IN A TUNISIAN MATERNITY LEVEL III H. Laajili1, F.Z. Chioukh1, A. Hajji, K. Ben Ameur1, R. Faleh, K. Monastiri1, & M. Sakouhi 1

Department of gynecology and obstetrics Department of reanimation and neonatal medicine – Maternal and neonatal Center of Monastir 5000 Tunisia Brief Introduction: Authors aim to analyze the decisional elements of delivery route and study the neonatal mortality and morbidity associated with breech presentation. Materials & Methods: We conducted a retrospective study of 896 newborns from singleton breech pregnancies, in which the term is greater than or equal to 28 weeks over a six years period. Clinical Cases or Summary Results: Neonatal mortality rate is estimated at 1.2%. We found no significant relationship between Apgar score and maternal age, parity, and BMI. Primiparity and obesity are not bad prognostic factors in breech presentation. Analysis of labor factors showed no significant relationship between Apgar score and cervical dilatation at admission to the labor room, premature rupture of membranes, working time and route delivery. A low Apgar score is more common with dynamic test of labor than with prophylactic cesarean section, with no significant difference. Conclusions: Use of protocol and delivery scores for breech would objectively select eligible parturient for vaginal delivery. Keywords: Breech - Breech dynamic test - Neonatal morbidity Neonatal prognosis Presenter: FZ Chioukh

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

ID 491

ANALYSIS OF CTG INTERPRETATION OF EXPERTOBSTETRICIANS – IS IT TIME FOR CHANGE? L. Hruban1, P. Janku˚1, J. Spilka2, V. Chuda´cˇek2, M. Bursˇa2, M. Huptych2, A. Hudec3, M. Kacerovsky´4, M. Koucky´5, L. Lhotska´2, M. Procha´zka6, V. Korecˇko3, J. Seget’a7, O. Sˇimetka7, V. Unzeitig7 1

Department of Obstetrics and Gynaecology, University Hospital of Masaryk University in Brno, Czech Republic, 2 Department Of Cybernetics, Faculty of Electrical Engineering, Czech Technical University in Prague, Czech Republic, 3 Department Of Gynecology and Obstetrics, Teaching Hospital of Charles University in Plzen, 4Department Of Gynecology and Obstetrics, Teaching Hospital of Charles University in Hradec Kralove, 5Department Of Gynecology and Obstetrics, Teaching Hospital of Charles University in Prague, 6Department Of Gynecology and Obstetrics, Teaching Hospital of University in Olomouc, and 7Department Of Gynecology and Obstetrics, Teaching Hospital of University in Ostrava Brief Introduction: To make clear and focused argument for introduction of the computer aided CTG evaluation based on thorough analysis of clinical evaluation. To evaluate intra and inter-observer agreement of obstetricians decision making and to relate their assessment to objective neonatal outcome measure such as pH. Materials & Methods: Nine obstetricians annotated 638 recordings (552 unique). The evaluation of each record was divided into four stages (two 30 minutes windows in the I. stage, one window in the II. stage, labor evaluation). The intra/inter observer agreement was evaluated using proportion of agreement and kappa value. The sensitivity and specificity was evaluated with respect to different neonatal outcome measures (pH, base deficit and Apgar score). Clinical Cases or Summary Results: The overall proportion of agreement was 48% with 95% confidence intervals (CI) (CI: 47–50). The proportions of agreement with respect to different classes were: 57% (CI: 54–60) for normal, 46% (CI: 44–48) for suspicious, 41% (CI: 36–46) for pathological, and 15% (CI: 10–21) for uninterpretable. The sensitivity and specificity of majority voting of clinicians with respect to umbilical artery pH (pH  7.05) 0.41 (CI: 0.35–0.47), 0.86 (CI: 0.82– 0.90), and for base deficit (BDecf  12) were 0.50 (CI: 0.44–0.56), 0.86 (CI: 0.82–0.90), respectively. Conclusions: The reported intra/inter observer variability, even when evaluated in respect to the pH and BDecf (objective measures of the neonatal outcome), is large and this holds irrespective of clinicians experience or work place. The results from this study support the agreement for introducing computer aided evaluation of CTG records. Keywords: cardiotocography, inter-observer variability, intra-observer variability Presenter: Lukas Hruban

ID 135

ANYTIME, ANYWHERE: TRANSMISSION OF ELECTRONIC FETAL MONITORING USING VOICE OVER INTERNET PROTOCOL TECHNOLOGY (SKYPE) S. Nematian1, L. Rivera2, & J. Sison3

193

DOI: 10.3109/14767058.2014.924236 1

Table 2. Reliability of Skype reading versus actual reading for Fetal Heart Rate

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Department of Obstetrics and Gynecology, University of Santo Tomas (UST) Hospital, Manila, Philippines, 2 Department of Obstetrics and Gynecology, University of Santo Tomas (UST) Hospital, Manila, Philippines, and 3 Department of Obstetrics and Gynecology, University of Santo Tomas (UST) Hospital, Manila, Philippines

Baseline FHR (range)

Brief Introduction: Cardiotocographic (CTG) monitoring remains the basis of intrapartum surveillance. The availability of the primary care physician to interpret the results limits the usefulness of EFM especially of problematic tracings. Nowadays, there are means for the off-site obstetrician to view the tracings and check for quick intervention and in turn limiting inter-observer variability in interpretation. This paper would want to assess the feasibility of using familiar, widespread and cost-effective technology to allow remote interpretation of real-time readings using the Voice Over internet protocol technology (Skype). Materials & Methods: 1-year cohort study of 122 tracings from 60 patients (32 AOG and beyond) at the USTDRCD. After consenting, their EFM tracings were sent via Voice Over Internet Protocol to a perinatologist reader at the same time the procedure was done. The actual EFM tracings were interpreteted one week from transmission. Cohen’s kappa coefficient was used to measure intra-rater reliability. For the presence of accelerations and decelerations, values were encoded 1 for the presence and 0 for the absence. Good variability encoded as 1 and poor variability as 0. The proportion of presence of accelerations and decelerations, adequate power and poor variability were computed and compared between the two groups using concordance correlation coefficient for the agreement between two variables. Clinical Cases or Summary Results: Interpretation for the baseline fetal heart tones was highly reliable with 93% of tracings in agreement. Variability, presence of accelerations and decelerations, uterine contraction interval, intensity and duration were 100% in agreement with perfect concordance between readings sent via Voice Over Internet Protocol (Skype) versus that which were read with the actual strips one (1) week after. Conclusions: There was perfect agreement between variability, uterine contraction characteristics and the presence/absence of accelerations and decelerations. Baseline fetal heart tones were 93% in concordance with the actual strips which is not statistically significant. Keywords: Electronic Fetal Monitoring, Skype (voice over internet protocol), University of Santo Tomas Hospital (UST) Presenter: L. Rivera

In agreement Not in agreement Lin’s coefficient of concordance Interpretation

Value 113 (93%) 9 (7%) 0.976 Highly reliable

Table 3. Reliability of Skype reading versus actual reading for Fetal Heart Rate Variability Variability (Good = 1 Poor = 0) In agreement Not in agreement Cohen’s Kappa Coefficient of Reliability Interpretation

122 (100%) 0 1.00 Perfect reliability

Table 4. Reliability of Skype reading versus actual reading for Presence/ Absence of Accelerations Presence of accelerations Present = 1 Absent = 0 In agreement Not in agreement Cohen’s Kappa Coefficient of Reliability Interpretation

122 0 1.00 Perfect reliability

Table 5. Reliability of Skype reading versus actual reading for Presence/ Absence of Decelerations Presence of decelerations Present = 1 Absent = 0 In agreement Not in agreement Cohen’s Kappa Coefficient of Reliability Interpretation

122 0 1.00 Perfect reliability

RESULTS For this study, the proponents were able to gather 122 tracings for interpretation of results. A sample size of 122 achieves a power of 98% to detect difference between the two groups. In comparing the EFM interpretation using Skype with that of actual EFM interpretation done by the same perinatologist, there was no statistically significant difference found. Table 1. Number of patients, age of gestation and number of tracings

Age of gestation 32–33 weeks 33–34 weeks 34–35 weeks 35–36 weeks 36–37 weeks 37–38 weeks 38–39 weeks 39–40 weeks 40–41 weeks 41–42 weeks TOTAL

Number of patients

Number of tracings

1 2 1 2 2 6 14 19 12 1 60

3 4 2 3 5 14 28 36 23 4 122

Table 6. Reliability of Skype reading versus actual reading for interval of uterine contractions Uterine contractions, interval, in mins (range) In agreement Not in agreement Coefficient of Concordance Lin’s coefficient of concordance Interpretation

122 0 1.00 Perfect concordance

Table 7. Reliability of Skype reading versus actual reading for duration of uterine contractions Uterine contraction duration, in sec (range) In agreement Not in agreement Coefficient of concordance Lin’s coefficient of concordance, using midpoint Interpretation

122 (100%) 0 1.00 Perfect concordance

194

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Table 8. Reliability of Skype reading versus actual reading for intensity of uterine contractions

ID 731

Uterine contraction intensity 0 = none 1 = mild 2 = moderate 3 = strong In agreement Not in agreement Wilcoxon Rank Sign Test W+ = 0 W() = 0 Z = 0 p = 0.000001 Interpretation

122 (100%) 0

Perfect agreement of Rankings

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ID 841

PULSE-OXIMETRY OBS500, OUR EXPERIENCE IN THE LAST 5 MONTHS M. Valverde, M. Esteva, R. Martı´nez de la Ossa, & E. Iniesta 1

Obstetric and gynaecology service. Area de Gestio´n Sanitaria Sur de Granada. Granada. Spain, 2Obstetric and gynaecology service. Area de Gestio´n Sanitaria Sur de Granada. Granada. Spain, 3Obstetric and gynaecology service. Area de Gestio´n Sanitaria Sur de Granada. Granada. Spain, and 4Obstetric and gynaecology service. Area de Gestio´n Sanitaria Sur de Granada. Granada. Spain Brief Introduction: The fetal pulse oximetry is a technology of constant fetal monitoring that determines the arterial saturation of oxygen (SaO2) in fetal blood. The arterial saturation of oxygen reflects the quantity of available this one for the fetal metabolism.The pulse oximetry OBS500 had a fetal sensor that places in fetal back and sends it to a monitor that sues her and expresses it. After numerous studies the normal values have showed for oxygen saturation in the fetuses were up to 30% and reflect an acid basic fetal normal condition and values lower than 30% indicate that the fetus can be in risk of fetal acidosis and it will be tolerated during a short period of time. The aim of our study is to value the efficiency of this method of monitoring. Materials & Methods: We did and observational study about all clinical cases that we use this monitoring method in the last 5 months. We analyzed obstetrical an fetal information. Clinical Cases or Summary Results: In the last 5 months in our center; AGS South of Granada, we have placed 11 sensors and our experience shows the following results: – Average of fetal arterial saturation: 77% – Average of minuits of monitoring: 53 min – End of pregnant: Spontaneous child birth: 3 Instrumental vaginal childbirth: 4 Cesarean section: 5 – End by risk of loss of fetal well-being: Instrumental vaginal childbirth: 2 Cesarean section: 2 – Average of umbilical fetal blood sampling: Arterial: 7,22 Venous: 7,34 Conclusions: Our experience is adapted, the results that we have obtained are good and have showed us that it is good pulse oximetry that it adapts to the needs of the current delivery rooms and it give us many very important information to follow the childbirth. Our study is very small and they would be necessary studies with a major sample. Keywords: pulse oximetry; pregnan; FHR monitoring; intrapartum monitoring Presenter: Mercedes Valverde

STRATEGY FOR THE PREVENTION OF THE MASSIVE OBSTETRICAL HEMORRHAGE IN THE PERINATAL CENTER A.N. Strizhakov, L.D. Belotsercovtseva, I.I. Kilitcheva, & I.V. Ignatko Russia, Moscow, First Moscow State Medical University IM SechenovRussia, Surgut, Surgut Clinical Perinatal Center, Medical Institute of Surgut State University, Khanty-Mansi Autonomous Region Brief Introduction: Obstetrical hemorrhage is a frequent and severe complication of pregnancy and childbirth. Overall, trends in the maternal postpartum women with significant and massive blood loss (including the so-called «near miss») shows a significant downward trend. In the perinatal center of great importance in our work is given to ongoing training of staff. Used for this purpose: video surveillance, individual discussion of not only personal, but also the most serious errors, the rating sheets medical personnel, individual and group training, regular taking tests on skills to assist in emergency situations. Maternal mortality from bleeding consistently rankes first in the world and is headed by the so-called "big five" causes of maternal mortality. Materials & Methods: Aim of this study was to evaluate the effectiveness of prevention strategies for the massive obstetric hemorrhage in Surgut perinatal center (clinical base of the Department of Obstetrics and Gynecology, Medical University Surgut State University, Khanty-Yugra). Overall trend in the number of women in childbirth and postpartum women with significant massive hemorrhage (includ-ing the so-called «near miss ») shows a significant downward trend. So, in 2006, all women with a significant and massive blood loss was 47 (8.2 %), in 2007 - 50 (8.1 %), in 2008 30 (4.6 %), in 2009 - 31 (4.5 %), in 2010 - 37 (4.9 %), in 2011 - 39 (5.0 %), in 2012 - 39 (4.4 %) within 6 months of 2013 - 18 (4.1 %). Clinical Cases or Summary Results: The excluded maternal deaths were -46% for the period from 2006 to 2013 years. Separately we accounted the number of women with severe acute maternal morbidity due to obstetric hemorrhage (survivors, but left without a uterus). General dynamics was -85.7% (from 26.8 % in 2006 to 0.4 % for 6 months of 2013). It should be noted that the fundamental importance were organizational arrangements and the introduction of modern technologies: in 2007 - introduced active tactics III stage of labor in 2008 - managed by balloon tamponade, in 2012 - training of medical staff (second-ary and tertiary) and fee exemptions. Conclusions: First: training in small groups; individual (in the workplace, in the simulator, using the resources of video, viewing and analysis of educational videos, work instruction in the workplace). Second: the formation of branches and the formation of duty brigades (obstetrician-gynecologist - 4, including 1 - leader; anesthetist-resuscitator - 2, 1 of them experienced; transfusiologist, hour laboratory diagnostics). Third: entry into the uterine cavity is not more than 1 times. Ensure the collection and early involvement of senior colleagues if necessary transition to the surgical step to stop bleeding (including physician - vascular surgeon). Fourth: the degree of implementation of technology and a clear algorithm for sequential execution - the protocol of care for obstetric hemorrhage: - active management of the third stage of labor; - the use of modern drugs (tranexamic acid, carbetocin, protrompleks, NovoSeven); - the use of blood products; - autoplasmadonation, reinfusion of autologous blood; - Controlled by balloon tamponade; - Compression sutures; Internal iliac artery ligation, hysterectomy. Fifth: the organiza-tion of the workplace - equipment delivery room/operating room.

195

DOI: 10.3109/14767058.2014.924236

Keywords: Obstetrical hemorrhage, prevention strategies, perinatal centers Presenter: I.V. Ignatko

ID 610

ASSESSMENT OF RISK FACTORS FOR INTRAUTERINE FETAL DEATH IN WOMEN REFERRED TO HEALTH CENTERS IN JAHROM UNIVERSITY OF MEDICAL SCIENCES J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

S. Abdollahifard Faculty member of Nursing and Midwifery, Dept. Jahrom University of Medical & Health Sciences. Jahrom. Iran Brief Introduction: Introduction: True pregnancy is very gratifying and exciting, and one of the sweetest events in a woman’s life is considered. Important events that occur during pregnancy, one of the most important is intrauterine fetal death. The problem of the twentieth week of pregnancy and occurs in 1% of all pregnancies. Despite the use of new methods in recent years, yet the cause of 50– 12% of intrauterine fetal death is not known. Materials & Methods: Materials and Methods: This cross-sectional study - descriptive analysis is the study of documents and completion of form practitioner for all women were found as intrauterin death fetus during pregnancy, after 19week of pregnancy and that refered to in Motahari Hospital Jahrom city of 2011 to 2013 in women. Record sheets including three of congenital factors, embryonic, placental and umbilical cord were recorded. The control group included 5042 women who had a live birth between births randomly selected from the same month and the same day. Data from the first 3 months were collected from November until the end of January Data were analyzed using SPSS 16 software for data analysis and chi-square test and T-test was used. Clinical Cases or Summary Results: Results: Logistic regression and odds ratios obtained showed that the variables that were significantly different in the two groups, the number of pregnancies (p = 0.001), the number of abortions (p = 0.01), labor problems (p = 0.01), congenital malformation (p = 0.001), fetal distress (p = 0.01), hydroamnious disorders (p = 0.01), true knot cord (p = 0.03), umbilical cord prolapse (p = 0.02) and umbilical cord wrapped around the baby ’s neck (p = 0.004), are risk factors for intrauterine fetal death. Conclusions: Conclusion: Evaluation of pregnant women with a history of intrauterine fetal death, and similar problems in pregnancy and childbirth can reduce the incidence of fetal death.employees, the people familiar with the risk factors and preventive measures should be emphasized. Keywords: intrauterine fetal death, maternal risk factors, risk factors, fetal, placental and cord factor Presenter: Sareh Abdollahifard

ID 358

SUCCESSFUL USE OF INTRAUTERINE BALLOON FOR UTERINE BLEEDING IN AMNIOTIC FLUID EMBOLISM: A CASE REPORT

K. Juvan Kramer1, H. Savc2, S. Kasnik Cas3, & N. Zadravec4 1

Gynecology and Obstetrics Dept, General Hospital Slovenj Gradec, Slovenj Gradec, Slovenia, 2Gynecology and Obstetrics Dept, General Hospital Slovenj Gradec, Slovenj Gradec, Slovenia, 3Gynecology and Obstetrics Dept, General Hospital Slovenj Gradec, Slovenj Gradec, Slovenia, and 4Anestesiology Dept, General Hospital Slovenj Gradec, Slovenj Gradec, Slovenia Brief Introduction: Amniotic fluid embolism (AFE) is a rare and catastrophic event with high maternal and fetal mortality. It consists of cardiac and pulmonary symptoms with consumptive coagulopathy. The patient presents with profound bleeding very soon and often hysterectomy is required despite successful placement of the balloon catheter. The maternal mortality is high (30–40%) in those patients who exhibit the presentation of acute hypoxia, cardiovascular collapse, mental status changes and disseminated intravascular coagulopathy (DIC). Survivors often have long term clinical sequelae. Materials & Methods: We report a case of AFE with cardiogenic shock, DIC and successful resuscitation of both mother and child with preservation of uterus due to use of intrauterine balloon placement. Clinical Cases or Summary Results: Case report. A healthy 33 year old G2P1 at 41 weeks gestation presented for induction of labour. In the evening, 7 hours after vaginal administration of the prostaglandine E2, she was admited to the labour ward and amniotomy was performed. The fetal pulse after amniotomy was normocardic. 10 minutes after amniotomy, while preparing to insert the intravenous line, the patient suddenly reported nausea and dyspnea. After a few seconds she became unresponsive and unconscious. The anaesthesiologist and obstetrician were immediately called. O2 was administered by nasal catheter, the patient became cyanotic, with profound hypotension. The fetal pulse was bradycardic. A quick response of the team and early suspicion of the AFE resulted in an emergent caesarean section. The baby was born with APGAR 1 and was transferred to intensive neonatology unit by helicopter. Symptoms of DIC developed towards the end of suturing the uterus. The heart ultrasound performed during the caesarean section, showed hyperechogenic masses in the right ventricle. The patient was transferred to the Intensive care unit and initial laboratory tests revealed consumptive coagulopathy, fibrinogen was immeasurable. For correction of coagulopathy she received fibrinogen concentrate, tranexamic acid, fresh frozen plasma (FFP), and calcium gluconate. Two hours after first results, we could see improvement in coagulation function and five hours later, almost normal results. During the night she needed 6 units of red blood cell to sustain haemoglobin level over 80 g/L and 2 additional units of FFP. Because of continuous need for anaemia correction, suspicion for abdominal bleeding was made. Obstetrician performed abdominal ultrasound looking for signs of bleeding. It was concluded that there was small amount of free fluid beside uterus with no other fluid collections elsewhere in abdomen. Due to vaginal bleeding two hours after caesarean section SOS BakriÕ balloon was carefully inserted into the uterine cavity and filled with 240 ml of warm saline. Consequently the uterine bleeding was stopped. The BakriÕ balloon was removed on the day 1 and afterwards the bleeding was controlled by uterotonics. The patient was extubated on day 5 and showed no neurological complications. She was discharged on day 14, with normal cardiopulmonal status and no neurological impairment. The baby was discharged on day 14 and shows no clinical or morphological pathology. Conclusions: A good teamwork and a concise communication is critical for an excellent outcome especially in critical care in obstetrics. We are happy to present that the mother and the child in this case report have no clinical sequelae at present. Keywords: Amniotic fluid embolism, intrauterine balloon, preservation of uterus Presenter: Katja Juvan Kramer

196

ID 475

ID 869

SAFE BIRTH CKECKLIST IMPLEMENTATION AS A KEY TOOL FOR INCREASING THE QUALITY OF THE HEALTH CARE PROVIDED AT THE END OF PREGNANCY

RETROSPECTIVE STUDY OF SHOULDER DYSTOCIA IN A TUNISIAN MATERNITY LEVEL III OVER A PERIOD OF 7 YEARS

A. Castillo Martı´n, C.S. Pin˜el Pe´rez, N. Pe´rez Pe´rez, & N. Izquierdo Me´ndez Hospital Clı´nico San Carlos, Madrid, Spain

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J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Brief Introduction: In our hospital we have drawn up –as part of Safe Birth Program- what we have denominated the Checklist for a Safe Birth (hereinafter, the Checklist). The Checklist is the result of the hard work of many people from different medical areas, and its objective is to increase the healthcare quality during the childbirth and immediate postpartum, so as to improve both perinatal and maternal results. The Checklist aims to reinforce the applicable security practices already accepted and foster the communication between professionals. Materials & Methods: Since the end of 2011 until Apr-2012, a working team formed by professionals -such as obstetricians, neonates specialists, midwives, anesthesiologists, patients’ safety experts and health care risks management department members – identified the relevant issues to design the Checklist, which was to be applied from May 2012. It is based on a three step process: Dilation period stage, in which the identity, background, medication requirements, informed consent, and specific tests should be assessed. This stage has to be fulfilled by midwives, obstetricians and anesthesiologists. Birth and subsequent events’ stage, which has to be fulfilled by midwives, obstetricians and neonates specialists. Immediate Puerperium stage, in which the four abovementioned professionals (midwives, obstetricians, anesthesiologists and neonates specialists) have an active role. The fulfillment of the Checklist is compulsory. Until the Checklist is properly filled in, it would not be allowed for neither the mother, nor newborn to leave the delivery room to access the relevant obstetric department. The Checklist should be used for any kind of birth (natural delivey, cesarean, dead fetus). The Checklist is user-friendly and quick to filling it out, avoiding mistakes in this regard. Pre- and post-results from the establishment of the Checklist were obtained from the prospective data collection of our department from year 2012 by a complete obstetric data base filled by obstetric researchers. Clinical Cases or Summary Results: The filling rate has been extraordinary. During this period, both maternal and neonatal infections have decreased, as well as the overall rate of complications (although not statistically significant -[p40.05]). From the implementation of the Checklist no maternal deaths have occurred. According to professional satisfaction and opinion survey, medical professionals are happy with the Checklist, recognizing that safety and effectiveness have increased. Conclusions: The establishment of the Checklist as part of Safe Birth Programs has improved the quality of the health care we provide to pregnant mothers. This has increased the safety levels of all processes in connection with births and immediate postpartum, with good results so far. Compliance regarding its implementation has been satisfactory. Keywords: Presenter: A. Castillo Martı´n

H. Laajili1, F.Z. Chioukh2, A. Hajji1, D. Toumi1, O. Zoukar1, K. Monastiri2, & M. Sakouhi1 Department of gynecology and obstetrics and 2Department of reanimation and neonatal medicine – Maternal and neonatal Center of Monastir 5000 Tunisia 1

Brief Introduction: Our study aims to assess the prevalence of dystocia in our maternity, identify risk factors of dystocia and obstetric brachial plexus palsy, and specify immediate and medium-term treatment of these newborns. Materials & Methods: We conducted a retrospective study of 54 infants who developed dystocia over a period of seven years. Clinical Cases or Summary Results: 54 births were complicated by dystocia on a set of 27,635 vaginally births with cephalic presentation, so a frequency of dystocia equal to 0.19%. Maternal obesity and diabetes were significant risk factors of obstetric brachial plexus palsy after dystocia. Macrosomia was significantly more common in infants who developed plexus palsy. There is no significant relationship between the occurrence of plexus palsy and a history of dystocia or gestational diabetes or macrosomia. There is no report as to gestational age, duration of labor, forceps delivery, practice an episiotomy or obstetric maneuver used to treat dystocia. Conclusions: Prevention methods of dystocia by calculating a risk by a counseling program are being evaluated. Only fast action and perfect control of obstetric maneuvers can improve prognosis of these infants. Keywords: shoulder dystocia - obstetric maneuvers - brachial plexus palsy Presenter: FZ Chioukh

ID 411

ANALYSIS OF THE EVITABILITY OF INTRAPARTUM ASPHYXIA WITH A PEERS REVIEW L. Batlle1, B. Guyard-Boileau1, O. Thiebaugeorges1, A. Caubisens1, MF. Vaquie1, F. Thiery2, O. Parant1, & C. Vayssiere1 1

Obstetric Dept., University Hospital of Toulouse, Maternite´ Paule de Viguier, France, and 2Paediatric Dept, University Hospital of Toulouse, Maternite´ Paule de Viguier, France Brief Introduction: To assess the quality of intra-partum care in birth asphyxia cases Materials & Methods: Prospective analysis of all cases of birth asphyxia in nine maternity units during one year (2010). Birth asphyxia was defined as the combination of at least one clinical factor (Apgar 7 at 5 minutes, signs of encephalopathy at birth) and at least one biological factor in cord (pH  7, BD  12 mmol/L, lactates410 mmol/ l). These cases were analyzed with a peer review from French guidelines 2007. Clinical Cases or Summary Results: Fifty cases of birth asphyxia were identified. After peer-review, they were defined as 46% non preventable, 27% possibly preventable, 24% definitely preventable and 3% not established. The main causes have been described as (i) misinterpretation of CTG during the first and second stages of labour, (ii) delayed response time to CTG anomalies and (iii) prolonged second stage.

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Conclusions: In half of the cases of birth asphyxia, this dreaded event was considered as preventable by a group of peers. Keywords: birth asphyxia, peer review, avoidable factors Presenter: L. Batlle

ID 298

MOBILIZATION OF THE PELVIS IN THE CHILDBIRTH PROCESS. S. Capdevila Bert1, M.C. Roig Garcia2, M.E. Borra`s Bentanachs3, V. Cortesa˜o Trevesset4, N. Martinez Coso5, C. Barana Vidal6, J. Aparı´cio Ferreras7, M.J. Tolosa Navarro8, & E. Mitjans Montoliu9 J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

1

Midwife. Hospital Universitari Arnau de Vilanova de Lleida, Spain, 2Nurse. Hospital Universitari Arnau de Vilanova de Lleida, Spain, 3Midwife. Hospital Universitari Arnau de Vilanova de Lleida, Spain, 4Midwife Student. Hospital Nostra Senyora de Meritxell (Andorra), 5Midwife. Hospital Universitari Arnau de Vilanova de Lleida, Spain, 6Midwife. Hospital Universitari Arnau de Vilanova de Lleida, Spain, 7Midwife. Hospital Universitari Arnau de Vilanova de Lleida, Spain, 8 Midwife. CAP Mollerusa, Pla d’Urgell, Lleida, Spain, and 9 Midwife. CAP Mollerusa, Pla d’Urgell, Lleida, Spain Brief Introduction: All the bibliographies recommend that the parturient adopts the position to give her more comfort, while guaranteeing the quality of care, the welfare psychoemotional and the control of fetal well-being. The position changes during the birthing process helps women to reduce the pain. The analgesia of choice is the epidural, although it should be with the minimum dose that allow the mobilization. Professionals should be trained to deliver the baby in different positions. It is not recommended to place a pregnant woman at dorsal lithotomy position during the dilation and the expulsion. Must be recommended walk during the dilation, and each woman must freely decide which position to adopt during the expulsion. Materials & Methods: We made a literature review on FAME, Guide of the normal delivery of the National Health System, NICE Guide in the care of childbirth, WHO, procedures of birth process and Cochrane. Clinical Cases or Summary Results: The birth canal is not straight, it is like a cylinder in a curved shape. The position of women is going to exercise a marked influence on the mechanics of the delivery.  POSITION LYING: makes the slippage of the fetus’ head, it interfered with the reflection of Ferguson and therefore becomes more difficult the process of dilation.  THE HORIZONTAL POSITION IS THE MOST UNFAVOURABLE.  FOOT POSITION AND SITTING: in this position, the gravity shifts the uterine fundus forward. The position of the fetus is more favorable for the slippage and favors the reflection of Ferguson. This position favors the expansion process.  SQUATTING POSITION: it favors the disappearance of the lumbar curvature, the promontory interferes least, occurs a iliac pronation, the pubis moves upward and the birth canal is done "straight". This position favors the desire to push and decreases the resistance of the birth canal.  Genu POSITION: According to some authors can encourage rotation of the fetus when offers a presentation later.  POSITION OF WALCHER: it favors the decrease of the fetal head to the foreground. Opens the anteroposterior diameter of the pelvis. It is important to seek the positions with asymmetry. This favors the adaptation of the head of the fetus within the mother’s pelvis. The postural changes should be carried out frequently. Conclusions: The midwife must know very well the pelvis, its mobilization and as the fetal head replacement falls within it.

The mobilisation of the pelvis during the birthing process can encourage a delivery is finished in a natural way, without the need of instrumentation in the expulsion. At the same time, the postural changes can be a tool for reducing the pain. In addition the satisfaction and comfort of the mother increase. MAIN ADVANTAGES OF THE DIFFERENT POSITIONS  SUPINE: reduced risk of blood loss intrapartum and postpartum hemorrhage. More comfortable for the professional.  OF FOOT: increased efficiency of uterine contractions. Best fetal oxygenation. Less need for analgesia and oxytocin. Lower rate of episiotomies.  LATERAL decubitus: decreases the lacerations of the perineum, an improved control of the fetal head during the birth and the further relaxation of perineal musculature.  SITTING: improving the effectiveness and direction of uterine contractions. Relieves the pain of the lower back.  CUADRUPEDIA: less perineal trauma since the seriousness away from the pressure of the perineum and at the same time favors the lower fetal. The perineal elasticity is greater in this position.  SQUAT: pelvic diameters increased. Less need of oxytocin and less instrumental deliveries. Keywords: Delibery process, pelvis’ movements, dilatation. Presenter: So`nia Capdevila Bert

ID 234

IMPORTANCE OF EVALUATION AND INTERPRETATION BY THE MIDWIFE OF REGISTERS CARDIOTOCOGRAPHICS

198 M.C. Roig Garcia1, S. Capdevila Bert2, M.E. Borra`s Bentanachs3, V. Cortesao4, N. Martinez Coso5 1

Midwife. Hospital Universitari Arnau de Vilanova de Lleida, Spain, 2Midwife. Hospital Universitari Arnau de Vilanova de Lleida, Spain, 3Midwife. Hospital Universitari Arnau de Vilanova de Lleida, Spain, 4Midwifw Student. Hospital Nostra Senyora de Meritxell (Andorra), and 5Nurse. Hospital Universitari Arnau de Vilanova de Lleida, Spain

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Brief Introduction: During childbirth women may be monitored for assessment of fetal heart rate (FHR) and uterine contractions (DU).

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Obtaining these records and the correct assessment and interpretation is vital for fetal well-being and effectiveness of DU during active birthing process. While abnormalities and early action before them. This allows the midwife to act according to a security professional scientific evidence and ensuring good professional praxix. In 1821 Alexandre J. Lejumeau became interested in the fetal biophysical control. The first instruments used were the Obstetric Stethoscopes. In the decade of the 60–80 electronic FHR monitoring systems and DU emerged. Currently there are modern telematics systems that enable monitoring and control of women mobillizacio´n Materials & Methods: Description of a praxis based on scientific evidence. Cocrhane Database Systematic Reviews, Spanish Society of

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Gynaecology and Obstetrics (sego), Federation of Midwives of Spain (FAME), etc: databases and consulting as national protocols. Clinical Cases or Summary Results: The normal rate is 120 FCF (110 intrapartum) -160 beats/min, with a variability between 5–25 beats/ min. and absence of transient FHR decelerations. Some authors must have accelerations. The DU appropriate in the active process of birth should be a frequency of 3–5 contractions in 10 min, an intensity of 30 mmHg at onset of labor and delivery at the end of 50 and 50 mmHg can add more at the time of pushing. The basic tone is between 8–12 mmHg. The contraction duration is usually between 45–60seconds. The pathology that we can find to get out of the normal limits of DU and/or FCF. The most important in relation to the FCF are:  fetal tachycardia or bradycardia, presence of decelerations. Alterations of DU include:  Hypodynamy: if hypotonia (low tone), bradisistolia (low frequency) and hiposistolia (low intensity).  Hyperdynamic: hypertension (high pitch), tachysystole (high frequency) and hypersystole (high intensity).  The DU may also have incoordinaciones or disdinamia. FHR decelerations in relation to DU also give us a lot of information because they are produced:  If the deceleration FHR coincides with the time of contraction (DIP 1) with a decrease not exceeding 100 beats/min may be due to a vagal reaction by compression of the fetal head on the descent down the birth canal. With a DIP1 we watchful waiting.  If deceleration is presented with an offset greater than 18 seconds are DIPS2 or late decelerations, are pathological and may indicate a compromise of blood supply to the fetus by placental problem.  A third type of decelerations are "Variables" which as the name suggests vary in shape, amplitude and duration. They can agree or not with the contraction. They may be preceded and followed by FHR acceleration and tend to indicate fonicular pathology. FHR variability can also give us information. A saltatory rate (above 25 variability) indicates a suspicious patron. And one in which the long- silent variability or sinus rhythm, and/or short term are low, indicating poor prognosis. Conclusions: The midwife must be well formed to assess and interpret the CTG Registries must be current in knowledge according to the latest scientific evidence. This allows us to ensure fetal well-being during the birthing process. Proper assessment of these parameters allows us to make safe decisions and allow a safe delivery is respectful and low intervention, allowing welcome the newborn in the most natural way possible if the situation permits. This review also allows us to have an expectant attitude towards a particular alteration, or also proceed to other tests of fetal biophysical monitoring as Doppler sonography, the pulse oximetry, the STAN methods, analysis of fetal blood gas analysis shell, or if extreme pathology, end the pregnancy. Keywords: CTG Registres, Delivery, fetal status Presenter: MARIA CARMEN ROIG GARCIA

ID 608

A ONE-YEAR SURVEY OF NEONATAL RESUSCITATION IN THE DELIVERY ROOM ARRANGED MOTAHARI HOSPITAL S. Abdollahifard Faculty member of Nursing and Midwifery, Dept. Jahrom University of Medical & Health Sciences. Jahrom. Iran Brief Introduction: Identification of high-risk deliveries and perform resuscitation at birth can lead to the prevention of asphyxia.

Materials & Methods: This cross-sectional descriptive - analytical review documents and complete form of medicine, for all neonates in Motahari Hospital jahrom city of Persian date March 2013 to December 2013 were born, and during the first hours after birth delivery room, in need of resuscitation was performed. This form includes variables such as gender, birth weight, gestational age, risk factors for neonatal resuscitation, resuscitation procedures, and the short-term prognosis. Data were analyzed using SPSS 16 software for data analysis and chi-square test and T-test was used Clinical Cases or Summary Results: 2418 infants born in the past 10 months were studied. Of the infants (25/0%) died during the first hours after birth, and (5/8%) patients were underweight. 91 cases (77/ 3%) were resuscitated in the delivery room needs. Among the risk factors, low birth weight, meconium-stained amniotic fluid and fetal distress and abnormal fetal heart rate and korioamnionitis and emergency cesarean delivery, factors predictive of the need for resuscitation in the delivery room were predict. Mortality rate was 25 per thousand live births and asphyxia was one of the main causes of neonatal deaths. The incidence of asphyxia in neonatal resuscitation group were much lower in infants who revived the action was performed. (p50.0001) Conclusions: It seems that low birth weight, meconium-stained amniotic fluid and korioamnionitis, the most significant risk factors associated with fetal distress requiring resuscitation in the delivery room are said. Keywords: CPR, baby, birth Presenter: Sareh Abdollahifard

ID 725

PLACENTAL ABRUPTION RECORDED WITH REAL-TIME ELECTROHYSTEROGRAPHY: CASE REPORT M.W.C. Vlemminx1, M.B. van der Hout2, S.G. Oei1,2 1 Department of Obstetrics and Gynaecology, Ma´xima Medical Centre, Veldhoven, the Netherlands, and 2Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands

Brief Introduction: A non-invasive technique based on real-time electrohysterography (EHG) is recently developed by our group and being tested at the labour ward (PUREtrace, Nemo Healthcare, Eindhoven, the Netherlands). We present a case of placental abruption and uterine hypertonia recorded with real-time EHG. Materials & Methods: Not applicable. Clinical Cases or Summary Results: A 33-year-old pregnant woman at 35 weeks of gestational age in her second pregnancy presented with vaginal blood loss. Her obstetric history revealed a uterus unicollis bicornis and an intrauterine fetal demise due to placental abruption at 26 weeks of gestational age. In the current pregnancy, prophylactic aspirin 80 mg was described from 12 up to 36 weeks. At admission there were no signs of fetal distress or retroplacental hematoma. The vaginal bleeding stopped, however several days later the pregnancy was complicated by preterm rupture of membranes followed by contractions and two centimetres of dilation. The fetal heart rate tracings showed a normal fetal condition, while monitoring uterine activity using external tocodynamometry was inconclusive. Therefore it was decided to use the EHG, by means of the Nemo Healthcare system consisting of a single abdominal electrode patch (Tocopatch, see Figure 1) and PUREtrace module connected to a Philips Avalon FM30 fetal monitor (Philips, Eindhoven, the Netherlands), which provided a cardiotocogram for real-time interpretation. Only half an hour later the pregnant woman presented acute onset of classical abruption signs such as severe abdominal pain, nausea, vomiting and

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fetal heart rate abnormality. The electrohysterogram showed a typical pattern of extreme uterine hypertonia (see Figure 2). Maternal vital signs were stable without vaginal blood loss. Within 15 minutes after the event an emergency caesarean delivery was performed, showing total detachment of the placenta. The neonate was born with a heart rate of 30 beats per minute and required neonatal resuscitation: Apgar score 0/6/8, umbilical artery pH 7.00, base deficit 17 mmol/L and neonatal body weight 2560 grams. During admission at the neonatal intensive care unit the newborn infant showed good clinical condition and no neurological sequels. Conclusions: This is the first report of real-time electrohysterography during placental abruption. The EHG showed a very typical pattern. Early recognition of this typical pattern might become important in patients with high risk of placental abruption. Keywords: Electrohysterography, placental abruption, cardiotocogram, uterine activity, hypertonia Presenter: Marion Vlemminx

ID 605

EXTRAPERITONEAL HEMATOMA WITH EMBOLIZATION OF CERVICO VAGINAL ARTERY IN VAGINAL DELIVERY. A CASE REPORT P. Argacha, M. Xiberta, J. Acosta, N. Souliman, J. Falco´*, & M.A. Jimenez

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Departments of Obstetrics and Gynaecology/*Interventional Vascular Radiology. Hospital General de Catalunya, IDC Salud; Barcelona, Spain Brief Introduction: Postpartum hemorrhage is the major cause of maternal mortality and morbidity worldwide, and the most preventable. However, its incidence in recent years has been increasing in developed countries. The clinical behavior and appropriate treatment in time means the difference between life and death. Severe postpartum hemorrhage can kill a healthy woman in 2 hours if you do not receive an adequate attention. Materials & Methods: Case report Clinical Cases or Summary Results: A 36 year old primigravida was admitted to our center at 38.2 weeks in labor. Normal vaginal delivery occurred without episiotomy, born male weighting 3180 gr. In the immediate postpartum develops hypovolemic shock requiring multiple blood transfusions and ICU admission. On pelvic examination was discarded uterine atony and proceeded to review the birth canal under general anesthesia, without evidence of cervical or vaginal bleeding. It was decided to perform angio TC, visualizing an abdominal hematoma of 16 cm. We made a pelvic arteriography, we observed bleeding in arterial phase from distal left cervicovaginal artery and we proceeded to embolization, with good radiological and clinical outcome. Then we decided to do a laparotomy for surgical drainage of large extraperitoneal hematoma in hypogastrium and left iliac fossa attached to urinary bladder and left pelvic vessels. The patient had a successful postoperative course. Conclusions: It’s important to consider the role of angio tac in cases of postpartum hypovolemic shock without obvious hemorrhage.

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Emergency arterial embolization is a save an effective means of control genital hemorrhage, reduces morbidity and preserve fertility. It is useful in cases of postpartum hemorrhage with uterine atony or artery laceration, refractory to medical treatment. Should be used before surgical treatment of pelvic bleeding. Keywords: postpartum hemorrhage, embolization Presenter: P. Argacha

ID 387

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PERINATAL MORTALITY OF THE LAST TWENTY YEARS IN A TERTIARY GREEK HOSPITAL C. Goudeli1, A. Kondi-Pafiti2, L. Aravantinos3, & D. Botsis4 1

Department of Gynecology, St.Savvas Hospital, Athens, Greece, 2Department of Pathology, University of Athens, Aretaieion Hospital, Athens, Greece, and 3,4Department of Obstetrics and Gynecology, University of Athens, Aretaieion Hospital, Athens, Greece Brief Introduction: Perinatal mortality reflects the level of health system in every country and constitutes one of the basic indicators of obstetric care. This study aims to present the perinatal mortality causes and rates during the last 20 years in a tertiary Greek hospital. Materials & Methods: This retrospective study is based on the pathology department-autopsies of fetuses and neonates of perinatal period (22 weeks of gestation to 7 days postpartum) regarding clinical information. We excluded pharmaceutical abortions and those containing vague variables. The macro/microscopic examination

was performed by a pathologist specialized in perinatal medicine. Throughout a range of more than 32 recorded classification systems, we selected the ReCoDe 2005(relevant condition of death) which best corresponded to the findings of our laboratory. Clinical Cases or Summary Results: The sample comprised 278 deaths of fetuses and newborns among 23.242 births. The registration was divided by time (1993–1997, 1998–2002, 2003–2007, 2008–2012) and gestational age (22–27 + 6, 28–31 + 6, 32–36 + 6, 37–41 + 6, 442). There was a statistically significant decrease in perinatal mortality (RR1993–1997 vs RR2008–2012 = 2,7, 95% CI 1.94–3,94, p50.0001) from 21,26% to 6,27% with greater reduction noted during 22–28 weeks of gestation. Among the 278 spontaneous abortions 263 were stillborns and 15 neonates; 21 undetermined sex, 135 males and 121 females. The maternal age varied from 14–52 years old. According to the ‘‘per unit’’ classification 44.6% of the deaths were attributed to fetus-conditions such as congenital defects, non-immune hydrops, while 19,42% to placental pathology. The abnormal function of umbilical cord and amniotic fluid provoked 7,19% and 3.6% of deaths respectively, while intrapartum causes, like asphyxia, resulted in 7,91% of deaths. Conclusions: The important reduction of perinatal mortality in a representative sample of the Greek area is an indicator of improvement in perinatal medicine. However, the target rates highlight the need for careful observation and recording of perinatal mortality etiology. Keywords: causes of perinatal mortality, stillbirth, neonatal death, Greek population Presenter: Christina Goudeli

MATERNAL PSYCHIATRIC DISORDERS AND PREGNANCY ID 018

INTIMATE PARTNER VIOLENCE AMONG EGYPTIAN PREGNANT WOMEN: INCIDENCE, RISK FACTORS AND ADVERSE MATERNAL AND FETAL OUTCOMES W. Sayed Ahmed1, Z.M. Ibrahim2, S.A. Elhameed3, & A.M. Hagras4 1 Obstetrics and Gynecology Department, Suez Canal University, Ismailia, Egypt, 2Obstetrics and Gynecology Department, Suez Canal University, Ismailia, Egypt, 3Family Medicine Department, Suez Canal University, Ismailia, Egypt, and 4Forensic Medicine and Clinical Pharmacology Department, Suez Canal University, Ismailia, Egypt

Brief Introduction: Violence against women is the most widespread yet under-recognized human rights violation in the world. The WHO 2002 World Report on Violence and Health defines intimate partner violence (IPV) as ‘‘any behavior within an intimate relationship that causes physical, psychological, or sexual harm to those in the relationship’’. The available reports about maternal and neonatal adverse outcomes due to violence during pregnancy are not conclusive. Some studies have shown positive associations between different forms of abuse and birth outcomes but others did not. Materials & Methods: After obtaining ethical approval, a total 1857 women aged 18 – 43 completed the study and were investigated using an interview questionnaire. The questionnaire contains five

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202 main items: demographic characteristics of women, intimate partner characteristics, assessment of IPV during current pregnancy and assessment of maternal as well as fetal/neonatal adverse outcomes. Clinical Cases or Summary Results: Exposure to IPV during pregnancy was reported among 44.1% of the studied women. Emotional violence was the most common form. Women exposed to violence were of younger age, higher parity, and lower educational level. Their partners were older, less educated and more likely to be addicted to drugs and alcohol. Women were also found to have significantly higher incidence of adverse pregnancy outcomes (miscarriage, preterm labor and premature rupture of membrane), and fetal/ neonatal adverse outcomes (fetal distress, fetal death and low birth weight). A total of 297 cases have been exposed to physical violence (15.9%) versus 32.6% and 10% exposed to emotional and sexual violence respectively. The most common form of physical violence was kicking. Conclusions: Violence during pregnancy is prevalent among Egyptian women. Exposure to violence was a significant risk factor for multiple adverse maternal and fetal health outcomes. Keywords: Intimate partner violence, domestic violence, maternal adverse outcomes, fetal adverse outcomes, pregnancy. Presenter: Waleed Ali SAYED AHMED

ID 930

FOSS TRIAL: ANTENATAL MATERNAL DHA AND AA LIPIDS AND THEIR PSYCHOBEHAVIOURAL STATUS E. Ogundipe1, K. Ghaus1, Y. Wang2, I. Talbot2, M.R. Johnson2, & M. Crawford2 Academic Obstetric Unit, and 2Neonatal Department, Chelsea & Westminster Hospital Campus, Imperial College London, UK 1

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Brief Introduction: Essential fatty acid (EFA) deficiency in pregnancy, in particular, docosahexaenoic acid (DHA) is linked to antenatal and postnatal depression. Brain DHA depletion in parous rats was associated with reduced density of D2-like dopamine receptors that mimic biochemical changes in depressed human brains. DHA, a major component of neural membranes is essential for nerve conduction, neurotransmitter release and uptake regulation. Maternal DHA is a main source for the foetus and women lose up to 3% brain DHA to support their foetus’s brain development. Global dietary trends over the last 3 decades reflect increased consumption of Linoleic acid (LA), parent of AA, an omega-6 FA over Omega-3s due to lower marine food consumption, a major source of DHA. DHA:AA balance is vital for brain function. Materials & Methods: 300 women at risk of developing pregnancyrelated complications and their controls were enrolled into FOSS trial and randomised at booking (8 – 12 weeks) to receive either DHA/AA fish oil (FO) supplement or placebo. At enrolment to the study, selfadministered psycho-behavioural assessments using the Gordon Personal Profile Index, (GPPI) were undertaken by the women. GPPI combines 4 personality traits: Stable and enduring, Ascendancy, Responsibility, Emotional Stability and Sociability which then measure Self-esteem, Cautiousness, Original thinking, Personal relations and Vigour. Their fatty acid profiles at enrolment were correlated to their psycho-behavioural outcomes. Clinical Cases or Summary Results: 78 women undertook the test, 9 had mild depression, 6 moderate and 3 severe depression and 33.3% of those depressed had a pre-conception history of depression. Of 78 women assessed, 66 (33%) women developed depression without antecedent history, a third of whom also had low self-esteem. Their DHA:AA ratio was inversely statistically significantly related to maternal self-esteem [rc-0.42; p50.000], emotional stability [rc-0.41; p50.000], personal relationships [rc-0.24; p = 0.036], responsibility [rc0.41; p50.000], original thinking [rc-0.24; p = 0.032] and vigour [rc0.32; p = 0.005]. Conclusions: The GPPI test outcomes, used as a marker of maternal psycho-morbidity, correlated negatively to their RBC DHA/AA ratios on lipid analysis. Women who were replete in the omega-3 series, DHA, had better emotional and psychological outcomes. These findings differ from other reports that have mainly reported on depression, some the results of which are conflicting. This study reports on the outcomes of other psycho-morbidities associated with pregnancy. Further confirmation is required by larger studies as there

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is the potential for significant public health benefit if better maternal nutrition and possibly appropriate DHA/AA supplements can help reduce the risk of antenatal and perinatal maternal psycho-morbidity. Keywords: Perinatal nutrition, Essential Fatty acids, DHA, Maternal Psychomorbidity, Perinatal Depression Presenter: Dr Karena Ghaus

ID 440

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POSTNATAL DEPRESSION AND ANXIETY IN MOTHERS OF PRETERM INFANTS A. Daskalaki1, N. Theofanopoulou2, P. Mexi-Bourna1, V. Sideri1, E. Sdona1, I. Kirkou1, I. Tasiopoulou1, & G. Bouras2 1

NICU, 3rd Pediatric Department, Attikon University Hospital, Athens Greece, and 2Clinical Psychologist Brief Introduction: Modern advances in perinatal medicine have resulted in a significant increase in the survival rates of preterm infants over the last decades. Preterm birth is a critical event that influences mothers’ psychological health and infant development. Maternal depression has been found to have negative effects for maternal responsiveness and sensitivity to infants, which in turn can have negative outcomes for the infant’s development (1), (2). The same applies to the presence of high levels of maternal anxiety, as it has been associated with emotional and behavioural problems during childhood and adolescence (3). The aim of the study is to measure levels of postnatal depression and anxiety in mothers of preterm infants compared to mothers who delivered at term. Materials & Methods: The study group consisted of mothers who had delivered at 23–36 weeks’ gestation with the baby having received care in the NICU for at least one week. Mothers were required to have working knowledge of the Greek language. Exclusion criteria were previously diagnosed mental disorders and drug use. 75 mothers who delivered 88 infants agreed to participate. A control group of 125 mothers who delivered 126 healthy infants at term was also recruited. The mothers completed the Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI-Y). The BDI is a 21-item self-report rating scale designed to assess the existence and severity of symptoms of depression. Higher scores indicate more severe depression symptoms. The BDI is one of the most widely used instruments for measuring the presence and the severity of depression and it has been reported to be highly reliable regardless of the population. The STAI-Y is a 40-item self-report questionnaire designed to evaluate anxiety in adults, consisting of two subscales, one for assessing state anxiety and one for trait anxiety. The range of scores is 20–80, with higher scores indicating greater anxiety. The guidelines for cut-off scores in the Greek population are 24.95 for state anxiety and 27.88 for trait anxiety. Clinical Cases or Summary Results: Bivariate analysis was carried out to examine the relationship between total scores on the state anxiety scale of the STAI-Y, state anxiety scores 24.95, total scores on the trait anxiety scale of the STAI-Y, trait anxiety scores 27.88 and preterm birth. The results revealed statistically significant associations between total state anxiety scores (p = 0.000), state anxiety scores 24.95 (p = 0.005), total trait anxiety scores (p = 0.000), trait anxiety scores 27.88 (p = 0.011), with the mothers who delivered preterm infants scoring higher in every scale than the mothers who delivered at term.. Mothers of preterm infants also had higher scores in the BDI (p = 0.001) It has been argued that physical contact, proximity, reciprocity and commitment are the central characteristics that promote the attachment between mother and child postnatally (4). When the pregnancy is abruptly terminated and the infant needs care in the

NICU immediately after the delivery, the separation from the baby complicates the establishment of the mother-infant bond, as the mother is not fully prepared, and the development of maternal identity is delayed. The mother of a preterm infant has to assume the maternal role under stressful circumstances for which she was not prepared. The separation from the infant, and lack of control of the situation have been found to be the most difficult and stressful aspects of the baby’s hospitalisation (5). Conclusions: The results of the present study show that preterm delivery has a significant influence on maternal psychological health. Taking into account the high percentage of postnatal anxiety and depression symptoms in preterm neonates’ mothers identified in this study, it is recommended that mothers who go through a traumatic, preterm delivery be routinely screened for postpartum depression and anxiety. It is also recommended that these mothers not to be separated from their preterm babies but to be allowed to freely visit them in the NICU and to provide them skin to skin contact. The individual and public health impact of perinatal conditions and maternal psychological adjustment demand for further research and understanding of their underlying mechanisms, patterns and risk factors to identify and treat affected women and prevent the negative consequences on their offspring. Keywords: prematurity, maternal depression, maternal anxiety Presenter: A. Daskalaki

ID 319

NEONATAL METABOLIC ALKALOSIS DUE TO MATERNAL EATING DISORDER S. Amoretti1, J. Barberan2, E. Lobera3, V. Sanmartin4, & R. Diez5 Hospital de Mataro´, Mataro´, Spain, 2Hospital de Mataro´, Mataro´, Spain, 3Hospital de Mataro´, Mataro´, Spain, 4Hospital de Mataro´, Mataro´, Spain, and 5Hospital de Mataro´, Mataro´, Spain 1

Brief Introduction: Transplacentally transmitted electrolyte disorders are rare and the few cases described are related to purging-type anorexia and bulimia nervosa of the mother. The main pregnancy related problem of bulimic or anorectic women is their impaired fertility, especially during low weight periods. The usual neonatal outcome of anorexia and bulimia nervosa in pregnancy is a lower birth weight. We present a case of early hypokalemic metabolic alkalosis due to maternal eating disorder. Materials & Methods: Case report Clinical Cases or Summary Results: A newborn born at 35 weeks of gestational age was admitted to the Neonatal Unit for prematurity. He was born by eutocic delivery to a woman with known eating disorder. Perinatal adaptation was uneventful. pH AU 7.43. His birth weight was 2110 grs. Clinical examination at admission was unremarkable. Venous blood sample at admission showed a pH 7.62, pCO2 39 mmHg, BE + 17.3 mmol/L and bicarbonate 40.1 mmol/L; K + 3.5 mmol/ L, Na 135 mmol/L and Cl 87 mmol/L. In order to rule out a renal disorder causing the metabolic alkalosis further investigations were carried out, which came back negative. We started oral substitution of sodium chloride, potassium chloride and supplementary fluids. Under substitution the clinical symptoms resolved and the laboratory values improved in five days. A routinely taken blood potassium level from the baby’s mother just before delivery was 2.7 mmol/L. Further investigations of the mother showed no signs of renal or metabolic disease. Conclusions: In the literature, there are only a few similar cases of transplacental electrolyte disorder in the newborn. Apart from this maternal etiology for the newborn’s disorder, endogenous pathologies of the newborn have to be considered. In endogenous diseases,

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the electrolyte disturbance rather evolves over the first few days. In other case reports of transplacental transferred electrolyte disturbances, laboratory values normalized as quickly as in our case. This shows that the endogenous regulation of the electrolyte metabolism works normally in the newborn. In conclusion, transplacentally acquired electrolyte disorders usually resolve quickly under sodium and potassium chloride substitution. Just some cases may be life-threatening when associated with compensatory hypoventilation. We should be aware of this problem and its consequences for the follow up.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

For all four disorders a drop in prevalence could be observed after birth. Conclusions: In our population of German health insurants, psychiatric disorder during pregnancy is linked to birth weight and CS. The decreasing postnatal prevalence of psychiatric disorders implies that pregnancy might play a role in triggering these conditions. In accordance with previous studies, claims data support the need to increase awareness of psychiatric disorder and its management and treatment in pregnancy.

Keywords:

Keywords: Cesarean section, psychiatric disorders, pregnancy, Germany, claims data

Presenter: Sonia Amoretti

Presenter: A. Gillessen

ID 072

ID 681

PSYCHIATRIC DISORDERS IN PREGNANCY IN RELATION TO BIRTH MODE AND BIRTH WEIGHT: EVIDENCE FROM SECONDARY DATA

RISPERIDONE USE IN SCHIZOPHRENIA DURING PREGNANCY

A. Gillessen, A. Lanfer, J. Weller, & C. Vietor

Brief Introduction: A schizophrenic gravida had an acute attack at the 27 th week of her pregnancy, and had been given Risperidone. We aim to present this case and review the risperidone use in pregnancy A schizophrenic gravida who has had at least one psychotic episode in pregnancy has twice the risk of abortus, stil birth, prematurity and small for gestational age infant- after all other accompanying possible risks are excluded. (1) Therefore, schizophrenia in pregnancy is a high risk situation. Materials & Methods: The G2P1 schizophrenic patient was 29 years old and was in remission until the 27 th week of her pregnancy, and she was regularly followed up in outpatient clinic. The only problem until then seemed to be that she needed a reassurence that her baby was alive in utero, so she was visiting the outpatient clinic evey 1 - 2 weeks. She has refused to take medication and any other treatment with the fear of ‘‘harming the baby’’. Clinical Cases or Summary Results: She had an apperently non complicated pregnancy, with fetal biometric measurements appropriate for gestational age. Bilateral choroid plexus cysts were noted in 18 th week, she denied genetic amniocentesis, and chose to continue regular follow ups. The cysts eventually disappeared by the 26 th week. Laboratory values were within the normal range throughout the pregnancy. Serial ultrasonic examinations showed appropriate growth, with normal amniotic fluid findings. At 27 th week, patient suddenly started to mention about how the baby disturbed her and made her sick, and she had to get rid of her. She was very anxious and kept coming to the clinic and asked the doctors to "take her baby out of her" since she could not tolerate it anymore. Psychiatric evaluation was made, and she had to be hospitalized since she could not cope with the situation. She had been started on risperidon -a category C drug. She quickly responded and 2 weeks later she was in remission Conclusions: She had a repeat cesarean delivery at 38 th week, the post partum evaluation of the infant was normal. She was lost to follow up after the delivery. In human studies, risperidone and its metabolite cross the placenta, however no increased teratogenic risks have been reported (data was limited) after maternal use. A single case of corpus callosum agenesis have been reported after in utero exposure to risperidone. Antipsychothics may increase the risk for extrapyramidal symptoms and withdrawal symptoms after delivery. In newborn ‘‘mild and self limiting to severe’’ agitation, feeding disorder, hypertonia, hypotonia, respiratory distress, somnolence, and tremor may be seen. (2)

Techniker Krankenkasse, Hamburg, Germany Brief Introduction: The association between psychiatric conditions such as stress, depression, anxiety and somatization disorders on birth mode and birth outcome is subject to debate. Most studies concentrate on neonatal outcome such as preterm delivery, low birth weight and small for gestational age, with inconclusive results. Only few studies consider caesarean section (CS) in relation to psychiatric disorders during pregnancy as most are interested in psychosocial consequences of CS after birth. We aim to investigate maternal antenatal depression, anxiety, acute stress- and somatization disorders in relation to birth mode and neonatal outcome by using out-patient, in-patient and pharmaceutical claims data of one of the largest German statutory health insurance companies (Techniker Krankenkasse). Materials & Methods: All female insurants who had given birth to a living baby in 2008 were identified and matched with the data of their newborns, if possible. As no valid information on preterm delivery was available, birth weight had to be used as a proxy measure. GDRGs and in- and out-patient diagnoses (ICD-10) were used to identify CS and vaginal delivery, birth weight as well as antenatal depression, anxiety, acute stress or somatization disorders from four quarters prior and eight quarters after birth. Psychotropic substance use was estimated by ATC-Code retrieved from prescription data. The associations between birth mode and psychiatric disorders were analysed via multiple logistic regression. Clinical Cases or Summary Results: Of all 38174 pregnant women included in the analyses, 9% suffered from depression, 17% from anxiety, 12% from acute stress disorder and 24% from somatization disorders. CS was reported for 30% of the mothers and 4% of the babies were underweight at birth. After adjustment for covariates, women with clinical depression were 1.7 times as likely to deliver an underweight baby. Acute stressand somatization disorders were not associated with delivering an underweight baby. Still, comparing women with and without treatment, a statistically higher probability of delivering an underweight baby was observed for mothers with any of the four conditions and simultaneous pharmaceutical treatment. Results for CS showed that all four conditions were associated with higher probabilities of CS (1.1Odds ratio1.4). The higher CS rate in women with psychiatric disorders was present in women with and without medical treatment.

K.E. Karasahin, U. Keskin, & C.M. Ercan Gu¨lhane Military Medical Academy Ankara Turkey.

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DOI: 10.3109/14767058.2014.924236

In our case, the infant and the mother did not show any of these. According to American College of Obstetrics and Gynecology the therapy during pregnancy should be individualized and treatment with psychiatric medications during pregnancy should incorporate the clinical expertise of the mental health clinician, obstetrician, primary healthcare provider, and pediatrician. (2) One should also be aware of Malignant neuroleptic syndrome which is a potentially fatal outcome of antipsychotic medication, and which requires at least the two of the following criteria: Diaphoresis, dysphagia, tremors, incontinence, cognitive changes from confusion to coma, mutism, tachycardia, increased blood pressure, leucocytosis, and laboratory findings of muscle injury (3). This is even hard to diagnose in pregnancy since differential diagnosis should rule out chorioamnionitis, convulsions (hypertensive disorders of pregnancy), thyrotoxicosis, intoxication, heat stroke, narcotic withdrawals, central nervous system pathologies, tetanos and acute porphyrias. Not only risperidone, but also sequential use of haloperidol + risperidone has been associated with malignant neuroleptic syndrome. The treatment should be stopped and cardiovascular system should be supported intensively. Dantrolen, bromocriptin or amantadine treatments have been suggested but the initial treatment is yet to be determined. (4).

pregnancy between 27 and 41 weeks. Oxytocin was necessary in mosr of the cases, episiotomy also. Cesarean section was indicated in 43.98% of the teenagers, motivated by restricted pelvis (11.01%), negative trial of labor (9.83%), prematurity (857%), previous c-section (7.63%), breech presentation (2.32%), pre-eclampsia (3.77%), abruptio placentae (0,86%). 15 from the 22 cases of uterine apoplexia were followed by hysterectomy. Alive newborns weighted between 1180 and 4050 grames, 31 of them(1,22%) did not survive after birth. Postnatal blues in young mothers was more frequent, troubles in breastfeeding were common, baby care was deficitary, newborn abandon was the attitude in 18 cases. Conclusions: Pregnancy in adolescence is raising in incidence in our region. School abandon is common for the young mothers. Frequentely these families are not or will not be biparental. Newborns are commonly illegitimate, may be neglicted, rejected or even sold. It is a matter of great concern regarding the change of habits in ourday world, its severe implications in health assistance and costs and the responsability for the future of youngsters in this part of Europe. Keywords: pregnancy, teenagers, delivery Presenter: L. Strat

References: 1) Nilsson E, Lichtenstein P, Cnattingius S, Murray RM, Hultman CM. Women with schizophrenia: pregnancy outcome and infant death among their offspring. Schizophr Res 2002;58:221–9. 2) Lexicomp. ‘‘Risperidone: Drug information ‘‘ In: UpToDate Accessed on April 14 th, 2014.) 3) Diagnostic and statistical manual of mental disorders. 4th ed.-text revision. Arlington (VA): American Psychiatric Association; 2000. 4) Bhanushali MJ, Tuite PJ. The evaluation and management of patients with neuroleptic malignant syndrome. Neurol Clin 2004;22:389–411. Keywords: Presenter: K.E. Karasahin

ID 843

HIGHSCHOOL: PREGNANCY. AN ALARM SIGN. L. Strat Obstetrics, Gynecology and Neonatal Surveillance Dept., University of Medicine and Pharmacy of Iasi, Iasi, Romania Brief Introduction: It is obvious that in the last years pregnancy in early teenage or quite in childhood is no longer a curiosity like it was twothree decades ago. Once it was a phenomena attributed exclusively to the gipsy girls in their subgroup of population in Romania, strictly connected with their marital habits. Today this is no longer true, even most of the cases still remain in this category. Our purpose is to analyze the incidence of pregnancy in teenagers in our region and to evaluate the consequences. Materials & Methods: We analyze retrospectively the lot of women who delivered naturally or by c-section in our hospital between January 2009 and January 2014. Patients were defined in three groups of ages: under 14, 14 - under 16 and 16 - under 18 years old. We analyzed the prenatal care in theese teenagers, the associated pathology, the way of delivery, the indications for c-section, the newborn weight and score, the psychiatric opinion Clinical Cases or Summary Results: The number of deliveries was constantly around 3500 per year. Teenagers were 2542. The global incidence of pregnancy in teenagers was 14.55% distributed like it follows: 6.3% in 2009, 9.9% in 2010, 17.11% in 2011, 19.05% in 2012, 20.4% in 2013. The lowest age was 12.3 and the highest 17.11 years old. Prenatal care was nule in two thirds of these patients. Natural delivery took place in hospital in 98% of the cases, at ages of

ID 290

SUBSTANCE ABUSE DURING PREGNANCY: MATERNAL AND NEONATAL EFFECTS M. Vucinovic1, D. Roje2, & A. Vucinovic3 1

Neonatology Dept., University Hospital of Split, Split, Croatia, Department of Obstetrics and Gynecology, University Hospital of Split, Split, Croatia, and 3Department of Obstetrics and Gynecology, University Hospital of Split, Split, Croatia 2

Brief Introduction:.In utero drug exposure can have a severe impact on not only the development of the fetus but also the child later in life.Perinatal death, prematurity, fetal growth retardation, neonatal abstinence syndrome (NAS), and a wide variety of other perinatal complications have been frequently observed in the offspring of drug abusing mothers. In 80% of cases, opiate addicts take at least 1 more drug or psychoactive substance along with heroin and more than 50% suffer from psychiatric comorbidity. The aim of the study was to assess perinatal outcome of pregnancy burdened with maternal addiction in comparison with an unselected population from a European transition country. Materials & Methods: Data on pregnancies complicated by illicit drug abuse (n = 85) managed during a 10-year period (2001–2011) at Split University Hospital were analyzed. Data on the type of drug, course of gestation and labor, and on perinatal outcome were considered. Data on all non-dependence pregnancies recorded during the study period were used as a control group. Clinical Cases or Summary Results: During the study period, there were 85 dependence-complicated pregnancies (0.2%). Use of heroin alone during pregnancy was recorded in 51 women (50%), methadone alone in 6 (7%), and a combination of heroin and methadone in 9 (11%). Premature delivery was significantly more common in the group of pregnant addicts (21% vs. 6%); 49% of pregnant addicts were carriers of hepatitis C virus (HCV) and 14% of hepatitis B virus (HBV). Neonatal abstinence syndrome developed in 61 infants (7%) born to addicted mothers. There were 4 cases (4.6%) of early neonatal death; 7 neonates had 5-minute Apgar score 5 or =7 (8%); 29 neonates had low birth weight for age (33%); and 7 neonates had congenital anomalies (8%). The risk of various congenital anomalies was 3-fold in the group of children born to addicted mothers Conclusions: The present study confirmed the problem of addiction in Croatia and pointed to a disturbingly low proportion of pregnant addicts being included in the system of institutional care and

206 surveillance. Addiction pregnancies present a small but high-risk group according to perinatal outcome. Children born to addicted mothers are faced not only with withdrawal syndrome but also have a significantly higher risk of neonatal morbidity and mortality. They had a higher rate of perinatal hypoxia and diseases unrelated to maternal addiction such as early sepsis caused by Streptococcus agalactiae, intracranial hemorrhage, and congenital anomalies. Appropriate obstetric and neonatal care can reduce the rate of complications in these pregnancies and improve perinatal outcome. Keywords: Illicit drug, pregnancy outcome, neonatal outcome Presenter: Mirjana Vucinovic

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ID 464

PERINATAL DEATHS N. Martinez Coso1, J. Aparı´cio Ferreras2, M.C. Roig Garcia3, M.E. Borra`s Bentanachs4, M..J. Tolosa Navarro5, E. Mitjans Montoliu6, C. Barana Vidal7, S. Capdevila Bert8, & V. Cortesa˜o Trevesset9 1

Nurse. Hospital Universitari Arnau de Vilanova de Lleida, Spain, 2Midwife. Hospital Universitari Arnau de Vilanova de Lleida, Spain, 3Midwife. Hospital Universitari Arnau de Vilanova de Lleida, Spain, 4Midwife. Hospital Universitari Arnau de Vilanova de Lleida, Spain, 5Midwife. CAP Mollerusa, Pla d’Urgell, Lleida, Spain, 6Midwife. CAP Mollerusa, Pla d’Urgell, Lleida, Spain, 7Midwife. Hospital Universitari Arnau de Vilanova de Lleida, Spain, 8Midwife. Hospital Universitari Arnau de Vilanova de Lleida, Spain, and 9Midwife Student. Hospital Nostra Senyora de Meritxell (Andorra) Brief Introduction: Perinatal deaths or perinatal losses involve a duel and all bereavement has a few stages that should move from a safe and healthy way. One of these stages is the denial and it is at this stage where the society is stagnant. In Spain, the perinatal deaths or perinatal losses includes deaths occurring after the 28th week of pregnancy until the first seven days of life per 1000 live births and deaths. The rate of perinatal losses is difficult to quantify at the national level because there are not many records. If we can accept as average rate 8 cases per thousand live births, since week 22 of gestation until the first 24 hours of life. But FIGO spoke about 4000 deaths per 500,000 births if placed neonatal deaths later (up to the 28 days of life). Materials & Methods: Description of a praxis based on scientific evidence. Cocrhane Database Systematic Reviews, Spanish Society of Gynecology and Obstetrics (SEGO), Federation of Midwives of Spain (FAME), World Health Organization (OMS) and the databases: Pubmed, Medline, Cochrane.. Clinical Cases or Summary Results: According to various articles that have studied this subject, lack rigorous studies in order to ensure that interventions to provide psychological help and support after a perinatal death, to mothers, couples and families. Due to the lack of randomized trials of high quality made in this area, the real benefits of the currently existing interventions aimed at providing support to the mothers, fathers and families who have suffered a perinatal death are unclear. In addition, the evidence currently available around the possible harmful effects of certain interventions (for example, the visualization and the celebration of a baby who died) are not conclusive in this point in the time. On the other hand, that there is scientific evidence that demonstrates the fact that parents see and give burial to their baby died is beneficial for its subsequent elaboration of mourning. As well as the use of symbols, spirituality, rituals and memories have shown to help give meaning to the loss. Different studies also make clear that if there are minors involved in the loss, they must participate in the rituals and practices of mourning.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

The purpose of this article is to explore the concept of perinatal grief and healing interventions based on the evidence to do so. The loss of a pregnancy or the death of a baby cause a deep pain, but society has minimized or ignored this penalty, which is one of the most painful experiences of long duel. Over the last century, research on the pain and the special needs of parents in mourning has changed the context of professional intervention for the protection of support. Although the child understanding of loss and pain differs with the age of development, they should also have the opportunity to participate in the rituals and practices of mourning. Professionals catering to grieving parents have a unique opportunity to offer support through validation of their pain, facilitating rituals, providing memories and leaving relatives to tell their stories. While no intervention can bring back their beloved children, the appropriate action can promote healing. Conclusions: The central axis of the interventions of duel is to help families in the healing, helping make sense of their loss. The use of symbols, spirituality and rituals has been shown to help give a meaning. Research has shown that the memories are the key to the cure, and the gender, age, and relationship to bring different expressions and experiences of grief. Further studies are required because it is a field in which still has not been investigated in depth and some studies are not conclusive. Midwives in the exercise of their profession can offer its support through validation of the pain, the facilitation of rituals, offering memories and allowing the family to tell their story. All these measures, through appropriate intervention promote healing from loss. The hospitals with maternity services, should create guides and specific protocols for action, as well as ensure that the health personnel are trained in this issue and promote from within the midwifery services self-midwives due to wear personal and professional that supposed to cope with such situations. Keywords: Perinatal deaths, psychological help, mourning Presenter: NATALIA MARTINEZ COSO.

ID 130

MATERNAL AND FETAL OUTCOMES IN PREGNANT WOMEN WITH CHRONIC KIDNEY DISEASE Y. Fukasawa Tokyo women’s Medial University Hospital, Tokyo Brief Introduction: The purpose of this study objective was to assess the risk factors related to the deterioration of renal function (DRF) after delivery in pregnant women with chronic kidney disease (CKD) and to compare the outcomes of CKD stage1 with another stages of CKD. Materials & Methods: This study includes 156 singleton pregnancies of 139 women with CKD at our institution from 2001 to 2010. DRF was defined as the shift of CKD stage from a lower to a higher stage. The relevant variables were compared between women who had DRF (n = 39) and the controls (n = 117). Clinical Cases or Summary Results: The number of transplantation or dialysis case after delivery was in nine pregnancies (5.8%). DRF occured in 39 cases (25%) in any stage of CKD, and there was no significant difference among stages. From a logistic regression model, the factors that influence DRF were the presence of glomerulonephritis (Odds Ratio (OR) 3.56, 95% Confidence interval (CI) 1.18–10.81), proteinuria prior to pregnancy (^0.3 g/day or 3 + more dipstick) (OR 3.43, 95% CI 1.14–10.33) and treatment of antiplatelet agents (OR 0.30, 95% CI 0.09–0.94). Receiver operating characteristic curve analysis confirms that the estimated glomerular filtration rate (eGFR) ^75 ml/min before conception is not a risk to develop DRF after delivery (negative predictive value 0.788).

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DOI: 10.3109/14767058.2014.924236

Conclusions: This was the first report that revealed the clear cut-off value regarding to DRF in pregnant woman with CKD. Keywords: chronic kidney disease, estimated glomerular filtration rate, pregnancy, receiver operating characteristic curve analysis Presenter: Y.Fukasawa

NEONATAL LUNG

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ID 524

CAFFEINE, A POTENT MODULATOR OF LUNG SURFACTANT HOMEOSTASIS AND AIRWAY REMODELING M. Fehrholz, S. Kunzmann, & C. P. Speer University Children’s Hospital, University of Wuerzburg, Germany Brief Introduction: Administration of caffeine is a common therapeutic intervention in the neonatal period. However, caffeine mediated effects on lung epithelial cells are still poorly defined. The aim of the present study was to assess the impact of caffeine on expression of surfactant proteins (SPs) as key parameters of surfactant homeostasis as well as on selected members of airway remodeling processes, like connective tissue growth factor (CTGF) and transgelin, implicated in the pathogenesis of bronchopulmonary dysplasia (BPD). Materials & Methods: The human airway epithelial cell lines A549 and H441 were treated with different doses of caffeine in combination with dexamethasone (DEX) or TGF-b1, respectively. After 24 h mRNA and/or protein expression of surfactant proteins A, B, C, and D, the SPB transcription cofactor erythroblastic leukemia viral oncogene homolog 4 (ErbB4), as well as CTGF and transgelin were determined by quantitative PCR and immunoblotting. Clinical Cases or Summary Results: While caffeine was able to modulate SP-B mRNA levels after induction with DEX in H441 (206 ± 59.7-fold, p50.001) and A549 cells (31.4 ± 11.1-fold, p50.05), respectively, SP-D mRNA levels in H441 cells were also affected, but to a lesser extend (4.8 ± 1.0-fold, p50.05). Levels of mature SP-B were also elevated by caffeine for high (p50.05) as well as low (p50.05) concentrations in combination with DEX. Caffeine was also able to induce higher expression of ErbB4 mRNA in H441 cells alone (5.1 ± 1.9-fold, p50.05) as well as in combination with DEX (7.0 ± 2.4-fold, p50.05). SP-A1 mRNA levels were not influenced by caffeine and SP-C mRNA levels were below the detection limit in both cell lines. After stimulation with TGF-b1, caffeine diminished the induction of CTGF mRNA (0.5 ± 0.1fold, p50.05) as well as transgelin mRNA (0.6 ± 0.1-fold, p50.05) in A549 cells, which could also be confirmed on the protein level. Conclusions: Given the observed effects, it is most likely that caffeine is able to influence diverse key parameters of surfactant homeostasis and airway remodeling processes. These results may help to understand how caffeine is able to improve lung function and innate host defense mechanisms of premature neonates. Keywords: surfactant, remodeling, caffeine Presenter: Markus Fehrholz

M. L. Ognean1, S.M. Stoicescu2, M. Cucerea3, A. Sorin Cra˘ciun4, O. Boanta˘1, L. Na˘sta2, C. Movileanu3, & A. Sta˘nescu4 1

Neonatology Department, Clinical County Emergency Hospital Sibiu, 2Institute for Mother and Child Care, Clinical Hospital of Obstetrics & Gynecology Polizu, University of Medicine and Pharmacy Carol Davila Bucure¸sti, 3University of Medicine and Pharmacy Tg. Mure¸s, Regional Center of Neonatal Intensive Care UGON Tg. Mure¸s, and 4Neonatology Department, Clinical Hospital Dr. I. Cantacuzino Bucure¸sti Brief Introduction: During the neonatal period, pneumothorax may occur spontaneously or may complicate the development of a respiratory distress syndrome mostly in preterm infants. Aim: The authors aimed to identify the incidence and the risk factors for pneumothorax in preterm infants 32 weeks gestational age. Materials & Methods: Material and methods: The prospective study was developed over a 2 years period (01.01.2010 - 31.12.2011) and as based on the information collected in the National Registry for Respiratory Distress Syndrome by 4 regional neonatal centers. All preterm infants 32 weeks gestational age were included and data analysis was performed using IBM SPSS Statistics 19 (for a statistical significant p50.05, 95% CI). Clinical Cases or Summary Results: Results: The study group comprised 762 preterm infants with a mean gestational age (GA) of 29.5 ± 2.2 weeks (23–32 weeks), and a mean birth weight (BW) of 1317.6 ± 389.7g (450–2460g). Pneumothorax occurred in 29 cases (3.8%). Preterm infants having pneumothorax has significantly lower GA (p 0.004), and Apgar scores at 1 and 5 minutes (p 0.000, 0.038). The presence of a pneumothorax was significantly associated with the presence of chorioamnionitis (p 0.007), any complication during pregnancy (p 0.049), and the need and the length for mechanical ventilation (p 0.000, 0.022). No significant correlations were found with other epidemiological data that were analyzed (including BW, gender, prenatal specified complications, antenatal corticosteroid administration, mode of delivery, presentation at birth, surfactant treatment, etc.). Conclusions: Conclusions: The incidence of pneumothorax was lower than cited in the literature but the main risk factors were similar with those identified by other researchers, usually factors identifying a more severe course of the respiratory distress syndrome (lower GA, chorioamnionitis, perinatal hypoxia, and the need for mechanical ventilatory support). Keywords: pneumothorax, preterm infant, ventilation, respiratory support, respiratory distress syndrome Presenter: Adrian Sorin Craciun

ID 022

ADRENOMEDULLIN HAS A DUAL EFFECT IN THE PROLIFERATION OF HUMAN FETAL PULMONARY ARTERY SMOOTH MUSCLE CELLS VIA THE CAMP/PKA/CREB PATHWAY C. Ramos, & X. Sun

ID 515

RISK FACTORS FOR PNEUMOTHORAX IN PRETERM INFANTS 32 WEEKS GESTATIONAL AGE

University of new Mexico, Department of Pediatrics, Division of Neonatology, Albuquerque, NM, United States Brief Introduction: Adrenomedullin (AM), is a peptide hormone with multiple effects in the cardiovascular system: vasodilatation, proliferation, anti-apoptosis, differentiation, migration and angiogenesis. Reports on the AM effects on the proliferation of vascular smooth muscle cells are conflicting: AM might promote proliferation via the

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mitogen-activated protein kinase (MAPK)/Extracellular signal-regulated kinase (Erk) pathway, but it might inhibit proliferation via the cyclic adenosine monophosphate (cAMP)/protein kinase A (PKA) pathway. AM is expressed in fetal lung tissue as early as 10 weeks of gestation and we hypothesized that AM plays a regulatory role in the development of the human fetal pulmonary vasculature by regulating the proliferation of fetal pulmonary artery smooth muscle cells (PASMC). Materials & Methods: Fetal PASMC were isolated from 15 weeks of gestation fetus and were identified based on immunoreactivity against smooth muscle-myosin heavy chain and smooth muscle 22-a. The cells were cultured in Dulbecco’s modified eagle media +10% fetal bovine serum or in serum-free conditions. The cells were treated for 48 h with 100 nM AM. Proliferation was measured by bromodeoxyuridine (BrdU) incorporation and by metabolic activity. Intracellular cAMP levels were measured by cAMP chemiluminescent assay kit. cAMP responsive element binding protein (CREB) and Erk phosphorylation was detected via Western blot analysis. To further evaluate the signaling pathways involved, a PKA activity inhibitor (KT5720) was used Clinical Cases or Summary Results: In standard growing conditions, AM inhibited the serum-stimulated proliferation of human fetal PASMC (p50.05) and increased the levels of cAMP (p50.01). AM decreased the expression of p-Erk and p-CREB as measured by Western blot (p50.01), suggesting a mechanism mediated by the cAMP/PKA/CREB pathway. To support this speculation, the inhibition of PKA activity by KT5720 abolished the AM effect. In quiescent human fetal PASMCs, as previously reported in murine VSMC, AM increased proliferation (p50.05) along with phosphorylation of Erk (p50.05), inhibition of PKA activity with KT5720 abolished this effect, suggesting a crosstalk mechanism between the cAMP/PKA/CREB and the MAPK pathways. Conclusions: AM has a dual role in the proliferation of human fetal PASMC: it promotes proliferation in quiescent cells and decreases proliferation in actively growing cells, suggesting a regulatory role in fetal pulmonary vascular remodeling. The AM effects were abolished by a PKA inhibitor, suggesting that AM effects on fetal PASMC are mediated by the cAMP/PKA/CREB pathway. Keywords: vasculature

Adrenomedullin,

proliferation,

fetal

pulmonary

evidence answer is lacking, and is urgently needed. The objective of this meta-analysis was to assess the efficacy of HHHFNC versus nCPAP in avoiding extubation failure in neonates. Materials & Methods: For studies prior to June 2010, we searched through the list of included and excluded studies generated in the systematic search of a recent Cochrane review (Wilkinson et al. 2011). We updated the search in PubMed, Embase and clinicaltrials.gov for randomised trials assessing the use of high-flow nasal therapy in neonates, published since 2010. The reference lists of articles reviewed in full-text were also screened for relevant studies. Randomised trials examining extubation failure rates in neonates extubated to HHHFNC compared to nCPAP were included. Data were extracted and risk of bias for each study assessed. Meta-analysis was performed with the Mantel-Haenszel method using a random-effects model. Clinical Cases or Summary Results: Three Randomised Controlled Trials (RCTs) with data for 726 neonates were identified for inclusion. Two RCTs (435 neonates) studied neonates born at less than 32 weeks gestational age with the outcome as treatment failure within 7 days of extubation. One RCT (291 neonates) studied neonates born between 28 and 42 weeks gestational age with re-intubation within 72 hours as the outcome. VapothermÕ , OptiflowÕ or Comfort FloÕ devices were used as HHHFNC. None of the studies reported a significant difference in extubation failure rates between HHHFNC and nCPAP groups. The average effect across all studies in the pooled analysis also showed no significant difference between HHHFNC versus nCPAP with respect to extubation failure rate (risk ratio 1.15, 95% confidence interval 0.67–1.97), with a high degree of heterogeneity between studies (I2 66%). Conclusions: There is no significant difference in the rate of extubation failure in neonates extubated to HHHFNC compared with those extubated to nCPAP. Given the advantages of HHHFNC with regard to nasal trauma and easier nursing, it may be attractive alternative to nCPAP following extubation. There is limited data for babies less than 26 weeks gestational age, and longer term outcomes, such as rates of bronchopulmonary dysplasia should be evaluated. Keywords: HHHFNC, CPAP, extubation, newborn Presenter: Dr Hazel Daish

Presenter: C. Ramos

ID 054 ID 070

HEATED HUMIDIFIED HIGH-FLOW NASAL CANNULA VERSUS NASAL CONTINUOUS POSITIVE AIRWAY PRESSURE FOR POSTEXTUBATION VENTILATORY SUPPORT IN NEONATES: A METAANALYSIS H. Daish1, & S. Badurdeen2 1

Royal Brompton & Harefield NHS Foundation Trust, London, UK, and 2Department of Paediatrics, Oxford University Hospitals NHS Trust, Oxford, UK. Brief Introduction: There has been remarkable interest in recent years in the use of heated humidified high-flow nasal cannula (HHHFNC) as a means of providing post-extubation ventilatory support in preterm neonates. Whilst the perceived advantages of reduced nasal trauma and ease-of-use make this an attractive therapy, there is ongoing debate as to its relative efficacy for providing non-invasive ventilatory support when compared to nasal continuous positive airway pressure (nCPAP). Recent trials have attempted to address this important question; however an upto date meta-analysis to provide a best-

THE EFFICACY AND SAFETY OF HEATED HUMIDIFIED HIGH-FLOW NASAL CANNULA FOR PREVENTION OF EXTUBATION FAILURE IN NEONATES L. Ma1, C.Q. Liu2, X.H. Gu3, XJ Liu4, & The Collaborative Group of Study on HHHFNC 1 Neonatology Dept, Hebei Provincial Children’s Hospital, Shijiazhuang, China, and 2Neonatology Dept, Zhangjiakou Women’s and Children’s Hospital, Zhangjiakou, China; 3Neonatology Dept, China National Petroleum Corporation Central Hospital, Langfang, China

Corresponding author: CQ LIU, Email: [email protected] Brief Introduction: To assess the efficacy and safety of the heated, humidified, high flow nasal cannula (HHHFNC) compared with nasal continuous positive airway pressure (NCPAP) on prevention of extubation failure in neonates. Materials & Methods: A prospective randomized, controlled unblinded study was conducted in 12 tertiary hospitals in Hebei Province from Dec 1, 2012 to May 31, 2013 in China. Neonates were eligible for this study if they needed noninvasive respiratory support after a period of mechanical ventilation with an endotracheal tube.

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Table 1 Comparison of variables between HHHFNC and NCPAP groups

Variable

HHHFNC (n = 128)

NCPAP (n = 127)

p Value

Ventilation time, h# Pre-extubation MAP, cmH2O# Pre-extubation FiO2, %# Noninvasive support time, h# Total oxygen supplement, d# Length of hospital stay, d# Days to full oral feedings, d Extubation failure, n (%) Mortality, n (%) BPD, n (%) Apnea, n (%) Gastric retention, n (%) Abdominal distention, n (%) Nasal mucosal swelling, n (%) Nasal septal damage, n (%) Air leak, n (%)

95.2 ± 72.5 7.8 ± 2.3 25.8 ± 3.7 61.9 ± 54.6 9.1 ± 6.6 21.5 ± 13.7 12 (15) 12 (9.4) 12 (9.4) 9 (7.0) 23 (20) 30 (26.1) 7 (5.5) 18 (15.7) 1 (0.8) 1 (0.8)

100.6 ± 122 7.9 ± 2.3 25.8 ± 3.5 60.4 ± 44.3 9.3 ± 8.4 21.5 ± 14.4 11 (8) 12 (9.4) 15 (11.8) 10 (7.9) 15 (13.0) 32 (27.8) 16 (12.6) 27 (23.7) 6 (4.7) 4 (3.1)

0.530 0.833 0.887 0.790 0.820 0.991 0.201 0.984 0.527 0.798 0.155 0.766 0.047* 0.126 0.054 0.173

N. Nakwan1, P. Lertpichaluk1, K. Chokephaibulkit2, M. Cusato3, M. Regazzi3, & R. Imberti3 1

# mean ± SD. Days to full oral feedings are shown as median (25–75%). *p50.05. Infants were randomly assigned to either HHHFNC or NCPAP group. BPD was defined as a requirement of supplement oxygen after 28 days of life for an infant with a gestational age (GA) 432 weeks, or 36 weeks’ corrected GA for an infant with a gestational age (GA) 432 weeks, or 36 weeks’ corrected GA for an infant 532 weeks. The study protocol was approved by the ethics committees of each participating hospital. Clinical Cases or Summary Results: Among the 255 cases included, 128 were in the HHHFNC group, and 127 in the NCPAP group. There were no significant differences in gestational age, birth weight, age at randomization, and male/female ratio between the two groups (p40.05). There were no differences between groups for days on ventilation, noninvasive respiratory support, oxygen requirement, hospital stay and time to full oral feedings (p40.05). The overall mortality of the studied population was 10.6%. The occurrence of extubation failure within 7 days was 9.4% whereas 29.0% in very low birth weight infants. There was no significant difference in the extubation failure for HHHFNC versus NCPAP, or in mortality for HHHFNC versus NCPAP (p40.05). No significant differences were found between the study groups in the occurrence of BPD and most of several adverse outcomes analyzed, including air leak syndrome, nasal trauma. The occurrence of abdominal distention during treatment was higher in NCPAP than HHHFNC group (p50.05). Conclusions: Among infants 7 d of postnatal age, HHHFNC appears to have similar efficacy and safety to NCPAP when applied immediately post-extubation to prevent extubation failure. Despite concerns on unmonitored pressure delivery during HHHFNC support, no increase of the occurrence of BPD, air leak syndrome and mortality were found. (Supported by grants from Hebei Provincial Health Bureau GL2012013 and Talents Training Project of Hebei Province 2012–334) Keywords: HHHFNC; NCPAP; extubation failure; neonates Presenter: L Ma

ID 185

PHARMACOKINETICS FOLLOWING A SINGLE DOSE AEROSOLIZED COLISTIMETHATE SODIUM IN MECHANICALLY VENTILATED NEONATES

Department of Pediatrics Hat Yai Medical Education Center, Hat Yai Hospital, Songkhla, Thailand, 2Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol Univerisity, Bangkok, Thailand, and 3Direzione Scientifica Fondazione IRCCS Policlinc Brief Introduction: Ventilator-associated pneumonia (VAP) caused by multidrug-resistant gram negative bacilli is a serious complication in critically ill neonates. Colistin is one of the very few effective and available drugs for these infections but with high toxicity and poor lung tissue penetration. Aerosolized administration directly delivers the drug to the lung with less systemic toxicity. The objective of this study was to study the pharmacokinetics (PK) and adverse effects of colistin following aerosol administration of colistimethate sodium (CMS) in the mechanically ventilated neonates with nosocomial VAP. Materials & Methods: We performed a prospective study in neonates to assess sputum and plasma concentrations after a single dose of 4 mg colistin base activity (CBA)/kg body weight of CMS administered by inhalation via Servo Ultra NebulizerÕ (Maquet, Solna, Sweden) or AeronebÕ Pro (Aerogen, Galway, Ireland). CMS was dissolved in 4 mL normal saline and administered immediately for 15 minutes Clinical Cases or Summary Results: Six neonates were analyzed in this study. All were complicated with VAP. The mean gestational age and birth weight were 36.7 ± 3.4 weeks and 2,809 ± 961 g, respectively. The median (range) sputum colistin maximum concentration (Cmax) was 20.85 (15.60–34.60) mg/mL with median (range) time to maximum level (Tmax) of 1.00 (0.50–6.00) h. The sputum Cmax were at least 10 times higher than the minimal inhibitory concentration breakpoint for Acinetobacter baumanii (2 mg/mL) up to 12 hours after inhalation. Plasma colistin was detected at 0.5 h after inhalation with median (range) Cmax of 0.55 (0.14–1.10) mg/mL, median (range) Tmax of 1.50 (0–6.00) h). The median (range) plasma concentration-time curve (AUC) was 5.42 (2.02–18.71) mg.h/mL) while the median sputum AUC was 198.75 (71.23–275.87) mg.h/mL). Aerosolized CMS was well tolerated with no adverse effect. Conclusions: CMS inhalation with a single dose of 4 mg CBA/kg body weight of CMS appears to be safe in the neonates with VAP. The PK results suggested that the dosing frequency of aerosolized CMS should be 12 hours. Keywords: colistimethate sodium, colistin, Ventilator-associated pneumonia, pharmacokinetics study Presenter: N Nakwan

ID 076

A RANDOMIZED, CONTROLLED STUDY OF NASAL INTERMITTENT POSITIVE PRESSURE VENTILATION VS. NASAL CONTINUOUS POSITIVE AIRWAY PRESSURE FOR PREVENTION OF EXTUBATION FAILURE IN VERY LOW BIRTH WEIGHT NEONATES C.Q. Liu1, Y.F. Xia1, & M. Xiao2 1 Neonatology Dept, Children’s Hospital of Hebei Province, Shijiazhuang, China, and 2Neonatology Dept, Central Hospital of Cangzhou, Cangzhou, China.

Correspongding author: CQ LIU, Email:[email protected]

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Table 1 Comparison of variables between NIPPV and NCPAP group

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Variables Baseline characteristics Male, n (%) Gestation age, weeks Birth weight, g SNAPPE-II Surfactant Blood gas data at different time 0h PaO2, mm Hg PaCO2, mm Hg PaO2/FiO2 ratio 24 h PaO2, mm Hg PaCO2, mm Hg PaO2/FiO2 ratio 48 h PaO2, mm Hg PaCO2, mm Hg PaO2/FiO2 ratio 72 h PaO2, mm Hg PaCO2, mm Hg PaO2/FiO2 ratio Total ventilation time#, h Oxygen exposure time, h Successful extubation, n (%) Frequent apnea, n (%) BPD, n (%) Severe IVH, n (%) PVL, n (%) ROP, n (%) Death, n (%) BPD and/or Death

NIPPV (n = 40)

NCPAP (n = 44)

t/2

p Value

1.328 4.380 3.320 2.580 0.508

0.249 0.440 0.920 0.930 0.476

50.6 ± 3.4 50.2 ± 4.5 2.065 47.8 ± 8.9 46.3 ± 6.9 2.324 106.2 ± 29.5 110.4 ± 18.2 1.932

0.076 0.068 0.082

54.2 ± 5.3 53.1 ± 4.0 2.231 48.5 ± 4.4 48.3 ± 6.7 1.894 170.1 ± 30.9 163.4 ± 20.8 2.087

0.070 0.096 0.072

63.2 ± 3.6 52.3 ± 6.7 2.990 40.3 ± 4.8 49.2 ± 6.6 2.948 243.2 ± 32.8 187.6 ± 34.0 2.810

0.002 0.005 0.010

66.4 ± 5.8 51.8 ± 5.9 2.750 42.2 ± 5.6 57.3 ± 6.9 2.772 280.6 ± 16.8 245.2 ± 40.5 3.345 130.9 ± 46.7 180.5 ± 50.1 2.960 190.6 ± 45.2 216.8 ± 54.4 1.314 37 (92.5) 33 (75.0) 4.620 6 (15.0) 15 (34.1) 4.073 1 (2.5) 7 (15.9) 4.372 8 (20.0) 10 (22.7) 0.093 6 (15.0) 8 (18.2) 0.153 3 (7.5) 2 (4.5) 0.327 1 (2.5) 2 (4.5) 0.255 2(5) 9(20.5) 4.397

0.031 0.020 0.001 0.004 0.130 0.032 0.044 0.037 0.761 0.696 0.568 0.614 0.036

15(37.5) 22(50) 30.0 ± 2.8 31.5 ± 4.0 1250 ± 570 1380 ± 690 23 ± 10 22 ± 12 24 (60) 23 (52.3) points after enrolment

Brief Introduction: To evaluate the efficacy of nasal intermittent positive pressure ventilation (NIPPV) in preventing extubation failure in very low birth weight neonates (VLBWI) in comparison with nasal continuous positive airway pressure (NCPAP). Materials & Methods: A single-center RCT was conducted from June 1, 2012 to May 31, 2013 at the NICU of Hebei Provincial Children’s Hospital. Preterm and VLBWI (BW51500 g) with respiratory failure and subjected to mechanical ventilation were eligible for the study if they needed non-invasive, assisted ventilation at the time of first extubation attempt. They were randomly assigned to receive NIPPV or NCPAP, using the rate of successful extubation as the primary outcome and the incidence of adverse events including bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), retinopathy of prematurity (ROP) as the secondary outcomes. Blood gas data were obtained at 0, 24, 48 and 72 h after extubation as enrolment for oxygenation and duration. Clinical Cases or Summary Results: There were 84 neonates enrolled but only 40 each were in NIPPV or NCPAP group. The rate of successful extubation in NIPPV was significantly higher as compared with NCPAP group (p50.05). The detail see attached table. Conclusions: Using NIPPV after extubation in VLBWI had beneficial effects as compared with NCPAP in these two cohorts. (Supported by the Talents Training Project of Hebei Province 2012–334) Keywords: NIPPV; NCPAP; extubation failure; VLBWI Presenter: CQ Liu

ID 167

PREDICTION OF THE DEVELOPMENT OF BRONCHOPULMONARY DYSPLASIA PRETERM INFANTS: A NEW SCORING SYSTEM AND PROSPECTIVE VALIDATION T. Gursoy1, M. Hayran2, H. Derin1, & F. Ovalı1 1 Neonatal Intensive Care Unit, Zeynep Kamil Maternity and Children’s Research and Training Hospital, Istanbul, Turkey, and 2Department of Preventive Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey.

Brief Introduction: As more premature neonates survive, bronchopulmonary dysplasia (BPD) incidence increases. Therefore, early prediction of BPD evolution becomes an important issue. The purpose of this study is to develop a clinical scoring system to predict the development of BPD in very low birth weight infants. Materials & Methods: Medical records of 652 infants who were 532 weeks and 51500 grams and survived beyond 28th postnatal day were reviewed retrospectively. Logistic regression methods were used to determine the clinical and demographic risk factors associated with BPD that can be obtained within the first 72 hours of life, as well as the weights of these factors on developing BPD. The predictive accuracy of the scoring system was tested prospectively at the same hospital. Clinical Cases or Summary Results: Birth weight, gestational age, gender, presence of respiratory distress syndrome, patent ductus arteriosus, intraventricular hemorrhage, hypotension were the most important risk factors for BPD. Therefore, a scoring system (referred to as the BPD-TM score) ranging from 0 to 13 and grouped in 4 tiers (0– 3: low, 4–6: low intermediate, 7–9: high intermediate and 10–13 high BPD risk) was developed based on these factors (Table 1). If the BPDTM score was less than 4, only 4.1% of infants (18/436) developed BPD. When the BPD-TM score was between 4 and 6, the percentage of infants developing BPD was 39.8% (47/118) and between 7 and 9, it was 81.2% (56/69). Above the score of 9, 100% (29 out of 29) of the infants developed BPD. The score was validated successfully in 172 infants. Conclusions: With this easy to use scoring system, one can predict the neonate at risk for BPD at 72 hours of life and direct aggressive preventive measures towards these infants. Keywords: Prematurity, bronchopulmonary dysplasia, prediction, risk factors, scoring method Presenter: T. Gursoy

Table 1. BPD-TM score Score Birth weight Gestational age (week) Gender HsPDA RDS Hypotension IVH/GMH

0 1200 427 Female Absent Absent Absent Absent

1

2

3

51200 27

51000

Male Present Present Present Present

HsPDA; hemodynamically significant PDA, RDS; respiratory distress syndrome, IVH/GMH; intraventricular/germinal matrix hemorrhage

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ID 437

CYP2B6 GENETIC POLYMORPHISM AND THE RISK OF BRONCHOPULMONARY DYSPLASIA IN PRETERM NEONATES A. Daraki1, S. Gavrili2, S. Zachaki1, E. Boudouvi2, D. Baroutis2, E. Polycarpou2, K.N. Manola1, & G. Baroutis2 1

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Laboratory of Health Physics, Radiobiology & Cytogenetics, NCSR ‘‘Demokritos’’, Athens, Greece, and 2Neonatal Intensive Unit, General District Hospital Athens ‘‘Alexandra’’, Athens, Greece. Brief Introduction: The development of bronchopulmonary dysplasia (BPD) involves genetic and environmental factors. Although supplemental oxygen is the most commonly used therapy, direct exposure to oxygen can damage the pulmonary epithelium through the generation of reactive oxygen species (ROS). CYP2B6, a phase I metabolic enzyme, encoded from the corresponding CYP2B6 gene, inactivates ROS protecting cells from oxidative stress. CYP2B6 G516T single-nucleotide-polymorphism changes the amino-acid sequence (Gln172His), resulting in enzymatic inactivation. Homozygous and heterozygous for the mutant T allele neonates present reduced capacity to counteract products of ROS and thus may be at increased risk of BPD. Materials & Methods: The aim of this study was to investigate the potential role of CYP2B6 germline polymorphism in BPD susceptibility. This case-control study enrolled 82 Greek premature neonates with gestational age 32 weeks. Among these, 33 developed BPD (case group) and 49 did not develop BPD (control group). Genomic DNA was extracted from peripheral blood samples of all neonates. The CYP2B6 genotype was performed by PCR-RFLPs. Clinical Cases or Summary Results: No significant difference was found between the BPD and control groups concerning sex and mode of delivery. However, mean birth weight and gestational age of BPD cases were significantly lower than controls’ (953 ± 196g vs 1325 ± 266g and 27.8 ± 1.6 vs 30.2 ± 1.7, respectively) (p1200g). The statistical analysis revealed a higher incidence of the variant genotypes in BPD neonates of 1200g than in no BPD neonates of the same birth weight cohort (46.6% vs 35.7%, respectively), but this difference did not reach statistical significance. Interestingly, all babies carrying the homozygous CYP2B6 mutant genotype developed BPD, while none of the control group carried the mutation in homozygous status. In conclusion, a higher frequency of heterozygous (G/T) and homozygous (T/T) neonates for the CYP2B6 polymorphism was observed among neonates who developed BPD compared to controls. Conclusions: Our study comprises the first investigation of the G516T CYP2B6 inactivating gene polymorphism in BPD development. Further studies including a larger number of BPD and no BPD preterm neonates are required to elucidate whether the nonfunctional CYP2B6 T allele is implicated in the BPD susceptibility. Keywords: Bronchopulmonary Dysplasia, genetic susceptibility, gene polymorphism Presenter: Stavroula Gavrili

ID 489

CPAP FAILURE IN PRETERM NEWBORNS WITH RESPIRATORY DISTRESS SYNDROME

E. Jazexhiu–Postoli1, E. Vevecka2, E. Petrela3, & E. Tushe4 1

Service of Neonatology, University Hospital for Obstetrics and Gynecology ‘‘Koc¸o Gliozheni’’, Tirana, 2Professor of Pediatrics, Faculty of Medicine, Tirana Medical University, and 3 Department of Statistics, Faculty of Medicine, Tirana Medical University Brief Introduction: Continuous positive airway pressure (CPAP) is a non-invasive treatment in preterm newborns with Respiratory Distress Syndrome (RDS). However some preterm infants fail with CPAP treatment. Aim: To evaluate the risk factors and neonatal outcomes associated with Nasal CPAP (NCPAP) failure in preterm newborns with RDS treated with two systems, Bubble and Biphasic NCPAP. Materials & Methods: A prospective randomised study involved 200 infants with gestational age (GA) 28–35 weeks, treated for RDS. They were assigned to Bubble NCPAP (n = 100) and Biphasic NCPAP (Infant Flow) (n = 100), using short binasal prongs. The characteristics registered were: gender, way of delivery, gestational age, birth weight, Apgar score at 1st and 5th min., need for resuscitation, antenatal corticosteroids and Surfactant use. Need for ventilation (CPAP failure), incidence of air leaks, incidence of intraventricular hemorrhage (IVH) and persistent ductus arteriosus (PDA), FiO2 at admission, mortality rate were outcomes measured. We studied relation between CPAP failure and gestational age, way of delivery, need for resuscitation, corticosteroids and surfactant use; relation between pneumothorax, IVH, PDA, FiO2 demand and CPAP failure was also assessed. Clinical Cases or Summary Results: Newborns in 2 groups had similar characteristics (gender, way of delivery, gestational age, birth weight, Apgar index, corticosteroids, Surfactant use); p40.05. CPAP failure was 20/100 in Bubble vs 20/100 in IF CPAP; pneumothorax 4/100 vs 4/100; IVH 12/100 vs 11/100; PDA 19/100 vs 18/100; FiO2 at admission 0.4 ± 0.1 vs 0.3 ± 0.1; mortality rate 8/100 vs 10/100. (p40.05) Using binary logistic regression analysis CPAP failure was moderately related with lower gestational age [Od 1.26 CI 95%: 0.38–4.21] (p = 0.07); CPAP failure was moderately related with need for resuscitation after birth (p = 0.056); no statitistic relation was found with way of delivery, corticosteroids and Surfactant use. Infants with pneumothorax and IVH had significantly higher risk for CPAP failure [Od = 3.35, CI95% :1.29–5.84] (p = 0.002), [Od = 6.8, CI95%: 2.06–7.96] (p = 0.002); persistent ductus arteriosus moderately increased risk for CPAP failure [Od = 2.89, CI95% :0.99–4.05] (p = 0.61); every increase in FiO2 was moderately related with CPAP failure [Od = 2.42, CI95% :1.00–3.62] (p = 0.057). Conclusions: Factors that can predict CPAP treatment failure in preterm newborns with RDS are extreme prematurity, need for resuscitation, higher FiO2 requirement, severe complications as pneumothorax and intraventricular hemorrhage. Keywords: Nasal CPAP, respiratory distress syndrome, Infant flow CPAP, NCPAP failure. Presenter: Eda Postoli

ID 577

COMPARING OUR PRACTICE WITH THE 2013 EUROPEAN CONSENSUS GUIDELINE FOR THE MANAGEMENT OF RDS C. Anderson1, & D.G. Sweet2 1 2

Royal Jubilee Maternity Service, Belfast, Northern Ireland, Royal Jubilee Maternity Service, Belfast, Northern Ireland.

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Table showing proportion of babies receiving first surfactant dose at different times Gestation (G wks) Delivery Suite surfactant Rescue surfactant via INSURE Rescue surfactant not via INSURE No surfactant

526

26 G 528

28 G 530

24 1 0

12 3 3

14 11 10

0

0

22

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Proportion shown as % Brief Introduction: The 2013 European Consensus Guideline for the Management of RDS recommends early non-invasive support, with rescue surfactant if required. Surfactant should be given when a baby needs intubated; or when FiO2 40.3 in babies’ 526 week’s and when FiO2 40.4 for those 426 week’s gestation. Surfactant should be given using the INSURE method where possible. We wanted to audit what actually happens in our unit over a recent time period. Materials & Methods: Medical records of all babies 530 week’s gestation admitted to the regional NICU in Belfast in 2013 were reviewed. Data was collected on the number of doses of surfactant, the timing of these doses, if prophylaxis or rescue therapy was used, if surfactant was administered because of intubation, whether or not the INSURE technique was employed, the number of days of ventilation and outcome in terms of BPD at 36 weeks’ gestation defined as persistent need for oxygen or respiratory support. Clinical Cases or Summary Results: Out of the 76 babies born at 530 week’s gestation, 78% received surfactant therapy: 28% as rescue (54% of these using INSURE method); and 50% were given surfactant as they were already intubated for stabilisation. The median time to first surfactant dose was within the first hour of life (IQR 0–3). The attached table demonstrates the proportion of babies receiving surfactant at different times, stratified according to gestational age. The median time spent on a ventilator was 3 days (IQR 0–10). The proportion of survivors with BPD at 36 weeks was 24%. Conclusions: The majority of infants born under 30 weeks are still being intubated in delivery suite for early surfactant, this is particularly true of those born under 26 week’s gestation. This highlights the importance of ongoing education of junior medical staff regarding the advice from the 2013 European Consensus Guideline for the management of RDS, in order to ensure that we maximise the use of non-invasive respiratory support. Keywords: Surfactant Presenter: Claire Anderson

ID 684

LOWER MATERNAL/NEONATAL VITAMIN D LEVELS ARE ASSOCIATED WITH INCREASED RISK OF BRONCHOPULMONARY DYSPLASIA (BPD) IN PRETERM INFANTS 1

1

1

2

M. Cetinkaya , A. Demirhan , G. Buyukkale , F. Cekmez , T. Erener-Ercan1, G. Aydemir2, F.N. Aydın3, T. Tunc4 1

Neonatology Dept., Kanuni Sultan Su¨leyman Training and Research Hospital, Istanbul, Turkey, 2Neonatology Dept., Gulhane Military Medical Academy, Istanbul, Turkey, 3 Biochemistry Dept. Gu¨lhane Military Medical Academy, Ankara, Turkey, and 4Neonatology Dept., Gu¨lhane Military Medical Academy, Ankara, Turkey

Brief Introduction: Vitamin D seems to play an important role in the pathogenesis of respiratory system diseases. Vitamin D deficiency was associated with lower lung function in adults. Even though there are strong data suggesting an association of maternal vitamin D intake during pregnancy and circulating 25-OHD levels with childhood wheezing and asthma, no study has prospectively investigated the effect of their association with immediate respiratory outcomes such as respiratory distress syndrome (RDS) and bronchopulmonary dysplasia (BPD) in preterm infants. The aim of this study was to evaluate the possible association between both maternal and neonatal 25-hydroxyvitamin-D (25-OHD) levels and the subsequent risk of bronchopulmonary dysplasia (BPD) development in preterm infants. Materials & Methods: Premature infants 32 gestational age who were admitted to Neonatal Intensive Care Unit with a diagnosis of RDS between December 2012 and December 2013 were included to this prospective study. Blood for neonatal and maternal vitamin D levels were obtained from all infants and their mothers at the time of hospital admission. The maternal and neonatal demographic features, maternal vitamin D usage, maternal head cover status, birth season and neonatal morbidities and mortality were all recorded. Maternal vitamin D supplementation was classified in terms of usage: no usage, insufficient usage (total usage 3 months) and vitamin D deficiency was staged as severe deficiency (serum 25-OHD510 ng/mL), insufficiency (serum 25-OHD between 11 and 32 ng/mL), and adequate (serum 25-OHD between 32 and 100 ng/mL).Plasmas of both maternal and neonatal blood samples were separated and stored until analysis. Levels of 25-OHD were determined by High Performance Liquid Chromatography (HPLC) system. Clinical Cases or Summary Results: A total of 100 preterm infants were included and 31 of them developed BPD. The mean birth weight and gestational age of infants with BPD were significantly lower than those who did not develop BPD (p50.05). As expected, the duration of mechanical ventilation and duration of total oxygen supplementation were found to be significantly longer in infants with BPD compared with those who did not develop BPD (p50.05). Both maternal (19 ± 2.2 vs 28.7 ± 7.6) and neonatal (7.1 ± 1.6 vs 14.8 ± 4.7) 25-OHD levels were significantly lower in infants with BPD compared with those who did not have BPD (both p50.05). Neonatal vitamin D levels were correlated with maternal levels. All of the infants with BPD had a 25-OHD level 510 ng/ml that represented severe vitamin D deficiency (p50.05). Conclusions: This study suggested for the first time that maternal/ neonatal vitamin D deficiency might be associated with increased risk of BPD in preterm infants. These data also underline the importance of adequate vitamin D supplementation during pregnancy for the possible prevention of BPD. However, there are still unanaswered questions about how tightly vitamin D levels are linked to lung development during fetal and early postnatal life and whether vitamin D supplementation during these periods reduces the likelihood of abnormal lung development that may be answered by future studies Keywords: Bronchopulmonary dysplasia, maternal vitamin D, neonatal vitamin D, vitamin D deficiency Presenter: Merih Cetinkaya

ID 578

CHANGES IN SURFACTANT PRACTICE OVER THE PAST 20 YEARS IN BELFAST C. Anderson1, & DG. Sweet2 1

Royal Jubilee Maternity Service, Belfast, Northern Ireland, and 2Royal Jubilee Maternity Service, Belfast, Northern Ireland.

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Table of results demonstrating patterns of surfactant use in Northern Ireland over the past 20 years Year

1993–1994

2003–2004

2013

Gestation (wks) 27 (25–28) 27 (25–28) 28 (24–28) Birthweight (g) 926 (730–1101) 890 (721–1145) 944 (740–1185) Received surfactant 44 90 78 Time of 1st dose (hrs) 3 0 (0–0) 0 (0–3) Ventilator days in 4 (0–9) 6 (2–21) 3 (0–10) survivors Survivors in oxygen 14 31 24 at 36 weeks

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Results shown as median (IQR) or % Brief Introduction: In the past babies with RDS were managed with selective rescue surfactant therapy. Studies demonstrated a survival advantage with prophylactic surfactant in the late 1990s and early intubation for surfactant became the norm. Since 2010, guidance has changed again, with the emergence of CPAP as primary respiratory support, regardless of gestation, and early rescue surfactant rather than prophylaxis is recommended. The 2013 European Consensus Guideline for the Management of RDS recommends that surfactant should be administered at the time of intubation, or for babies on CPAP when FiO2 40.3 in babies 526 week’s and when FiO2 40.4 for babies 426 week’s gestation. Surfactant should be administered by the INSURE technique, avoiding mechanical ventilation where possible. Materials & Methods: This retrospective study compares the practice of surfactant administration in Belfast in babies 530 week’s gestation in 2013, with that in 2003 and 1993. Data was collected from the baby’s medical records and included the number of doses of surfactant, the timing of these doses, whether prophylaxis or rescue therapy employed, or if administered at the time of intubation, whether the

INSURE technique was used, the number of days of ventilation and the outcome in terms of development of BPD at 36 weeks defined as persistent need for oxygen. These data were compared with historical data presented previously in 2004. Clinical Cases or Summary Results: The groups did not vary greatly in terms of median gestation or birth-weight. Out of 76 infants born at 530 week’s gestation in 2013, 78% received surfactant therapy: 28% as rescue (54% of these via the INSURE technique); and 50% were administered surfactant as they were already intubated for stabilisation. This is in contrast with 90% of infants receiving surfactant in 2003. The median time to first surfactant dose in 2013 was within the first hour of life (in delivery suite), which is similar to that recorded in 2003, although sub-group stratification demonstrated that it was more common for those delivered at 526 week’s gestation to be electively intubated for surfactant in delivery suite than those born at later gestations. The median amount of time spent on a ventilator was 3 days, compared with 6 days in 2003. The proportion of survivors with BPD at 36 weeks was 24% compared with 31% in 2003. See attached table for a summary of the findings. Conclusions: In 2013, less babies received surfactant than in 2003 and there is a trend towards more early rescue surfactant, rather than automatic intubation for prophylactic surfactant. Babies born under 30 week’s gestation are being ventilated for fewer days and have a lower rate of BPD. However in 2013 there has not yet been a notable change in practice in the timing of early surfactant therapy, in particular in the cases of babies delivered at 526 week’s gestation. These results include data from the 6 months preceding the publication of the 2013 European Consensus Guideline on the management of RDS. There is improvement in terms of a reduction in the use of mechanical ventilation and in the associated development of BPD in more recent years. Keywords: Surfactant Presenter: Claire Anderson

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ID 553

ID 346

CLINICAL AND SURGICAL APPROACH TO NEONATES WITH CONGENITAL DIAPHRAGMATIC HERNIA FROM OUTBORN NEONATE INTENSIVE CARE UNIT

RESPIRATORY MORBIDITY AFTER ELECTIVE CAESAREAN SECTION IN TERM NEWBORNS

M.E.J. Ceccon1, E.M. A. Diniz2, M.S. Grassi1, M.M. Silva1, U. Tannuri3, & W.B. Carvalho2 1

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J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Outborn Neonate Intensive Care Unit-Children’s Institute, Hospital das Clı´nicas School of Medicine University of Sa˜o Paulo-Brazil, 2Discipline of Neonatology, Department of Pediatrics-School of Medicine University of Sa˜o Paulo-Brazil, and 3Discipline of Pediatric Surgery,Department of PediatricsSchool of Medicine University of Sa˜o Paulo-Brazil Brief Introduction: Congenital diaphragmatic hernia is the most common developmental abnormality of the diaphragm and occurs in about 1/2000 to 1/5000 live births. The main consequence is pulmonary hypoplasia and severe pulmonary hypertension. Mortality is high at all medical centers ranging from 20 to 80%. Objectives: To characterize the newborns with CDH, describe the treatment and verify the survival and factors associated with good prognosis. Materials & Methods: Methodology: We study 20 infants with diagnosis of CDH and pulmonary hypertension confirmed by echocardiography with color Doppler: presence of right-left shunt through the foramen ovale and ductus arteriosus in all infants, and increased systolic pulmonary artery pressure, admitted to a NICU, from January 2011 to February 2013. Clinical Cases or Summary Results: Results: Data from 20 infants were analyzed. Regarding gender 12 newborns (60.0%) were male and 15 (75%) term newborns. The hernia was more frequently at the left side of the thorax in 15 newborns (80.0%) The diagnosis was made during the prenatal in 14 infants (70%) and in 40% of cases had associated malformations: heart (hypoplastic left heart defect and atrial and ventricular septum) followed by genitourinary. All infants were on mechanical ventilation since birth, always initially in conventional mode. Remained in this mode 11 infants (55.0%) and 9 (45%) used high-frequency ventilation. Inhaled nitric oxide (in), associated with conventional or high- frequency ventilation was used in 20 infants (100, 0%), when the IO was 20. How vasodilator addition of in was used milrinone with monitoring PAM and echocardiography, associated with norepinephrine when hypotension were present. The newborns were operated almost always in third day of life and when the newborns were stable sildenafil was administered. 15 patients survived (75%) and 5 died (25.0%). Those who survived despite being serious they had good prognostic factors such as: good oxygenation in the VM in conventional mode, pre - ductal saturation between 88 and 92%, PaCO2 to 60 mmHg with pH 47.20, no refractory hypotension, and relative lung/chest circumference diameter 41. Conclusions: Conclusions: The treatment of newborns with CDH remains a challenge despite therapy’s available. Good prognostic factors and conservative treatment seems to be the most appropriate, since these infants partially respond or not respond to treatment with iNO alone and high-frequency ventilation. Keywords: Congenital Diaphragmatic Hernia, Newborn, surgery Presenter: Edna Maria de Albuquerque Diniz

A. Estape´ Fiol, I. Anquela Sanz, A. Ortega Rolda´n, J. Bosch Castells, & M. Catala` Puigbo´ Hospital General de Granollers, Granollers, Spain (Neonatology Unit, Paediatric Dept.) Brief Introduction: The rate of caesarean section (CS) has increased substantially in the last few decades and a large portion is attributed to elective caesarean section (ECS). CS is associated with an increased risk of neonatal respiratory morbidity, especially when carried out before the beginning of labour. In addition, lack of physiological changes which occur during labour may cause an increase in afterbirth complications such as hypoglycaemia or hypothermia. The aim of the research was to examine the rate of respiratory morbidity in term neonates, comparing neonates delivered by ECS before the onset of labour or rupture of membranes versus vaginal delivery (VD). Materials & Methods: The study group consisted of all term neonates with respiratory distress admitted to our Neonatal Unit during an 8 year period (2006–2013). Patients with congenital anomalies affecting the cardiorespiratory system, foetal abnormalities, asphyxia or respiratory distress caused by extrapulmonary diseases, were not included. Clinical Cases or Summary Results: Of the 1,975 patients admitted to the Neonatal Unit, 1,232 (62.4%) were term neonates. Postnatal respiratory problems were found in 144 newborns (11.7%). These included: transient tachypnea of the newborn (TTN) (122;84.7%); meconium aspiration syndrome (13;9%), pulmonary air leak (8;5.6%) and neonatal pneumonia (1;0.7%). 59% (85) were males, average gestational age 39,2 weeks (37–41), birth weight 3,449 grams (2,065– 5,200), mother age 30,7 years (20–49). Apgar 57: 20.1% (29) at 10 and 4.2% (6) at 50 . 88.3% (15) of the ECS were performed at 37/38 weeks of gestation and the main indications were previous caesarean section (8;47.1%) and breech presentation (6;35.3%). 43.8% (63) were delivered by CS (overall CS rate 21.9%), 11.8% (17; all of them TTN) were ECS (overall ECS rate 6.5%). There was a higher rate of hypoglycaemias (3.9% vs. 2.1%) and hypothermia (2% vs. 0.8%) in CS vs. VD. The TTN rate of VD was 0.6%, of non elective CS was 1.2% and of ECS was 1.7%. 48.4% of the newborns with TTN needed some kind of respiratory support (76.3% within the first 24 hours of life). The absence of labour before birth was associated to a longer duration of oxygen supplementation (70 hours vs. 31 hours) and higher rates of continuous positive airway pressure therapy (CPAP) (35.3% vs. 26.7%) and mechanical ventilation (MV) (5.9% vs. 1%). Conclusions: TTN is the most common cause of neonatal respiratory distress in term neonates. The rate of respiratory morbidity and particularly TTN was higher in neonates delivered by ECS. In fact, the overall rate of ECS was substantially higher in newborns with TTN. The absence of labour in newborns with TTN was associated to higher rates of CPAP, MV and a longer duration of oxygen supplementation. Other after-birth complications in term neonates such as hypoglycaemia and or hypothermia were double in CS. Keywords: caesarean respiratory morbidity

section;

Presenter: Anna Estape´ Fiol

transient

tachypnea

newborn;

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DOI: 10.3109/14767058.2014.924236

ID 184

FACTORS ASSOCIATED WITH EARLY OUTCOME IN PERSISTENT PULMONARY HYPERTENSION OF THE NEWBORN IN THAI NEONATES N. Nakwan & S. Pithaklimnuwong

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Neonatal Intensive Care Unit, Department of Pediatrics, Hat Yai Medical Education Center, Hat Yai Hospital, Songkhla, THAILAND Brief Introduction: Prevalence and mortality rate of persistent pulmonary hypertension of the newborn (PPHN) in which is one of the most serious neonatal respiratory diseases remains high in low-income countries. It is still important to more identify risks associated with mortality, because this is the only way to achieve successful intervention in preventing death. The objective of this study to describe the clinical characteristics, diagnostic methods, treatment modalities, and complications, and identify mortality risk factors at short-term of infants with PPHN. Materials & Methods: The clinical data of infants who diagnosed with PPHN at Hat Yai Hospital in southern Thailand from January 2010 to February 2014 were retrospectively reviewed. Clinical Cases or Summary Results: During study period, 119 infants were analyzed. The prevalence of PPHN (based on inborn births) was 2.8 per 1000 live births. The all causes mortality rate was 39.5%. The mean gestational age and birth weight were 39.1 ± 1.6 weeks and 3,044 ± 563 g, respectively. Of 119 infants, 75 (63.0%) infants were male, and 33 (27.7%) were born outside hospital. Meconium aspiration syndrome (54.6%) was the most common etiology of PPHN. High frequency oscillatory ventilation was used in 80.7%, inhaled nitric oxide of 31.1%, sildenafil of 69.7%, and intravenous iloprost of 80.7% overall. Multivariate Cox regression analysis indicated that, pneumothorax (adjusted Hazard ratio (HR) = 1.99, p = 0.04) and acute kidney injury (adjusted HR = 2.91, p50.01 were factors associated independently with an increased risk for death, while infants who received total parental nutrition (adjusted HR = 0.23, p50.01) was associated with lower mortality Conclusions: The mortality of PPHN in Hat Yai Hospital remains high rate. Pneumothorax and acute kidney injury were factors associated independently with an increased risk for death. Keywords: PPHN, mortality, persistent fetal circulation, newborn Presenter: N. Nakwan

ID 055

SAFETY AND EFFECTIVENESS OF ORAL BETAMETHASONE FOR BRONCHOPULMONARY DYSPLASIA IN ELBW INFANTS T. Smolkin, I. Ulanovsky, H. Jubran, S. Blazer, & I. Makhoul Neonatology Department, Meyer Children’s Hospital, Rambam Health Care Campus and Rappaport Faculty of Medicine, Technion – Israel Institute of Technology, Haifa, Israel Brief Introduction: Dexamethasone (DEXA) for bronchopulmonary dysplasia (BPD) increases cerebral palsy risk. We compared safety and

effectiveness of betamethasone (BETA) for BPD with relevant literature. Materials & Methods: We studied 35 extreme-low-birth-weight (ELBW) infants (birth weight  1000g, gestational age 28 weeks) with BPD, were mechanically ventilated 7 days, received 430% FiO2, failed respiratory weaning over 3 days, and received oral BETA (7 days): 0.1mg/kg/dose twice daily (3 days), 0.05mg/kg/dose twice daily (2 days), and 0.05mg/kg/dose once daily (2 days). Clinical Cases or Summary Results: We compared our own-BETAtreated group (OBTG) with the DeCastro-BETA-treated and DEXA-treated groups (DBTG and DDTG, respectively; J. Perinatol 2009;29:297–304). Gestational age was comparable in the three groups; OBTG had therapy at older age: 31 ± 13.6 vs. 18 ± 2 vs. 18 ± 6 days. Therapy duration, drug administration route and total drug exposure (OBTG: 0.9mg/Kg, DBTG: 0.375mg/Kg, DDTG: 2.5mg/Kg) differed between groups. On BETA start, 24 of 35 infants were intubated and ventilated. Reduction of 420% of oxygen requirement occurred in 68.6%, 40% and 54%, respectively. Extubation by day 7 of treatment occurred significantly more in OBTG: 58.3% vs. 20% and 18%, respectively. All groups had comparable PVL rates (2.8% vs. 0% vs. 7%, respectively) and maximal increase in weight and blood glucose. Significantly lower maximal increase in systolic blood pressure was noted in OBTG. Conclusions: Compared to published BETA and DEXA use for BPD, medium doses of oral BETA allowed greater reduction of oxygen requirements, more extubations, lower increase in systolic blood pressure, and comparable PVL, and maximal increases of weight and blood glucose. Keywords: Betamethasone, bronchopulmonary dysplasia, corticosteroids, dexamethasone, very low birth weight infant, growth Presenter: Tatiana Smolkin

ID 913

CONTRIBUTION OF CYTOGENETIC IN THE DIAGNOSIS OF CAUSES OF GENITAL DEVELOPMENT ABNORMALITIES IN CHILDREN I. Ben Hadj Hmida1, A. Hajlaoui1, J. Mathlouthi3, K. Ben Helal2, H. Hannechi1, S. Dimassi1, M. Kammoun1, H. Seboui3, A. Saad1, & S. Mougou-Zerelli1 1

Departments of Cytogenetics and Reproductive Biology, Farhat Hached University Teaching Hospital, Sousse, Tunisia, 2 Departments of Pediatic, Hospital Ibn El Jazar Kairouan, Tunisia, and 3Departments of Neonatology, Farhat Hached University Teaching Hospit Brief Introduction: Disorders of sex development (DSD) constitute a large array of disorders that affect the genito-urinary tract and often include the endocrine system. DSD-related phenotypes include cryptorchidism and hypospadias. Some of these disorders are rare such as 46, XY cases with complete or partial gonadal dysgenesis which affect approximately 1:50,000 individuals, while other DSDrelated phenotypes are more common such as hypospadias and/or cryptorchidism, which can affect around 1: 50 newborn males. Materials & Methods: A careful clinical examination will primarily interest to define the sexual ambiguity Prader score and the whole genital and extra genital malformation context. Our study focuses on cases referred to the department of Cytogenetics and Reproductive Biology CHU Farhat Hached for ambiguous genitalia cytogenetic exploration from January 2010 to January 2014. Clinical Cases or Summary Results: In recent years there has been a considerable effort to identify the underlying genetic anomalies in these cases. However, only 50% of 46, XY children with DSD will

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receive a definitive diagnosis. A specific molecular diagnosis is identified in only 20% of cases of DSD. Understanding the genetic basis of these disorders is a high priority. The 246 patients studied with ambiguous genitalia of varying severity, 80% were younger than 10 years. 7.5% of them showed chromosomal abnormalities. In 3 patients, the chromosomal abnormalities involved the autosomes 4, 5 and 1 with a 4p deletion in Wolf-Hirschhorn syndrome, deletion 5p in Cri-du-chat syndrome and 1q deletion revealed by Comparative Genomic Hybridization- array. Theses anomalies are associated with loss function of genital differentiation protein. In 9 other patients abnormal sexual chromosome number was identified. For 205 children with normal karyotype 46, XY, SRY gene molecular cytogenetic screening was performed. A deletion may in these cases explain the phenotype. Conclusions: The appearance of the external genitalia in the newborn male is a biological readout of the consequences of a marked increase in fetal hormonal production. This process occurs between 8 and 14 weeks of gestation in the human and constitutes a male programming window with organizational effects. Identification of gene rearrangements causing uro-genital birth defects can have an impact on the diagnosis and genetic counseling. Thus more studies are necessary to find new candidate genes in signaling pathways regulating sexual differentiation. Keywords: sexual differentiation; genetic anomalies; karyotype; ambiguous genitalia; Comparative Genomic Hybridization- array. Presenter: Soumaya Mougou-Zerelli

ID 285

AUDIT OF EARLY MANAGEMENT OF PRETERM BABIES WITH CHRONIC LUNG DISEASE A. Mohammed1 & J. Preece2 1

ST4 Neonates - Neonatal unit, Hull Royal infirmary, Hull, UK, and 2Consultant Neonatologist - Neonatal unit, Hull Royal infirmary, Hull, UK Brief Introduction: Chronic lung disease is a common problem in preterm babies. There are various factors that influence the incidence of chronic lung disease among which the key factors include antenatal steroids, early surfactant, lung protective ventilation strategies, as few infections as possible and PDA prevention. Co-morbidities like NEC, Gr3–4 IVH, Cystic PVL, are also associated with chronic lung disease. We looked at preterm babies with chronic lung disease from our unit and audited with the departmental guidelines for the early management of preterm babies Materials & Methods: It was a retrospective study over 2year period from Jan 2011 till Dec 2012. We had 37 babies with chronic lung disease and out of which 6 were born in a different hospital so excluded. We used Neonatal Badger database, Case notes and Xrays to get all the information Clinical Cases or Summary Results: 77% of our babies had antenatal steroids out of which only 55% had full course.The median GA was 27wks(24–32wks), Median Birth weight was 925g(660g-1560g), Male:Female was 1.8:1. Out of 31 babies 18 were 528wks GA babies. Median time for intubation was 6min, median number of attempts at intubation was 2 (1–4). Experienced team members intubated 83% of our preterm babies. Two babies received less than 100mg/kg of prophylactic surfactant dose and one 5200mg/kg of rescue dose. Nearly half of them receive surfactant between 15–25 min after birth. 19% of our babies had admission temp 536.50c. All babies except one was on

volume guarantee ventilation.16% of the babies had PIE changes and 6% developed pneumothorax.35% had positive blood cultures out of which 32% were peripheral and positive for CONS. Co-morbidities: 16% developed NEC, 55% had PDA and all were treated except one, 23% had laser therapy for retinopathy of prematurity, 19% had cystic PVL, 16% Gr3–4 Intraventricular haemorrhage Conclusions: Chronic lung disease in preterm babies is multifactorial. The positive points from the audit were that we had good ventilation strategies, attendance of senior Doctors at delivery and treatment rates of PDA Following the audit we reinforced the importance of correct dose of surfactant and thermoregulation after birth. We took measures to improve the intubation skills of our Junior Doctors so that the Surfactant can be given quickly and educated the juniors to take adequate aseptic precautions for peripheral blood culture sampling to aid evaluation of true infection rates in NICU babies We are also looking in to changing our guidelines for the initial management of preterm babies after reviewing the 2013 update of European Consensus Guidelines on the Management of Neonatal Respiratory Distress Syndrome in Preterm Infants Keywords: Chronic Lung disease, preterm babies Presenter: Dr A. Mohammed

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DOI: 10.3109/14767058.2014.924236

ID 673

ADVERSE EFFECTS OF SURFACTANT THERAPY IN PRETERM INFANTS WITH PULMONARY HYPOPLASIA DUE TO OLYGOHYDRAMNIOS Y. Kawase, K. Hine, K. Saito, N. Mizukaki, S. Hagihara, H. Arai, & H. Yoda

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Department of Neonatology, Toho University School of Medicine, Tokyo, Japan Brief Introduction: Olygohydramnios after premature rupture of membranes is known to cause severe respiratory failure in preterm infants. Surfactant is often administered as an early rescue therapy in these severe cases before a definitive diagnosis of respiratory distress syndrome. We reviewed the adverse effects of surfactant therapy in pulmonary hypoplasia due to olygohydramnios. Materials & Methods: A retrospective study of the preterm infants with birth weight 52000g and 534weeks of gestational age who had pulmonary hypoplasia due to olygohydramnios admitted from Jan 1994 to Dec 2013. 34 infants were included. The gestational age, the birth weight, the timing and the duration of rupture of membranes, and the initial treatments and their complications were reviewed in each case. Clinical Cases or Summary Results: The mean gestational age and birth weight were 27.1 ± 3.1(weeks) and 942 ± 379(g). 16 of 34 infants were treated with high frequency oscillation. Surfactant was administered in 30 of 34 infants. 22 infants were treated with the inhalation of nitric oxide. 12 infants had pneumothorax and 8 infants had intraventricular hemorrhage and all these cases had received surfactant therapy. 6 infants died within 24 hours after birth and all the cases had received surfactant therapy. Conclusions: Surfactant therapy was associated with severe complications in preterm infants with pulmonary hypoplasia due to oligohydramnios and may be associated with poor prognosis. In these conditions, it is better to avoid the immediate surfactant therapy after birth. Keywords: oligohydramnios, pulmonary hypoplasia, surfactant Presenter: Yasuhiro Kawase

ID 702

A CASE-CONTROL STUDY OF CHOLESTASIS OF PREGNANCY INDUCED RESPIRATORY DISTRESS SYNDROME IN NEONATES Y. Yu1, Y.C. Lu2, C.L. Zhou3, X.F. Zhang4, H.F. Huang5, & X.F. Yang6 School of Medicine, University of Zhejiang, Woman’s Hospital, Hangzhou, Zhejiang, CHINA, PR 310005. Brief Introduction: Recently, maternal intrahepatic cholestasis of pregnancy(ICP) has also been recognised as a risk factor for neonatal respiratory distress syndrome (RDS) in term or near-term neonates. To investigate the association between ICP and neonatal RDS, a casecontrol study was conducted. The average levels of cholyglycine(CG) in maternal serum was significant higher in the study group than that in the control group. This was similar in the comparison of the average level of neonatal cholylglycine. The odd ratio for NRDS was 4.57 among newborns in the study group in contrast to the control

group. Conditional Logistic Regression mode showed delivery in advance of expected date, cholylglycine levels of umbilical cord blood above 500 ug/dl were the major risk factors of neonatal RDS. Materials & Methods: A case-control study was conducted. There were 75 childbearing women identified with ICP in the study group and 75 cases in the control group. In both groups, maternal and umbilical cord blood cholylglycine levels were tested after delivery. Mothers and infants were followed up to 7 days after delivery. Incidence of NRDS was compared between two groups. Conditional Logistic Regression mode was used for analysis of risk factors of NRDS. Clinical Cases or Summary Results: The average levels of cholyglycine(CG) in maternal serum was significant higher in the study group than that in the control group (t = 20.36, p50. 05).This was similar in the comparison of the average level of neonatal cholylglycine (t = 7.19, p50. 05). The odd ratio for NRDS was 4.57 among newborns in the study group in contrast to the control group (OR = 4.57,95%CI 1.23  16.94). Conditional Logistic Regression mode showed delivery in advance of expected date (OR = 0.57, 95%CI 0.40  0.83), cholylglycine levels of umbilical cord blood above 500ug/dl (OR = 11.59, 95%CI 3.14  42.71)were the major risk factors of NRDS. Conclusions: Maternal ICP was significantly associated with the occurrence of RDS in the newborn. Keywords: Respiratory distress syndrome; Cholestasis; Pregnancy; Neonate; Cholylglycine Presenter: Ying Yu

ID 949

BRONCHOPULMONARY DYSPLASIA(BPD)INCIDENCE AND PREDICTOR FACTORS IN INFANT 32 WEEKS GA A LOCAL EXPERIENCEA LOCAL EXPERIENCE A. Alsulaiman, MD2, M. Abuouf, MD1, & M. Abou Al Seoud, MD1, King Fahad Armed Forces Hospital (KFAFH), Jeddah, Saudi Arabia, and Al Azizzia Hospital, Jeddah, Saudi Arabia Brief Introduction: Bronchopulmonary dysplasia (BPD) is the most common complication of preterm birth with a major morbidity &mortality. In Saudi Arabia the data is limited on the incidence of BPD in preterm infants and usually is a single center–based studies with small sample size. Knowledge of BPD incidence is important during parent counseling in anticipation of a preterm birth. Several predictive models have been developed for BPD that might be of value for clinical trials. The trends in BPD reflect variation in practice that could stimulate performance improvement projects for a better outcome Aim of the study is to assess incidence of BPD among in-born premature infants at 32weeks gestation and less at KFAFH and to identify predictor factors for BPD in our patient population Materials & Methods: Research Study was approved by research and ethics committee at KFAFH. Retrospective, Observational Cohort Study at KFAFH From January 1st 2008 to December 31st 2012. VLBW and ELBW Infants of gestational age between 24-32weeks in-born were enrolled. Exclusion criteria: Infants died before 28days and Congenital Anomalies. We have used the Maternal and neonatal Demographic Data(Table 1&2) were collected from medical records Following definitions/practices were used: Definition of BPD and Severity –Based Diagnostic Criteria for infants at 36 wk PMA or discharge (Ehrenkranz 2005)

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218 Sepsis was defined as positive culture (blood, urine, CSF) early sepsis 572 hours and late sepsis 472hours. PDA if size 41.5mm by ECHO Statistical Analysis: Using SPSS version20. Univariate analysis (logistic regression) was done at 28 day postnatal age and at 36 weeks corrected age Clinical Cases or Summary Results: Bronchopulmonary Dysplasia (BPD) was detected in 34 cases (10%). 24 out of 34 cases met the criteria of severe BPD (7.2% of the total population analyzed). The incidence of BPD@36wks PCA in our studied population was 10%, 7.2% were classified as sever BPD Using the univarate analysis the following variables were identified: Perinatal factors has low predictive value for BPD in our population including antenatal corticosteroids. Gestational age and Birth weight were strong predictors for BPD. Gender was not a risk factor in our population. The initial resuscitative measures at birth have a low predictive value compared to ventilation mode and oxygen requirement on day 14 of life. Fluid intake more than 150ml/ kg/day in day 14PNA increases the risk of CLD.The likely hood of developing BPD is increased by 5.5 times in the presence of PDA. Hospital acquired infection is a major predictor of sever BPD. In our population there is a High correlation between BPD and other neonatal co-morbidities (stage 3 ROP and PVL). Conclusions:  Our BPD rate is comparable to what has been reported in the literature  Performance improvement action plan developed for implementations: Increase the uptake of ante natal steroids (76%) Optimize prophylactic surfactant treatment as per our policy (24% of patients receive surfactant within the 1st 30 minutes) T-Piece Resuscitator (used in only 18% of cases) Infection control bundles (on going QIP) Increase EBM utilization (only 15% exclusive EBM vs. 74% combined) Vitamin A supplementation for 51000 grams babies Keywords: BPD, ROP, PVL. Presenter: A. Alsulaiman, MD

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Clinical Cases or Summary Results: Among the total number of observed children BPD was diagnosed in 61 children -10.7% over a period from 2009 to 2012. The diagnostic criteria of BPD were: low birth weight, gestational age, duration of mechanical ventilation, the clinical manifestations of respiratory failure, oxygen dependence to 28 days of age and older and radiographic criteria for BPD on the results of chest radiography and computed tomography of the lungs. The frequency of BPD was in 2009 - 5.7% (8), in 2010 - 4.9% (8), 2011– 11.6% (18) and in 2012- 24% (25). In newborns the frequency of bronchopulmonary dysplasia were met more often among boys in 57% (35) and a lesser was in girls 43% (26). Among infants with extremely low birth weight (1000 grams) determined a progressive increase in BPD - from 23% to 60%, in a group-1000 to 1500 g from 9.3% to 18% and in the group from 1500 to 2000 g - with 2% to 6%. Conclusions: Thus, for the past 4 years we determined the increase of the frequency of BPD in all weight groups in 4 times. The introduction in practice of neonatal nursing modern technology significantly reduced the mortality rate in the group of premature infants with extremely very low body weight, but also led to a progressive increase the frequency of bronchopulmonary dysplasia, in this group of small babies. Keywords: Presenter: D. Kachurina

ID 516

PNEUMOTHORAX – IMPLICATIONS DURING PERINATAL IN PRETERM INFANTS 32 WEEKS GESTATIONAL AGE M. L. Ognean1, S.M. Stoicescu2, M. Cucerea3, A. Sorin Cra˘ciun4, O. Boanta˘1, L. Na˘stase2, C. Movileanu3, A. Sta˘nescu4 1

ID 010

THE FREQUENCY OF BRONCHOPULMONARY DYSPLASIA IN NEWBORNS D. Kachurina, K. Rayus, Z. Tulebaeva, & A. Pirmakhanova Scientific Center of Pediatrics and Pediatric Surgery Ministry of Health, Republic of Kazakhstan Brief Introduction: The bronchopulmonary dysplasia (BPD) in the last anniversary become a great problem all around the world. According to neonatal research group of the National Institute of Child Health and Human Development (NICHD), the frequency of BPD in the U.S., in a population of preterm infants with gestational age 22–28 weeks is 68%, in Sweden - 73%. There is no the statistics about bronchopulmonary dysplasia in Kazakhstan now. That is why the aim of our study was to investigate the dynamics of the frequency of bronchopulmonary dysplasia in premature infants, who took treatment in the department of neonatology and neonatal surgery Scientific Center of Pediatrics and Pediatric Surgery, Ministry of Health of the Republic of Kazakhstan from 2009 to 2012 years. Materials & Methods: 570 premature infants with gestational ages from 28 to 34 weeks and birth weight from 500 to 1000 g., at the age of 30 days to 2 months of postnatal life, which were in the department of neonatology and neonatal surgery.

Neonatology Department, Clinical County Emergency Hospital Sibiu, 2Institute for Mother and Child Care, Clinical Hospital of Obstetrics & Gynecology Polizu, University of Medicine and Pharmacy Carol Davila Bucure¸sti, and 3 University of Medicine and Pharma Brief Introduction: Pneumothorax may complicate the perinatal course of the preterm infants, mainly in those requiring mechanical ventilation. Aim: The authors aimed to identify the impact of the presence of pneumothorax on the clinical course and outcome in preterm infants 32 weeks gestational age. Materials & Methods: Material and methods: The prospective study was developed over a 2 years period (01.01.2010 - 31.12.2011) and as based on the information collected in the National Registry for Respiratory Distress Syndrome by 4 regional neonatal centers. All preterm infants 32 weeks gestational age were included and data analysis was performed using IBM SPSS Statistics 19 (for a statistical significant p50.05, 95% CI). Clinical Cases or Summary Results: Results: The study group comprised 762 preterm infants with a mean gestational age (GA) of 29.5 ± 2.2 weeks (23–32 weeks), and a mean birth weight (BW) of 1317.6 ± 389.7g (450–2460g). The preterm infants that had pneumothorax needed more frequently (p 0.000) and for a longer time mechanical ventilation (0.022), and a longer duration of oxygen therapy (0.000; OR 8.4[3.1– 22.5]). These associations persisted even excluding deaths. A significant association was found between the presence of pneumothorax and death (p 0.000; OR 8.0[3.5–18.1]). Pneumothorax was associated with an increased risk for persistent ductus arteriosus,

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apnea of prematurity, chronic lung disease, periventricular leukomalacia, and retinopathy of prematurity (p40.05). Conclusions: Conclusions: The presence of pneumothorax is complicating the course of the respiratory conditions in preterm infants. More invasive and longer respiratory support is, most probably, the cause of the significant impact of pneumothorax on the death risk. Keywords: pneumothorax, preterm infant, respiratory distress syndrome, outcome, complications Presenter: Adrian Sorin Craciun

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ID 798

EVALUATION OF ASSOCIATION BETWEEN ADAM33 GENE POLYMORPHISM AND SUSPECTIBILITY TO BRONCHOPULMONARY DYSPLASIA IN PRETERM INFANTS M. Cetinkaya1, I. Varturk2, M.A. Korachi2, I.M. Akın3, S. Guven4, G. Buyukkale1, T Erener-Ercan1, & S. Ozumut 1 Neonatology Dept., Kanuni Sultan Su¨leyman Training ad Research Hospital, Istanbul, Turkey, 2Genetics and Bioengineering Dept., Yeditepe University, Istanbul, Turkey, and 3Neonatology Dept., Medeniyet University Go¨ztepe Training and Research Hospital, Istanb

Brief Introduction: ADAM 33 is a disintegrin and metalloproteinase glycoprotein that is involved in intercellular and cell-matrix interactions. It was suggested to be important for normal lung development in the embryo as the expression of ADAM 33 can be observed as early as 8–12 weeks after gestation. Although several studies have demonstrated an association between ADAM33 and asthma, bronchial hyperresponsiveness, progression of wheezing illness, airway remodelling, lower lung functions, accelerated lung function decline and higher specific airway resistance in children, no study evaluated the role of ADAM33 in bronchopulmonary dysplasia (BPD). The aim of this study was to investigate the possible association between ADAM33 gene polymorphism and susceptibility to BPD development. Materials & Methods: A total of 120 preterm infants born at gestational age 32 weeks and admitted to the Neonatal Intensive Care Unit (NICU) were enrolled to this prospective study. BPD was defined according to the National Institute of Child Health and Human Development.Detailed perinatal history (birth weight, gestational age, Apgar score at 1, and 5 min after birth) and history of treatment in the hospital (duration of mechanical ventilation and total oxygen therapy, need of surfactant treatment, other morbidities) were recorded during the study period. Blood samples were stored at 20  C. Genomic DNA was extracted from these samples. ADAM33 gene at rs 2280090 was analyzed. Allelic frequencies and genotype frequencies were determined from BPD patients and healthy controls. Clinical Cases or Summary Results: A total of 120 preterm infants were enrolled. The frequency of AA genotype and GG genotype were significantly higher than those of GA genotype in infants with BPD compared with the infants without BPD. Comparison of the frequency distribution of ADAM 33 in BPD and healthy control groups revealed the presence of A allele was a risk factor for BPD infants. The homozygos AA and GG genotypes were found to be associated with BPD development. Conclusions: To our best of knowledge, this is the first study that suggested a possible association between ADAM33 gene polymorphism and increased frequency of BPD in preterm infants. Future studies are needed to assess the contribution of ADAM 33 to the

pathogenesis of BPD and to determine if ADAM 33 gene polymorphisms may be helpful to identify infants at high risk for BPD. Keywords: Bronchopulmonary polymorphism

dysplasia,

ADAM

33,

gene

Presenter: Merih Cetinkaya

ID 490

BRONCHOPULMONARY DYSPLASIA IN EXTREMELY LOW BIRTH WEIGHT INFANTS P. Radulova, B. Slancheva, G. Petrova, St. Hitrova, T. Pramatarova, N. Yarakova, L. Vakrilova, Z. Emilova, & A. Popivanova Clinics of Neonatology, University Hospital ‘‘ Maychin Dom ‘‘, Sofia, Bulgaria Brief Introduction: Aim: To evaluate the factors that lead to Bronchopulmonary Dysplasia/BPD/in extremely low birth weight infants. To evaluate the frequency of BPD in newborns 528 week of gestation. Materials & Methods: A prospective study. Patients: infants with birth weight51000 gr., treated in NICU of Clinics of Neonatology for period of two years. Infants are divided by gender, weight and gestational age. The following parameters are analyzed: presence of corticosteroid prophylaxis before birth, presence of perinatal asphyxia, presence of data for maternal- fetal infection/MFI/, severity of RDS, time of administration of surfactant after birth, presence of PDA, duration of assisted ventilation, duration of O2-therapy. The infants are followed for complications: Bronchopulmonary Dysplasia. Clinical Cases or Summary Results: The frequency of BPD in infants 528 week of gestation is very high: above 90%. All patients with BPD have MFI, prolonged duration of assisted ventilation and O2-therapy. Conclusions: Shortening of the duration of the respiratory ventilation after Surfactant therapy leads to reduction of the long term morbidities. The successful early extubation in extremely low birth weight infants after surfactant administration depends extremely on the presence of corticosteroid prophylaxis and the absence of MFI. The decision for early extubation should be taken after receiving all the laboratory data specifying the absence of MFI. Keywords: BPD, MFI, assisted ventilation, corticosteroid prophylaxis, O2-therapy Presenter: P. Radulova

ID 688

USE OF ERYTHROPOIETIN AND BPD WITH PREMATURE NEWBORNS BELOW 30 G.W N. Yarakova, T. Pramatarova, B. Slancheva, St. Hitrova, P. Radulova, & A. Nikolov Neonatology department; University Hospital of Obstetrics & Gynaecology Maichin Dom, Sofia, Bulgaria Brief Introduction: In spite of increased survival rate in premature newborns below 30 g.w. some complications (anaemia, BPD) persist. The aim of the study is to establish whether the use of erythropoietin (EPO) for anaemia of prematurity influences incidence and severity of BPD. Materials & Methods: Premature newborns below 30 g.w. admitted to the NICU of our hospital, treated with surfactant Curosurf,

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who survived 36 g.w.; classified according gestational age, birth weight and length, gender, way of delivery, Apgar score, pH u.a., BE, antenatal corticosteroids (AC), inborn infection, time\dose of surfactant, duration of mechanical ventilation (MV) and O2 therapy, incidence of BPD, anaemia, EPO treatment, ROP. EPO is applied in standard doses and regime as prophylaxis and treatment. Exclusion criteria: severe inborn malformations and IVH gr. IV. Clinical Cases or Summary Results: No significant differences were found in Apgar score, pH, AC, time\dose of surfactant. Incidence of BPD – 36 g.w. increases of course in babies born 28, 27, 26 g.w. Low incidence of severe ROP and death due to BPD is registered. A higher incidence of blood transfusions is found in babistudy still not completed, but preliminary data indicates that EPO treatment reduces BPD. Conclusions: The study still not completed, but preliminary data indicates that EPO treatment reduces BPD. Keywords: anaemia, BPD, erythropoietin Presenter: N. Yarakova

ID 968

NEONATAL PULMONARY HEMORRHAGE AND HYPOTHYRODISM R. Sacy, W. Fayyad, D. Hamod, & C. Saba Saint George Hospital University Medical Center, Balamand University; Beirut, Lebanon Brief Introduction: This is a 2 months old boy, born preterm (35 wks) by C-section, for pre-eclampsia, product of IVF, transferred to our hospital for tracheostomy. He was born with a good APGAR, with birth weight of 2600g, with normal neonatal screening at birth. At day 15 of life, baby was found to have cold extremities with decrease PO intake, so he was admitted to a peripheral hospital at day 17 for hypothermia, hypotonia, pallor and dehydration, and found to have peripheral and perioral cyanosis. Patient intubated, and upon suctioning from endotracheal tuge, he was found to have fresh blood. Materials & Methods: Case observation of one patient with abnormal presentation. Clinical Cases or Summary Results: Labs revealed low Hemoglobin and low platelet count, diagnosed of having septic shock and pulmonary hemorrhage, so he was given ionotropes, hydration, and covered with Amikacin, Cefotaxime, and Ampicillin. Chest XR showed bilateral pulmonary infiltrates. Echocardio showed PDA with L-R shunt and pulmonary HTN, so started on Sildenafil. Patient had failure to extubate (Several trial done), so transferred to our ICU for tracheostomy and further workup of pulmonary hemorrhage. Endocrinology workup done for suspected hypothyroidism, and TSH was 103 microU/ml, with FT4: 0.43 ng/dl, so patient diagnosed with hypothyroidism, and started on Levothyroxine. Repeat levels in 2 wks showed TSH 0.47 microU/ml and FT4 2.30 ng/dl, and ultrasound of thyroid showed normal thyroid size, homogenous and normal echotexture, measuring 1  0.8cm on right, and 0.8  0.84cm on left. We also ruled out autoimmune hypothyroidism: Anti thyroglobulin Ab (0.58IU/ml) and microsomal Ab (0.22 IU/ml) normal. Neonatal screening repeated on neonatal blood and was normal. Patient was successfully extubated, and discharged home on Levothyroxine, with follow up TSH and FT4 to be done in 2 weeks. Conclusions: We report a case of baby presenting at neonatal period with unusual presentation of hypothermia and pulmonary hemorrhage with normal neonatal screening, diagnosed later with hypothyrodism of unknown etiology (Which might be transient). Keywords: Neonatal pulmonary hemorrhage, hypothyrodism Presenter: Prof Robert SACY

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NEUROSCIENCE (THE FETAL AND NEONATAL BRAIN) ID 187

FETAL EEG AND ULTRASONOGRAPHY: A NEW APPROACH FOR THE STUDY OF THE DEVELOPMENT OF THE NERVOUS SYSTEM IN UTERO F. Stamatian1, T. Kovacs1, B. Florea1, & F. Amzica2 1

University of Medicine and Pharmacy ‘‘IuliuHatieganu’’, ClujNapoca, Romania, and 2Department of Stomatology, School of Dentistry, Universite´ de Montreal, Montreal, Canada Brief Introduction: Electroencephalography (EEG) is widely used to investigate the nervous system in both children and adults. Its earliest application ever performed was at birth. Here we tested the possibility to record fetal EEG before birth (weeks 26 to 38). The purpose of the study was to obtain (a) correlative data with putative structural anomalies disclosed by ultrasonography, and (b) serial recordings at various fetal ages with respect to the appearance of EEG patterns of activity during the development of the nervous system. Materials & Methods: Four electrodes were placed, under ultrasonographic guidance, on the belly of the mother at locations that corresponded to the traditional C3, C4, P3 and P4 sites (reference above Pz). Recordings lasted for several minutes (generally till a movement of the fetus secluded his head from the recording site) and occurred in parallel with ultrasonographic monitoring of the fetus.Events that were recorded and considered as artifacts were eye blinking or movements of the limbs. Clinical Cases or Summary Results: The following results were obtained: (1) Fetal EEG recordings are feasible and yield to stable, easily readable recordings. The mean amplitude of the EEG was 14.5 ± 4.3 mV (N = 8 sets of 1 min recordings). (2) Cases of (partial) agenesis of the corpus calosum resulted in reduced coherence (540%), especially in the range of slow (delta, 1–4 Hz) oscillations between the two hemispheres (C3 vs. C4, and P3 vs. P4). This also resulted in disorganized intrahemispheric coherence (C3 vs. P3, and C4 vs. P4). (3) Following the evolution of fetal EEG patterns from weeks 34 to 38 resulted in increased delta oscillations at all recorded sites, moderate modifications (generally diminution) within y (4–7 Hz) and s (7–14 Hz) frequency bands, while b-g activities (14–48 Hz) where drastically diminished. Conclusions: In conclusion, fetal EEG recordings are possible before birth and bear promising results. Keywords: fetal EEG, CNS, ultrasound Presenter: Florin Stamatian

ID 970

INCIDENTAL FINDINGS ON ROUTINE MRI SCANS AT TERM CORRECTED AGE OF EX-VLBW BABIES M. Malova1, L.A. Ramenghi1, A. Parodi1, M. Severino2, G. Morana2, A. Sannia1, & A. Rossi2 1

Neonatal Intensive Care Unit, Istituto Giannina Gaslini, Genova, Italy, and 2Pediatric Neuroradiology Unit, Istituto Giannina Gaslini, Genova, Italy

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ID 872

Brief Introduction: Many NICU’s have adopted the practice of performing routine MRI in ex- Very Low Birth Weight (VLBW) babies at term corrected age (TCA). There are a number of lesions already diagnosed via brain ultrasound screening but MRI allows a better description of the severity of acquired lesions, a better diagnosis of mild white matter abnormalities (i.e. punctuate lesions) and of cerebellar haemorrhages. In addition, markers of a good brain maturation such as the appearance of adequate myelination at the level of PLIC (posterior limbs of internal capsule) can be assessed. The aim of the study is to highlight the number of unexpected congenital abnormalities in this population of babies known to be at high risk just for acquired lesions Materials & Methods: We retrospectively reviewed a series of 160 consecutive MRI scans performed as a part of a follow-up program for all babies born in our Institute under 32 weeks and/or with birth weight under 1500 gr. Patients were screened at term corrected age from April 2012 to March 2014. All MRI scans were performed on a 1.5 Tesla system using the "feed and wrap" technique. Clinical Cases or Summary Results: Among 160 VLBW patients, 95 (59.4%) presented prematurity-related acquired lesions (germinal matrix haemorrhage/intraventricular haemorrhage, cerebellar haemorrhage, periventricular leukomalacia, punctuate lesions, PLIC asymmetry) at MRI (including minor forms of haemorrhage detected with sophisticated techniques like SWI), and in more than half of the cases (63 patients) the diagnosis was suspected already at cranial ultrasound (CUS) examination. On the other hand, 19 patients (11.8%) presented MRI findings that were considered incidental (not evidenced at ultrasound screening nor clinically suspected). Eight babies out of 19 (42%, or 5% of VLBW population) did not need any further investigation or treatment and the anomalies were communicated to the family during routine follow-up visit. This group included small subependimal cysts, minor forms of developmental venous anomalies, septum pellucidum anomalies and one cerebellar lipoma. The remaining 11 babies (58%, or 6.8% of VLBW population) required further intervention. In four patients with brain malformations (2 patients with isolated corpus callosum anomalies, one with polymicrogyria, and one with occipital meningocele associated with complex cerebral malformations) genetic investigations and neurological follow-up were performed, and the last patient was successfully operated. Three patients were directed to the endocrinologist for the absence of ‘‘bright spot’’ or the evidence of ectopic neurohypophysis, and two of them started medical treatment. Two patients were advised for MRI follow-up for cerebellar tonsillar ectopia, and one of them has developed Chiari I malformation at 8 months with hydrocephalus, promptly treated by neurosurgeons. Finally, two patients (homozygous twins) were diagnosed with tuberous sclerosis and directed to neurological follow-up. At the moment (one year after the diagnosis) they remain asymptomatic Conclusions: Incidental findings can present not only a diagnostic but also a management challenge. This retrospective observational study seems to suggest that MRI incidental findings in VLBW population are not rare (11.8%), and in some cases (4 patients) it is possible to ameliorate prognosis. This new population of VLBW patients with many twin pregnancies (62 patients out of 160,38.7%) partly deriving from Assisted Reproductive Technologies may deserve a higher level of attention even in screening for subtle congenital abnormalities. Keywords: Presenter: TBA

THERAPEUTIC HYPOTHERMIA ENHANCED BY MGSO4 FOR HYPOXIC-ISCHEMIC ENCEPHALOPATHY IN THE NEONATES AND ITS INFLUENCE ON BIOMARKERS OF ASPHYXIA AND COURSE OF HOSPITALIZATION E. Gulczynska1, J. Gadzinowski2, W. Walas3, A. Ma˛czka3, T. Talar1, M. Kesiak1, J. Caputa2, & B. Sobolewska1 1

Neonatal Department, Research Institute of Polish Mother Memorial Hospital, 2Neonatal Department, Medical Univeristy, Poznan, Poland, and 3Regional Medical Center, Opole, Poland Brief Introduction: Since therapeutic hypothermia has become a standard care among newborns with HIE, further studies are focused on the possibility of the enhancement of beneficial effect of hypothermia by an additional effect of some neuroprotective drugs. Among this MgSO4 is also considered. Materials & Methods: 78 newborns with HIE were enrolled for the therapeutic hypothermia program. The Apgar score was 4,1@ 10 min, mean BBW 3230g (2420–4070) and GA 38,8 weeks (36–41). A moderate or severe brain injury was confirmed by an aEEG. The studied neonates underwent the method of selective head cooling or total body hypothermia. The neonates were randomized to either the study group (hypothermia plus MgSO4) or the control group (hypothermia). Neonates in the study group received magnesium sulfate in a dose of 250 mg/kg initially within 1st hour after the birth followed by 125 mg/kg at 24 and 48 h of birth. mg/dL Along with the Mg concentration at 24; 48; 72 hours of life we also assessed the concentration of biomarkers of hypoxia.Additionally we analyzed clinical status and hospitalization course. Clinical Cases or Summary Results: Serum lactate dehydrogenase (LDH), creatine phosphokinase (CPK), creatine kinase -MB (CK MB) and troponin-T concentration were significantly increased in both groups at 1st, 3th, 6th day of life following asphyxia, although the values were almost twice as high in the control group. The differences between groups were statistically significant at all-time points. (p50.05). In the Mg treated group we observed significantly shorter: respiratory support time, oxygen supplementation time, duration of TPN and hospitalization time. The time of bottle feeding was only slightly shorter and the duration of antibiotic therapy was similar in both group. Conclusions: In this study we observed not only significant reduction of cardiac biochemical response to the hypoxic-ischemic insult among the babies treated with therapeutic hypothermia combined with magnesium sulphate but also better clinical course. The beneficial effect of Mg should be confirmed by a long term follow-up. Supported by the grant number NN407547538 form Polish Ministry of Education and Science Keywords: therapeutic hypothermia, HIE Presenter: E. Gulczynska

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ID 755

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SAFETY AND EFFICACY OF TOPIRAMATE IN NEONATES WITH HYPOXIC ISCHEMIC ENCEPHALOPATHY TREATED WITH HYPOTHERMIA: PRELIMINARY RESULTS OF A PILOT STUDY L. Filippi1, L. Padrini1, M. Daniotti1, C. Amador1, E Laudani1, R.T. Scaramuzzo2, M. Giampietri3, E. Fiorentini3, L. Bartalena3, M. Falchi4, R. Guerrini4, G. Cioni5, A. Guzzetta5, & G.P. Donzelli1 1

Medical Surgical Fetal-Neonatal Department, Children’s Hospital ‘‘A. Meyer’’, Florence, Italy, 2Scuola Superiore Sant’Anna, Pisa, 3U.O. Neonatologia, Azienda OspedalieroUniversitaria Pisana, and 4Neurosciences Department, Children’s Hospital ‘‘A. Meyer’’ -Un Brief Introduction: In countries with a high level of perinatal care, the incidence of asphyxia responsible for moderate or severe encephalopathy (HIE) is still 2–3 per 1,000 term newborns. Moderate hypothermia can significantly improve survival and reduce neurologic impairment in neonates with HIE, so that it is now assumed as the standard therapy. A number of drugs have been being tested, searching for add-on neuroprotective effects. Among these, Topiramate (TPM) has been proven to reduce brain injury in animal models of HIE but not in humans so far. We aimed to perform a pilot study in order to assess TPM safety in neonates and verify whether the efficacy of moderate hypothermia can be increased by concomitant TPM treatment. We present preliminary results of a multicenter randomized controlled trial. Materials & Methods: Term newborns (gestational age 36 weeks and birth weight 1800 g) with metabolic, clinical and amplitudeintegrated electroencephalographic (aEEG) signs of HIE, were randomized according to their aEEG pattern (i.e. moderate or severe), to receive TPM added to moderate hypothermia (cases) or moderate hypothermia alone (controls). TPM was orally administered at 10 mg/kg once a day for the first 3 days of life. Its concentrations were measured on serial dried blood spots. Patients were evaluated at a 18-month clinical and neuroradiological follow up, in order to evaluate global neurodevelopmental outcome. Clinical Cases or Summary Results: We recruited 44 patients, randomized in equal numbered blocks. No side effect imputable to TPM was observed and none of the patients were prematurely discontinued because of limiting adverse events during TPMhypothermia co-treatment. Although a similar incidence of early-onset seizures in NICU, during the follow up epilepsy incidence was 10% in cases while of 25% in controls. Moreover, in cases epilepsy occurred only in severe HIE, while in controls even in moderate HIE. As regards gross motor function, no significant difference was found between the two groups. However, stratifying patients according HIE severity, we observed that none had complete motor impairment in patients with moderate HIE. Moreover, among patients with moderate HIE, the medium percentile rank for motor domain at Bayley scale was 29 in cases while only 16 in controls. In controls, 66% of children showed a severe motor impairment defined as a percentile rank 510 at Bayley scale, while none in cases (p = 0.06). We verified that poor motor outcome was significantly more frequent in children with no fidgety movements (F) at 3 months of age (*p = 0.04). All patients assessed as F+ had a normal percentile rank at Bayley scale for motor domain (meaN ± SD, 48 ± 7.6). Fidgety assessment showed a sensitivity of 100% and a specificity of 87.5%.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Also concerning cognitive and linguistic development, we found relevant differences among patients with moderate HIE. Indeed, the Bayley scale scoring in cognitive domain showed a median percentile rank of 9 in controls, while 16 in cases. As regards linguistic domain, a similar result was reported: median percentile rank was 4 in controls vs 18 in cases. Conclusions: Our research was a pilot trial, so intended to be a small scale preliminary study conducted in order to evaluate feasibility, time, cost, adverse events, and effect size in an attempt, to improve upon the study design prior to performance of a full-scale research project. Furthermore, follow up is still on coming in one out of three participating centers, and we have only partial results so far. Nevertheless, we showed some intriguing observations. Firstly, we reported a promising trend in epilepsy prevention due to TPM-hypothermia co-treatment, especially in subgroup with moderate asphyxia. This observation was interesting, since epilepsy is assumed to influence in a negative way both cognitive development of affected children in the scholar age and quality of life of their family. Moreover, it is suitable according to basic research evidence: indeed, AMPA receptors, i.e. TPM pharmacological target, are assumed to contribute to seizures during HIE. Secondly, among children with moderate aEEG abnormalities, TPM co-treatment related to a better outcome in terms of motor, cognitive and mental performances. Even if we did not get statistical significance, we identified encouraging trends. Indeed, major disabilities (i.e. complete motor impairment and mental performances definitely under the normative range) were detected almost always in children receiving hypothermia only. Keywords: neonatal asphyxia, hypothermia Presenter: L. Filippi

ID 015

COGNITIVE DEVELOPMENT AT 18–22 MONTHS, NEONATAL WHITE MATTER MICROSTRUCTURE AND BRONCHOPULMONARY DYSPLASIA IN VERY-LOW-BIRTHWEIGHT PRETERM CHILDREN: A DIFFUSION IMAGING STUDY R. Vassar1, N. Barnea-Goraly2, K. Cahill-Rowley3, D. Stevenson4, S. Hintz4, & J. Rose1 1

Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, CA, 2Center for Interdisciplinary Brain Sciences Research, Stanford University School of Medicine, Stanford, CA, and 3Department of Bioengineering, Stanford University, S Brief Introduction: Very-low-birth-weight (VLBW) children born preterm have a higher incidence of adverse outcomes than full-term infants; approximately 40% may develop cognitive impairment, developmental coordination disorder, or language delays. Subcortical white matter (WM) known to mediate cognitive function may be vulnerable to injury associated with preterm birth. Certain clinical factors such as bronchopulmonary dysplasia (BPD) have been shown to be associated with higher risk for adverse outcomes. Initial findings are reported from a longitudinal study of brain microstructure using diffusion tensor imaging (DTI) at near-term age and cognitive development in VLBW preterm children at 18–22 months corrected age.

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DOI: 10.3109/14767058.2014.924236

Materials & Methods: 102 VLBW infants (1500g BW; 32wks gestational age (GA)) were recruited prior to routine near-term brain-MRI, 66 of the 102 infants also had DTI scans. Brain MRI scans were performed on 3T MRI and included T1-, T2- and diffusionweighted scans. DTI was processed with JHU neonatal atlas and DiffeoMap to perform semi-automated segmentation of WM tracts with fractional anisotropy (FA)40.15. FA was measured in WM regions related to cognitive function including the genu, body, and splenium of the corpus callosum (CC), anterior and posterior limbs of the internal capsule (ALIC and PLIC), retrolenticular part of the internal capsule (RLC), and the external capsule (EC). Neurodevelopment was assessed with the Bayley Scales of Infant Development, 3rd ed. (BSID-III) at 18–22 months corrected age. Partial correlations, controlling for PMA-at-scan, were used to analyze associations between regional DTI values and BSID-III cognitive composite score. Two-tailed significance was defined as p50.05. Clinical Cases or Summary Results: Among the 66 infants with DTI, mean BW was 1090 ± 266g, GA-at-birth was 28.9 ± 2.3 wks, and PMAat-scan was 36.5 ± 1.3wks. 60 returned at 18–22 months to complete the BSID-III; 59 completed cognitive testing and were included for this analysis. Mean BSID-III cognitive composite score was 96.0 ± 13.1 (65–125), 7/59 infants had scores 580 indicating cognitive delay. The incidence of BPD was 38%. BSID-III cognitive score at 18–22 months was lower among infants with a history of BPD (92.0 ± 12.7, N = 25) compared to infants without neonatal BPD (99.0 ± 12.8, N = 34) (p = 0.030). Among the total population of children with DTI and BSID-III cognitive composite score (N = 59), there were no correlations between cognitive composite score and FA values in any WM region analyzed. However, among infants without neonatal BPD, there were significant, positive correlations between cognitive function and FA values in the genu (r = 0.359, p = 0.040), L ALIC (r = 0.403, p = 0.020), L PLIC (r = 0.386, p = 0.026), L and R RLC (r = 0.530, p = 0.002; r = 0.395, p = 0.023), and L and R EC (r = 0.467, p = 0.006; r = 0.519, p = 0.002). In comparison, among infants with neonatal BPD there were no positive associations between regional FA values and cognitive score; in fact, all associations were negative and one reached significance: genu FA was negatively correlated with cognitive score (r = -0.576, p = 0.003). Conclusions: Initial results suggest complex associations between BPD, WM microstructure, and neurodevelopment in VLBW infants. The influence of BPD on WM architecture and subsequent neurodevelopment warrants further investigation with larger sample sizes. Preliminary analysis of this ongoing research may provide neonatal clues to early cognitive development and ultimately guide early intervention to improve quality of life for preterm children. Keywords: preterm neonates, bronchopulmonary dysplasia, MRI, diffusion tensor imaging, white matter microstructure, brain development Presenter: Rachel Vassar

humans there is evidence of relation between impaired neurocomportamental development and reduction of brain’s volume of: Frontal Cortex, Thalamus and Hippocampus(3,4).Data in literature are scarce.The echo 2D and the MRI present confidence limits to predict the neurodevelopment (4).Recently, the cerebral echo 3D has been proposed to estimate the volumes of brain structures. Aim of the study:Feasibility of the volume of the brain’s structures estimation. Evaluating differences among preterms, IUGR and healthy newborns (5,6). Materials & Methods: Population and methods: We estimated volumes (mean of 4 measures, in ml.) with the cerebral echo 3D (GE Vocal Software) in 95 neonates, 30–40 days old (corrected age in preterms and IUGR), without major abnormalities of the brain or IVH41 grade(table). Clinical Cases or Summary Results: Conclusions: Discussion: Variance was 510% for each measure, Preterms IUGR Healthys (Group A) (Group B) (Group C) A vs B and C

N = 32

N = 27

N = 26

24–32 32.8

35–38 32.5

38–40 48.7

p50.001 p50.001

5.4 0.86 37.1

5.45 1.0 38.1

7.7 3.6 56.9

p50.001 p50.001 p50.001 p50.001 p50.01 p50.001

Gestational Age (w) Frontal Cortex (median ml.) Thalamus (median ml.) Hippocampus (median ml) Frontal Cortex + Thalamus (median ml)

B vs C

p50.001

therefore the cerebral echo 3D is a reliable tool to estimate the volume of frontal cortex, thalamus and hippocampus. All volumes were smaller in group A vs B -C and in group B vs C. Interestingly, also the volume of frontal cortex- +thalamus were smaller (7). The differences among volumes of group A and B vs C were statistically significant (p50.001).In a group of infants included in neurocomportamental follow-up we performed the echo 3D at 3 and 6 months of corrected age, to investigate the brain’s volume compared to the healthy ones: the growth trajectory of the volumes seemed different among the ‘‘goods’’ and the ‘‘ poors’’(Brazelton methods)at 6–9 months of life. Conclusions: The estimate of of brain’s structures volumes in newborns with echo3D is feasible and reliable. The preterms and IUGR show a significant reduction of these volumes, so the differences might be an important cause of impaired development. The ultrasound estimate is useful to perform screeenings, in addition to neurocomportamental evaluation, to predict the risk later in life. Keywords: Presenter: B. Cappuccini

ID 529

ID 125

A NEW APPROACH TO THE EVALUATION OF THE NEWBORN’S NEURODEVELOPMENT:THE CEREBRAL ECHO 3D

THREE-YEAR POSTNATAL ASSESSMENT OF NEURODEVELOPMENTAL OUTCOMES BY EARLY EEG, AND SERUM AND CEREBROSPINAL FLUID BRAIN-SPECIFIC PROTEINS IN INFANTS WHO UNDERWENT THERAPEUTIC HYPOTHERMIA

B. Cappuccini1, V. Bini2, G. Clerici2, S. Pericoli2, G. Barboni1, & G.C. Di Renzo2 1

Neonatal Department, 2MISEM, 3Perinatal Medicine, University Hospital of Perugia, Italy.GeBiSa Research Foundation, Italy. Brief Introduction: Prematurity, IUGR, uterine environment, pain and stress are the most remarkable insults of the brain during fetal life and in the neonatal period (1,2,3,4) These factors may cause deleterious effects on behavioural development, later in life. In animals and

A. Takahashi1, T. Mukai1, T. Kodera1, K. Matsuo1, S. Go1, H. Tokumasu1, F. Nakagawa1, M. Sawada1, T. Hayashi1, M. Kubota1, Y. Nishida1, & S. Watabe1

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Department of Pediatrics, Kurashiki Central Hospital

Brief Introduction: Until recently there were no available therapies for perinatal hypoxic-ischemic encephalopathy (HIE), but therapeutic hypothermia in infants with HIE has been reported to result in a significant reduction in death and disability at 18-months follow up. And now, therapeutic hypothermia will make a change of improving of neurological outcomes and increasing of mild residual influence in infants with HIE. At starting of school period, we will find that a part of these infants have mild mental retardation and autism spectrum disorder. We assessed the prognostic value of bedside biomarkers for development in infants treated with hypothermia at 3 years-old. Materials & Methods: There were 39 patients who underwent therapeutic hypothermia at our hospital between 2006 and 2010, inclusive, and 32 patients who completed the revised Kyoto scale of psychological developmental test (revised Kyoto scale) for 3-year-old infants were enrolled in this study. Patients were divided according to their development quotient (DQ) into DQ585 and DQ85 groups for retrospective analysis of the psychological developmental test data. Clinical Cases or Summary Results: There was no significant difference between the two groups in patient background characteristics. There was a significant difference between the two groups for pH on admission, base excess (BE) on admission, early postnatal EEG findings, one-week postnatal neuron-specific enolase (NSE) in cerebrospinal fluid (CSF), maximum serum brain-specific creatine kinase (CK-BB) within 48 hours postnatally, and MRI findings at discharge. According to step-wise selection analysis, early EEG findings, NSE in CSF, and CK-BB were the most qualified biomarkers. A combination of early EEG findings (flat pattern or burst suppression), CK-BB (cutoff value, 78mg/dL) and NSE in CSF (cutoff value, 35ng/mL) had high predictive values of sensitivity (89%) and specificity (86%) in the DQ585 group. Conclusions: A combination of early EEG findings, serum CK-BB and NSE in CSF had high predictive values in the neurological outcomes of therapeutic hypothermia in infants with HIE. Keywords: perinatal hypoxic-ischemic encephalopathy Presenter: A. TAKAHASHI

ID 421

STUDY OF THE PREMATURE BRAIN DEVELOPMENT, USEING THE APPARENT DIFFUSION COEFFICIENT TO DETERMINE MYELINIZATION OF BRAIN WHITE MATTER P. Engstfeld1, V. Neubauer2, & D. Junker3 1

Student at Innsbruck Medical University, Innsbruck, Austria, Paediatric Dept., Innsbruck University Hospital, Innsbruck, Austria, and 3Dept. of Radiology, Innsbruck University Hospital, Innsbruck, Austria 2

Brief Introduction: Myelinisation of the brain white matter is correlated to a decrease of the apparent diffusion coefficient (ADC) in brain MRI. The aim of this study was to find out, if ADC measurement in certain regions of the brain can be a reliable tool for measuring brain development in premature newborns. Materials & Methods: Brain MRI at term-equivalent age (TEA) was performed on 97 preterm infants born at 532 gestational weeks.The ADC values of frontal, parietal, central and occipital regions were evaluated.The Gestational age (GA) at birth and the Apgar scores were recorded for all infants.The psychomotor (PDI) and mental (MDI) outcome at a corrected age (CA) of 12 months was assessed using

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

the Bayley Scales of Infant Development II.The ADC values were correlated with the 5 min. Apgar score, GA at birth and the neurodevelopmental outcome. Clinical Cases or Summary Results: There was a slight correlation between Apgar scores and ADC values in the parietal and central brain regions. A tendency for decreasing ADC values with increasing GA was found in the occipital region. There was no correlation of ADC values at TEA and neurodevelopmental outcome at a CA of 12 months. Conclusions: In this study ADC values in brain MRI correlated with initial Apgar scores, but did not prove to be a valuable prognostic marker for neurodevelopmental outcome in preterm infants at CA 12 months. Keywords: Presenter: Philipp Engstfeld

ID 132

THE OUTCOME OF CEREBRAL PATHOLOGY BY THE END OF THE FIRST YEAR OF LIFE IN NEWBORN BABIES WITH CYTOMEGALOVRUS INFECTION L. Kravchenko, M. Levkovich, L. Zaurova, M. Demidova, & A. Afonin Rostov Scientific-Research Institute of Obstetrics and Pediatrics, Rostov-on-Don, Russia Brief Introduction: Cytomegalovirus infection (CMVI) is one of the principal causes of mortinatality, morbidity of newborn babies and infant mortality. Objective: to study costimulatory molecules (CD28, CD40) on lymphocytes of the peripheral blood in newborn babies with CMVI and to determine prognostic indi-ces of the cerebral pathology outcome by the end of the first year of life in newborn babies, who had CMVI. Materials & Methods: 54 newborn babies with severe CMVI were examined. A control group was com-prised of 15 healthy newborns. The content of lymphocytes, expressing CD28, CD40, CD3+, CD4+, CD28+, CD20+, was determined using laser flow cytofluorometer ‘‘Beckman COULTER’’ Epics XL II (USA) by means of monoclonal antibodies to the clusters of differentiation CD3+, CD20+, CD4+, CD28+, CD40+ of IMMUNOTECH Company (France). In order to evaluate the statistical significance of the differences between the compared groups, we used a nonparametric test of Wilcoxon. The differ-ences of the compared values were recognized as statistically significant with the level of significance p50.05. The analysis of multidimentional nonlinear dependen-cies was performed using PolyAnalist 3.5. Pro package. Clinical Cases or Summary Results: In children with severe CMVI, as compared to the control group, there was a significant (p50.04) decrease of cells with costimulatory markers CD3+CD28+ [(at 50.55 (46.80–60.20)% and 68.10 (42.05–85.50)% correspondingly]. It was noted that in children with severe CMVI there was an increase of the activated lymphocytes with costimulatory markers CD20+CD40+ in comparison with the control group [18.20 (10.60–27.95)% and 5.90 (3.15–11.45)% correspondingly] (p50.0001). We ex-amined 114 children at the age of three months, who had CMVI during neonatal pe-riod. In 37 children neurological remained by the end of the first year of life. ((CD3-CD28 + * 0.074) + CD4 + *(-0.182) + (CD3 + CD28- *0.035) + CD40*(-0.2862) + CD3*0.1062) + (CD28 *0.1952)) – 0.4588 If the results of the calculation according to the formula is more 0.39 than a child will have brain damages by the end of the first year

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of life. Sensitivity is 71.43%, specificity – 88.89%. The likelihood of the positive result is 13.5. Conclusions: In case of severe CMVI, there was an increased level of the relative number of cells without costimulatory markers CD3 + CD28- and an expressed decrease of the number of cells with the markers CD3 + CD28+, through which costimulatory signals are conducted into the cell. It was one of the reasons of the severe course of the dis-ease. High significance of the determination of the increased content of B-cells, ex-pressing receptors (CD20 + CD40+) on their surface, reflects the importance of the direct contact between T- and B-cells performed through this molecule. The determination of CD3+T-lymphocytes, lymphocytes, expressing CD 28 in the total population, T-lymphocytes without the costimulatory marker CD28 (CD3 + CD28-) and also B-lymphocytes, expressing CD 40 on their surface, is signifi-cant for the prognosis of neurological symptomatology preservation by the end of the first year of life. Keywords: Presenter: A. Afonin

ID 058

OUTCOMES OF INFANTILE VENTRICULOPERITONEAL SHUNT IN KOCHI, JAPAN H. Maruyama1, Y. Nakata1, A. Kanazawa1, H. Watanabe1, Y. Shigemitsu1, Y. Iwasaki1, C. Tokorodani1, M. Miyazawa1, R. Nishiuchi1, M. Morimoto2, & K. Kikkawa1 1

Pediatric Dept., Kochi Health Sciences Center, Kochi, Japan, Neurosurgery Dept., Kochi Health Sciences Center, Kochi, Japan 2

Brief Introduction: Ventriculoperitoneal shunt (VPS) is used for the treatment of hydrocephalus. Shunt failure is often seen. Thus, we analyzed the outcomes of infantile VPS in our hospital for finding out the risk factors of the shunt failure. Materials & Methods: We chose the infants, who had the first operation of VPS in our hospital, from March 2005 to December 2013. We observed them until the end of January 2014. We checked their basic characteristics, perioperational factors and the shunt outcomes. Clinical Cases or Summary Results: There were 24 cases. Male was 13 (54.1%). Median (range) of gestational age, birth weight and birth head circumference were 37weeks 4days (27weeks 1day-39weeks 5days), 2736 (686–3788)g and 35.3 (23.0–45.3)cm, respectively. Major etiology of hydrocephalus was myelomeningocele (10 cases). Mean (SD) of observational period was 48 (37)months. Total shunt procedures were 45. Shunt infection rates were; 0.13/shunt, 0.0014/ shunt/year. Shunt failure rates were; 0.51/shunt, 0.0053/shunt/year. Six out of 7 shunt failures within 6 months after the first VPS occurred in 2013; infection 2, coiling 2, obstruction 1, VPS tube in inferior horn 1. Both infection cases had fever within a month after surgery, caused by coagulase negative Staphylococcus, which was found in the skin culture before surgery. One of the coiling cases had cerebrospinal fluid leakage, resulting in fluid collection in the subcutaneous space. VPS tube in inferior horn was inserted from occipital site. Conclusions: The shunt infection and shunt failure rates of our hospital were almost the same as the previous reports. But shunt failure cases increased in 2013, which causes were various. We must care about each risk factor. Keywords: Shunt failure; Shunt infection; Ventriculoperitoneal shunt Presenter: H. Maruyama

ID 888

CEREBELLAR MALFORMATIONS IN THE PRENATAL PERIOD: THE PATHOLOGIST’S ROLE V. Toto1, F. Servadei2, L. Manganaro3, & E. Silvestri4 1

Aging Research Center, G. D’Annunzio University Foundation, Chieti, Italy, 2UOC Anatomia Patologica, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy, and 3Department of Radiological, Oncological and Anatomopathological Sciences, Umberto I Hospital, Sapienza University of Rome, Rome, Italy Brief Introduction: Human cerebellum develops from the early embryonic period until the first postnatal years, thus it is susceptible to a wide spectrum of developmental disorders. Widespread use of ultrasonography (US) and magnetic resonance (MRI) allows the detection of cerebellar abnormalities at a very early stage of development. As a consequence, distinguishing a normal developing structure vs a true malformation remains a critical challenge. For this reason, a complete pathologic brain examination is crucial for assessing cerebellar development and eventually confirming previously suspected lesions. Several classifications have been suggested to report cerebellar malformations; here we propose a novel case-based approach to cerebellar malformation, including both on morphologic and radiological data. Materials & Methods: All the reported cases come from termination of pregnancy performed in the Gynecology and Obstetric department between the 18th and the 23rd week of gestation. The US and MRI images come from the Gynecology and Obstetric and Radiology departments. Classification Our scheme of classification identifies three major groups: – agenesis: complete or partial absence of cerebellar structures, involving the vermis and/or one or both hemispheres; – hypoplasia: reduced biometric values of an otherwise normal structure; – dysgenesis or dysplasia: disorganized development of cerebellar structures affecting the whole cerebellum or limited to the hemispheres Clinical Cases or Summary Results: Here we present a number of explicative cases. Agenesis: (complete and partial) a case of a Joubert syndrome and a case of Dandy-Walker malformation; Hypoplasia: a case of Walker Walburg syndrome Dysplasia: a case of Aicardi syndrome Conclusions: The rapid evolution of imaging techniques allows an early detection of cerebellar lesions, when even the normal structures are in their developing. In the evaluation of cerebellar malformations, the pathologist’s role is crucial to confirm the lesions identified during the prenatal period and to recognize clinically latent morpho-functional alterations. The comprehension of cerebellar malformations, and in particular those of the vermis, is still in progress and a rigorous and validated approach for their study is needed. However, a rigid classification of cerebellar malformation is not clinically useful, in particular when multiple malformations are found or a single alteration cannot be classified within a syndrome complex. Here we proposed a novel simplified scheme of classification where the distinction of the cerebellar malformation in three principal categories can offer a better and integrated view for their comprehension. Keywords: cerebellar malformations, pathologist Presenter: V. Toto

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ID 158

ID 215

PROGNOSIS OF AN EARLY MANIFESTATION OF HYPOXICISCHEMIC INJURY OF THE CENTRAL NERVOUS SYSTEM IN NEWBORN BABIES FROM MOTHERS WITH PLACENTAL INSUFFICIENCY

NEURODEVELOPMENTAL ABNORMALITIES IN A PROSPECTIVE SAMPLE OF 4553 PREMATURE INFANTS LESS THAN 1501 GR FOLLOWED UP TO 1 YEAR OF CORRECTED AGE IN AN OUTPATIENT KANGAROO MOTHER CARE PROGRAM (KMCP)

V. Linde, M. Levkovich, & T. Plakhotya

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Rostov Scientific-Research Institute of Obstetrics and Pediatrics, Rostov-on-Don, Russia Brief Introduction: The problem of hypoxic-ischemic injury of the central nervous system (CNS) remains relevant because of a high level of morbidity and mortality in newborn babies and small children. The most frequent cause of the fetus hypoxia development is placental insufficiency. At present there is no doubt that the immune system plays a key role in pathogenesis, clinical course and outcome of hypoxic and infectious diseases in newborn babies and the mechanisms of formation of compensatory-adaptative and structural abnormalities in CNS are caused by immunopathological cytokineinduced reactions. Objective: to determine the content of TNF-a, IL-6, S-100b in the amniotic fluid (AF) of the pregnant women with urogenital infection and placental insufficiency. Materials & Methods: 62 pregnant women at the term of 38–39 weeks of gestation were included in the research; they were divided into clinical groups depending on neuropathologist’s diagnosis of their newborn babies on the first day after delivery. Group 1: apparently healthy (control group), (n = 23), group 2: cerebral ischaemia (n = 39). The levels of TNF-a and IL-6 were determined by immune-enzyme analysis with the use of Cytokine diagnostic kits and Sigma diagnostic kits for S-100b. To determine the statistical validity of the difference between the studied groups we applied Mann-Whitney test with the maximum allowable error level p = 0.05. Clinical Cases or Summary Results: As a result of the performed analysis in the groups of the pregnant women with various perinatal outcomes we determined statistically significant differences of the levels of TNF-a (81.2 ± 6.4 pg/ml compared to 35.6 ± 9.1 pg/ml) (p50.01), IL-6 (170.4 ± 68.1 pg/ml and 24.6 ± 5.1 pg/ml correspondingly) and S-100b (1021.6 ± 188.2 ng/l compared to 524.45 ± 16.7 ng/l) in the AF. The increase in the level of TNF-a and IL-6 caused by their participation in the immune reaction of the organism under the influence of hypoxia and microbial invasion leads to the development of inflammatory responses in CNS; the disturbance of the resistance of the brain-blood barrier is the reason of the release of neurospecific protein S-100b, possessing high antigenicity, into blood. On the other hand, antigen stimulation leads to the intensification of the cytokine release. At that the results of the correlation analysis revealed direct relation of TNF-a content in the AF and the level of S-100b (r = 0.7, p = 0.03). Conclusions: Thus, the study of the level of proinflammatory cytokines and neurospecific proteins in the AF of the pregnant women with the verified urogenital infection and placental insufficiency proves the role of neuroimmune conflict in the pathogenesis of cerebral ischaemia in their newborn babies and will open new possibilities to prognosticate brain damages with the purpose of an early prescription of appropriate therapy to prevent the formation of persistent disabling conditions. Keywords: Presenter: V. Linde

N. Charpak1 & S. Fernandez2 1 Kangaroo Mother Care Program, Hospital Universitario San Ignacio, Universidad Javeriana, Bogota, Colombia. Kangaroo Foundation, Bogota, Colombia, and 2Kangaroo Foundation, Bogota, Colombia.

Brief Introduction: Low birth weight (LBW) deliveries are highly prevalent, particularly in middle and low income countries (12% in Colombia). Since 1993 The Kangaroo Foundation is monitoring around 1000 LBW infants a year in the outpatient KMCPs. Materials & Methods: Subsample of 4553 NB less than 1501 gr at birth from a prospective cohort of 22.730 premature (537 weeks) and/or LBW (52500 g) infants followed up to one year of corrected age in the outpatient Kangaroo Mother Care Programs in Bogota, Colombia between 1993 and 2013. Study Variables: Weight and gestational age at birth, acute fetal distress, anoxia, stay in NCIU, any grade of intraventricular hemorrhage, type of ventilation, seizures, bronchopulmonary dysplasia. Outcomes: Neurologic exam at 3, 6, 9 and 12 months of corrected age; Somatic growth; Psychomotor development at 6 and 12 months of corrected age; neurosensorial sequelae and high risk of cerebral palsy and mortality rate at one year of corrected age. Clinical Cases or Summary Results: 4553 eligible infants (1500 g. at birth) of 22.730 LBWI were admitted in the ambulatory KMC programs, 52.9% 30 weeks of GA. 59.2% were NICU graduates and 43.7% of them had been ventilated. 49.7% of infants were oxygen-dependent at entry and 22.7% had any grade of intraventricular hemorrhage (34% in NB51000 gr, 29.1% in530 week). Lost to follow up was 27.4% from entry into KMC to one year of CA. Overall mortality in the cohort was 3.7% up to one year, 2.6% of deaths occurring between discharge and 3 months (10% in 1994 versus 0.3% in 2013). Average weight, length and head circumference were 2648 g, 45,5 cm, 34 cm at term (36% Exclusive Breastfeeding y 60% BF + Formula), and 8180 g, 71 cm and 45 cm at one year of corrected age. Retinopathy was detected in 19.8%, ophthalmic surgery with laser in 2.6%, and blindness in 0.4%. Diagnosis of high risk of cerebral palsy at one year was 13.3%. Mean developmental coefficient at 6 months was 93,1 and at 12 months was 97. Conclusions: The KMCP is a good strategy and unique opportunity for the follow up of high-risk infants as the premature or low birth weight newborn in Colombia. One year of corrected age is the minimum acceptable follow up for these children, taking into account the data obtained from this 20 years quality monitoring. The opportunity for close monitoring and intervention is essential to detect and reduce reversible alterations in growth and development. Keywords: Neurodevelopment, preterm infant, Kangaroo Mother Care Presenter: S. Fernandez

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ID 150

ID 449

FREE RADICAL PROCESSES IN CASE OF PLACENTAL INSUFFICIENCY AND THEIR ROLE IN PERINATAL CENTRAL NERVOUS SYSTEM DAMAGE IN NEWBORNS

RESVERATROL CONFERS A NEUROPROTECTIVE EFFECT WHEN ADMINISTERED IMMMEDIATELY BEFORE THE PERINATAL ASPHYXIA

I. Krukier, I. Loginova, N. Drukker, V. Avrutskaya, A. Nikashina, A. Degtyareva, & V. Linde

O. Arteaga1, H. Montalvo1, M. Revuelta1, D. Alonso1, L. Urigu¨en2, E. Hilario1, & A. A´lvarez1

Rostov Scientific-Research Institute of Obstetrics and Pediatrics, Rostov-on-Don, Russia

Department of Cell Biology & Histology, and 2Departement of Pharmacology, School of Medicine & Dentistry, University of the Basque Country, Leioa, Bizkaia, Spain.

Brief Introduction: In case of a complicated pregnancy the placental insufficiency is formed as a result of profound metabolic changes in the organism of a mother, against which the intrauterine fetus development is going. It is accompanied with the development of fetal hypoxia and as a consequence with perinatal and postnatal damage of tissues and organs of a newborn. Free radical processes may act as a universal modifier of functional properties both of placenta and amniotic fluid and of blood serum under the conditions of intrauterine hypoxia. Taking into account the importance of the above-stated processes the objective of this research is the study of the activity of free radical processes in amniotic fluid, placenta and umbilical blood in case of a physiological and complicated pregnancy. Materials & Methods: We examined 74 women and their children. The first group was comprised of 30 women, whose pregnancy and delivery were without complications. The second group was comprised of 44 women, whose pregnancy in the second and the third trimesters was complicated by the development of placental insufficiency. It was proved by the complex clinical and laboratory examination. The concentration of peroxynitrite, NO-glutathione and NO-tyrosine in biological fluids was determined spectrophotometrically using molar extinction coefficients, the content of nitric oxide metabolites (NOx) was determined using the classical Griess reaction. Clinical Cases or Summary Results: We recorded the increase of production of nitric oxide and its derivatives (peroxynitrite, NO-glutathione and NO-tyrosine) in umbilical blood and in amniotic fluid of pregnant women from the second group with the high level of perinatal risk. Since peroxynitrite participates in the regulation of oxygen-binding properties of hemoglobin it is evident that in case of high level of its production the reduction of oxygen saturation resulting in hypoxia will be observed. At the same time in case of placental insufficiency another dynamics of indicators was recorded: along with the increase of nitric oxide, peroxynitrite and NO-tyrosine production we registered the reduction of NO-glutathione level. The detected shifts indicate the development of ‘‘oxidative stress’’, which finally results in the disturbance of metabolic, trophic and other functions. Conclusions: We detected a cause-effect relation between the activation of free radical processes in placenta, amniotic fluid, umbilical blood and the degree of intrauterine hypoxia. The change of the regulation of free radical processes in the system «mother-placenta-amniotic fluid-fetus» may be one of mechanisms of negative influence of oxidative stress characteristic for the complicated pregnancy. Thus, the determination of nitric oxide and its derivatives level in umbilical blood and amniotic fluid may be used as an additional prediction criterion of the development of the central nervous system damage in newborns. Keywords: Presenter: V. Linde

1

Brief Introduction: Despite advances in neonatal care, hypoxicischemic (HI) brain injury continues being serious problem, which is responsible of a great percentage of perinatal mortality, cerebral palsy, motor impairment and cognitive deficits. Resveratrol (RVT) is a natural polyphenol present in the red wine with anti-oxidant and antiinflammatory properties that is thought to be neuroprotectant against experimental brain injury. The aim of the present work was to investigate if reveratrol plays a protective effect when administered 10 minutes before or immediately after HI brain injury in neonatal rats determining infact area, oligodendroglial injury and long-term consequences using the Rice-Vannucci model. Materials & Methods: Forty seven-day-old (PN7) rats were randomly assigned to: one control group and three HI groups, one of them receiving i.p. single dose of 20 mg/kg of resveratrol 10 minutes before (RVT before) and another immediately after HI event (RVT after). Injury was induced by permanent ligature of the left common carotid artery and then by asphyxia for 2 hours and a quarter with 8% O2.. Brains fixed by perfusion (PN14) were stained with Nissl to evaluate brain infarction and immunolabelled with MBP (Myelin Binding Protein) to determine oligodendroglial injury. On PN90 we evaluated the long-lasting behavioral alterations by T-maze, hole-board and novel object recognition tests. One- factor ANOVA was performed and p50.05 was considered statistically significant. Clinical Cases or Summary Results: The quantitative analysis of the infarct area by Image J program showed a high percentage of damage in HI group in comparison with Control and RVT before. RVT after revealed also a severe percentage of tissue loss. The semiquantitative neuropathological scoring system demonstrated a damage located at the level of hippocampus and parietal cortex of ipsilateral hemisphere in HI group. Protection effect by resveratrol injected 10 minutes before the injury was evident when injury was assessed by neuropathological scoring, but resveratrol did not protect when is injected just after. Furthermore, MBP-immunostaining pattern, whose loss is considered a hallmark of white matter damage, showed a significant decrease in the HI group in comparision with the Control, that was restored when resveratrol is administred before hypoxia. On PN90, RVT before animals performed better at the T-maze, hole-board and novel object recognition tests. Conclusions: Our results suggest that a pretreatment with resveratrol led to a neuroprotective effect reducing infarct volume, preserving oligodendroglial viability and improving functional outcome. Keywords: hypoxia-ischemia, neuroprotection, resveratrol Presenter: O. Arteaga

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ABNORMALITIES OF CEREBRAL BLOOD FLOW IN NEONATES WITH BIRTH ASPHYXIA

In the case of severe asphyxia at birth (3 Sarnat stadium) it can be observed a significant decrease in the resistivity index and a significant increase in end-diastolic velocity, which can lead to a marked increase in cerebral blood flow in diastolic. This increase could be related to reperfusion injury. For a future study the following question remains: this increase perfusion may have a prognostic value?

A. Popescu1 & A.I. Toma2

Keywords:

1

‘‘Prof. Dr. Panait Sarbu’’ Obstetrics Gynecology Hospital, Bucharest, Romania, and 2Life Memorial Hospital, Bucharest, Romania.

Presenter: Alina Popescu

Brief Introduction: Objectives: The research objective was to investigate the evolution of cerebral blood flow in newborn babies with birth asphyxia during the first 3 days after birth. For it was also necessary to determine the normal values of cerebral blood flow in normal newborns at term, which constituted a control group. Materials & Methods: Measured parametres were: systolic velocity (PSV), end-diastolic velocity (EDV), resistive index (RI). Measurements were made in the anterior cerebral artery (ACA). For each patient were performed two ultrasound measurements during the first 72 hours of life. The study was conducted during Jan 2003 – Dec 2004. The control group consisted of 50 term newborns without signs of asphyxia at birth. Average weight at birth was 3450 g (standard deviatioN + 250 g), average gestational age was 39.7 weeks. Group studied was composed of 18 infants with severe asphyxia at birth (corresponding Sarnat stage III, patients were borned in the hospital or transferred from other departments). Average weight at birth was 3620 g (standard deviation +238 g), average gestational age was 39.8 weeks. There were no statistically significant differences between the two groups regarding birth weight and gestational age. Regarding systolic velocity (PSV)), there is a statistically significant difference in the first day of life, velocity was lower in children with hypoxia at birth, on days 2 and 3 are not observed statistically significant differences between the two groups. End diastolic velocity is significantly higher in newborns with birth asphyxia group than in the control group. Resistivity index (RI) has a statistically significant lower values in neonates with birth asphyxia than in normal infants group. Clinical Cases or Summary Results: Discussion The study is significant because it has sufficient numbers of infants in the two groups. Also noteworthy is the large number of neonates with asphyxia Nastri relative to the incidence of the condition in the population. There are several limitations of the study. Method of estimation of cerebral blood flow velocity by determining systolic and end-diastolic pressure and resistivity index in the anterior cerebral artery does not account for variation in vessel diameter. Newborn has been shown that there is very little variation in the diameter of the vessels in the cerebral circulation. Also, another limitation is the absence of continuous measurements of hemodynamic parameters, which is shown at fixed points in time. Regarding the evolution of brain hemodynamic parameters for normal term infants we can tell that data analysis for control group in the first 72 hours of life shows that there is a slight decrease in systolic velocity, a slight increase end-diastolic velocity and an increase in the resistivity index. In children with birth asphyxia there was a marked increase in diastolic velocity and a decrease in resistivity index - the result is an increase in diastolic flow. A low systolic velocity in the first 24 hours of life in neonates with asphyxia at birth to normal babies may be a consequence of cardiac function in the first category of children affected. The differences between the two groups in terms of end-diastolic velocity and the resistivity index can be an expression of reperfusion injury that accompanies the increase in cerebral blood flow. Conclusions: Conclusions

ID 413

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ID 897

PRENATAL DIAGNOSIS MAY CHANGE LONG-TERM OUTCOME OF TUBEROUS SCLEROSIS COMPLEX P. Curatolo1, R. Moavero1, & EPISTOP consortium2 1

Child Neurology and Psychiatry Unit, Tor Vergata University Hospital of Rome, Italy, and 2EPISTOP consortium Brief Introduction: Prenatal diagnosis of tuberous sclerosis is possible due to the presence of cardiac rhabdomyomas and cortical tubers, respectively detected by the gestational age of about 20 and 26 weeks. The incidence of tuberous sclerosis when multiple cardiac rhabdomyomas are detected is almost 100%. Prenatal or early postnatal diagnosis allows a strict clinical and EEG surveillance leading to early recognition of subtle focal seizures and/or infantile spasms, and allowing a prompt treatment. Materials & Methods: We recently followed up three infants in which we were able to make a prenatal or early postnatal diagnosis due to the presence of multiple cardiac tumors. Fetal MRI confirmed the diagnosis before birth in all of them. Clinical Cases or Summary Results: In these infants we were able to detect subtle EEG changes preceding seizure onset, and we started vigabatrin the same day. Conclusions: Current evidence showed that both preventative treatment or early treatment with vigabatrin can reduce the risk of an epileptic encephalopathy and improve long-term neurodevelopment outcome. A new international long-term, prospective study (EPISTOP) is now ongoing, to compare the effects of standard antiepileptic treatment in infants with tuberous sclerosis diagnosed as having epilepsy after clinical versus after epileptiform EEG activity. Keywords: tuberous sclerosis, epilepsy, prenatal diagnosis Presenter: Paolo Curatolo

ID 255

THE EFFECT OF EXCHANGE TRANSFUSION ON REGIONAL OXYGENATION IN TERM NEONATES WITH SEVERE HYPERBILIRUBINEMIA D. Sankavets, O. Svirskaya NICU, Republican Scientific Practical Cenrte ‘‘Mother and child’’, Minsk, Belarus

Glutathione (mM)

ID 360

Catalase (U/mg)

THE PROTECTIVE EFFECT OF ERYTHROPOIETIN ON BILIRUBIN NEUROTOXICITY

0.122 ± 0.006 0.117 ± 0.008 0.118 ± 0.005 0.118 ± 0.005 0.117 ± 0.008 56.02 ± 0.50 41.73 ± 0.58 54.59 ± 1.01 52.62 ± 1.08 36.48 ± 0.74 326.30 ± 3.23 535.73 ± 3.04 328.74 ± 1.82 380.07 ± 5.07 484.72 ± 2.03 27.38 ± 0.46 82.92 ± 1.68 34.20 ± 2.66 70.64 ± 0.50 45.35 ± 1.12 5.19 ± 0.04 2.95 ± 0.05 22.85 ± 0.19 593.60 ± 2.97 20.47 ± 0.82 5.63 ± 0.62 11.05 ± 0.93 5.56 ± 0.22 8.60 ± 0.61 8.13 ± 0.65 0.10 ± 0.05 0.12 ± 0.08 0.13 ± 0.04 0.14 ± 0.05 0.13 ± 0.02 100.00 ± 0.50 27.05 ± 0.26 104.43 ± 0.63 66.62 ± 1.91 48.34 ± 5.07

Brief Introduction: Cellular and molecular mechanism of unconjugated bilirubin (UCB) neurotoxicity, which is still an important problem of newborns, is not exactly known. While UCB in physiological level is against oxidative stress; moderate/high UCB levels can cause necrosis or apoptosis in neurons, and cause clinically acute bilirubin encephalopathy or kernicterus, by inducing oxidative stress, lipid

Control Bil Epo Epo + Bil Bil + Epo

Neonatology Department, Pamukkale University Faculty of Medicine Hospital, Denizli, Turkey, 2Medical Biology Department, Pamukkale University Faculty of Medicine Hospital, Denizli, Turkey, and 3Anatomy Department, Pamukkale University Faculty of Medicine Hospital, Denizli, Turkey

Cell viability (%)

1

Groups

Apoptosis (%)

K. Ku¨c¸u¨kta¸sc¸ı1, H. Ergin1, H. Akc¸a2, O. Tokgu¨n2, & B. O¨zdemir3

0.82 ± 0.01 0.42 ± 0.03 0.83 ± 0.01 0.64 ± 0.02 0.58 ± 0.02

Presenter: Dzmitry Sankavets

15.35 ± 0.34 3.96 ± 0.16 16.76 ± 0.24 12.20 ± 0.05 9.49 ± 0.29

Keywords: Exchange transfusion, near infrared spectroscopy, regional oxygenation, neonatal hyperbilirubinemia

8.74 ± 0.15 3.83 ± 0.12 9.69 ± 0.17 4.91 ± 0.23 5.00 ± 0.24

GPx (U/mg)

SOD (U/ml)

Total Nitrate/ Nitrite (mM)

IL-1b (pg/ml)

IL-6 (pg/ml)

TNF-a (pg/ml)

LDH (mU/ml)

Brief Introduction: Exchange transfusion (ET) was first introduced in 1951 by Diamond to decrease the mortality of hemolytic disease of the newborn and to prevent kernicterus in surviving patients. Improved prenatal management of alloimmune haemolytic disease and improvements in the management of neonatal hyperbilirubinemia have resulted in a decline in the rates of significant neonatal hyperbilirubinemia. However, ET still has been irreplaceable therapy in sick newborns with severe hyperbilirubinemia. Near infrared spectroscopy (NIRS) offers the possibility of noninvasive and continuous bedside investigation of regional oxygenation in neonates. Using this technique we investigated the relationship between changes in cerebral and peripheral oxygenation, and changes in some physiological variables during ET. Materials & Methods: We investigated the effect of ET using the arterial/venous 2 line technique on cerebral and peripheral regional oxygenation in 4 term neonates using NIRS. A total of 4 ET for the treatment of severe hyperbilirubinemia were performed. We used the two-way exchange method, in which the umbilical artery was used for withdrawal, and a vein for infusion. In all neonates, 10 ml of blood was exchanged during each cycle. All neonates were on spontaneous breathing and did not need supply oxygen. The changes in the respiration, blood pressure, blood gas, electrolytes and some biochemical indices during and after ET were evaluated. Measurement of regional oxygenation was performed by using INVOS 5100c (Somanetics, USA). Cerebral regional (crSO(2)) and peripheral regional (prSO(2)) NIRS parameters were recorded every 20 minutes during ET and 20 minutes after the procedure. Cerebral fractional tissue oxygen extraction (cFTOE), was calculated based on crSO(2) and arterial saturation (SaO(2)). Clinical Cases or Summary Results: No obvious alterations occurred in the respiration, blood pressure, or saturation of blood oxygen during ET. Each blood withdrawal during ET resulted in only an insignificant increase in heart rate without changes in the other variables measured. Cerebral fractional tissue oxygen extraction, decreased after ET; median (range): 0,334 (0,253 – 0,445) versus 0,146 (0,105 – 0.229) respectively; crSO(2) and prSO(2) increased after treatment: 65,5 (51,8 – 73,5) versus 77,5 (70,8 – 82,0) and 39 (32,8 – 46,8) versus 49 (33,8 – 65,3) respectively. Conclusions: Exchange transfusion using the arterial/venous 2 line technique improves cerebral and peripheral oxygenation in term neonates with severe hyperbilirubinemia.

1.04 ± 0.11 51.10 ± 1.15 5.03 ± 0.07 28.72 ± 0.29 36.13 ± 0.42

MDA (mM)

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Table. Reports of groups

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peroxidation, proinflammatory cytokine releasing and extracellular glutamate deposition. Erythropoietin (Epo) can protect the neurons from cytotoxicity by antiapoptotic, anti-inflammatory, antioxidant, antinitrosative, angiogenic and neurotrophic mechanisms. However, the effect of Epo on neurotoxicity caused by UCB has not been known yet. Materials & Methods: Astrocyte cells culture were prepared from brains of 1-day-old Wistar albino rat pups by a modification of Cole and de Vellis method. UCB concentration toxic to 50% of astrocytes (TC50) was found to be 50 mM, and Epo concentration increasing cell viability 100% was found as 2.5 IU/ml. Apoptosis due to bilirubin toxicity was evaluated by TUNEL staining technique. After and before four hours bilirubin incubation Epo treatment was administered. In astrocyte cell cultures, apoptosis, catalase, superoxide dismutase (SOD), glutathione peroxidase (GPx), lactate dehydrogenase (LDH) activities, glutathione, malondialdehyde (MDA), total nitrate/nitrite, interleukin (IL)-1b, IL-6 and TNF-a levels were investigated after 24 hours of bilirubin incubation and also cell viability after 72 hours was evaluated. Clinical Cases or Summary Results: Compared with the control group, approximately 75% decrease in cell viability, and fifty times increase in apoptosis was found in UCB group (p:0.000). Epo application for prophylaxis and treatment was found to decrease apoptosis, total nitrate/nitrite, IL-6, and TNF-a levels (p:0.000, p:0.007, p:0.004, p:0.000 respectively) and to increase cell viability, catalase and GPx activities, glutathione and IL-1b levels (p:0.001, p:0.005, p:0.001, p:0.000, p:0.000 respectively). While prophylactic Epo increased LDH activity (p:0.001); therapeutic Epo decreased it (p:0.001). There was not any significantly difference among the groups in terms of SOD and MDA levels (p:40.05) (Table). Conclusions: In this study, it was the first time shown that prophylactic and therapeutic Epo had protective effects on bilirubin neurotoxicity because of antiapoptotic, antioxidant, antiinflammatory and antinitrosative properties. Keywords: Bilirubin, erythropoietin, neurotoxicity, newborn Presenter: Hacer Ergin

ID 799

NEUROPATHOLOGICAL FINDINGS AT AUTOPSY IN FIVE CASES OF WALKER-WARBURG SYNDROME (TYPE II LISSENCEPHALY) J. Methlouthi1, S. Nouri1, S. Meddeb2, M.T. Yacoubi3, C. Fallet-Bianco3, M. Fekih2, N. Mahdhaoui1, & H. Seboui1 1

Neonatology department F Hached universitary Hospital, susah, Tunisia, 2G obstetrics department F Hached universitary Hospital, susah, Tunisia, and 3Pathologic department F Hached universitary Hospital, susah, Tunisia Brief Introduction: Walker Warburg Syndrome (WWS) is a lethal, genetically heterogeneous autosomal recessive disorder characterized by Type II lissencephaly (Cobblestone lissencephaly), retinal malformation, cerebellar malformation, and congenital muscular dystrophy. Materials & Methods: objective: The neuropathological findings at autopsy in five cases of type II lissencephaly are presented. Clinical Cases or Summary Results: We report the autopsy findings of 5 cases, two of them siblings referred to pathology department for major hydrocephalus discovered on ultrasound between 20 and 22 weeks GA in 3 cases and later at 37 Weeks for the two others. Hydrocephalus was associated with occipital encephalocele in one case and with 4th ventricle cyst suggesting a Dandy-Walker malformation in the other case. Medical interruption of pregnancy was indicated at 22 Weeks in 3 cases. For the two others, one

was stillborn at term and the other died few hours after birth. Pathology findings in all cases showed lissencephaly, hydrocephalus, diffuse and severe cerebral and cerebellar cortical dysplasia with glial and neuronal displacement into the leptomeninges. Conclusions: The fetal hydrocephalus associated with this syndrome, while not necessary for diagnosis, was the key manifestation for its prenatal detection. These cases highlight the importance of a careful search for associated malformations in a fetus or newborn infant with hydrocephalus for a better prenatal diagnosis and genetic counseling. Keywords: Presenter: J. Methlouthi

ID 808

NEUROLOGICAL DISTRESS IN A NEONATAL INTENSIVE CARE UNIT OF TUNISIA: CAUSES AND CLINICAL FEATURES F.Z. Chioukh1, T. Khmissi1, K. Ben Ameur1, H. Ben Hmida1, M. Bizid1, M. Doggi2, & K. Monastiri1 1

Department of Intensive care and Neonatal Medicine, University Hospital Fattouma Bourguiba Monastir, Tunisia, and 2Department of Neurophysiology, University Hospital of Sahloul, Sousse, Tunisia Brief Introduction: Neurological troubles are a common reason for hospitalization in the neonatal intensive care units. The aim of this study is to specify epidemiological and clinical aspects of neurological distress in newborns. Materials & Methods: This is a retrospective study over a period of 3 years (June 2009 – December 2012) in the Department of Intensive Care and Neonatal Medicine of Monastir. Were included neonates presenting with neurologic symptoms such as tonus disorders, weakness of primary reflexes, excitability or seizures. These newborns were evaluated according to Sarnat and Sarnat classification. The circumstances of occurrence were identified as well as biological, radiological and electroencephalographic (EEG) abnormalities. Clinical Cases or Summary Results: The study involved 187 infants representing 2.1% of hospitalized newborns. Neurological troubles occurred mainly in males (sex ratio = 2), most often born by vaginal delivery (54.5%), at term (67.9%). and after a normal pregnancy (85.6%) The main clinical manifestation was axial hypotonia (48.7%) and seizures (31%). The EEG, performed in 95 infants, was abnormal in 15.8% of cases. Post-anoxic encephalopathy was the most common etiology (58.3%).Neurologic distress was grade II and III respectively in 16.6% and 11.8% of cases. Other etiologies were represented primarily by metabolic diseases (8.4%) and infections of the central nervous system (3.2%). The cause was undetermined in 23.5% of cases. Death occurred in 16% of cases and survivors have shown poor neurodevelopmental outcome in 12% of cases. Conclusions: Neurological distress leads to a high rate of morbidity and neonatal mortality. Its management requires a detailed clinical analysis to check other causes than frequent post-anoxic encephalopathy, like metabolic diseases frequent in Tunisia. Keywords: Neurological distress- Perinatal asphyxia- Hypoxicischemic encephalopathy. Presenter: F.Z. Chioukh

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ID 093

VESSEL MALFORMATION AS HEMORRHAGIC BRAIN DISORDERS CAUSE IN CHILDREN S. Kizatova1, M. Tusupbekova2, B. Tukbekova3, & S. Zhakupova4 1,3

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Children’d Diseases Dept., Karaganda State Medical University, Karaganda, Kazakhstan, 2Pathological Anatomy Dept., Karaganda State Medical University, Karaganda, Kazakhstan, and 4Foreign Languages Dept., Karaganda State Medical University, Karaganda, Ka Brief Introduction: Problem of cerebrovascular pathology in children is especially actual particularly in form of hemorrhagic disorders, as stroke consequences can be very difficult in plane of prognosis both for child and for parents, as there are not only medical aspects. Objective: to study disease and mortality structure of hemorrhagic brain disorders in children. Materials & Methods: Children under one year with hemorrhagic stroke which were treated in the lesions of central nervous system department of Karaganda Regional Clinical Children’s Hospital in 2010–2012 were the object of investigation. Complex investigation was made to all children: general and biochemical investigations, instrumental investigations – electrocardiogram, echocardioscopy, computed tomography of brain. Clinical Cases or Summary Results: The results of investigation showed the cerebrovascular diseases incidence increase: from 9.4% in 2010 to 11.9% in 2012. Hemorrhagic strokes were presented mainly by subarachnoid (69%) and intracranial bleedings (31%). In clinical description of the episode beginning in children of early age is typical during the breastfeeding of a healthy child the general tonic convulsions with consciousness loss, apnea episodes, repeating vomiting suddenly appeared, later on the intracranial hypertension clinic increases. The big fontanel bulging and tension with separation of cranial structures and lack of pulsation, evidence of vascular hypodermic pattern on the head were defined on sight. The mortality of patients with hemorrhagic strokes was 5.4% from general quantity of patients. When conducting histological investigations of brain vessels autopsy material arteriovenous malformations and aneurisms mainly placed supratentorially were revealed in 55.5% cases. Conclusions: Patient’s state severity was defined by the peculiarity of morphological substrate marked in the vascular malformation massiveness and brain structure lesions combination. All cases of hemorrhagic stokes were accompanied by massive subarachnoid bleedings. 69% patients had the bleeding in brain structures isolated by natural anatomic barriers. In 31% cases intracranial bleedings were localized in brain parenchyma or occupied covered spaces under both hemispheres and back cranial fossa. Received results of investigation showed that the cerebrovascular diseases increase among infants, which reveal subarachoid (69%) and intracranial (31%) bleedings. Pathomorphological investigation of autopsy material showed that in 55.5% observations arteriovenous malformations and aneurysms were revealed during the brain vessels histological investigation, it demands further study of reasons and pathogenetic mechanisms of hemorrhagic brain lesions in children. Keywords: newborn, hemorrhagic sroke, brain

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

ID 886

AGENESIS OF THE CORPUS CALLOSUM, PRENATAL DIAGNOSIS AND GENETIC COUNSELING W. Dahleb1, M. Kammoun1, S. Meddeb2, J. Mathlouthi3, I. Boukadida2, A. Saad1, & S. Mougou1 1 Department of Cytogenetics, Molecular Genetics and Reproductive Biology, Farhat Hached University Teaching Hospital, Sousse, Tunisia, 2Department of Gynaecology, Farhat Hached University Teaching Hospital, Sousse, Tunisia, and 3Department of Neonatology, Farhat Hached University Teaching Hospital, Sousse, Tunisia

Brief Introduction: Agenesis of the corpus callosum (ACC) is a common brain malformation of variable clinical expression. It can be complete or partial and occurs whether isolated or associated with other brain malformations. The prenatal screening for ACC can be done after week 20 of gestation. It currently appears difficult to distinguish, in antenatal, between forms to be symptomatic of those who will not be, which leads to face a delicate situation regarding the genetic counseling. Here we report a discussion of 3 cases of parental ACC seen in a cytogenetic study. Materials & Methods: Three women were referred for amniocentesis, the first is 31 years old and at 21 weeks of gestation prenatal ultrasound showed agenesis of the corpus callosum, hydrocephalus and a diffuse cortical thinning. The second is 32 years old, the fetus had ACC, agenesis of the vermis and a cerebellar hypotrophy, the last is referred because she delivered previous pregnancy with ACC. Clinical Cases or Summary Results: Cytogenetic analysis revealed normal karyotypes of 46, XX for the three fetuses. Conclusions: Face to the normality of karyotypes and the clinical features revealed in fetuses by sonography, we can conclude that the resolution of conventional karyotype may not allow a reliable genetic screening and that further cytogenetic investigation with higher resolution like CGH-array is needed in order to provide a suitable counseling for the parents. In fact, genetic counseling depends on the form of ACC, thus, diagnosis should trigger detailed assessment to establish whether it is isolated, then it has a good prognosis, or associated and then it has a dark prognosis. The medical team is meant to provide detailed informations for the parents, they choose either to interrupt or to continue the pregnancy. In both cases, an antenatal or a postnatal follow-up should be considered. Besides, a fetopathological examination seems essential in order to advance a clear etiological diagnosis for subsequent pregnancies like in our third case. In general, prenatal diagnosis of abnormal corpus callosum should alert subtle chromosome aberrations and prompt molecular cytogenetic investigation if necessary. It represents an essential clue for the genetic counseling and for understanding the etiology of the malformation. Keywords: Agenesis of the corpus callosum (ACC), prenatal diagnosis, genetic counseling Presenter: J. Mathlouthi

Presenter: S. Kizatova

ID 195

DYSGENESIS OF THE CORPUS CALLOSUM: AN 8 CASE REPORT A. Ben Haj Hassine, R. Arfaoui, A. Ouni, & R. Rachdi

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Department of Gynecology and Obstetrics - Military Hospital of Tunis - Tunis - Tunisia Brief Introduction: Dysgenesis of the corpus callosum is a malformation of the midline. It represents 3–5% of malformations of the central nervous system and includes total and partial agenesis. This defect can be isolated or associated with other facial or brain damage can enter a specific syndrome. Materials & Methods: This is a retrospective study over a period of 6 years between 2003 and 2008. Clinical Cases or Summary Results: - 8 cases of dysgenesis of the corpus callosum (7 cases of agenesis of the corpus callosum and one hypoplasia of the corpus callosum). Sonographic signs found: Absence of direct visualization of the corpus callosum in 5 cases. Ventriculomegaly in all cases. No display of the peri-callous artery in 4 cases No septum pellucidum visualization in all cases Hypoplasia of the corpus callosum: The corpus callosum is very thin. – Fetal MRI was performed in 4 cases: search for other central nervous system in 3 cases and a better characterization of lesions in 1 case (agenesis of the corpus callosum associated with low lumbar meningocele. – Associated anomalies: choroid plexus cyst, low lumbar meningocele, single umbilical artery, CIA, VIC . . . – Karyotype performed in 3 cases: 2 cases of trisomy 18, 1 case of trisomy 21. – Pregnancies outcome: 5 medical termination of pregnancy (between 16 and 29 SA)

We report 2 neonatal deaths: hypoplasia of the corpus callosum with metabolic disease, agenesis of the corpus callosum within a Fryns syndrome. – A full-term pregnancy with delivery of a newborn carrier agenesis of the corpus callosum. The clinical neurological examination of the newborn was normal. At 1 year, psychomotor development is satisfactory. Conclusions: The prognosis is not well established in case of dysgenesis of the corpus callosum. It depends on the total or partial nature of the dysgenesis and the presence of associated malformations. Keywords: corpus callosum, prenatal diagnosis Presenter: A. Ben Haj Hassine

ID 021

EARLY DETECTION OF BRAIN DAMAGE IN THE NEWBORN WITH PERINATAL ASPHYXIA IN THE TUZLA CANTON F. Skokic´1, A. Poljic´2, A. Selimovic´1, S. Muratovic´3, I. Hudic´3, A. Halilbasˇic´1, E. Hasanovic´1, M. Hadzˇifejzovic´4, & M. Halilbasˇic´5 1

University Clinical Center Tuzla, Childrens hospital Tuzla, Bosnia and Herzegovina, 2Ministry of labour, social and refugees affairs, Tuzla Canton, Bosnia and Herzegovina, and 3 Clinic for Gynecology and Obstetrics, University Clinical Center, Tuzla, Bosnia a Brief Introduction: Perinatal asphyxia is a cause of acute mortality and chronic neurological disorder among survived newborns. The aim of this paperwork is to examine the frequency, type and degree of brain damage in newborns with perinatal asphyxia. Materials & Methods: Methods: A prospective study conducted in the period 1 January 2011- 31 December 2013 at the Clinic of Gynecology and Obstetrics, University Clinical Center Tuzla, Bosnia and Herzegovina, included live newborns with perinatal asphyxia, both genders, from the singleton pregnancies and no visible abnormalities (n = 267). They are divided into two groups: the group of newborns with brain damage (the respondents) (n = 227) and control group of newborns without brain damage (n = 40). The brain damage is diagnosed by multiple cranial ultrasound examination (cerebral hemorrhage is defined according to the Papile four- level system and hypoxic ischemic encephalopathy according to the Sarnat grading scale stage III. Clinical Cases or Summary Results: Results: The brain damage had 227/267 (85.01%) of tested newborns. The incidence of bleeding among 267 examinees was 154/267 (57.67%), and hypoxic ischemic ecephalopathy was 113/267 (42.32%). A statistically significant difference was found ( = 47.48; p50.0001), with a higher chance of bleeding than hypoxic ischemic ecephalopathy [RR = 4.164 (95% CI = 2.750–6.303)]. Considering the degree of bleeding, a minor brain bleeds prevailed in patients (91/154;59.09%), while hypoxic ischemic encephalopaty was of a severe degree (64/113; 56.63%). Conclusions: Conclusion: The incidence of brain damage in newborns with perinatal asphyxia is high and manifests itself more often as a severe degree of hypoxic ischemic encephalopathy, which has a worse outcome. Keywords: newborn, perinatal asphyxia, brain damage Presenter: Fahrija Skokic

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ID 507

THE PROTECTIVE EFFECT OF GINKGO BILOBA ON BILIRUBIN NEUROTOXICITY O¨. S¸ ahin1, H. Ergin1, H. Akc¸a2, A. Demiray2, C¸. Yenisey3, & B. O¨zdemir4 1

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Neonatology Department, Pamukkale University Faculty of Medicine, Denizli, Turkey, 2Medical Biology Department, Pamukkale University Faculty of Medicine, Denizli, Turkey, 3 Biochemistry Department, Adnan Menderes University Faculty of Medicine, Aydın, Tu Brief Introduction: Inspite of the recent improvements in neonatology, neurotoxicity caused by unconjugated bilirubin (UCB) is still being an important problem. UCB is thought to have two sided affects on cells, being antioxidant at physiological levels, while causing oxidative injury at pathological levels. Ginkgo biloba (EGB-761) are known to have antioxidant, antiapoptotic, antinitrosative, vasorelaxant, antiaggregant, and antiinflammatory effects in central nervous system, but there is no knowledge about its effects on neurotoxicity caused by UCB. The aim of the present study was to evaluate the effects of UCB and EGB-761 on newborn rat astrocyte cell cultures, and to investigate protective effects of EGB-761 on UCB neurotoxicity. Materials & Methods: Astrocyte cells culture were prepared from brains of 1-day-old Wistar albino rat pups by a modification of Cole and de Vellis method. UCB concentration toxic to 50% of astrocytes (TC50) was found to be 10 mM. The apoptotic cell death due to UCB toxicity was evaluated by TUNEL staining method. The concentrations of EGB-761 that increased cell viability 100% and 110% were determined as 10mg/ml and 0.5mg/ml, respectively. The study included control (C), bilirubin10(B10), ginkgo10(G10), ginkgo10bilirubin10(G10B10), and bilirubin10ginkgo10(B10G10) groups. In B10 group 10 mM UCB, and in G10 group 10 mg/ml EGB761 was administered to cell cultures for 48 hours, while in control group no medication was given. In G10B10 group, 4 hours after 10 mg/ml EGB-761 pretreatment, 10 mM UCB was administered for 48 hours. In B10G10 group 4 hours after 10 mM UCB administration, 10 mg/ml EGB-761 was administered for 48 hours. Clinical Cases or Summary Results: Compared with the control group, approximately 50% decrease in cell viability, and five times increase in apoptosis was found in B10 group (p:0.001, p:0.001). EGB-761 administration for prophylaxis and treatment was found to significantly increase cell viability (p:0.001, p:0.001), and significantly decrease apoptosis (p:0.001, p:0.001), when compared with the control group. Conclusions: This study indicates that, UCB is cytotoxic on astrocytes in-vitro, and administration of EGB-761 for prophylaxis or treatment reduces the cytotoxic effects of UCB. Keywords: gingko biloba, astrocyte, uncongugated bilirubin, neurotoxicity Presenter: Hacer Ergin

ID 592

CLINICAL CEREBRAL AND SOMATIC OXIMETRY VERSUS PULSOXIMETRY FOR A BETTER THERAPY MANAGEMENT IN NEONATAL CARE – CASE REPORT N. Ionita1, M. Dima2, A. Agoston-Vas1, C. Ilie2, I. Enatescu2, D. Iacob2, & R. Tanase1

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437 1

County Emergency Hospital Timisoara, Romania, and University of Pharmacy and Medicine ‘‘V. Babes’’ Timisoara, Romania 2

Brief Introduction: Noninvasive procedures are eligible when taking care of a neonate. The INVOS System is a noninvasive device which provides regional, not systemic oximetry by near infrared spectroscopy (NIRS). Often provides earlier warning than traditional measures such as SpO2. Our aim is to improve the clinical management of neonates in our care and so to take advantage of the newest technologies. We are presenting the clinical case of a premature newborn who was monitored using NIRS which helped us to detect and correct oxygenation issues such as those associated with low cardiac output, shock, seizures, renal failure or neurologic damages. Materials & Methods: Premature infant, gestational age 30 weeks, birth weight 1300g. History: premature membrane rupture over 3 weeks, maternal infection with Escherichia Coli. Apgar score = 6/10 , 4/50 . He presented arterial ischemia at birth which affected his right arm and he needed cardiac and respiratory resuscitation. We monitored cerebral and somatic oxygenation using an INVOS device; we used neonatal sensors placed over the brain and abdomen area. At the same time we used sensors for preductal and postductal pulsoximetry. Clinical Cases or Summary Results: We started the monitoring 48 hours after birth and during 72 hours. The INVOS device generates a vital sign called regional hemoglobin oxygen saturation (rSO2), which is a venous-weighted measure of the hemoglobin bound oxygen remaining after tissues have taken what they need. The lower and upper alarm limits have been set at 50 and 90%. Nurses have been trained to mark all the interventions. Transfontanelar ultrasound has been made before, during and after monitoring to detect brain injuries. There have been detected several periods of hypo or hyperoxia which have not been detected on time by pulsoximetry device or by laboratory investigations. Care team intervened by changing the ventilatory parameters, repositioning the baby or administering fluids. Conclusions: Decreases in the venous reserve of oxyhemoglobin indicate increased ischemic risk and compromised tissue perfusion. It is very important to intervene at the right time in order to prevent or lessen ischemic complications and injury. Newborns admitted in the NICU are sensitive to apparently minor changes in therapeutic management or manipulation this is why it is very important to take advantage of all the noninvasive methods of monitoring and diagnose to improve their outcome and NIRS gives us an important helping hand. Keywords: prematurity, cerebral, oximetry. Presenter: N. Ionita

ID 736

CASE REPORT OF A NONKETOTIC HYPERGLYCINEMIA IN A NEONATE O. Grebennikova1,2, A. Zavadenko1,2, M.G. Degtyareva1,2, M. Medvedev1, & S. Rogatkin1 1

Department of Neonatology, Postgraduate Faculty, N.I. Pirogov Russian National Research Medical University (RNRMU), Moscow, Russia, and 2Research Laboratory of Diagnostics and Prevention of Neonatal Hypoxic Ischemic Brain Injury, N.I. Pirogov Russian Natio Brief Introduction: Nonketotic hyperglycinemia (NKH) is a rare metabolic autosomal recessive disorder with severe, frequently fatal, neurologic manifestations. The neonatal form manifests duing the first hours (days) of life with progressive lethargy, hypotonia,

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myoclonic jerks, hiccups, and apnea, which often lead to coma or death. Reliable and accurate diagnosis depends on careful interpretation of laboratory findings. The clinical suspicion should lead to determination of glycine levels in plasma and cerebrospinal fluid (CSF). Increased glycine concentrations in CSF and elevated CSF–to– plasma glycine ratio are considered essential for NKH. An early diagnosis, though not affecting clinical outcome, allows proper genetic counseling, with the possibility of prenatal diagnosis. Materials & Methods: We report a case of typical neonatal nonketotic hyperglycinemia diagnosed in Municipal Hospital No. 8, Moscow, Russia, in 2014. Clinical Cases or Summary Results: A full-term newborn boy to a 25-year-old fifth gravida mother with a history of 3 medical abortions and 1 spontaneous miscarriage of previous pregnancies and Herpes labialis infection at 39 week during thr current pregnancy. Family history revealed a non-consanguineous couple. Labor and vaginal delivery with a vacuum extraction. Apgar scores at birth were 7 at 1 minute and 8 at 5 minute, birth body weight 3760 g, birth length 55 cm. Physical and neurologic examinations were normal except for mild hypotonic muscle tone. On the 2nd day of life increasing lethargy with poor feeding was observed. The clinical condition of the baby continued to deteriorate during the next few days. He developed repeated apnoea, desaturation (SaO2 = 80–84%) on day 3 of life. Besides generalized myoclonic seizures were detected. He was transferred to NICU and then managed with endotracheal intubation and mechanical ventilation because of impending respiratory failure. aEEG monitoring was conducted during days 3 to 5, and ‘‘burst-suppression + ’’ pattern was registered with repeated seizure activity clinically accompanied with multifocal or generalized myoclonic seizures. Seizure frequency increased even under antiepileptic treatment. Laboratory examination showed that blood cell count, electrolyte, glucose, ammonia, and lactate levels were all within the normal range. CSF cell counts, protein and sugar levels were normal. Brain echography showed negative findings. So perinatal infections and intranatal trauma were excluded and inborn errors of metabolism were suspected. The diagnosis of NKH was made on day 5, based on a markedly elevated CSF/plasma glycine ratio of 0.14 (normal ratio is 0.08) with a CSF glycine level of 198.7 mmol/L (normal range 1.6–19.5mmol/l) and plasma glycine of 1429.8 mmol/L (normal range 104–740mmol/l). Brain MRI performed at 14 day of life showed agenesis of the anterior portion of the corpus callosum. The baby got supportive management. His clinical condition improved slightly with more spontaneous eye opening. Respiratory efforts improved and apnea episodes disappeared. The baby was extubated at the 21st day of life. Long-term video-EEG monitoring on day 22 showed burst-suppression pattern and multifocal epileptic form discharges clinically associated with multifocal myoclonic seizures of face and limbs. Seizures were resistant to phenytoin administration. Now this 5-month-old baby is in a palliative care department, still being fed through a nasogastral tube and has rare seizures. Conclusions: Nonketotic hyperglycinaemia can be one of the major differential diagnosis in neonates with disturbances in consciousness with seizures in the absence of distinct acid-base disturbances. However, the prognosis of the disease is still poor, making the proper diagnosis is important because genetic counselling and prenatal diagnosis can be offered at the subsequent pregnancy. Keywords: Presenter: Olga Grebennikova

1

The Clinic for Gynecology and Obstetrics, Clinical Center Nisˇ, Center for Radiology, Clinical Center Nisˇ, and 3Clinic for eye disease, Clinical Center Nisˇ

2

Brief Introduction: Microcephaly is a rare neurological condition, usually found as a result of the brain developing anomaly, and can be caused by a variety of genetic and environmental factors. The aim of this study is to present a newborn baby with microcephaly and craniosynostosis. Materials & Methods: Clinical, neurological and ultrasound examinations, indirect ophtalmoscopy, MRI, total blood cells count, glycemia, ELISA on TORCH and Epstein-Barr virus (EBV). Clinical Cases or Summary Results: The male newborn from first pregnancy of a 25 year-old woman, suffering from vitiligo. The birth weight was 3900g, birth length 56cm, the head circumferency was 32cm (below 10th percentile), Apgar score was 9, gestation age 38 weeks. The head was microcephalic and sinostotic, the face looked normal. The intracranial ultrasound exam was impossible because of sinostosis. MRI showed microcephaly, incomplete lissencephaly, dysplasio corticis, encephalomalatia cystica, absence of the septum pellucidum, hypoplasia of the optic nerves (DDg dysplasia septo-optici), and reduction of supratentorial brain tissue. Cariotypisation was 46XY. The ultrasound of heart and abdomen was regular. This brain anomaly was not recognized prenatally. Ophtalmologic examination showed small diameter of left papilla n. optici, and possible vision problems. Neurological exam shows abnormal neonatal reflexes, hipertonus with spasticity, and poor neurological outcome. Prenatal infections were ruled out. All laboratory tests were within normal values. Conclusions: A newborn with suspected congenital anomaly needs exact diagnosis. It is very important to perform prenatal ultrasound examination. It is necessary to work as a team and use a wide diapason of diagnostic methods. Keywords: microcephaly, congenital malformation Presenter: Marina Jonovic

OTHER ID 448

SAFETY AND IMMUNOGENICITY OF AN INVESTIGATIONAL TRIVALENT GROUP B STREPTOCOCCUS VACCINE IN HEALTHY NON-PREGNANT AND PREGNANT WOMEN – A PHASE IB/ II TRIAL S.A. Madhi1,2,3, C.L. Cutland1,2, L. Jose1,2, A. Koen1,2, N. Govender1,2, S. Stenglein4, F. Wittke4, S. Baker4, P. Dull4, V. Narasimhan4, & K. Slobod4 1

CONGENITAL MALFORMACY OF THE BRAIN

Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa, and 2Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the

M. Jonovic´, B. Miljkovic´, N. Stojanovic´, G. Jovanovic´, S. Stamenovic´1, I. Markovic´2, & M. Vujanovic´3

Brief Introduction: Group B streptococcus (GBS) is a leading global cause of neonatal and early infant sepsis and meningitis, even in

ID 471

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236 regions where intrapartum antimicrobial prophylaxis is administered. Early-onset newborn infection is largely vertically acquired and maternal immunisation offers the potential to protect young infants by transfer of antibodies across the placenta. Transferred antibodies are especially important for protection against vertically acquired pathogens, such as GBS, which are transmitted before infant immunization can induce protection. Maternal immunisation could reduce the burden of disease, but no licenced vaccine exists. In this dose-range study, we assessed the immunogenicity and safety of an investigational, trivalent GBS vaccine in pregnant and non-pregnant women. Materials & Methods: In total, 60 non-pregnant (NPG) and 320 pregnant (PG) women were enrolled at a single site in South Africa. NPG women received two injections (one month apart) of placebo or alum-adjuvanted GBS trivalent vaccine containing 20mg each of CRM197-conjugated GBS capsular polysaccharides representing serotypes Ia, Ib and III. PG women at 28–35 weeks gestation received one injection of placebo or non-adjuvanted GBS vaccine, containing 0.5mg, 2.5mg or 5.0mg (of each of the three serotypes). GBS-specific antibody was measured on Days 31, 61, 91, 181 and 361 (NPG women) or Day 31, delivery and Days 91, 181 and 361 post-partum (PG women). Solicited adverse reactions were recorded and unsolicited adverse events (AEs) were monitored throughout the study. Clinical Cases or Summary Results: Significantly higher GBS-specific antibody concentrations were observed in NPG and PG women, regardless of vaccine dose, compared to placebo (p50.05). The difference was still significant for all vaccine doses at Day 361 (17–23 fold higher in non-pregnant women, and 4–7 fold, 7–8.5 fold and 7–14 fold higher in the 0.5mg, 2.5mg or 5.0mg pregnant women groups, respectively). In pregnant women, highest fold differences (for serotype Ia) versus placebo were seen for the 5.0mg group. Additionally among PG women with undetectable Ia-specific antibody at baseline, the highest Ia-specific responses were observed after 5 mg dosage versus the 2.5 mg or 0.5 mg dosages. Vaccine tolerability and safety were similar to placebo. Conclusions: All doses of the vaccine induced enhanced antibody concentrations compared with placebo, in NPG and PG women, and were well-tolerated with no safety signals. Antibody levels remained significantly higher than placebo levels against all serotypes a year after vaccination. The 5 mg dosage has been advanced for further clinical development. (NCT01193920). Keywords: Presenter: S. Stenglein

ID 301

EXPRESSION OF SMALL PROLINERICH PROTEIN 2 IN MOUSE UTERUS IS REGULATED BY ESTROGEN W. Park1#, S. Na2#, & S. Hong3* 1

Physiology Dept., School of Medicine, Kangwon National University, Chuncheon, South Korea, 2Obstetrics and Gynecology Dept., Kangwon National University Hospital, School of Medicine, Kangwon National University, Chuncheon, South Korea, and 3Internal Medicin Brief Introduction: The steroid hormone estrogen is an important regulator of uterine physiological events, which is mediated via the nuclear estrogen receptors, ERa and ERb. To identify the estrogenregulated genes underlying uterine physiology, we previously profiled early and late responsive genes in the ovariectomized mouse uterus exposed to 17b-estradiol (E2) for 6 h and 12 h (OVX/ estrogen treatment/6-h and 12-h protocol) using a cDNA microarray.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Small proline-rich protein 2a (Sprr2a) mRNA, an identified component of cornified envelope, showed the highest level of up-regulation in the OVX/estrogen treatment/12-h protocol. Using laser capture microdissection, we also reported that the Sprr2 gene family was upregulated more in luminal epithelial cells than in stromal and myometrial cells by E2. Materials & Methods: In the present study, we introduced RT-PCR to analyze the expression patterns of the Sprr2 gene family in immature and adult mouse reproductive organs: ovary, oviduct, uterus, and testis. In addition, we observed that the expression of Sprr2 protein in mouse uterus is regulated by E2 using immunohistochemistry. Clinical Cases or Summary Results: The present study is the first to reveal that the Sprr2 gene family is only detected in the uterus, and not in the ovary, oviduct, or testis. Exceptionally, Sprr2g mRNA is weakly detected in immature and adult oviduct. We also demonstrated that Sprr2 protein is tightly regulated by E2 in mouse uterus. Conclusions: Collectively, our studies suggest that Sprr2 has a unique function and play important roles in the mouse uterus during the early pregnancy period and the estrous cycle. Keywords: estrogen, uterus, estrogen receptor, Sprr2 Presenter: S. Hong

ID 344

EVALUATION OF CHILD DELIVERY TRAUMA ON ANAL SPHINCTER MUSCLE BY MEANS OF SURFACE ELECTROMYOGRAPHY (RESULTS OF THE MULTICENTER STUDY TASI-2) V. Zacˇesta1, O. Zelenova1, K. Drusany-Staricˇ2, E.E. Raimondi3, K. Martsidis4, O. Protsepko5, K. Baessler6, C. Cescon7*, & R. Merletti7 Riga Maternity Hospital (Latvia), 2University Medical Centre Ljubljana (Slovenia), 3Ospedale S. Anna Como, presidio Cantu` Como (Italy), 4University of Cagliari (Italy), 5Hospital of Vinnitsa (Ukraine), and 6Charite´ Universita¨tsmedizin Berlin (Germ 1

Brief Introduction: Recent studies demonstrated that there is a significant correlation between anal sphincter damage during vaginal birth, with or without episiotomy, and subsequent development of anal incontinence in women. Functional asymmetry of pelvic floor innervation has been shown to exist in healthy subjects. Episiotomy is the most common obstetric surgical intervention; right side mediolateral episiotomy is usually performed in Europe. The damage of pudendal nerve during episiotomy could lead to anal sphincter mass decrease and anal incontinence. Pre-emptive location of innervation zones (IZs) with anal sphincter electromyography (EMG) could allow choosing the least invasive side for episiotomy. Avoiding the incision of IZs would presumably reduce the incidence of anal incontinence. Materials & Methods: The aim of the study is to validate the surface EMG as a screening tool to locate the IZs of anal sphincter, and to evaluate the effect of episiotomy related trauma on the external anal sphincter muscle. In this prospective cohort study, 511 pregnant primiparous women, by nine clinical partners from five European Countries, were involved and surface EMG was performed to detect the distribution of IZs of external anal sphincter. EMG measurements were performed at the 28th - 34th gestational week and 6–8 postdelivery week (end of puerperium). The study was conducted in double blind, meaning that the clinical partners did not receive any

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Figure 1.

Figure 2. information regarding the IZs of the patients and the signal analysis was performed without having information regarding the type of delivery. Clinical Cases or Summary Results: 331 women returned, after delivery, for the second examination. The subjects were divided in four groups according to the delivery mode (Caesarean, vaginal with no evident damage, spontaneous lacerations and episiotomies). The numbers of IZs were compared before and after delivery. In the 82 women who underwent right mediolateral episiotomy, a statistically significant reduction of IZs was observed (mean = 0.62, 95%CI [-1.03:-0.21]), after delivery in the right ventral quadrant (side of episiotomy) of the external anal sphincter, while women who had Caesarean section, spontaneous lacerations or no evident damage did not present any significant change in the innervation pattern. Figure 1 shows graphical representation of the estimates of the difference (pre-post) in the number of innervation zones in the four

quadrants for two groups of subjects (Caesarean section, episiotomy, panels a and b respectively). The four sectors of the anal sphincter (LV, RD, LD, RV) are coloured in a shade of grey corresponding to the difference in the number of innervation zones, where lighter colours correspond to a decrease of the number of innervation zones and darker colours to an increase of the number of IZs. Figure 2 (a) is a picture of the disposable rectal probe. The probe is a plastic cylinder of 14 mm diameter holding a thin printed circuit with 16 equally spaced electrodes, (b) is an example of sEMG signals detected from the external anal sphincter of a subject during rest, (c) representation of the motor units, and their innervation zones (dark spots) in the external anal sphincter. Conclusions: Right episiotomy reduces the number of IZs on the rightventral side of the EAS. Knowledge of the pre-partum distribution of IZs allows obstetricians to evaluate the risk of episiotomy and to choose the side where to perform it in case it would be necessary at the time of delivery. This knowledge, which can be obtained with

238 a disposable probe and a minimally invasive surface EMG pre-partum test, is expected to reduce the consequences of episiotomy.

1

Keywords: episiotomy, innervation zone, external anal sphincter, multichannel sEMG

Brief Introduction: In South Africa, approximately 70% of maternal deaths and 50% of all under-five child deaths are associated with Human Immunodeficiency Virus (HIV) infection. The immune control of HIV infection relies critically on the cytotoxic T lymphocyte (CTL) response to the virus. Protective CTL human leukocyte antigen (HLA) molecules drive the selection of escape mutants that reduce viral replicative capacity through HLA-associated polymorphisms. Transmission of viruses with low replicative capacity result in lowering of early viral set-point and a higher CD4 count in the recipients. Therefore the immune control of HIV can contribute to the prevention of mother-to-child transmission and reduction of maternal and child mortality and morbidity at a population level. Materials & Methods: Here we investigated two comparable postnatal cohorts of HIV-infected, antiretroviral-therapy-naı¨ve women recruited from the same site in Umlazi, Durban, in 2002–5 (n = 328) and in 2012–13 (n = 250), respectively. We hypothesized that the immune responses and immune control in the current cohort of HIV-infected mothers would differ as a result of exposure to virus with accumulated HLA-associated polymorphisms, contributing to the reduction in viral set-point observed over a 10-year period in Umlazi, Durban, at the epicenter of the global HIV epidemic. Clinical Cases or Summary Results: Preliminary results demonstrate significantly lower viral loads, increased CD4 counts and increased number of HLA-associated polymorphisms in the 2012–13 cohort compared with the 2002–5 cohort (p50.001). Moreover we found a significant decrease in viral load and increase in CD4 count when correlated with total number of HLA-associated polymorphisms per Gag sequence across the two cohorts (p50.001). Conclusions: This initial data suggests that the lower viral loads and increased CD4 counts observed in the 2012–13 cohort is strongly correlated with the accumulation of HLA-associated polymorphisms at a population level, with consequent reductions in viral replicative capacity and improved immune control. Further analyses are required to evaluate the impact of HIV adaptation to protective HLA molecules such as HLA-B*57 on changing virulence of the HIV epidemic over a 10-year period. These initial results have important implications in the prevention of mother-to-child transmission of HIV.

Presenter: Vita Zacesta

ID 502

MATERNAL MORTALITY IN PAKISTAN: CAUSES AND CORRELATES S. Khan1 & Donna Strobino2 J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

1

Maternal Newborn and Child Health Program, PATH, Seattle, USA, 2and Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, USA. Brief Introduction: An estimated fifteen thousand Pakistani women die of maternal causes every year. Pakistan is a signatory to MDG 5(a) and is committed to reduce maternal mortality to 140/100,000 live births by 2015. However, currently available literature provides limited population-based information on the causes and determinants of maternal mortality in Pakistan. Materials & Methods: We used data from the 2006–07 Pakistan Demographic and Health Survey. The survey collected information on mortality among women of reproductive age through verbal autopsies. Demographic and reproductive health information was also collected for women aged 15–49 in the same communities. This study used logistic regression to estimate the odds of maternal death associated with maternal socio-demographic, and community characteristics Clinical Cases or Summary Results: Postpartum hemorrhage, eclampsia and sepsis were the major reported causes of maternal mortality. Primiparity, poor obstetric history and maternal age 430 years were associated with increased odds of maternal death. Most community variables were not, or weakly, associated with maternal deaths when adjustment was made for maternal variables. Conclusions: Maternal mortality correlated closely with individual-level risk factors. Safe motherhood programs should focus on women at the highest risk of mortality who are often those delivering at home. Programs for safe birth are currently focused on promoting facility based deliveries. However, given almost 60% of births still occur in the home, as in "in the meanwhile" strategy, these programs should also focus on provision of community level interventions to equip front line health care providers with skills and tools for prevention of maternal complications and stablization of women prior to referral

Department of Paediatrics, Oxford University, United Kingdom

Keywords: Presenter: Allison Hempenstall

ID 300

Keywords: Maternal mortality, risk factors for maternal death, causes of maternal death, Pakistan

BASIC FIBROBLAST GROWTH FACTOR IMPROVES PROLIFERATION OF HUMAN UMBILICAL CORD-DERIVED PERIVASCULAR STEM CELLS

Presenter: Sadaf Khan

S. Na1, B. An2, S. Yang3, W. Park4*, & S. Hong2* 1

ID 188

IMPACT OF RECENT HIV INFECTION IN POSTNATAL MOTHERS IN DURBAN, SOUTH AFRICA A. Hempenstall1, M. Muenchhoff1, E. Adland1, A. Carlqvist1, T. Ndung’u1, & P. Goulder1

Obstetrics and Gynecology Dept., Kangwon National University Hospital, School of Medicine, Kangwon National University, Chuncheon, South Korea, 2Internal Medicine Dept., School of Medicine, Kangwon National University, Chuncheon, South Korea, and 3Thoracic Brief Introduction: Mesenchymal stem cells (MSCs) are have been locally and globally testing for the treatment of various diseases at the preclinical or clinical levels. However, MSCs isolated by enzymatic treatment display morphological, phenotypic and functional heterogeneity, which results in variations between cell lines and remains the biggest obstacle to evaluate their regenerative capacity. Recently, perivascular cells (PVCs) around blood vessels turn out to be

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the origin of all MSCs and possess the greater proliferation and differentiation potential than bone marrow-derived MSCs. Therefore, efficient isolation and expansion of PVCs from various fetal and adult tissues is an essential tool for providing sufficient amount of PVCs for more than one treatment. Materials & Methods: In this study, we newly developed a simple nonenzymatic (NE) method for isolation of multipotent PVCs from human umbilical cord (HUC) and compared it with collagenase treatment (COL) in terms of growth rate and immunophenotypes. Clinical Cases or Summary Results: While both methods displayed similar patterns or levels of phenotypic expression and growth rate, NE method had an increased frequency of CD146(+) population compared to COL method over passage. We also found that supplementation of basic fibroblast growth factor (bFGF) significantly enhanced PVC proliferation by driving the cells into S phase and increased a proportion of SSEA-4(+) population within PVC cultures without alteration of other immunophenotype. Conclusions: Taken together, our findings suggest that a combination of NE method and bFGF supplementation can be an epoch-making way to isolate more homogeneous PVC population from HUC, which will enhance the utility of PVCs for cell therapy for various diseases.

Conclusions: We have noted a high number of transfers into surgical units of infants with confirmed or suspected NEC that had no indication for surgery at the time of referral or transfer and did not go on to have surgery. Our results suggest that referral patterns could be modified to optimize surgical cot usage. In recent years clinicians have started referring patients with NEC who may not necessarily have indications for surgery into surgical units for joint medical and surgical oversight. However surgical bed pressure has increased as a consequence. Depending on careful clinical assessment and review of the abdominal X-ray, a more informed decision can be made as to whether an infant with suspected NEC needs to be transferred to a tertiary medical or surgical unit. Guidelines on indication for transfer in surgical patients could be effective in avoiding unnecessary transports to surgical centres.

Keywords: perivascular cells, basic fibroblast growth factor, CD146, SSEA-4

CARDIOVASCULAR MATERNAL DEATHS IN NORWAY, 1996–2011

Presenter: S. Hong

Keywords: Presenter: E. Molnar

ID 579

L. Ellingsen1 & S. Vangen2

ID 797

IS IT ALWAYS REASONABLE TO TRANSFER BABIES WITH NECROTIZING ENTEROCOLITIS TO NEONATAL SURGICAL UNITS? E. Molnar, E. Fukari-Irvine, C. King, B. Kawa, & N. Ratnavel Neonatal Transfer Service, London, United Kingdom Brief Introduction: Necrotising Enterocolitis (NEC) is the most common gastrointestinal emergency and a major cause of morbidity and mortality in preterm infants. Based on severity of the disease, treatment can involve a medical approach or surgical intervention. Whilst babies requiring medical treatment can be managed in a nonsurgical neonatal intensive care unit (NICU), patients that require surgery need to be transferred to a tertiary surgical NICU. In recent years, the sense that an increasing number of patients transferred to surgical centres had no clear surgical indication has arisen. In addition neonatal surgical bed capacity is under constant strain. Materials & Methods: Our aim was to quantify the number of babies referred for NEC who were transferred directly to neonatal surgical units in London and to see what proportion of these had a clear need for surgery and proceeded to have surgical intervention. The Neonatal Transfer Service (NTS) provides neonatal transfers across London. In this observational retrospective study, we collected data from 66 babies who were transferred with the diagnosis or suspicion of necrotising enterocolitis between July 2012 and June 2013. We recorded if the receiving hospital was a tertiary level medical NICU or a tertiary surgical unit, the clinical and abdominal X-ray findings in the referring hospital, the transport events, whether the baby needed surgical treatment and the mortality. We also compared the referral patterns between 2 epochs; July 2012-June 2013 versus January 2011-December 2011. Clinical Cases or Summary Results: All babies (100%) with suspected NEC were transferred to tertiary surgical NICUs. 31/66 (47%) did not require surgical intervention and were successfully managed with medical treatment only. 35/66 (53%) underwent surgery in the receiving hospital.

1 Norwegian Resource Centre for Women’s Health, Department of Women and Children’s Health, Oslo, Norway, and 2Norwegian Resource Centre for Women’s Health, Department of Women and Children’s Health, Oslo, Norway.

Brief Introduction: Cardiovascular diseases in pregnancy increases, and is the most common cause of indirect maternal deaths in European countries like England, Sweden, Denmark and Netherlands. The aim of the study was to identify maternal deaths with special emphasis on cardiovascular disease, and to identify learning points for clinical care through audit assessment Materials & Methods: Information of maternal deaths in Norway 1995 -2009 was collected by linkage of The Medical Birth Registry, the Causes of Death Registry and information from obstetric wards. Medical records were requested in each case and closely scrutinized by the audit group. Learning points for clinical care were elaborated in cooperation with cardiologist and anesthesiologist Clinical Cases or Summary Results: In total we identified 68 maternal deaths in the period 1996–2011; 23 indirect and 45 direct deaths. Cardiovascular disease was the most common cause (n = 10) of indirect maternal deaths: ratio 1/100.000 maternities. Five died from dilatation/dissection of aorta, 2 of myocardial infarction, 1 of pericarditis and 1 of myocarditis. One woman had a tumor in the left heart ventricle and died after heart biopsy. Learning points for clinical care: be aware of the increasing group of pregnant women with known or unknown heart disease and the increased risk of deterioration by pregnancy end delivery. Follow local guidelines and cooperate with cardiologists with special knowledge in the field Conclusions: Cardiovascular disease was the most common cause of indirect maternal deaths in Norway this period. 50% of these cases were related to dilatation/dissection of aorta. Pregnant women with signs of moderate or severe cardiovascular disease should be referred to a tertiary referral center with a multidisplinary team experienced in the management of cardiovascular diseases during pregnancy. Keywords: MAternal Mortality, Maternal deaths Presenter: Liv Ellingsen

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ID 620

FETAL HEART RATE VARIABILITY DURING PREGNANCY J. van Laar1, G. Warmerdam2, K. Verdurmen1, & S. Oei1 1 The Department of Obstetrics & Gynaecology, Ma´xima Medical Centre, Veldhoven, the Netherlands, 2The Department of Mecial Physics, Ma´xima Medical Centre, Veldhoven, the Netherlands

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Brief Introduction: Cardiotocography, the worldwide used method for fetal surveillance, has a poor diagnostic value for detecting fetal Table 1. Mean values of the median absolute and normalized low frequency and high frequency power for the active and quiet state for the gestational age period of 34 to 41 weeks. Spectral estimate 2

Absolute LF (ms ) Absolute HF (ms2) Normalized LF Normalized HF

Active

Quiet

p value

555 62 0.77 0.10

151 38 0.59 0.26

0.002 0.09 0.005 0.002

distress. Fortunately, non-invasive spectral analysis of fetal heart rate variability is a promising new field in fetal monitoring. As in human adults, spectral analysis can be used to monitor autonomic nervous system modulation. During labour, it has previously been shown that spectral estimates are likely to predict fetal distress in an early stage. In order to validate spectral analysis as a new method for fetal surveillance properly, we studied the relationship of gestational age and the influence of fetal rest-activity state on spectral estimates of fetal heart rate variability. Materials & Methods: A prospective longitudinal study was performed in a teaching hospital with tertiary perinatal care. A total of 35 healthy women with an uneventful singleton pregnancy were included after written informed consent. Non-invasive fetal electrocardiogram measurements via the maternal abdomen were performed at regular intervals between 14 and 40 weeks of gestation. The measurements were processed to detect the beat-to-beat fetal heart rate. Simultaneous ultrasound recordings were performed to assess fetal rest-activity state. The main outcome measures were absolute and normalised power of fetal heart rate variability in the low (0.04–0.15 Hz) and high (0.4–1.5Hz) frequency band, using a Fourier Transform. Clinical Cases or Summary Results: 14% of all measurements (330 segments in total) were usable for spectral analysis. The period 521 weeks and 30–34 weeks of gestation were excluded from further analysis, since too little usable segments could be retrieved. During 21–30 weeks of gestation, a significant increase in both absolute low and high frequency power was observed (Figure 1). During the active

Figure 1. The association between absolute low frequency and high frequency power and gestational age, for the period of 21 to 30 and 34 to 41 weeks of gestation. (a) R2: 0.20 (p ¼ 0.009), (b) R2: 0.08 (p ¼ 0.26), (c) R2: 0.37 (p ¼ 0.0004) and (d) R2: 0.12 (p ¼ 0.15).

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DOI: 10.3109/14767058.2014.924236

Figure 2. The association between absolute low frequency and high frequency power and gestational age for the active and quiet state, for the period of 34 to 41 weeks of gestation. (a) R2: 0.08 (p ¼ 0.41), (b) R2: 0.04 (p ¼ 0.44), (c) R2: 0.23 (p ¼ 0.14) and (d) R2: 0.10 (p ¼ 0.22).

state near term, absolute and normalised low frequency power were significantly higher and normalised high frequency power was significantly lower compared with the quiet state (Table 1). Non-significant trends in absolute low and high frequency power were seen after 34 weeks of gestation for periods of fetal rest and activity (Figure 2). Conclusions: The increase in absolute spectral estimates in preterm fetuses was probably due to increased sympathetic and parasympathetic modulation, and might be a sign of autonomic development. Non-invasive spectral analysis of fetal heart rate variability is a promising new field in fetal monitoring, that can be used both intraand antepartum, during the term and preterm period. However, further improvements in signal processing are needed before it can be introduced in clinical practice. Keywords: fetal heart rate variability, fetal monitoring, autonomic development Presenter: Kim Verdurmen

ID 793

MANAGEMENT OF NEONATAL ABSTINENCE SYNDROME IN AUSTRALIA AND NEW ZEALAND C. Smirk1, E. Bowman2, L. Doyle3,4, & C. Kamlin1,3,4 1

Newborn Services, Royal Women’s Hospital, Parkville, Australia, 2The Women’s Alcohol and Drug Service, Parkville, Australia, 3Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Australia, and 4Newborn Research, Royal Women’s Hospital, Parkville, Australia Brief Introduction: Neonatal abstinence syndrome (NAS) secondary to maternal substance exposure is becoming more common worldwide. The treatment varies depending on the exposure. Previous studies have examined the approach to NAS in the United Kingdom and America. We aimed to describe the management of NAS in Australia and New Zealand. Materials & Methods: Invitations were sent to all tertiary perinatal units in Australia and New Zealand as well as level 2 special care nurseries in Victoria, Australia. Participants were asked to complete an online survey, providing details about different aspects of their

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242 management, including location of treatment, medications, weaning protocols and use of home based therapy. Participation was anonymous. Clinical Cases or Summary Results: Response rate of the survey was 77%. Most perinatal centres (75%) treated more than10 infants per year. Level 2 hospitals also care for significant numbers of substanceabusing mothers, with 30% of respondents caring for over 50 women per year. Infants at risk are generally monitored on the postnatal ward for 7 days. The most common medications used for treating NAS were morphine and phenobarbitone and most units used formal protocols and the modified Finnegan scoring chart to guide treatment weaning. Treatment locations included special care nursery (87%), home (37%) and the postnatal ward (13%). Conclusions: Infants with NAS provide a significant workload for many nurseries in Australia and New Zealand. The majority of infants at risk of withdrawal spend 7 days in hospital for monitoring. Medical management of NAS appears to follow appropriate guidelines in many cases and there is little variation in pharmacotherapy used to treat severe withdrawal. Although most infants are treated in the nursery, a significant number are actually treated in home-based programs, which are not well described in the literature. Keywords: Neonatal Abstinence syndrome, drug withdrawal, management

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Clinical Cases or Summary Results: One year after delivery, 20 (3.9%) women met the full PTSD and 77 (14.7%) the subsyndromal PTSD criteria (PTSD-SR questionnaire). Forty-one (7.9%) had an IES score20 and 12 (2.3%) an IES score 31, considered as a marker of need for specific care. Factors associated with PTSD in multivariate analysis were previous PPH (aOR 4.4(1.4;14.2)), labor longer than 6 hours (aOR 2.2 (1.3;3.7)), and episiotomy (1.7 (1.0; 2.9)). Bad experience of delivery was reported at day 2 post partum by 50% of women who developed full PTSD, 29% of women who developed subsyndromal PTSD and 8% of women with no PTSD after one year. Conclusions: PTSD is not rare one year after delivery in a low risk population. A simple question at day 2 postpartum may identify those women most at risk of developing PTSD. Keywords: post-traumatic stress disorder, childbirth Presenter: P. Jeanneteau

ID 527

Presenter: Cameron Smirk

PERINATAL DIAGNOSIS OF SPHEROCYTOSIS: A GUIDE TO DECIDE

ID 260

O. Andres1, S. Eber2, & C.P. Speer1

POST-TRAUMATIC STRESS DISORDER ONE YEAR AFTER DELIVERY IN AN UNSELECTED POPULATION P. Jeanneteau, MD1, C. Deneux-Tharaux, MD, PhD2, F. Maillard, MS2, P.E. Bouet, MD1, P. Descamps, MD1, F. Goffinet, MD, PhD2,3, & L. Sentilhes, MD, PhD1 1

Department of Obstetrics and Gynaecology, University Hospital, Angers, France, 2INSERM U953, Epidemiologic Research in Perinatal, Women’s, and Children’s Health, Pierre et Marie Curie University, Paris, France, and 3Port-Royal Maternity Unit, Department Brief Introduction: Evidence suggests that childbirth can be psychologically traumatic and lead to the development of post-traumatic stress disorder (PTSD). PTSD has potential major consequences on somatic and psychological health of the woman and her baby’s development. Most studies have reported the prevalence of PTSD shortly after birth and in high-risk subgroups. However, PTSD may be present in women whose delivery was seen as uncomplicated by the clinicians. Our objectives were to assess the prevalence of PTSD resulting from childbirth in an unselected population one year after delivery, and to identify characteristics of labor and delivery associated with this disorder. Materials & Methods: Mail questionnaires were sent one year after delivery to the 1103 women who delivered vaginally in 2010 in a French university hospital and were enrolled in the Tracor trial -this trial found no impact of controlled cord traction in third stage of labor on the incidence of postpartum hemorrhage-. Filled questionnaires were returned by 549 women (49.8% response rate). Respondents were at lower obstetric risk than non respondents. Post-traumatic stress disorders were assessed using the IES (Impact of Event Scale) and PTSD-SR validated scales. The characteristics of women, labor and delivery were extracted from the Tracor database. The prevalence of full and subsyndromal PTSD was measured according to the DSM-IV criteria. The associations of PTSD with characteristics of women and delivery were tested by crude and adjusted odds ratios.

1 2

University Children’s Hospital, Wu¨rzburg, Germany, and Pediatric Hematology and Oncology, Munich, Germany

Brief Introduction: With a prevalence of 1:5,000, hereditary spherocytosis (HS) is the most common congenital hemolytic anemia in Europe characterized by increased red cell osmotic fragility and membrane loss due to defective structural membrane proteins. Since spherocytes and reduced osmotic resistance are physiologic for fetal erythrocytes and common for several membrane defects or pyruvate kinase deficiency, diagnosis of HS around birth is widely considered unreliable. Materials & Methods: In our specialized laboratory for red cell defects we have examined 470 blood samples for HS by combining microscopy, acidified glycerol lysis (AGLT) and eosin-50 -maleimide test (EMA). For analysis of 25 neonatal blood samples, among them one after red cell transfusion, we have developed a modified EMA test that considers the elevated mean corpuscular volume (MCV) of neonatal red cells. Additionally, in an antenatal case of suspected hereditary stomatocytosis we measured intracellular cation concentrations in fetal red cells. Clinical Cases or Summary Results: Shortened AGLT half-time and diminished EMA fluorescence confirmed diagnosis of HS in 14, even in one sample after transfusion, and normal values excluded HS in 11 of the neonatal blood samples. In no case pyruvate kinase deficiency was interfering with diagnosis of HS. Overhydrated hereditary stomatocytosis was identified by proof of unbalanced intracellular cation concentrations (sodium 97 and potassium 34 mM) in fetal red cells. Conclusions: HS can be reliably diagnosed in neonatal infants by combining AGLT and our modified EMA test. AGLT replaces time and sample consuming assays with hypotonic salt solution. No overlap with pyruvate kinase deficiency has been observed. Keywords: spherocytosis, congenital hemolytic anemia, AGLT, EMA Presenter: O. Andres

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ID 504

PROGESTOGEN FOR THREATENED MISCARRIAGE: A RANDOMISED CONTROLLED TRIAL COMPARING MICRONISED PROGESTERONE AND DYDROGESTERONE J. Y. S. Siew1, J. C. Allen2, R. Malhotra3, T. Østbye3, S. He1, & T. C. Tan1,4 Duke-NUS Graduate Medical School, Singapore, 2Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore, and 3Health Services and Systems Research, DukeNUS Graduate Medical School, Singapore; Duke Global Health Institute, Durham, North Carol

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1

Brief Introduction: Low levels of serum progesterone and progesterone-induced blocking factor (PIBF) have been associated with subsequent miscarriage. In certain practices, women who present with threatened miscarriage are given progestogen supplement, either as micronised progesterone or dydrogesterone. However it is not known if such supplementation increases serum progesterone and PIBF and whether it is associated with an improvement of symptoms or a reduction in the incidence of miscarriage. The primary aim of this randomised controlled trial is to compare change in serum progesterone and PIBF from recruitment till between day 4 to 6 of treatment in women with threatened miscarriage. The secondary outcomes are extent of bleeding at day 4 to 6 compared to that at presentation and incidence of miscarriage. Materials & Methods: A total of 40 women with a single intrauterine pregnancy presenting with threatened miscarriage between 6 to 10 weeks of gestation were recruited with informed consent. Sociodemographic information and blood samples were collected at presentation. Serum progesterone and PIBF levels were quantified using ELISA. Participants were then randomised to receive either micronised progesterone or dydrogesterone. Blood samples were collected again and extent of per vaginal bleeding (increased, similar, decreased, resolved completely) ascertained during a follow-up visit at day 4 to 6 post-treatment initiation. Women were contacted at 16 weeks of gestation to assess occurrence of spontaneous miscarriage. Clinical Cases or Summary Results: Of the 40 participants, 22 were treated with micronised progesterone (M) and 18 were treated with dydrogesterone (D). The two groups were comparable in terms of age, body mass index, gestational age, number of days of bleeding prior to presentation, number of previous miscarriages and serum progesterone levels at presentation (M = 60.7nmol/L, D = 57.7nmol/L, p = 0.68). However, serum progesterone at day 4 to 6 post-treatment initiation was significantly higher in women treated with M (M = 174.1nmol/L, D = 56.6nmol/L, p = 0.01). Thus, change in serum progesterone was much higher and significantly so (p = 0.01) in the M group (113.3nmol/L) relative to the D group (-1.1nmol/L). The distribution of extent of bleeding at day 4 to 6 was also significantly different between both groups (p = 0.03). A higher percentage of participants treated with dydrogesterone reported bleeding that resolved completely than those treated with micronised progesterone (M = 50.0%, D = 83.3%, p = 0.05). Conclusions: Among women with a single intrauterine pregnancy presenting with threatened miscarriage between 6 to 10 weeks of gestation, treatment with micronised progesterone led to a greater increase in serum progesterone level at day 4 to 6 of treatment compared to treatment with dydrogesterone. However, a higher percentage of patients reported resolution of bleeding at day 4 to 6 when treated with dydrogesterone. Keywords: threatened miscarriage, progesterone, progesterone induced blocking factor, micronised progesterone, dydrogesterone Presenter: Shayna SIEW

ID 975

VACUUM EXTRACTION: A COMPARISON OF INSTRUMENTS R.R. Aapkes1, I. Van der Tweel2, & K.L. Deurloo3 1 Department of Gynaecology and Obstetrics, Diakonessenhuis Utrecht, Utrecht, The Netherlands, 2Department of Biostatistics and Research Support, University Medical Center Utrecht, Utrecht, The Netherlands, and 3Department of Gynaecology and Obstetrics, Diakonessenhuis Utrecht, Utrecht, The Netherlands

Brief Introduction: To retrospectively compare the effectiveness of three frequently used vacuum extraction instruments, two soft cups (the Mystic pump (MP) (Coopersurgical Inc, Trumbull) and the Kiwi omnicup (Clinical Innovations Inc, Salt Lake City) and the conventional metal cup (Medela Inc, MCHenry). Materials & Methods: All women requiring assisted vaginal delivery by ventouse in our hospital, from October 2012 to January 2014 were identified and included. Data regarding maternal demographics, labour complications, mode of delivery, as well as maternal and neonatal outcome were collected. Experienced teams performed all deliveries. The primary outcome was the success rate of the instrument (failure, cup detachments and number of tractions). Secondary outcome was the maternal and neonatal morbidity were compared in terms of perineal lacerations, Apgar score, blood gas analysis, fetal scalp trauma and need for neonatal admittance. Data was analysed using SPSS 17.0. Results were compared using Chi square and ANOVA test. Clinical Cases or Summary Results: A total of 362 patients were included: 281 required conventional metal cup group, 35 Kiwi omnicup and 51 the MP. There were no differences in patient characteristics between each group. The reason for vacuum extraction (fetal or maternal), onset of labour (spontaneously versus induced), the use of analgesia and the caput position at time of vacuum cup application were comparable between the groups. We found no difference in failure rates of the instruments (conventional 7.8%, Kiwi 14.3%, MP 3.9%, p = 0.21) and no difference in dup detachments (conventional 10.3%, Kiwi 17.1%, MP 13.7%, p = p = 0.773). Although Hodge levels at time of vacuum cup application were slightly lower in the MP group, as well as the number of tractions. Rates of maternal or neonatal morbidity were very low and similar in both groups. Conclusions: The conventional cup, Kiwi omnicup and Mystic pump appear to be very safe and seem to have comparable high effective rates to achieve successful assisted delivery. The experience of the obstetrician should have an influence on the decision. Keywords: Presenter: R.R. Aapkes

ID 671

NEUROLOGICAL DEVELOPMENT OF NEONATES AND CHILDREN BORN TO FEMALE LIVER OR RENAL RECIPIENTS B. Kociszewska-Najman1, B. Pietrzak2, J. Schreiber-Zamora1, A. Drozdowska-Szymczak1, N. Czaplin´ska1, B. BorekDzie˛cioł1, M. Wielgos2 1

Division of Neonatology; 1-st Department of Obstetrics and Gynecology Medical University of Warsaw, Poland, and

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1-st Department of Obstetrics and Gynecology Medical University of Warsaw, Poland

Brief Introduction: The aim of this study was to analyze the neurological development of neonates and children born to female liver or renal transplant recipients in the 1-st Department of Obstetrics and Gynecology Medical University of Warsaw Materials & Methods: The Study group - 65 children born to female liver or renal recipients from 2001 to 2011  38 neonates/children born to liver transplant recipients (LTx) 20 boys and 18 girls  27 neonates/children born to renal transplant recipients (RTx) 14 boys and 13 girls The Control group - 62 neonates of not-transplanted mothers, born consecutively after newborns from the study group, at the same gestational age The neurological development was analysed by a specialist in pediatric neurology:  normal development  moderate disorders  severe disorders Clinical Cases or Summary Results: Normal neurological development was observed in 35 (92.1%) from LTx group and 21 (77.8%) from RTx group and 55 (88.7%) from control group. Moderate disorders was observed in 3 (7.9%) from LTx group and 6 (22.2%) from RTx group and 7 (11.3%) from control group. Neurological examination showed lower frequency of moderate disorders in LTx 7.9% vs RTx 22.2% vs Control group 11.3% These differences were not statistically significant (Fischer’s test):  LTx and RTx group p = 0.1468  Control group and both LTx, RTx groups p = 0.79105 Conclusions: Neither LTx and RTx children reported any severe neurological disorders Keywords: neurological development, liver transplantation, renal transplantation Presenter: Bo_zena Kociszewska-Najman

ID 791

SOCIO-DEMOGRAPHIC INEQUALITIES ACROSS A RANGE OF HEALTH STATUS INDICATORS AND HEALTH BEHAVIOURS AMONG PREGNANT WOMEN IN PRENATAL PRIMARY CARE R. Baron1, J. Mannie¨n2, S. te Velde3, T. Klomp4, E. Hutton5, & J. Brug6 1

Midwifery Science, AVAG and the EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, Netherlands, and 2Midwifery Science, AVAG and the EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, Ne

Brief Introduction: Previous research has reported educational and ethnic inequalities in health-related issues in the general population, including pregnant women. Less attention has been given to health control beliefs, antenatal class attendance and nutritional factors such as daily fruit and vegetable consumption and meal patterns during pregnancy. Our study aimed to determine to what extent the prevalence of a wide range of low health status indicators and suboptimal health behaviours of pregnant women under prenatal primary care differ according to educational level and ethnicity. Materials & Methods: The data was obtained from the DELIVER study, a multicenter prospective cohort study in the Netherlands, conducted

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

from September 2009 till March 2011. The current paper is a crosssectional study on a total of 6696 women in prenatal primary care, including 6006 who completed questionnaire 1 (535 weeks of pregnancy) and 3413 who completed questionnaire 2 (35 weeks to birth). Multilevel multiple logistic regression was performed to test the relationship of educational level and ethnicity (Dutch, western and non-western minority groups) with 13 health status indicators and 10 health behaviours during pregnancy, adjusting for parity, number of weeks of pregnancy, maternal age and education or ethnicity. Clinical Cases or Summary Results: There were socio-demographic differences in almost all health status indicators and health behaviours. Notably more likely in women of low compared to high education were smoking (Odds Ratio (OR) 11.4; 95% confidence interval (CI) 7.7–16.9), low health control beliefs (OR 10.4; 95% CI 8.4– 12.8), passive smoking (OR 7.0; 95%CI 4.4–11.2), no antenatal class attendance (OR 4.5; 95%CI 3.5–5.8) and no folic acid supplementation (OR 3.5; 95%CI 2.7–4.5). Those of low education were more likely to skip breakfast daily, to be obese, underweight and depressed or anxious. Alcohol consumption was less likely in those of low education compared to high education (OR 0.6; 95%CI 0.4–0.9). Notably more likely in those of non-western compared to Dutch ethnicity were no folic acid supplementation (OR 4.5; 95%CI 3.5–5.7), low health control beliefs (OR 4.1; 95%CI 3.2–5.3) and no antenatal class attendance (OR 3.3; 95%CI 2.0–5.4). Those of non-western ethnicity were also more likely to have nausea, back pains, dizziness and passive smoking exposure. Conclusions: In western countries, such as the Netherlands, substantial social inequalities persist in medically low risk pregnancies with respect to many health-related issues. Low health control beliefs, smoking, passive smoking exposure, no antenatal class attendance, no folic acid supplementation, depression or anxiety, obesity and underweight, skipping breakfast daily and back pains showed the most notable social inequalities. Improved understanding by prenatal health care providers is needed of the non-medical factors associated with pregnancy outcomes. Pre-conceptual and prenatal strategies are needed to address the specific needs of socio-demographic groups at higher risk. Keywords: Prenatal primary care, social inequality, prenatal health behaviours, prenatal health status indicators Presenter: Ruth Baron

ID 263

DOES PLACENTA LOCATION HAVE AN EFFECT ON THE ACCURACY OF SONOGRAPHIC ESTIMATED FETAL WEIGHT AT TERM? E. Ashwal, L. Hiersch, M. Hod, R. Bardin, & Y. Yogev Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Brief Introduction: The literature available concerning the relationship between placenta location and sonographic estimation of fetal weight (EFW) is scarce. Thus, we aimed to evaluate whether differences placenta location has any influence on sonographic EFW. Materials & Methods: A retrospective cohort study. All term (37–41 weeks), singleton pregnancies which underwent an estimation of fetal weight (using abdominal circumference and femur length) and determination of placenta location in our sonar unit within a week from birth date were included. Cases were stratified into 4 categories according to placenta location: (1) Anterior (reference group), (2) Posterior, (3) Lateral (right or left) and (4) Fundal location. In cases in which there was a description of anterior- or posterior-lateral/

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DOI: 10.3109/14767058.2014.924236

fundal placenta, a preference was given to the anterior or posterior location rather than the lateral/fundal location. Inaccurate EFW was defined if there was more than absolute 15% difference between sonographic EFW and the actual birthweight. Clinical Cases or Summary Results: Overall, 1,908 pregnancies were identified (997, 787, 31 and 93 respectively). Demographic data and gestational age (39.2 ± 1, 39.2 ± 1, 39.1 ± 1 and 39.4 ± 2 weeks, p = 0.71) were similar between the groups. Mean EFW was 3,359 ± 535g, 3,337 ± 535g, 3,145 ± 483g and 3399 ± 570, p = 0.13, respectively. 4) Mean birthweight was 3,232 ± 537g, 3,257 ± 580g, 3,124 ± 460g and 3,265 ± 582g, p = 0.47, respectively. Mean amniotic fluid index value was 104 ± 86mm, 114 ± 89mm, 86 ± 80mm and 94 ± 75mm, p = 0.01, respectively. Inaccurate EFW rate was similar between the groups (7.5%, 6.1%, 6.5% and 8.6%, p = 0.62, respectively). On multivariate analysis, placenta location wasn’t associated with EFW accuracy (OR 0.84, 95% C.I 0.4–1.8, p = 0.66 for posterior location, OR 0.64, 95% C.I 0.3–1.4, p = 0.27 for lateral location and OR 0.77, 95% C.I 0.1–3.9, p = 0.75 for fundal location). Conclusions: Our data shows that for term, singleton pregnancies placenta location doesn’t have any impact on EFW accuracy. Keywords: Estimated fetal weight; Accuracy; Placental location

identification of new genetic lesions responsible for IPEX-like phenotypes, helping to gain more knowledge on autoimmune mechanisms. Moreover we would like to highlight the importance of a multidisciplinary approach for the clinical management of the disease that often arises in the perinatal age, since different areas are involved (immunology, endocrinology, gastroenterology, dermatology). Keywords: Rare disease, Immunedysregulation, Multidisciplinary Presenter: E. Gambineri

ID 388

ASSOCIATION BETWEEN OXIDATIVE STRESS AND FAMILY HISTORY OF HYPERTENSION T. Kogawa1, S. Ebina2, I. Kashiwakura3 1

Presenter: Eran Ashwal

ID 807

PERINATAL RARE DISEASES: THE CASE OF IPEX/IPEX-LIKE SYNDROME M. Vignoli1,2, S. Ciullini Mannurita1,2, G. Colarusso1, R. Bacchetta3, M. Cecconi4, A. Tommasini5, G. Donzelli1,2, & E. Gambineri1,2 1

Department of Neuroscience, Psychology, Drug Research and Child’s Health, University of Florence, Italy, 2Department of Paediatrics, Fetal and Neonatal Medicine, Anna Meyer Children’s Hospital, University of Florence, Italy, 3San Raffaele Telethon Ins Brief Introduction: IPEX syndrome is a rare disorder causing lifethreatening autoimmunity due to immune dysregulation. The hallmark features comprise severe early-onset enteropathy, dermatitis, elevated IgE levels and autoimmune endocrinopathies (earlyonset insulin-dependent diabetes mellitus and/or thyroiditis). Patients develop symptoms at birth/early in infancy and most die prematurely if not promptly treated with immunosuppressive drugs or hematopoietic stem cells transplantation. It is caused by mutations in the FOXP3 gene, coding for a transcription factor critical for the development and function of T regulatory cells and the maintenance of peripheral tolerance. There is a group of patients with clinical features resembling IPEX, without FOXP3 mutations, whose phenotype has been defined as IPEX-like. Materials & Methods: Patients from different italian and international centres were referred to us for the molecular analysis. Patients were selected for the investigation of FOXP3, CD25 and/or STAT5b genes by direct sequencing according to their clinical features and to the results of Tregs and FOXP3 expression by flow cytometry. Clinical Cases or Summary Results: Overall, we collected 93 patients with suspect of IPEX syndrome. FOXP3 mutations were identified in 16.1% of the cases and a variable FOXP3 expression by flow cytometry was observed. Absent expression of CD25 was detected in two patients with CD25 mutations. Moreover one patient was described as a STAT5b deficency. Conclusions: We confirm that IPEX phenotype can be described in patients that don’t harbour FOXP3 mutations and can be due to alterations in other proteins involved in FOXP3 pathway. Molecular investigations on other FOXP3-related genes could lead to the

Department of Health Promotion, Hirosaki University Graduate School of Health Sciences, Hirosaki, Japan, 2 Sapporo Medical University Graduate Course in Midwifery, Sapporo, Japan, and 3Department of Radiological Life Sciences, Hirosaki University Graduate Brief Introduction: Oxidative stress of the placenta plays an important role in the pathogenesis of many pregnancy complications. Pregnancy-induced hypertension can also lead to long-term health problems like chronic hypertension, kidney failure, or nervous system disorders. However, family history and environmental factors are also involved in the progression of hypertension. Major risk factors in childhood for the development of essential hypertension include obesity and a family history of hypertension. At a minimum, it is necessary to avoid hypertension before pregnancy. However, little is known about the correlation between oxidative stress and a family history of hypertension; thus, this study sought to determine the association between the two conditions in adolescents. Materials & Methods: This study enrolled 764 adolescents (400 males, 364 females) from northern Japan. Oxidative stress was evaluated by measuring the serum level of reactive oxygen metabolites (ROM), while antioxidant capacity was evaluated by measuring the serum level of biological antioxidant potential (BAP). Body weight and percent body fat were measured using body composition analyzer (MC-190EM; Tanita, Tokyo, Japan). Blood pressure was measured twice with each subject in the seated position using an automated blood pressure recorder, and the second measurement was used in this study. A family history of hypertension (father, mother, or both) was determined using a written questionnaire. The significance of the differences in the mean values of the two groups was analyzed using Student’s t-test. Analyses of covariance were conducted on family history as well as, clinical independent variables. Clinical Cases or Summary Results: The mean ROM level in females (319.5 ± 61.5 Carratelli units [U.CARR]) was slightly higher than that in males (308.0 ± 58.4 U.CARR), while the mean BAP level in females (2561.4 ± 230.7 mmol/L) was slightly lower than that in males (2648.1 ± 215.3 mmol/L). ROM levels were significantly higher in the father hypertension group than in the normal group in both males (p = 0.04) and females (p50.001), whereas the BAP level did not differ significantly according to family history. In the normal group, the ROM level in females was significantly higher compared that males (p = 0.02). The BAP levels in females were significantly lower compared to those in males in both the normal group (p50.01) and the mother hypertension group (p = 0.036). Conclusions: Here we reported two novel findings. First, the ROM levels in all subjects correlated with a positive history of hypertension in the father. Second, ROM levels in females were higher compared to in males, while BAP levels were low in the no family history group. The results of this study indicate that oxidative stress is influenced by both environmental and genetic factors. In addition, these finding

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suggest the possibility that oxidative stress levels are naturally high females during this period. Therefore, lifestyle choices that increase the antioxidant potential or maintain low oxidative stress levels in young adult for females may prevent future pregnancy complications. Keywords: oxidative stress, sex, hypertension Presenter: T.Kogawa

VERY PRETERM NEONATES CORD BLOOD HARBORS A HIGH NUMBER OF HEMOPOIETIC PROGENITOR CELLS F. Sabatini1, M. Bruschettini2, M. Podesta`1, C. Cossu1, O. Romantsik2, I. Azzari1, G. Bentivoglio3, L. Ramenghi2, & F. Frassoni1

ID 049

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ID 593

SIGNIFICANT IMPROVEMENT IN THE MANAGEMENT OF MAJOR OBSTETRIC HAEMORRHAGE WITH A ROTEM GUIDED ALGORITHM USING FIBRINOGEN CONCENTRATE

Lab of postnatal stem cells and cell therapy, 2Neonatal Intensive Care Unit, and 3Obstetrics and Gynecology; Istituto G. Gaslini, Genoa, Italy.

1

S. Mallaiah, P. Barclay, C. Chevannes, A. Bhalla, & I. Harrod Liverpool Women’s NHS Foundation Trust, Crown Street, Liverpool L8 7SS, Merseyside, United Kingdom. Brief Introduction: Massive Obstetric Haemorrhage (MOH) is often associated with coagulopathy of dramatic onset. Fibrinogen depletion in early post-partum haemorrhage (PPH) remains the single variable independently associated with progression to a severe PPH.1,2 Rotational Thromboelastometry (ROTEM, TEM International GmBH) is a reliable near patient test for coagulation defects that allows rapid identification and correction of fibrinogen deficiency and may result in safer and more cost-effective management of major PPH.3 Materials & Methods: We carried out a retrospective audit of two algorithms for prompt fibrinogen replacement in MOH used at Liverpool Women’s Hospital: (1) a formulaic replacement using shock packs in all women who bled41500 ml and had a FibTEM A5512 mm (from April 2011 to March 2012, n = 42) and (2) a new algorithm using ROTEM guided Fibrinogen Concentrate administration (from July 2012 to June 2013, n = 52) Clinical Cases or Summary Results: The results are summarised in the attached table. There were no deaths in either group. Conclusions: ROTEM guided administration of Fibrinogen concentrate resulted in significant reduction in the use of blood products and TACO and may lead to a clinically important reduction in the need for postpartum hysterectomies.

Brief Introduction: Background: Umbilical cord blood (UCB) contains hematopoietic cells currently utilized as a source for transplantation. There are suggestions, but yet not evidence, that UCB contains also cells possibly useful for regenerative medicine therapeutic programs. However, little is known on the cellular composition and on the mechanism regulating commitment and self-renewal of the progenitors circulating in preterm cord blood (CB). Objective: To identify and quantify the hematopoietic progenitors (HP) present in the preterm CB compared to term CB. Materials & Methods: Forty preterm (n. 14 = 23–32 wks gestational age; n. 26 = 33–36 wks.g.a.); and 56 term CB (437 wks g.a) were studied to determine the number of HP committed to myeloid, erythroid and mixed lineages, the percentage of the CD34+ population and

Keywords: Massive obstetric haemorrhage, coagulopathy, fibrinogen Presenter: S Mallaiah

Results Maternal Complications Post Partum Hysterectomies Transfusion Associated Cardiac Overload (TACO) ITU admissions Haemostatic products (total) Fresh Frozen Plasma (units) Cryoprecipitate (units) Fibrinogen Concentrate (g) Total Fibrinogen Mass used (g) Red Blood Cells used No. of patients receiving46 units of RBCs Total RBC units transfused (units) There were no deaths in either group.

Shock pack Group (n = 42)

Fibrinogen Concentrate Group (n = 52)

6 4 4

3 0 1

NS p = 0.037 NS

161 70 3 193

50 0 65 90

p50.0001 p50.0001 p = 0.0003

14 196

3 161

p = 0.044 NS

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the presence of endothelial progenitors (EPC). In addition, 9 nonidentical twins (pre-term group) were studied. Clinical Cases or Summary Results: Preterm CB grew higher colony number compared to term :12.2 + 1.5/104 nucleated cells (NC) vs 5.8 + 0.36/104 NC, p = 0.0002 and were able to grow in secondary culture at the same frequency (12.2 + 1.5/104 NC vs 9.2 + 2.8/104 NC, p = 0.31) of the first generation. Only preterm CB could grow the third generation. Preterm CB (n. 40) showed higher percentage of CD34 + cells compared to term (2.56% + 1.2 vs 0.64% + 0.5 p = 0.002) but the main difference was found in the very preterm CB (532wks). Gestational age (weeks 23 to 40) of the fetus inversely correlated with percentage of CD34+ cells (r2 = 0.4039; p = 0.0002). Twins presented comparable number of CD34+, depending on gestational age. EPC frequency showed great variability and did not differ in preterm compared to term CB (median 2.6/107 vs 5.0/107). Conclusions: Preterm CB contains high number of hematopoietic progenitors which are lost at delivery, this number is consistent, in particular in very preterm infants. These cells might turn out to be an important source of hematopoietic and non-hematopoietic cells.

consultations. C-section rate varied from 28–49% (mean 38.4%). Prevalence of low birth weight went from 6.6 to 19.2%, while prematurity went from 6 to 13%, among CRAISaR. Early neonatal mortality rates varied from 4–6 neonatal deaths per 1000 live births. Fresh stillbirths ratio varied from 1.4 to 9.8 per 1000 live births. Overall in Mexico during 2012, 25% and 13% of maternal deaths occurred in women less than 20 years and over 34 years of age, respectively. Among a group of 281 physicians observed in the five hospitals, 75% performed umbilical cord clamping during the first 30 seconds after birth. These observations also showed that three out of five hospitals, 79% newborn babies offered breastfeeding during the first hour of life. Conclusions: There is a wide range of reproductive outcomes among CRAISaR. The main problems in maternal health in Mexico include pregnancy in adolescents, and the fact that over 50% begin prenatal care after the 1st trimester, where several intervention opportunities are missed. These situations represent an opportunity to improve maternal health, and consequently have a direct impact in perinatal and neonatal health.

Keywords: preterm cord blood hemopoietic progenitor cells neonate preterm

Keywords: Mexico, CRAISar, reproductive health, Presenter: Javier Mancilla

Presenter: Olga Romantsik

ID 950

ID 314

REGIONAL CENTERS OF COMPREHENSIVE CARE IN REPRODUCTIVE HEALTH (CRAISAR), A NATIONAL HEALTH INITIATIVE IN MEXICO

VEIN OF GALEN ANEURYSMAL MALFORMATIONS: A REVIEW OF 18 CASES

1

2

3

4

J. Mancilla , T. Murguia , R. Ayala , I. Rodriguez , V. Ramı´rez5, & N. Galindo-Sevilla6 1

Instituto Nacional de Perinatologia Isidro Espinosa de los Reyes, Mexico City, Mexico, 2Instituto Nacional de Perinatologia Isidro Espinosa de los Reyes, Mexico City, Mexico, 3Instituto Nacional de Perinatologia Isidro Espinosa de los Reyes, Mexico Ci Brief Introduction: Maternal mortality ratio (MMR) in Mexico has decreased from 90 (1990) to 42.8 cases (2012) per 100,000 live births. It is obvious that, the 5th millennium development goal will not be achieved by 2015. Maternal health is a priority for the Mexican Government; therefore, the National Institute of Perinatology (INPer) started an intervention program in 2013, named Centers for Comprehensive Care in Reproductive Health, CRAISaR (acronym in Spanish). The program aims to improve maternal health and quality care of pregnant women and their newborns. Materials & Methods: Five different states in Mexico were selected to have a CRAISaR, each of them includes one hospital and its most important dependent health centers (HC). Overall, 5 hospitals and 22 HC were included. Each region was chosen for their moderate to high MMR (31–62), accessibility, safety and political collaboration. During the first evaluation phase (Nov 2013–Feb 2014), quantitative analyses data were retrieved from the National Health Statistics 2010–2013 and files from hospitals and health centers. Part of the analysis involved the non participative observation in the five hospitals. The observation aimed to report the clinical path that started from the arrival of the mother until delivery of the newborn, deficiencies in medical care, and context of care. Clinical Cases or Summary Results: Of all pregnancies reported in the five regions during 2013, (n = 29,573), about 30% (range: 26–30%; n = 8,916) occurred in adolescents. A 40% average of pregnant women had their first prenatal consultation during the 1st trimester (range: 19–85% at HC) and 73% (64–80%) had 5 or more prenatal

A. Dingankar1 & J. Brierley2 1,2

Intensive Care Unit, Great Ormond Street for Children, London, United Kingdom Brief Introduction: Background: Vein of Galen Arterio-venous malformation (VGAM) causes severe morbidity and occasionally mortality, especially in the neonatal period. We reviewed the clinical features, initial medical management and outcomes of children with VGAM transported by the Children’s Acute Transport Service (CATS) from 2009–2012. Our purpose was to Review: 1.Important aspects of assessment and stabilization prior to PICU admission. 2 Specific information regarding inotropes used to manage associated cardiac failure.3.Outcomes. Materials & Methods: Methods: Retrospective CATS database interrogation and subsequent detailed CATS and receiving hospital clinical notes review. Demographic data and vasoactive medications were recorded. Clinical Cases or Summary Results: Results: Of 18 VGAMs transferred (2009–2012).6 were transferred by air others by ambulance. 9 of them had antenatal diagnosis. High output cardiac failure was clinically diagnosed in 15 cases including 3 with multiple organ failure (MOF). 2 had echocardiographic evidence of severe pulmonary hypertension. There were no cardiac arrests or other concerning events during transfer.Inotrope use – Dopamine and Milrinone were first choice alone or in combination. Adrenaline and Dobutamine were added in infant with intractable heart failure. Conclusions: Outcome: Endovascular embolization was performed in 14 cases, 4 having such severe parenchymal brain injury that ICU care was withdrawn without embolization. Of those embolized the mortality rate was 35%.Conclusions: Transfer of infants with VGAM can be undertaken safely, and contributes to improving outcomes compared to historic data. Keywords: Presenter: A. Dingankar

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ID 922

ID 849

SCREENING FOR CRITICAL CONGENITAL HEART DEFECTS (CCHD)

UMBILICAL MARKERS OF PERINATAL HYPOXIA

H. Agiza, MD, M. Madjus, RN, & M. Abou Al-Seoud, MD

Chair and Department of Neonatology, Medical University of SIlesia, School of Medicine, Katowice, Poland

King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia

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Brief Introduction: Prenatal diagnosis and clinical examination do not identify all infants with critical congenital heart defects before hospital discharge. In September 2011, the Secretary of Health and Human Services (HHS) recommended that screening for Critical Congenital Heart Defect (CCHD) to be added to the Recommended Uniform Screening Panel (RUSP) for newborns. Subsequently the American Academy of Pediatrics published a policy statement endorsing Health and Human Services Recommendation for Pulse Oximetry Screening for Critical Congenital Heart Disease (Pediatrics, January, 2012). At KFAFH we implemented the newborn pulse oximetry screening in 2013. The objective of this report is to evaluate the results of this implementation. Materials & Methods: Starting in April 2013 we trained the WBN staff nurses to use the CCHD screening program toolkit adapted from children’s national medical centre, as 6 educating lectures were given and 129 babies were screened in the training period (which were excluded from our statistics). We excluded from screening the following: 1.babies less than 35 weeks gestation, 2. babies less than 24 hours of age or more than 7 days old, 3. Babies with antenatal diagnosis of congenital heart disease 4. Babies required admission to the NICU in the first 24 hour of age. The program became part of the WBN From 1st of May 2013. The data presented is part of an on-going audit for the efficacy of the screening program. we analyzed data collected from the starting point till end of March 2014. All babies discharged from WBN were screened at 24 hours of age using disposable probes; this was done together with the discharge assessment and the TMS withdrawal. In order to ensure that we did not miss any CCHD through the screening program we reviewed all ECHOES requested for discharged newborn that required hospital re-admissions within the 1st week of life for the same time period. Clinical Cases or Summary Results: 4398 newborns were eligible for screening representing 81.9% from a total number of newborns (5370) at same time period. The mean number per month of babies screened at 24 hours of age at WBN was 400. 4 cases failed the pulse ox screen, echocardiogram done for all. Two of them found to have CCHD in the form of total anomalous pulmonary venous drainage (TAPVD) and hypoplastic left heart syndrome, one case with atrial septal defect (ASD II) and the fourth case had a normal echo finding. The readmitted cases to the NICU who were discharged from the WBN none of them were diagnosed with CCHD. 249 echocardiogram done for babies aged 1 to 7 days (other than the cases we detected by the pulse ox) 3 cases with CCHD were detected from our in-born as they had symptoms before 24 hours of age that required admission to NICU and echocardiography (1 had harsh murmur AT 18 hours of age Fallot Tetralogy, 1 cyanosis & RDS at birth TGA 1 diagnosed ante-natal as Fallot Tetralogy confirmed on postnatal echo). We calculated sensitivity and specificity of this test to detect CCHD and it was 100% and 99.9% respectively with a positive predictive value of 50% and negative predictive value of 100%. Conclusions: CCHD Screening Program should be part of the standard of care at any hospital to avoid discharging babies with unrecognized critical congenital heart disease. Keywords: Oximetry, congenital heart disease/defects, newborn screening, Presenter: Hisham Agiza, MD

M. Fiala, M. Baumert, P. Surmiak, & Z. Walencka

Brief Introduction: Perinatal hypoxia may lead to multiorgan damage with the most severe complications affecting the central nervous system, cardiovascular system and kidneys. The most promising markers of perinatal hypoxia are Activin A and neutrophil gelatinaseassociated lipocalin (NGAL). The aim of the study was to evaluate Activin A and NGAL as potential early markers of perinatal hypoxia. Materials & Methods: We prospectively studied 58 full-term infants; 24 infants of which suffered from perinatal hypoxia, and 34 asymptomatic babies of comparable age and sex, were used as a control group. We obtained cord blood samples for blood gas analysis, lactate concentration and subsequent measurement of Activin A and NGAL concentration from all subjects immediately after delivery. A correlation was made between those biomarkers and lactate concentration, blood gas measurements and neonatal outcomes. Clinical Cases or Summary Results: Activin A levels were significantly higher in hypoxic than non-hypoxic newborns. NGAL levels were also higher in asphyxiated babies than in the control group. There was a positive correlation between NGAL and Activin A concentration. NGAL concentration was negatively correlated with Apgar score in the 5th minute as well as with the pH value, HCO3, base deficit and lactate concentrations. Activin A was only negatively correlated with the pH value. A cutoff value 33.9 ng/ml for NGAL could differentiate asphyxiated neonates from non-asphyxiated neonates, with a sensitivity of 100% and specificity 78.3%, whereas, a cutoff value 0.208 ng/ml for Activin A had a sensitivity of 93.1% and only 26.7% specificity. Conclusions: Asphyxiated neonates demonstrate significantly increased NGAL and Activin A levels in comparison to healthy controls. The high correlation of NGAL with clinical and biochemical signs of fetal and neonatal hypoxia, as well as higher sensitivity and specificity of NGAL in differentiation asphyxiated from nonasphyxiated neonates lead us to suggest that this protein could be a better marker of perinatal hypoxia than Activin A. Keywords: perinatal hypoxia; newborn; NGAL; Activin A. Presenter: Piotr Surmiak

ID 929

PATCHING THE DIAPHRAGM AFFECTS ORTHOPAEDIC OUTCOME IN CONGENITAL DIAPHRAGMATIC HERNIA PATIENTS: A FIVE YEARS FOLLOW-UP L. Valfre, A. Braguglia, A. Conforti, F. Bevilacqua, L. Morini, F. Aite, A. Dotta, & P. Bagolan Department of medical and surgical neonatolgy Bambino Gesu` Children’s research hospital Rome Brief Introduction: The increased survival rate reached in congenital diaphragmatic hernia (CDH) infants has shown a concomitant increase in late morbidity. It was demonstrated that patch repair influence late morbidity in CDH survivors, however it is not

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Chest wall asimmetry Pectus excavatum Scoliosis

1y patch  tot 69

1y patch + tot 27

p

2ys patch  tot 55

2ys patch + tot 22

P

5ys patch  tot 35

5ys patch + tot 15

p

15 23 3

10 10 3

0.2 0.8 0.3

21 21 3

12 11 5

0.2 0.4 0.04

18 16 8

13 8 13

0.03 0.8 50.0001

investigated how defect size influence late orthopaedic outcomes. Aim of the present study is to evaluate the influence of patch repair (proxy of diaphragmatic defects size) on late orthopaedic outcomes. Materials & Methods: All high risk (prenatal diagnosis and/or respiratory symptoms within 6 hours of life) CDH survivors, and treated at our Institution between 2004 to 2011 were followed up in a multidisciplinary outpatient clinic as part of a longitudinal prospective study. Orthopedic evaluations were determined at specific time point: 1, 2 and 5 years of age. Patients were divided on regard of patch repair. Fisher’s exact test were used as appropriate. p50.05 was consider significant. Clinical Cases or Summary Results: 96 out of 110 survivors (87%) were enrolled and prospectively evaluated in follow-up. Table summarizes main results Conclusions: our data suggest that patch repair significantly correlates with higher incidence of scoliosis at 2 years of age and higher chest wall asimmetry and scoliosis at 5 years of age. Developmental orthopaedic anomalies became more and more frequent with age and required a carefull follow-up. Keywords: Congenital Diaphragmatic Hernia, thoracic anomaly Presenter: L. Valfre

(Spearman r = 0.4731, p = 0.0015) and non-pregnant patients (Spearman r = 0.6214, p50.0001). Median p62 concentrations were higher (7.4 ng/ml) when PBMCs were incubated with sera from pregnant women than with sera from non-pregnant women (2.7 ng/ ml) (p50.0001). Even in the presence of rapamycin, median p62 levels were elevated in the presence of pregnancy sera (1.3 ng/ml), as compared to non-pregnant sera (0.8 ng/ml) (p = 0.0184). Median hsp70 concentrations were 7.0 ng/ml for PBMCs incubated with sera from pregnant women vs. 3.5 ng/ml for PBMCs incubated with sera from non-pregnant women (p = 0.0022). Conclusions: The extent of autophagy induction in mononuclear lymphoid cells by sera from pregnant or non-pregnant women is inversely proportional to the hsp70 concentration in these cells. Sera from pregnant women inhibits autophagy to a greater extent than does sera from non-pregnant women and induces higher hsp70 production. Therefore, induction of an hsp70 stress response may be a stronger inhibitor of autophagy activity in pregnancy. Any cellular stress that results in hsp70 induction may have the potential to interfere with autophagy-related events required for proper placental and fetal development. Additional studies are needed to further assess the consequences of specific stress inducers on hsp70 production and autophagy-involved cellular processes during pregnancy. Keywords: Autophagy, hsp70, p62

ID 226

INDUCTION OF THE 70KDA HEAT SHOCK PROTEIN (HSP70) STRESS RESPONSE INHIBITS AUTOPHAGY: POSSIBLE CONSEQUENCES FOR PREGNANCY OUTCOME T.T. Kanninen1,2, G. Sisti1, G.C. Di Renzo2, & S.S. Witkin1 1

Division of Immunology and Infectious Diseases, Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA, and 2Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy Brief Introduction: Autophagy is an essential intracellular process that maintains homeostasis. Defects in autophagy induction during gestation have been involved in the etiology of preeclampsia and abnormal placentation. HSP70 is induced when cells encounter nonphysiological conditions such as infection, hypoxia or oxidative stress. We evaluated the relationship between intracellular concentrations of hsp70 and the extent of autophagy induction in human peripheral blood mononuclear cells (PBMCs) following exposure to sera from pregnant or non-pregnant women. Materials & Methods: PBMCs from female donors were incubated with sera from 42 pregnant women at mid-gestation or from 45 nonpregnant healthy reproductive age women. After 48 hours cells were collected, lysed and assayed by ELISA for p62, a cytoplasmic protein essential for induction of autophagy, and for hsp70. The intracellular cytoplasmic p62 concentration is inversely proportional to the extent of autophagy induction (high p62 = low autophagy). As controls PBMCs were incubated with the autophagy inducer, rapamycin. Clinical data and source of sera were accessed after completion of all experiments. Clinical Cases or Summary Results: The p62 concentration was highly correlated with the intracellular hsp70 level in both pregnant patients

Presenter: Tomi T. Kanninen

ID 435

CORRELATION OF MATERNAL PLASMA CELL-FREE TOTAL AND FETAL DNA WITH FIRSTTRIMESTER SPONTANEOUS ABORTIONS REGARDLESS OF FETAL GENDER Y.J. Han1, J. H. Lim2, M.H. Kim1, D.W. Kwak1, J.Y. Han1, M.Y. Kim1, S.Y. Kim2, S.Y. Park2, & H. M Ryu1,2 1

Department of Obstetrics and Gynecology, Cheil General Hospital and Women’s Healthcare Center, Kwan Dong University college of Medicine, Seoul, Korea, 2Laboratory of Medical Genetics, Medical Research Institute, Cheil General Hospital and Women’s Healthc Brief Introduction: The aim of this study was to evaluate the correlations of maternal plasma cell-free total and fetal DNA levels with first-trimester spontaneous abortions(SA) regardless of fetal gender. Materials & Methods: A nested case-control study was conducted with maternal plasma collected from 266 women in the first-trimester of pregnancy. The case group included 65 women with first-trimester SA. For analysis of the difference in fetal aneuploidy, women in the case group were divided into two subgroups: SA with fetal aneuploidy (n = 26) and with normal karyotype (n = 39). The control group consisted of 201 pregnant women who delivered a healthy baby at term. The cell-free total and fetal DNA were extracted from maternal plasma. The GAPDH and unmethylated PDE9A gene were

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250 used to measure the maternal plasma levels of total and fetal DNA. Odds ratio (OR) was adjusted for maternal age and estimated using multiple logistric regression analysis. Clinical Cases or Summary Results: Levels of maternal plasma cell-free total and fetal DNA were significantly higher in women with SA than in the normal controls (p50.001). SA with fetal aneuploidy showed higher levels of cell-free total and fetal DNA than SA with normal karyotype. The risks for first-trimester SA were as follows: adjusted OR was 18.3 [95% confidence interval(CI): 8.9–37.4] for cell-free total DNA level and 12.4 [6.1–25.3] for cell-free fetal DNA level. Adjusted odds ratio of cell free fetal DNA was more elevated in SA with aneuploidy (OR = 14.2, 95% CI: 4.9–40.7) than normal karyotype (OR = 8.1, 95% CI: 3.5–18.8). Conclusions: Levels of cell-free total and fetal DNA were elevated significantly in women with SA during first trimester. In cell-free fetal DNA, the risk for SA with aneuploidy was higher than normal karyotype. Therefore our results are helpful in understanding the molecular mechanism of cell-free total and fetal DNA in early pregnancy loss.

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because there is lower risk of hypotrophy and prematurity in newborns. Keywords: liver transplantation, pregnancy Presenter: Bronisława Pietrzak

ID 275

NEONATAL DEATHS CAUSED BY MAJOR BIRTH DEFECTS. ASSESSMENT AND COMPARISON BETWEEN TEN YEARS APART A. Iglesias Deus, J.R. Cervilla, A. Ban˜a Souto, M.J. Fernandez Seara, & M.L. Couce Pico

Keywords: cell free total DNA, cell free fetal DNA, spontaneous abortion, PDE9A gene

Neonatal Unit. Pediatric Assistance Area. Hospital Clinico Universitario (CHUS) Santiago de Compostela (SPAIN)

Presenter: You Jung Han

Brief Introduction: Global birth prevalence of major birth defects (MBD) is around 2–3%. There are rare studies over contribution of MBD as a cause of neonatal deaths (ND) and courses in live births (LB) over long time periods, yet significant diagnosis’s advances had taken place lately. Regarding MBD as a primary cause of ND, our goal was to assess their rate of ND caused by MBD. We have considered neonatal extended period (while the infant with a MBD is in neonatal care till the three month life) between 1992–2012. This period was subdivided into two subperiods (1992–2002) and (2003–2012) taken advantage of our removal to a new brand hospital. Materials & Methods: Examination, assessment and diagnosis, were done after the MBD diagnostic rules approved by EUROCAT and VON (Vermont-Oxford-Network), by any member of the neonatology team using similar diagnosis protocols. A comparison was made between results of the two periods studied: 27.453 LB in the first and 27.687 LB in the second. An overall consecutive 55.140 LB had been studied regarding MBD and the rate of ND due to MBD in both periods. Clinical Cases or Summary Results: The overall rate of MBD over total LB remained nearly in the same range (1.6% vs.1.5%) with a slight decrease of (- 6.1 percent). The number of cases of MBD between the two periods (440 vs. 415) also decreased. Regarding ND due to MBD, a significant decrease in mean ± SD rate number (3.5 ± 2.2 vs. 1.8 ± 0.9) p = 0.03 and in total number (39 vs. 18) (- 47.3%) were observed. The total neonatal mortality rate (NMR) also diminished in a 30% (3.8% vs. 2.6% LB). The mean percentage ratio of lethal MBD regarding total number of MBD decreased significantly (8.9% vs. 4.3%) (-51%). The mean percentage ratio of lethal MBD regarding overall NMR declined a 34 percent (37.5% vs. 24.3%) between the two periods. Conclusions: Our rate of MBD is very low (range 1.5% -1.6%). Higher rates are published in US (mean 4.0%) and EU countries (EUROCAT 2.2%). Regarding MBD associated with deaths (per % LB) in the first period, we had a rate of 1.4 that decreased strikingly to 0.6 in the second one. This rates are in the range 0.81% LB, published by EUROCAT in the period (2006–2010). The rate of MBD as a cause of ND decreased significantly in the last ten years (-47.3%), thanks of improvements in surgery and neonatal intensive care of the infants affected. Our percentage rate of lethal MBD although diminished, remains higher (24.3%). than other US reports (about 20%). The low overall rate of MBD reaching the birth, in likely related with the available use of non-invasive diagnostic techniques in early pregnancy.

ID 675

PREGNANCY IN LIVER TRANSPLANT RECIPIENS B. Pietrzak1, B. Kociszewska –Najman2, N. Czaplinska2, A. Drozdowska-Szymaczak2, J. Schreiber-Zamora2, & M. Wielgos1 1 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Poland, 2Division of Neonatology, 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Poland

Brief Introduction: Treatment of end-stage liver failure by organ transplantation allows women in childbearing age conceive and enjoy biological progeny. The aim of this study was to assess the course of pregnancy in liver-transplanted women. Materials & Methods: We retrospectively analyzed pregnancy and delivery courses in liver (LTx) or renal (RTx) transplant recipients who had delivered baby in the First Department of Obstetrics and Gynecology in Warsaw in 2001–2012. Clinical Cases or Summary Results: 51 LTx patients (average age 28,94 (SD ± 5,2)) delivered 51 babies and 39 RTx patients (average age 30,25 (SD ± 4,4)) delivered 44 babies. Complications in LTx and RTx patients are: hypertension in 7 (16%) LTx vs 34 (87%) in RTx (p50.001), proteinuria in 11 (21.5%) LTx vs 28 (71%) RTx, (p50.0001). Common complication was anemia, that had 24 (47%) LTx patients and 25 (64%) RTx patients (p = 0.35). In 5 RTx patients it was severe anemia, treated with red blood cells transfusions and erythropoetin and in 3 LTx patients treated with red blood cells transfusions. The mean gestational age at delivery in LTx patients was: 37,9 (SD ± 2,9) vs 33,5 (SD ± 4,2) weeks in RTx patients (p = 0.001). 2 (3.9%) LTx and 7(17.9%) RTx patients delivered before 34 week (p = 0.039). 5(12.8%) RTx patients delivered before 32 week, after LTx: none. Intrauterine hypotrophy less than 10th percentile occured in 7(13.8%) LTx newborns and 16 (33%) RTx newborns (p50.05). Severe hyptrophy less than 5th percentile was observed in 2 (4%) LTx neonates and 12 (27.3%) RTx neonates (p50.001). 2 newborns delivered by RTx women died after delivery due to extremely prematurity. Conclusions: Pregnancy in women who underwent liver transplantation in case of common complications is high-risk pregnancy. Prognosis is better, than in women after renal transplantation,

Keywords: Presenter: J.R. Cervilla

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ID 602

EXPRESSION OF MELATONIN RECEPTOR 1B AND ALPHAAMYLASE IN PLACENTA OF WOMEN WITH ASTHMA OF VARYING SEVERITY Y.R. Dymarskaya1, O.V. Lavrova2, & L. B. Zubzhitskaya3 1

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Dept. of Obstetrics and Gynecology, First Pavlov State Medical University of St.-Petersburg, Saint-Petersburg, Russia, and 2Laboratory genetic mechanisms of lung diseases, First Pavlov State Medical University of St.-Petersburg, Saint-Petersburg, Russia Brief Introduction: Asthma is a common chronic respiratory disease that adversely affects the course of pregnancy and fetal development. Hypoxia and chronic placental insufficiency are the most common

complications for the fetus and may result in asphyxia, neurological disorders in newborns. The fetus is in a constant interaction with the antigens in the mother’s placenta which is unique organ that performs two opposite functions simultaneously: ensures the safety of allogeneic fetoplacental unit from the aggression of fetal immune system, and shows high activity against heterogeneous antigens that fall into the mother’s body. This fact makes the placenta interesting object of scientific research in terms of immunology. Immunohistochemical features of the placenta of women with asthma are not studied enough. Materials & Methods: We conducted an immunohistochemical analysis of 33 samples of placental tissue of women with asthma: 9 women with mild intermittent asthma (group 1); 10 women with mild persistent asthma (group 2); 14 women with moderate and severe asthma (group 3). In all cases asthma was allergy-based, all subjects did not have clinical or laboratory symptoms of gestational hypertension and/or preeclampsia. Control group consisted of 8 women with physiological pregnancy and delivery without allergic symptoms and pulmonary diseases, also without gestational hypertension and/or preeclampsia. The average age of all patients was 27,8 ± 0.84 years. Immunohistochemical analysis for detecting expression of melatonin receptor 1B (Rc-M-1B), and expression of alpha - amylase (a-Amyl) was performed on cryostat sections, using primary rabbit polyclonal antibody to RC-M-1B and primary mouse monoclonal antibody a-Amyl, biotinilized anti-mouse immunoglobulin as secondary antibodies. Clinical Cases or Summary Results: The largest area of structures, expressing a-Amyl detected in group 3 (9.43 ± 1.27%) and was significantly higher than in 1 group (2.58 ± 0.65%) and the control group (4,9 ± 1,75%) (p50.01). Area structures expressing Rc-M-1B in the placenta of the 1 group of women was 12.82 ± 2.31% and it was significantly higher than in the 1 and 2 groups (4,71 ± 1.13% and 5,42 ± 1,62%, p50.01, respectively) and in the control group (5,22 ± 1,62%, p50.01). Conclusions: Results of immunohistochemical study of the placenta in patients with asthma show that the expression of Rc-M-1B in tissue of the placenta increases with increasing severity of asthma. Rc-M-1B is needed for the activation of the antioxidant effects of melatonin. We also observed that expression of a-Amyl was the highest in placentae of women with moderate and severe asthma. a-Amyl is known as one of the enzymes that catalyzes degradation of carbohydrate molecules. In the condition of the fetal hypoxia, associated with asthma, these findings may indicate to activation of compensatory mechanisms in placenta. Keywords: asthma, placenta, immunohistochemistry Presenter: Yulia Romanovna Dymarskaya

ID 364

MATERNAL BACTERAEMIA AND AN OBSTETRIC EARLY WARNING SYSTEM P. J. Maguire1, A. C. O’Higgins1, K. A. Power1, N. Daly1, M. Farren1, A. McKeating1, & M. J. Turner1 1 UCD Centre for Human Reproduction, Coombe Women and Infants University Hospital, Cork Street, Dublin 8, Ireland

Brief Introduction: Maternal sepsis and its adverse consequences have emerged as a major concern in contemporary obstetrics in developed countries. At the same time, early warning systems have been introduced into acute hospitals to improve the early identification and treatment of the critically ill patient. The aim of this retrospective audit was to examine whether the use of the recently-developed Irish Maternity Early Warning System (IMEWS) would have been beneficial in cases of proven maternal bacteraemia.

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252 Materials & Methods: The case records of all cases of maternal bacteraemia during the four years 2009–12 were reviewed. The IMEWS chart was applied to the records retrospectively. The four observations examined were heart rate, blood pressure, respiratory rate and temperature. The clinical and socio-demographic details were computerised for analysis. Clinical Cases or Summary Results: During the study, 37 584 women delivered an infant weighing 500g and 2628 were recorded as having experienced a miscarriage. There were 56 cases of maternal bacteraemia, of whom 37.9% were nulliparous. Their mean age was 29.8 years (SD +/ 6.1). Of these 56 women, in comparison to the Hospital’s obstetric population the rate of preterm birth in the index pregnancy was higher (13.8% vs. 6.7%, p = 0.03) and there were fewer current smokers (3.4% vs. 14.2%, p50.001). Women with bacteraemia did not differ from the Hospital population in terms of age, body mass index or employment status. The patient observations were recorded in different sections of the medical charts. Of the 56, the observations were recorded by narrative in the clinical notes in 82% (n = 46), observation charts in 43% (n = 24), partograms in 41% (n = 23) and hospital Modified Early Obstetric Warning System (MEOWS) charts in 16% (n = 9). Women admitted to the Delivery Suite had partograms filled out. The observations usually were recorded in more than one place. There was no standardisation as to the frequency of the recordings and the recordings of the four parameters often did not occur at the same time. In particular, the respiratory rate was under-recorded. Of the 56, two women had their blood culture specimen sent in the setting of normal vital signs. Of the remaining 54 cases, a maternal pyrexia 38  C would have triggered a red alert in 82% (n = 46) of cases. Other vital signs would have triggered a red alert or more than two yellow alerts in 14% (n = 8) of cases. The triggering of the IMEWS for pyrexia  38  C was associated with a shorter trigger-antibiotic administration interval than trigger based on other maternal parameters (50mins vs. 236mins, p50.001). The interval from IMEWS trigger to antibiotic administration was 1 hour in 88% of cases. Conclusions: Retrospective application of the IMEWS demonstrated that it has the potential to improve the quality of patient observations. Pyrexia of 38  C is a sensitive trigger for prediction of maternal bacteraemia and leads to early (51 hour) clinical assessment and intravenous antibiotic administration. Keywords: Maternal sepsis. Bacteraemia. Early warning system. Presenter: Patrick J. Maguire

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

ID 098

MEDICAL ALARM MANAGEMENT IN A SINGLE-ROOM NEONATAL INTENSIVE CARE UNIT (NICU): EVALUATION AFTER ONE YEAR H.V.D. Mortel, C. van Pul, E. Ploem, J.V.D. Bogaart, T. Mohns, & P. Andriessen Department of Neonatology, Ma´xima Medical Centre, Veldhoven, 2Clinical Physics, Ma´xima Medical Centre, Veldhoven, and 3Hogeschool Zuyd, Heerlen, and 4Medical and Information Technology, Ma´xima Medical Centre, Veldhoven, The Netherlands. Brief Introduction: In 2012, the level III NICU of Ma´xima Medical Centre changed from 3 open-bay rooms with 5–7 incubators per room to an 18 single-room care unit. While this concept is considered optimal for newborns and parents, the caregivers are challenged to monitor their newborns appropriately and safely. The setting of alarm limits are a trade-off between narrow limits generating false alarms and the risk of alarm fatigue, while wide alarm limits may lead to missing events. Materials & Methods: Simultaneous to the change of the NICU, the medical alarm system was rearranged. Alarm signals of the patient monitors (Philips) are send to a central post, Emergin server and Ascom alarming system. A multidisciplinary user group defined alarm limits. Vital signals beyond these limits are forwarded to a handheld of the nurse. Alarm-logs from May 2012 to May 2013 from the Emergin server were automatically read and all alarm types were counted. We distinguished first alarm from repeated alarm events. If there was no response to the first alarm, a repeated alarm was automatically send to the care giving nurse and back-up nurse. Evaluation of alarm event over the day provides information about the alarm handling of the nurse. Clinical Cases or Summary Results: The averaged occupation of our unit was 14 patients per day. In a 12-month period a total of 234k alarms were generated, equivalent to approximately 27 alarms per hour in a 18-bed NICU (2 alarms per patient per hour). An overview of the alarm events is shown in Figure 1. The largest source of alarms

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are oxygen desaturation alarms followed by bradycardia alarms. In this period, 13k repeated alarms occurred. This involved a variety of alarms, including desaturation and sensor loss or technical alarms. The number of repeated was low: 3% of the oxygen desaturation alarms and only 0.2% of bradycardia alarms. Figure 2 shows the fluctuation of alarms of the unit during the day. Conclusions: Most alarms are desaturation alarms followed by bradycardia alarms. Remarkable are the low numbers of apnea alarms. However, several studies suggest that the apnea algorithms of commercial monitors may not adequately detect apnea in preterm infants. This issue requires our further investigation. The amount of repeated alarms is low, means quickly response to alarms. The 24-hour analysis shows peaks of alarming events during the predefined nursing rounds. This may be related to caregivers who do not inactivate the monitor alarms during care. It suggest that further improvement is necessary in order to decrease the number of alarms and prevent alarm fatigue. Keywords: Neonatology, Medical alarm management, alarmfatigue, Presenter: Heidi van de Mortel

ID 852

BILE ACIDS INDUCE ENDOPLASMIC RETICULUM STRESS IN HUMAN PLACENTA TROPHOBLATIC CELLS IN INTRAHEPATIC CHOLESTASIS OF PREGNANCY Y. Yu1, C.L. Zhou1, A.X. Liu2, X.F. Yang3, & H.F. Huang4 Woman’s Hospital, School of Medicine, University of Zhejiang, Hangzhou, Zhejiang, China, PR 310006. Brief Introduction: Intrahepatic cholestasis of pregnancy (ICP) usually occurs in the third trimester and associated with increased risks in fetal complications, and the exact cause of which is not fully understand. In this study we aim to investigate the expression of endoplasmic reticulum stress (ERS)-related protein GRP-78 in human placentas and the changes they undergo in the placentas from ICP women accompany or without accompany dead fetus, and to explore the regulatory mechanisms of ERS in swan-71 cells in response to cholylglycine treatment in vitro, which may participate in the

Figure 1. Transmission electron micrographs comparing the typical endoplasmic reticulum observed in (A) normal placenta, and (B) ICP placenta. (A) normal placenta: Note the abundant profiles of microvillus (MV) and endoplasmic reticulum (ER). (B). ICP placenta. The cisternae of the ER are greatly dilated and mitochondria display a condensed configuration. The nucleus is rounded, with severe loss of euchromatin. (A1, B1  3700: A2, B2  30 000 original magnification; uranyl acetate, lead citrate).

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J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Figure 2. GRP-78 in human placentas

molecular mechanisms of ICP-related pathological and physiological changes. Materials & Methods: 13 pregnant women with severe ICP accompany dead fetus and 10 pregnant women with severe ICP with live fetus were recruited. 10 normal pregnant women served as control. The localization of GRP-78 was investigated by immunohistochemistry in human placental trophoblastic cells from three groups. Endoplasmic reticulums were observed with electron microscopy in normal placenta and placenta from severe ICP with live births.

In vitro, swan-71 cells was stimulated by different concentration of cholylglycine with different times. The expression levels of GRP-78 gene was analyzed by quantitative Real-time PCR. Quantification of GRP-78 protein expression level detected by Bio-rad Quantity One. Endoplasmic reticulums were observed with electron microscopy in swan-71 cells treated or untreated with 0.5 mM CG for 24 h. Clinical Cases or Summary Results: Compared with placentas from normal pregnancies, the expression of GRP-78 was increased in human placenta trophoblastic cells from severe ICP with live fetus,

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Figure 3. CG changed levels of ER-related protein GRP-7S in swan-71 cell. and decreased in human placenta trophoblastic cells from severe ICP with dead fetus. By electron microscopy, the cisternaes of endoplasmic reticulums are greatly dilated and mitochondria display a condensed configuration in placenta from sever ICP with live fetus, while orthodox endoplasmic reticulums were observed in normal placenta. In vitro, cholylglycine treatment induced a significant increase in the expression of GRP-78 gene and protein in concentration-and time-dependent manners. By electron microscopy, swan-71 cells treated with cholylglycine displays ER stress, as evidenced by the dilatation of the cisternae of endoplasmic reticulums. Meanwhile, endoplasmic reticulum display an orthodox configuration in untreated control swan-71 cells. Conclusions: Our data suggests that bile acids induce human placenta trophoblastic cells occur ERS in vitro and in vivo, which may be implicated in the pathophysiology of ICP. Keywords: endoplasmic reticulum stress; GRP-78; human placenta; Cholestasis; Pregnancy Presenter: Ying Yu

frequency of respiratory and circulatory failure, and incidence of AKI in this time. We also investigated the accuracy for prediction of AKI, diagnosed before cardiac surgery in neonates born with HLHS, based on umbilical NGAL concentrations. Clinical Cases or Summary Results: Among 1,271 infants hospitalized in the NICU, we enrolled 21 neonates with HLHS as the study group. Control group comprised 40 full-term and healthy newborns, randomly selected during the time of study. We observed higher concentrations of NGAL in umbilical cord blood of infants with HLHS compared with the control group. Among neonates diagnosed with HLHS, 8 children had AKI detected on average on the 3rd day of life. We evaluated that NGAL concentration was significantly higher in the group of infants with AKI, compared to those without AKI. In newborns with AKI, respiratory insufficiency and circulatory failure occurred significantly more often compared to children with HLHS without diagnosed AKI. NGAL level correlated with the length of stay in the NICU. ROC curve analysis demonstrated a critical level of NGAL in the umbilical cord blood 466.6 ng/mL, and this allows with high sensitivity and specificity to predict AKI in newborns with HLHS. Conclusions: We suggest that the umbilical blood NGAL concentration may be an early marker to predict AKI in neonates with HLHS.

ID 814

Keywords: NGAL, HLHS, newborn, AKI

UMBILICAL NGAL LEVEL AS PREDICTIOR OF ACUTE KIDNEY INJURY IN INFANTS WITH HYPOPLASTIC LEFT HEART SYNDROME

Presenter: Piotr Surmiak

P. Surmiak, M. Baumert, M. Fiala, Z. Walencka, & M. Paprotny Chair and Department of Neonatology, Medical University of SIlesia, School of Medicine, Katowice, Poland Brief Introduction: The present study focused on evaluation of neutrophil gelatinase-associated lipocalin (NGAL) levels, as an early biomarker predicting acute kidney injury (AKI) in neonates born with hypoplastic left heart syndrome (HLHS). NGAL level rises markedly after tubular damage following ischemic/reperfusion kidney injury. Acute or chronic dysfunction of the heart or kidneys result in secondary dysfunction or injury to the other, known as cardiorenal syndrome. In our opinion, children with HLHS may also present cardiorenal syndrome. The aim was to compare the umbilical plasma NGAL concentration between neonates born with HLHS and healthy infants, as well as to analyze whether the determination of NGAL in umbilical cord blood could be used as an early indicator of kidney injury in children with HLHS. Materials & Methods: A prospective case-control study was performed. We evaluated the course of the preoperative period in neonates with HLHS, length of stay in the Neonatology Intensive Care Unit (NICU),

ID 559

IMPROVING THE MATERNAL/ FETAL OUTCOME OF PREGNANCIES COMPLICATED BY PREVIOUS SLE NEPHRITIS: REVIEW OF 8 YEARS OF DATA IN A SINGLE INSTITUTION S Simeone1, CL Cirami2, P. Gallo2, L. Marchi1, G. Mello1, M.P. Rambaldi1, C. Serena1, & F. Mecacci1 1

High Risk Pregnancy Unit. Careggi University Hospital, Florence, Italy, and 2Unit of Nephrology, Dialysis and Transplant. Careggi University Hospital, Florence, Italy Brief Introduction: Systemic lupus erythematosus (SLE) commonly affects women of childbearing age. Hypertension, anti-phospholipid syndrome and previous lupus nephritis are risk factors for adverse maternal/fetal outcome. Different prophylactic approaches usually combine aspirin ± LMWH. The aim of this retrospective cohort study is to evaluate pregnancy outcome in women with and without previous lupus nephritis (SLEn), using a combined prophylactic approach.

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256 Materials & Methods: Data were collected from 87 SLE pregnancies. Twenty-six women affected with previous SLEn formed the study group and were compared with 61 pregnancies without previous SLEn. The prophylactic management provided: low dose aspirin (LDA) in case of previous SLEn; LDA plus low molecular weight heparin (LMWH) in case of antiphoshpolipid syndrome; LMWH in case of the presence of antiphospholipid antibodies. Results are expressed as mean ± SD and percentages. Chi-squared test was used for nonparametric data and the Student T-test for parametric data (significant values when p50.05). Logistic regression assessed the predictive value of each variable. Clinical Cases or Summary Results: The groups were comparable for baseline charachteristics, except mean serum creatinine (p50.0018), proteinuria (p50.0001) and hypertension (0.0039) at booking. Live birth rate resulted 86.9% in the study group versus 90.6% in the controls. Mean gestational age at delivery did not differ between the groups (37.7 ± 2.82 vs 37 ± 3.50). Similarly, the difference in terms of preterm delivery (1.2mg/dL (OR13). IUGR was more frequent when chronic hypertension and active disease were present at booking (OR 4.85 and 4.96, respectively). Conclusions: SLE nephropathy significantly affects pregnancy: HELLP, IUGR and preterm delivery are more frequent when renal involvement is present. However, our cohort shows a lower incidence of maternal/ fetal complications comparing to the literature, probably due to the provided prophylactic approach often including both LDA and LMWH. Keywords: SLE, previous nephritis, pregnancy Presenter: Serena Simeone

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

obtaining informed consent from mothers. Immediately after normal vaginal delivery, a segment of the umbilical cord was double clamped and CB was collected in a sterile collection bag. CB 8-OHdG levels were measured with ELISA kits. The relationships between 8-OHdG levels and infant birth weight, placental weight, and placental weight/ birth weight (pw/bw) ratio were assessed. Clinical Cases or Summary Results: The maternal age ranged from 18–43 y (median 31 y), and 53.3% of the mothers were primiparous. The birth weights ranged from 2502–4304 g (median 3176 g); 58.3% of the infants were male, and the median gestational age at birth was 39 weeks. Placental weights ranged from 385–850 g (median 555 g). 8-OHdG levels in the CB ranged from 0.11–1.19 ng/ml (median 0.41 ng/ml; mean: 0.43 ± 0.21 n/ml). Significant positive correlations were observed between 8-OHdG levels and placental weight or pw/ bw ratio (r = 0.343, p = 0.007; r = 0.368, p = 0.004; respectively). However, no significant correlations were observed between 8-OHdG levels and infant birth weight. In addition, when maternal body mass index (BMI) was classified into BMI518.5, BMI 18.5–24.9, and BMI  25.0, significant positive correlations were observed between 8-OHdG levels and the pw/bw ratios in the BMI 18.5–24.9 group and between 8-OHdG levels and placental weight in the BMI 25 group. Conclusions: The present findings suggest that CB 8-OHdG levels correlate with placental growth, and that the maternal physique affects this correlation. Because oxidative stress may influence the long-term health outcomes of infants, understanding perinatal maternal, fetal, and neonatal stress conditions may help improve their health. Keywords: oxidative stress, 8-OHdG, placental/umbilical cord blood, body mass index, placenta Presenter: S. Ebina

ID 108

ASSOCIATION BETWEEN THE LEVELS OF A DNA DAMAGE BIOMARKER, 8-HYDROXYDEOXYGUANOSINE (8-OHDG), IN PLACENTAL/UMBILICAL CORD BLOOD AND MATERNAL/ NEONATAL CHARACTERISTICS AT FULL-TERM BIRTH S. Ebina1, T. kogawa2, & I. Kashiwakura3 1

Sapporo Medical University Graduate Course in Midwifery, Sapporo, JAPAN, 2Department of Disability and Health, Hirosaki University Graduate School of Health Sciences, Hirosaki, JAPAN, and 3Department of Radiological Life Sciences, Hirosaki University Graduate School of Health Sciences, Hirosaki, JAPAN Brief Introduction: Oxidative stress is associated with the development of various diseases including cancer, arteriosclerosis, pregnancyinduced hypertension, gestational diabetes mellitus, and metabolic syndrome. However, little is known about the involvement of the DNA damage biomarker, 8-hydroxy-deoxyguanosine (8-OHdG) during the perinatal period. Indeed, few studies have investigated the correlation between 8-OHdG levels and the physical status of the mother and neonate. This study aimed to estimate the relationship between placental/umbilical cord blood (CB) 8-OHdG levels and maternal/neonatal characteristics for full-term births. Materials & Methods: The Medical Ethics Committees of both Hirosaki National Hospital and Hirosaki University Graduate School of Medicine (Hirosaki, Japan) approved this study. CB was collected at a single hospital (Hirosaki National Hospital, Hirosaki, Japan) after

ID 628

MULTIPLE SCLEROSIS AND PREGNANCY – MATERNAL AND PERINATAL OUTCOMES M.L. Muner1, N. Martı´nez1, L. Sotillo1, A. Robles2, & J.L. Bartha1 1 Obstetric and Gynecology Department, Universitary Hospital La Paz (Madrid), and 2Internal Medicine Department, Universitary Hospital La Paz (Madrid)

Brief Introduction: Multiple sclerosis (MS) is an autoimmune, demielinizating and neurodegenerative disease, which affects women in a proportion three times larger than men. The mean age at the apparition of the first symptoms is 30, during fertility period in women. MS has a similar behavior during pregnancy to other autoimmune disorders, resulting in a significant decrease of the disease activity during pregnancy, and an increase in the number of attacks during postpartum period. The aim of this study is to investigate the role of different disease factors and the effect of disease-modifying drugs in perinatal outcomes. Materials & Methods: We conducted an observational, retrospective, unicentric study involving all patients with MS attending High Risk Pregnancy Unit at Universitary Hospital La Paz, between 2008–2012, a total of 57 pregnancies. The cases were matched with a similar control group. The variables studied included sociodemographic features (age, previous pregnancies), disease-related indicators (type, years of evolution, previous attacks, disease-modifying treatment), pregnancy control (number of attacks, blood testing, screening of chromosome abnormalities, presence of congenital malformations), perinatal outcomes (delivery, neonatal weight, arterial pH, Apgar) and clinical evolution during postpartum period (number of attacks, need of disease-modifying therapy, breastfeeding). Clinical Cases or Summary Results: The results observed in the study show that perinatal outcomes are similar in both groups. There was

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statistical difference in the chromosome abnormalities screening test, with medium risk of 1/1916 in MS patients and 1/5170 in controls, although both are al low risk of chromosome disorders. No differences were found in the incidence of C-section, mean gestational age or weight at birth, but there was a significant difference in weight percentile (40 in cases, 60 in control group). We observed that only one patient (0.57%) had an attack during the postpartum period, and there were no attacks in patients which restarted drug-modifying therapy. Conclusions: MS seems to have favorable perinatal outcomes, with normal fetal development and growth, and with a decrease in the number of attacks during pregnancy. More studies (sonography or invasive techniques) can be offered to MS patients in order to establish a more accurate prognosis concerning chromosome abnormalities. Although disease-modifying therapies have not been associated to adverse perinatal outcomes, there is a need for more studies to assess safety of use. Keywords: multiple sclerosis, pregnancy, perinatal outcomes Presenter: Marta Luisa Muner Hernando

(serum 25-OHD between 11 and 32 ng/mL), and adequate (serum 25-OHD between 32 and 100 ng/mL). Levels of 25-OHD were determined by High Performance Liquid Chromatography (HPLC) system Clinical Cases or Summary Results: Both maternal and neonatal 25-OHD levels in the Study group were significantly lower compared with those of the Control group (p50.001). A positive correlation was detected between maternal and neonatal 25-OHD levels. Both maternal and neonatal 25-OHD levels were significantly higher in summer and with regular vitamin D supplementation during pregnancy. Severe vitamin D deficiency was also significantly more common in the sepsis group. Conclusions: Early onset sepsis in term infants is associated with significantly lower maternal and neonatal 25-OHD levels. We also found that levels of 25-OHD in neonates were positively correlated with those in mothers. These data suggest the importance of adequate vitamin D supplementation during pregnancy that may be helpful to prevent EOS in term neonates. Keywords: Neonatal sepsis, maternal vitamin D, neonatal vitamin D, vitamin D deficiency Presenter: Tugba Erener Ercan

ID 694

LOWER VITAMIN D LEVELS ARE ASSOCIATED WITH INCREASED RISK OF EARLY ONSET NEONATAL SEPSIS IN TERM INFANTS M. Cetinkaya1, F. Cekmez2, G. Buyukkale1, T. Erener-Ercan1, F. Demir1, T. Tunc2, F.N. Aydın3, G. Aydemir2, & Y. Cekmez4 1

Neonatology Dept., Kanuni Sultan Suleyman Training and Research Hospita, Istanbul, Turkey, 2Neonatology Dept., Gulhane Military Medical Faculty, Istanbul, Turkey, 3 Biochemistry Dept., Gulhane Military Medical Faculty, Ankara, Turkey, and 4Obstetrics Brief Introduction: Besides its well known role in bone metabolism, vitamin D also has immunomodulatory effects. It might also have a role in the optimal functioning of the innate immune system by inducing antimicrobial peptides in epithelial cells, neutrophils and macrophages. The relationship between vitamin D deficiency and infections, especially lower respiratory tract infections (RTIs) has been demonstrated in children and newborns. Although the link between vitamin D deficiency and various infections has been reported, no study has evaluated the effect of vitamin D levels on neonatal sepsis.The aim of this study was to evaluate the effect of vitamin D levels on early-onset sepsis (EOS) in term infants. The association between the severity of vitamin D deficiency and EOS was also investigated. Materials & Methods: This prospective study was performed in term infants with clinical and laboratory findings of EOS who were 437 weeks of gestational age and were admitted to Neonatal Care Unit of Kanuni Sultan Suleyman Training and Research Hospital between March 2012 and December 2012. Fifty term infants with clinical and laboratory findings of EOS (Study group) and 50 healthy infants with no signs of clinical and laboratory infection (Control group) were enrolled. Blood for neonatal and maternal vitamin D levels were obtained from all infants and their mothers at the postpartum period at the time of hospital admission. The maternal demographic features including age, educational level, socioeconomic status, presence of disease, mother’s head cover status were all recorded. Gestational age, birth weight, sex, mode of delivery, Apgar scores, birth season of all infants were also recorded. Season of birth was classified into three groups during the study period: spring, summer and fall. Maternal vitamin D supplementation was classified in terms of usage: no usage, insufficient usage (total usage 3 months). Vitamin D deficiency was staged as severe deficiency (serum 25-OHD510 ng/mL), insufficiency

ID 151

SERUM CREATININE DURING PHYSIOLOGICAL PERINATAL DEHYDRATION MAY ESTIMATE INDIVIDUAL NEPHRON ENDOWMENT G. Ardissino1, F. Tel1, I. Possenti1, L. Baca2, D. Li Vecchi2, M. Pavesi3, G. Forni4, P. Salice2, S. Testa1, L. Colombo5, S. Ghirardello5, D. Consonni6, G. La Marca7, A. Edefonti1, & F. Mosca5 1

Pediatric Nephrology Unit - Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, via Commenda 9, 20122 Milan, Italy, 2Pediatric Cardiology Unit - Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, via Commenda 12, 20122 Milan, Italy, and 3Depart Brief Introduction: It is well known that the nephron endowment of healthy subjects is highly variable and that individual nephron mass has potentially important implications both in health and disease. However nephron count is technically still impossible in living subjects. We hypothesised that serum creatinine levels during the physiological perinatal dehydration, might be helpful in identifying subjects with a reduced nephron mass. Materials & Methods: The serum creatinine levels of normal Caucasian neonates were determined 48–96 hours after birth and their association with a family history of arterial hypertension (AH) was evaluated. Moreover, renal volume measured between the second and third month of life, in a subset of subjects, was correlated with the level of perinatal serum creatinine. Clinical Cases or Summary Results: Serum creatinine levels were determined in 182 normal newborns (90 males) at a mean of 61 + 8 hours after birth (range 46–82). Newborns with paternal AH had a higher mean serum creatinine level (0.7 + 0.3 vs. 1.0 + 0.3; p50.006). No differences in mean serum creatinine levels were found in relation with mother or grandparent’s history of AH. Kidney volume negatively correlated (slope of -13.5 mL per unit of serum creatinine; 95% CI: -26.2 to -0.9; p = 0.04) with serum creatinine levels in the subset of children who underwent kidney ultrasonography. Conclusions: The determination of serum creatinine level during perinatal dehydration seems a promising tool for identifying normal subjects with a reduced nephron mass with potential important

258 implications in understanding the individual outcome of renal diseases (including drug toxicity), expanding our knowledge on the pathophysiology of common renal and extrarenal diseases and providing clues for individualized preventive measures. Keywords: nephron mass, serum creatinine, newborn, hypertension Presenter: Gianluigi Ardissino

ID 384

INTERVENTRICULAR SEPTUM SHORTENING IN NORMAL FETUSES J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

M. Velipasaoglu, R. Ayaz, & H.M. Tanir Maternal-Fetal Medicine Unit, Obstetrics and Gynecology Dept. Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey Brief Introduction: Fetal cardiac assessment is a standard part of antepartum obstetric ultrasound evaluation. Heart examination including four-chamber view and outflow tract views should be routinely performed to all women as recommended by The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) [1]. Altough anatomical survey of fetal heart is well-defined, current knowledge on myocardial contractility is scarce. The aim of our study was investigate the interventricular septum (IVS) shortening in normal fetuses. Materials & Methods: Pregnant women applied to Eskisehir Osmangazi University, Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Unit in second trimester of pregnancy were included. Ultrasound examinations were performed twice (at second

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

trismester [22 weeks 0 days to 27 weeks 6 days of gestation] and at third trimester [28 weeks 0 days to 34 weeks 6 days of gestation]) for all fetuses. Fetuses with intrauterine growth restriction and women with gestational or pre-gestational diabetes and any kind of hypertension (gestational, chronic, preeclampsia) were excluded. Cardiac 4D XI spatiotemporal image correlation (STIC) volumes were acquired with a Samsung-Medison Accuvix A30 system and a 2 to 6 MHz transabdominal transducer (Medison, Seoul, Korea). Standart acquisition plane was lateral 4 chamber view which the interventricular septum was completely horizontal to the transducer. Multi-planar render (MPR) images were evalueted later off-line. Interventricular septum lenght was measured from just below the septum primum to the junction point of the apexes of left ventricle, right ventricle and interventricular septum during systole and diastole. Data were analyzed using Statistical Package for Social Sciences (SPSS) version 20.0 (IBM Corp.). Statistical significance was defined as a p value 0.05. Clinical Cases or Summary Results: A total of 25 fetuses and 50 images were included to the study. Four ultrasound studies were later excluded because of poor XI STIC image quality so these 4 fetuses and 8 images were excluded. 42 ultrasound studies of 21 fetuses were analyzed. Mean gestational age at examination in secon and third trimester were 24.4 weeks (±1.6 weeks) and 21.3 weeks (±2 weeks) respectively. Systolic and diastolic Interventricular septum lenght was significantly correlated with gestational age (Figures 1 and 2). Area under the curve for p values were .667 and 50.0001 for diastolic lenght and .673 and .05). Conclusions: In this study, offline analysis of four-dimension XI-STIC images were used to determine interventricular septum contractility. Altough interventricular septum lenght was increased with gestational age, interventricular septum shortening index was independent of fetal size. Fetal cardiac contractility is a subject that recently gained attention. There are few studies to define reference values of fetal myocardial function. Two-dimensional speckle tracing

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echocardiography is the most frequently used method to assess contractility [2–5]. But this technique is not easy to perform and measurements assessed using different software packages or different ultrasound machines are not always comparable [6]. However, the method used in our study should be evaluated in a

larger patient population and intraobserver/interobserver differences should also be assessed. Keywords: fetal myocardial contractility Presenter: M. Velipasaoglu

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ID 570

A COMPARISON BETWEEN AMNIOTIC FLUID INDEX AND THE SINGLE DEEPEST VERTICAL POCKET TECHNIQUE IN PREDICTING ADVERSE OUTCOME IN PROLONGED PREGNANCY P. Rosati, P. Ciliberti, S. Buongiorno, M. Tintoni, I. Mappa, M. Viggiano, A. Ciardulli, AF. Cavaliere, & L. Guariglia

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Obstetrics and Gynecology Dept., Catholic University of the Sacred Heart, Rome, Italy Brief Introduction: Prolonged pregnancy is considered as menstrual age ranged from 41 to 41 6/7 weeks of gestation, while a pregnancy beyond 42 0/7 weeks is defined postterm and both are frequently associated with oligohydramnios The aim of our study is to compare perinatal outcome in induced postterm pregnancies with normal amniotic volume and in patients with prolonged pregnancy undergone induction for oligohydramnios, evaluated by two different ultrasonographic methods. Materials & Methods: Amniotic fluid volume was measured, using Single Deepest Vertical Pocket (SDVP) and Amniotic Fluid Index (AFI), in 961 singleton uncomplicated prolonged pregnancies. In 109 of these patients, hospitalization was planned for induction of labor, during or after 42 weeks of gestation, for oligohydramnios, postterm pregnancy and other indications in 47, 51 and 11 cases, respectively. Perinatal outcome included: rate of caesarean section, fetal distress, non reassuring fetal heart tracing, presence of meconium, umbilical artery pH 57.1, Apgar score at 5 minutes 57, admission to neonatal intensive care unit (NICU). Clinical Cases or Summary Results: Oligohydramnios was diagnosed in 4.89% of cases, when at least one of the two methods was used. A reduced AFI and SDVP value identified 4.47% and 3.75% of cases, respectively, even if without statistical difference. No statistical differences were reported in perinatal outcomes in postterm versus prolonged pregnancies with oligohydramnios, also in relation to the two different ultrasonographic methods. Conclusions: Oligohydramnios is more frequently diagnosed using AFI than SDVP, consequently determining a higher rate of induction of labor. Moreover, perinatal outcome in prolonged induced pregnancies is not affected by oligohydramnios. Keywords: amniotic fluid index;post-term pregnancy; prolonged pregnancy; single deepest vertical pocket Presenter: P. Rosati

ID 874

MATERNAL CARDIOVASCULAR PROFILE BY IMPEDANCE CARDIOGRAPHY IN THE SECOND TRIMESTER OF NORMAL PREGNANCY R.M. Sima1, L. Ples2, C. Ciornei1, R. Papacocea1, M. Popescu1, & I.A. Ba˘da˘ra˘u1 1

‘‘Carol Davila’’, University of Medicine and Pharmacy, Department of Physiology, and 2‘‘Carol Davila’’, University of

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Medicine and Pharmacy, Obstetrics and Gynecology, ‘‘Bucur’’ Maternity Brief Introduction: During pregnancy, it is preferable to use a noninvasive, accurate and reproducible method to obtain data for maternal stroke volume and cardiac output. Impedance cardiography is an excellent technique which is also highly accessible and easy to perform, lately gaining interest in the obstetric field. Materials & Methods: We prospectively evaluated 20 patients in the second trimester of pregnancy and 20 non - pregnant healthy women. We used general information such as maternal age, body mass index, blood pressure and status of smoker/nonsmoker. All of them were evaluated using impedance cardiography obtaining dates such as: systemic vascular resistance (SVR), heart rate (HR), stroke volume (SV), cardiac index (CI) and base impedance (Z0). Clinical Cases or Summary Results: In this study we observed that systemic vascular resistance, base impedance were correlated with blood pressure for both study groups. Base impedance was an important parameter which correlated with body mass index. The blood pressure didn’t exceed the normal values for pregnant patients. Base impedance increased in the second trimester of pregnancy (36.56 ± 6.03 Ohm). Heart rate increased significantly in this period of pregnancy (85.47 ± 4.6 b/min), especially in smoker and obese patients (p50.005). Systemic vascular resistance decreased in pregnant women compared with non-pregnant women, while cardiac index and stroke volume increased, but all of them with no statistical significance (p40.005) Conclusions: Heart rate and base impedance were the significant changes in the second trimester of pregnancy according to our study. This study proved that impedance cardiography can offer feasible information about cardiovascular status in second trimester pregnant women. Keywords: Presenter: R.M. Sima

ID 868

PREGNANCY IN WOMEN WITH MYELOPROLIFERATIVE NEOPLASMS E. Polushkina1, R.G. Shmakov1, M. Sokolova2, & M. Vinogradova1 1

Federal State Budget Institution Research Center for Obstetrics, Gynecology and Perinatology Health Ministry of Russia, Moscow, Russian Federation, and 2Federal State Budgetary Institution Hematology Research Center of Health Ministry of Russia, Moscow, Russian Federation Brief Introduction: Myeloproliferative neoplasms (MPN) are very infrequent in women of childbearing age. But in recent years it becomes more often that young women suffer from these diseases. The development of new therapeutic options resulted in better survival rate and life prognosis in this group of patients. All this requires special options for management of pregnancy in women with MPN. The aim of our study was to develop the programme of preconception planning and pregnancy management and to evaluate pregnancy outcomes and complications in women with MPN. Materials & Methods: 110 pregnancies in 90 women were analyzed in our study. The prospective group (group 1) included 67 women who were treated according to the developed programme. Retrospective group (group 2) contained 23 women with 43pregnancies who did not receive a special treatment of MPN during pregnancy. Women with three main MPNs were included in the study: essential thrombocythemia, polycythemia vera, primary myelofibrosis. The programme of diagnostic contained blood count and coagulogram twice a month, the inherited trombophylia testing, homocystein

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level, antiphospholipid syndrome diagnostic and hematologic examination including trepanobiopsy and JAK2V617F mutational status. Treatment options varied from cytoreductive therapy, aspirin, vitamins of group B to systemic anticoagulation and plasmapheresis. Interferon alfa was the drug of choice for the cytoreductive therapy during pregnancy and its planning. Clinical Cases or Summary Results: Medical abortion was perfomed in 2 (3%) women of group 1 and in 3 (6.9%) women of group 2 (OR – 2,44; 95% C.I.: 0,265; 30,109). The incidence of pregnancy loss was very high in the group of women without treatment and occurred in 62.8% of pregnancies. In the group 1 only 6% of pregnancies (4 pregnancies) ended in spontaneous abortions (OR – 16,88; 95% C.I.: 4,655; 74,177). First and second trimester spontaneous abortions in group 2 prevailed among all the miscarriages – 15 (34.9%) cases, stillbirth occurred in 12 (27.9%) cases. Preterm labor occured in 5 (7.4%) and 6 (14%) pregnancies in 1 and 2 groups respectively (OR – 2,01; 95% C.I.: 0,471; 8,899). Pregnancies ended in term in 83.6% (56 pregnancies) and 16.3% of cases (7 pregnancies) in two groups (OR – 26,18; 95% C.I.: 8,441; 85,448). Complications of pregnancy were analysed in 61 and 13 women in 1 and 2 groups respectively. Pregnancy was uncomplicated in 21 (34.4%) and 2 (15.4%) cases in 1 and 2 groups respectively (OR – 2,89; 95% C.I.: 0,544; 28,852). The most often pregnancy complication was increased risk of pregnancy loss: in 25 (41%) and 10 (76.9%) cases had threatening miscarriage in 1 and 2 groups respectively (OR – 0,21; 95% C.I.: 0,034; 0,937). Among other complications were: anemia in 22 (36%) and 4 (30.8%) cases (OR – 1,27; 95% C.I.: 0,307; 6,289), placental isufficiency in 14.8% (9 pregnancies) and in 30.8% (4 pregnancies) of pregnancies, intrauterine growth retardation complicated 5 (8.2%) and 2 pregnancies in groups 1and 2 respectively. Conclusions: The risk of pregnancy loss in women with MPN is very high without careful monitoring and special treatment. In our study it occured in 62.8% without treatment and complications of pregnancy developed in 84.6% cases. The programme of preconception planning and pregnancy management allowed to reduce miscarriages to 6% (p50.001) and pregnancy complications to 65.6% (p = 0.3). Keywords: Myeloproliferative neoplasms, pregnancy, miscarriage Presenter: E. Polushkina

ID 639

PREGNANCY, DELIVERY AND PERINATAL OUTCOMES IN PATIENTS WITH UTERINE LEIOMYOMA AFTER UTERINE ARTERY EMBOLIZATION (UAE) G. Savalyeva1,2, R. Shalina1, M. Simukhina3, & A. Kubataeva3 1

Center of family planning and reproduction, Moscow, Russian Federation, 2City Clinical Hospital No. 31, Moscow, Russian Federation, and 3Pirogov Russian National Research Medical University, Moscow, Russian Federation Brief Introduction: Uterine artery embolization (UAE) is proved to be an effective treatment for uterine fibroids in patients who completed their reproductive function. The matter of using UAE for the treatment of uterine fibroids in women planning pregnancy remains open. Therefore, the aim of research is to compare perinatal outcomes in groups with different tactics for uterine leiomyoma: after selective UAE and without it. Materials & Methods: 137 patients with uterine leiomyoma and their children were examined. They were divided in 2 groups depending on the way of tactics for fibroids. Group I: 64 patients with uterine leiomyoma after UAE. Group II: 73 patients with uterine fibroids with

no treatment for fibroids (UAE was not performed). The size of fibroids before UAE in group I: from 8cm to 20cm, after UAE their size decreased (30%-60%). The majority of pregnancies after UAE (84.4%) occured in 1–2 years after operation. During pregnancy in both groups women underwent fetal biometry, CTG and utero-placental Doppler ultrasound; after delivery Apgar score at 1st and 5th minutes measuring, neurosonography, echocardiography, anthropometric data assessment were performed. Clinical Cases or Summary Results: The rate of intrauterine hypoxia was 3 times higher in group II. IUGR-only in group II-7(9.5%); one child - stillborn. Preterm delivery - only in group II - 14 (19.2%), which is 2.5 times higher than in the population. Frequency of CS in patients after UAE - 45.2%, in II group - 54.8%. In 50% of CS the indications were large sizes of leiomyoma or it‘s rapid growth. 1st minute Apgar score in group I: 8 points - 95.2%, 7 points - 4.8%; in group II: 8 - 87.5%, 7 - 10.9%, 6 - 1.4%. Birth weight in group I was mostly 3000 – 4000 grams (87.5%). In group II almost half of newborns (48.6%) were less than 3000g weigh. The results of neurosonography: group I - no pathology; group II: ischemic changes - 12.5%, immaturity - 2.8%, subependymal cysts - 1.4%, intraventricular hemorrhage - 1.4%. Congenital hip dislocation - 1.4%, muscle dystonia - 2.8%, rickets - 1.4%, flat-footedness - 1.4% all occurred only in group II. High infection index (4–6) in group I - 3 (4.8%), in group II - 9 (12.3%). Conclusions: UAE in patients with uterine fibroids is a non-invasive organ-sparing surgery, which also reduces the number of complications in neonatal period. Results of the research allows to recommend this treatment for leiomyoma in women planning pregnancy. Keywords: Uterine Artery Embolization (UAE). Pregnancy. Delivery. Perinatal outcomes Presenter: M. Simukhina

ID 250

FACTORS THAT PREDICT SHORTTERM MORTALITY IN PATIENTS WITH ACUTE FATTY LIVER OF PREGNANCY Qi Li1, Te-Xuan Zhu2, & Wei-She Zhang2 1

Department of Clinical Medicine, Undergraduate School of Central South University, Xiang-Ya Medical School of Central South University, Hunan, Changsha 410083, China, and 2 Department of Obstetrics and Gynecology, Xiang-Ya Hospital, Central South University, Brief Introduction: Acute fatty liver of pregnancy (AFLP) is an uncommon but potentially life-threatening perinatal complication. AFLP is associated with low morbidity but considerable mortality. In the past 20 years, maternal mortality from AFLP has declined to about 10% in company with decreasing perinatal mortality. Although mortality due to AFLP has declined in recent years, it is important to further lower the mortality rate by early diagnosis and treatment of this disease.Moreover, the risk factors for AFLP-related mortality are not well established. Up to now, lack the report of prognostic criteria or model for AFLP, rendering the prediction of clinical outcomes difficult. We therefore aimed to develop a more accurate model to predict mortality from AFLP. Materials & Methods: This retrospective study included 44 AFLP patients admitted to Xiangya Hospital, Central South University, Hunan, China between November 2006 and December 2013. The 44 patients fulfilled both the clinical and laboratory criteria and the Swansea criteria for the diagnosis of AFLP.(Figure 1) Clinical and laboratory data obtained on admission were used for analysis. Univariate and multivariate analyses were used to identify predictors of mortality and build a model for AFLP(M-AFLP).Comparison was

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Keywords: Acute fatty liver of pregnancy; prognostic factor; prediction model; mortality; outcome Presenter: Wei-She ZHANG

ID 080

STRESS OF VAGINAL DELIVERY ACTIVATES FETAL GLUCONEOGENESIS K.A. Simbi, G. Straface, & V. Zanardo

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Division of Perinatal Medicine, Policlinico Abano Terme, Piazza C. Colombo1, 35031 Abano Terme, Italy

made within the M-AFLP, model for End Stage Liver Disease(MELD), model for end-stage liver disease with the incorporation of serum sodium(MELD-Na), integrated model for end-stage liver disease (iMELD) and model for pregnancy-specific liver diseases (PSLD model). Clinical Cases or Summary Results: Univariate analysis identified international normalised ratio (INR), Alanine transaminase (ALT), and blood ammonia as significant variables. Multivariate analysis confirmed INR and ammonia as predictors of mortality. M-AFLP was calculated as [(0.493  INR) + (0.052  ammonia)]. The predictive accuracy of the M-AFLP, as measured using area under the receiver operating characteristic curve(AUC), was 0.932. The AUCs of the PSLD model, MELD-Na, iMELD and the MELD were 0.742, 0.72, 0.712 and 0.697, respectively. (Figure 2)A cut-off M-AFLP score of 3.834 yielded 100% sensitivity and 78.8% specificity. And the M-AFLP model calibrated well with Hosmer-Lemeshow 2 = 6.207, p = 0.516. The inconsistent rate between the predicted and actual outcomes was 20.45%. While the inconsistent rate of the PSLD(MELD)iMELD and the MELD-Na model were 25%, 25%, 25% and 27.27%, respectively. Conclusions: M-AFLP based on the INR and ammonia was a reliable tool for predicting short-term mortality in patients with AFLP, with a sensitivity of 100% and a specificity of 78.8%. Further prospective studies are needed to validate this model.

Brief Introduction: Glucose is a major source of energy for organ function and the almost exclusive source of energy for the foetal and neonatal central nervous system. Stress of delivery results in marked elevations of catecholamine levels and activates fetal gluconeogenesis. We examined glucose and acidemia levels in umbilical artery blood at birth in healthy term neonates by vaginal and cesarean delivery. Materials & Methods: We prospectively tested glucose and pH levels after 341 spontaneous and 25 vacuum extractor vaginal deliveries (VD) and after 85 elective and 49 emergency cesarean sections (CS) performed at the Department of Obstetrics and Gynecology of Policlinico Abano Terme, Abano Terme (Padua) from January to December 2013 using an ABL90 FLEX Radiometer analyzer (Copenhagen, Denmark). Data analysis was performed with SPSS for Windows statistical package (version 13), (SPSS, Chicago, IL, USA). Clinical Cases or Summary Results: The mean (+/ SD) average neonatal blood glucose at birth in the whole population was 90.1 (+/22.0) mg%. In particolar it was 95.0 (+/ 20.6) mg% in the spontaneous VD group, 101.4 (+/ 30.6) mg% in the vacuum extractor VD group, 69.9 (+/ 13.8) mg% in the elective CS group and 85.4 (+/ 16.1) mg% in the emergency CS group. The VD by vacuum extractor group had significantly increased neonatal cord blood glucose values (p50.001) and a significantly lower cord blood pH than the other groups (p50.001). Conversely, the elective CS group showed significantly reduced neonatal cord blood glucose values (p = 0.004) and significantly higher cord blood pH than the other groups (p50.001). In addition glucose levels in the total population and in the VD by vacuum extractor group were significantly negatively correlated with umbilical artery pH (r = -0.094, p = 0.036 and r = -0.594, p = 0.007, respectively). Conclusions: The stress of labour and delivery increases both umbilical cord blood glucose and acidemia levels in healthy, term neonates. In addition, cord blood glucose inversely correlates with pH, in a stronger way, in VD by vacuum extractor. It appears from our data that a single, universal definition of neonatal hypoglycaemia, extracted from data obtained on infants born by vacuum extractor VD, might not be appropriate to infants delivered by CS. Keywords: stress, gluconeogenesis, vaginal delivery, umbilical artery pH Presenter: K.A. Simbi

ID 626

BIOLOGIC THERAPY IN PREGNANT WOMEN WITH INFLAMMATORY BOWEL DISEASE N. Martı´nez1, A. Abascal1, L. Sotillo1, A. Robles2, S. Go´mez3, & J.L. Bartha1

263

DOI: 10.3109/14767058.2014.924236 1

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Obstetric and Gynecology Department, Universitary Hospital La Paz (Madrid), 2Internal Medicine Department, Universitary Hospital La Paz (Madrid), and 3Gastroenterology Department, Universitary Hospital La Paz (Madrid) Brief Introduction: Inflammatory bowel disease (IBD) is a very frequent disease in childbearing women. Biologic therapy (BT) is used in this patients to mantain stable the disease. No flares in the clinical evolution is one of the most important items for good perinatal outcomes. The objective is to evaluate maternal and perinatal outcomes in patients with IBD exposed and not exposed to BT. Materials & Methods: Retrospective study of maternal records of pregnant women with IBD since 2009 to 2013. A total of 68 women with IBD were evaluated. 30 patients (44.1%) had Crohn Disease (CD) and 38 (55.9%) ulcerative colitis (UC) and had an average of 8.3 years of disease evolution. Mean maternal age was 34.3 years old (4.42 DS) with a body mass index (BMI) medium of 24 (4.76 DS). Most of them (44, 64.7%) were primiparous. Mesalazine was the most used treatment (22, 33.8%) and 8 patients (12.3%) were exposed to BT (5 infliximab and 3 adalimumab). All BT were started before pregnancy and most of them (6, 75%) continued until third trimestre. Clinical Cases or Summary Results: 60 pregnant women not exposed to BT and 8 exposed to BT were studied. Mean gestational age at birth was 38.1 and 37.5 weeks respectivebly. There were not any severe flare in any of both groups. There was a 12.5% (n = 1) of prematurity rate in BT group compared with 6.3% in not BT exposed group, similar general population. Mean newborn weigh percentils at birth were similar in both groups and there was a 12.5% of small for gestacional age (SGA) in BT group vs 9% in not BT group. The cesarean section rate was higher in both groups when compared with general population but adjusted to obstetric causes, it was very similar in both groups (20–25%) when compared with general population. There was no mayor congenital disorders in both two groups and no neonatal infections were detected. Conclusions: BT during pregnancy in IBD pregnant women is not associated to more congenital malformations, preterm birth, SGA neither cesarean section than IBD pregnant women not exposed to BT. Keywords: inflammatory bowel disease, pregnancy, biologic therapy, treatment Presenter: Nuria Martı´nez Sa´nchez

ID 835

DELAYED NEURODEVELOPMENTAL OUTCOMES IN PRE-/EARLY SCHOOL-AGED VPT/VLBW CHILDREN

and K-ABC-II subtests. Experimental paradigm of neuronal networks training was studied: it is based on neuronal ability to enhance memorizing/storage in repeated postponed testing and during the same test (includes three trials with 51 stimulus presentations in each trial), that means improvement in repeated test results. We emphasized VPT/VLBW children may have worse attention parameters (time-span of response, true/false answer balance) vs. term peers. Our practical reason was testing implicit attention deficit in VPT/ VLBW preschool/school-aged children, implicating the fact of ADHD prevalence in mild/very preterm children publications according to publication data and our practice. Inclusive criteria to the VPT/VLBW group were as follows: age of 6–8 years, gestation age 33 weeks, body mass born 1500 g. Exclusive criteria: severe CNS perinatal damage (IVH 3–4, large-cystic PVL); severe mental/locomotor disability (cerebral palsy, or mental handicap with IQ less 70) or severe sensorial deficit (bradyacuasia IIIIV, blindness or low vision); psychiatric or severe somatic disease; genetic syndromes, chromosome diseases, malformations. Mean gestation age was 31 ± 1.3 in VPT/VLBW and 39 ± 0.07 in controle; mean testing age was 86 ± 8 months in VPT/VLBW group and 87 ± 10 months in control (p40.05). Clinical Cases or Summary Results: We found evidence-based lower attention-test (ANT) results in VPT/VLBW children vs. term peers, p50.01 for true/false answers and p.05. There was no substantial correlation between perinatal brain damage and cognitive outcomes, according to the tests applied, in VPT/VLBW group that is also concordant with topic studies. Conclusions: VPT/VLBW children have slight attention deficit, without obligatory cognitive test-derived differences, in comparison with term-born peers. But still attention malfunctioning may be critical and quite sensitive for learning efficiency and school-education success, signifying delayed consequences of preterm birth and particularly, long-term perinatal brain affects. Keywords: very preterm, very low birth weight, spatial attention, preschool/early schooll Presenter: Ziborova Maria I.

ID 222

SINGLETON PREGNANCY OUTCOMES IN ADVANCED MATERNAL AGE K.J. Lee1, D.S. Park2, & D.H. Cha3 1,2,3

Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Korea Brief Introduction: Maternal age has been markedly increasing in many developed countries. We aimed to investigate maternal and perinatal outcomes in women aged 40 years or older in comparison with those in women aged 25–34 years.

M. Ziborova, E. Keshishian, E. Sakharova, J. Burdukova 1,2,3

Center of Toddler Development Correction, ScienceResearch Clinical Institute of Pediatrics, Moscow, Russia, and 4 Moscow State University of Psychology and Education, Moscow, Russia Brief Introduction: Objectives: The aim of the study was to assess and compare neurodevelopment, in particular, (1) visual lateralized selective attention in VPT/VLBW children with their term peers in pre-/early school-age (6–8 years) with computer Attention Network Test (ANT), and (2) mental/cognitive functioning measured by Kaufman Assessment Battery for Children (K-ABC-II ed, 2004). Materials & Methods: 30 children aged 6–8 years (15 VPT/VLBW vs. 15 term peers in control) were included in the prospective study. Children were tested twice – with a shift period 7–10 days, using ANT

Table 1. Pregnancy characteristics according to maternal age

Age (years, mean) GA (days, mean) Primiparity Baby Weight(g, mean) Delivery type Vaginal delivery Vacuum Cesarean section Use of IVF (%)

40 y (N = 907)

25–34y (N = 1269)

41.27 ± 1.67 269.72 ± 12.16 408 (44.98%) 3209.36 ± 493.09

31.08 ± 2.11 273.33 ± 11.92 912 (71.87%) 3217.31 ± 431.05

268 33 606 604

(29.55%) (3.64%) (66.81%) (66.59%)

811 (63.91%) 133 (10.48%) 325 (25.61%) 108 (8.51%)

GA, gestational age; IVF, in vitro fertilization

p Value 50.0001 50.0001 50.0001 0.690 50.0001

50.0001

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Table 2. Pregestational and gestational maternal complications according to maternal age. 40 y (N = 907)

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Leiomyoma Adnexal mass Chronic hypertension Diabetes mellitus Thyroid disease Cardiac disease Asthma Collagen vascular disease GDM Preeclampsia Placenta abruption Placenta previa Postpartum Haemorrhage Transfusion ICU transfer

125 19 9 5 54 10 9 3 94 20 4 29 26 31 22

25–34y (N = 1269)

(13.78%) (2.09%) (0.99%) (0.55%) (5.95%) (1.10%) (0;.99%) (0.33%) (10.36%) (2.21%) (0.44%) (3.20%) (2.87%) (3.42%) (2.43%)

153 33 2 2 82 6 5 2 92 19 11 29 8 12 10

(12.06%) (2.6%) (0.16%) (0.16%) (6.46%) (0.47%) (0.39%) (0.16%) (7.25%) (1.5%) (0.87%) (2.29%) (0.63%) (0.95%) (0.79%)

OR (95% CI) 1.17 0.80 6.35 3.51 0.92 2.35 2.53 2.10 1.48 1.49 0.51 1.41 4.65 3.70 3.13

(0.99–1.50) (0.45–1.42) (1.37–29.46) (0.68–18.14) (0.64–1.31) (0.85–6.48) (0.85–7.59) (0.53–12.61) (1.10–2.00) (0.79–2.80) (0.16–1.60) (0.838–2.380) (2.10–10.32) (1.89–7.26) (1.48–6.64)

p Value 0.235 0.447 0.018 0.134 0.629 0.100 0.097 0.416 0.011 0.221 0.245 0.195 0.000 0.000 0.003

GDM, gestational diabetes mellitus; ICU, intensive care unit; OR, odds ratio; CI, confidence interval Table 3. Neonatal Outcome According to Maternal Age 40 y (N = 907) GA532 GA537 LBW VLBW NICU admission Perinatal death

12 60 54 11 63 5

(1.32%) (6.62%) (5.95%) (1.21%) (6.95%) (0.55%)

25–34y (N = 1269) 11 61 51 7 96 7

(0.87%) (4.81%) (4.02%) (0.55%) (7.57%) (0.55%)

OR (95% CI) 1.53 1.40 1.51 2.21 0.91 1.00

(0.67–3.49) (0.972–2.03) (1.02–2.24) (0.86–5.73) (0.66–1.27) (0.32–3.16)

p Value 0.308 0.071 0.039 0.102 0.584 0.99

GA, gestational age; LBW, low birth weight; VLBW, very low birth weight; NICU, neonatal intensive care unit; OR, odds ratio; CI, confidence interval Materials & Methods: This study was a retrospective cohort study of singleton-pregnant aged 40 years or older. We included 907 women aged 40 years or older and 1269 controls aged 25–34 years. We analysed associations between maternal age and pregnancy outcomes.

Clinical Cases or Summary Results: The risks for gestational diabetes mellitus (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.10–2.00), postpartum haemorrhage (4.65, 2.10–10.32), transfusion (3.70, 1.89– 7.26), and transfer to the intensive care unit (2.67, 1.25–5.73) were higher in the older women. The rate of low birth weight among the older women was significantly higher than that among the controls (OR 1.51, 95% CI 1.02–2.24). After adjusting for primiparity, in vitro fertilization, leiomyoma, preexisting hypertension, diabetes mellitus, gestational diabetes mellitus, and preeclampsia, maternal age was not associated with neonatal outcomes. Conclusions: In this study, the singleton-pregnant women aged 40 years or older were at a significantly higher risk for some maternal complications, especially gestational diabetes mellitus and postpartum haemorrhage. However, the risks for adverse neonatal outcomes, except low birth weight, were not significantly increased. Keywords: maternal age, pregnancy outcome Presenter: K.J. Lee

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ID 957

A COMPARISON OF INTRAPARTUM FETAL ELECTROCARDIOGRAPHY VERSUS CONVENTIONAL CARDIOTOCOGRAPHY IN PROLONGED GESTATIONS: PRELIMINARY RESULTS R.J. Go´ngora, S.M. Naveiro, D.S. Ruiz, P.A. Puertas, A.M. Barranco, & B.M.P. Carrillo J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

1

Obstetrics Dept., Virgen de las Nieves University Hospital, Granada, Spain Brief Introduction: Oxygen deficiency affects fetal brain and fetal heart in the same way. So, the information from the myocardium is an indirect measurement of the fetal brain oxygenation during labor. The purpose of this study is to compare this two fetal monitoring methods (fetal ECG and conventional cardiotocography) to determine if there are differences in maternal and perinatal outcomes. Materials & Methods: A randomized study was performed with two arms: in group 1 we used conventional cardiotocography (CTG) and in group 2 we used fetal electrocardiography (ECG). We included 100 pregnant women with prolonged gestation (290 days of gestation) admitted to Virgen de Las Nieves University Hospital (Granada) from January 2013 to March 2014. The inclusion criteria were: singleton fetus in cephalic presentation, not previous cesarean

section, 290 days of gestation and prior normal CTG at least 30 minutes). Clinical Cases or Summary Results: 56 patients were assigned to the CTG group and 44 to the STAN group (results are in the table). No significant differences between groups were found in days of gestation and initial Bishop index. Labor was induced in 96% of the patients. We found an higher percentage of spontaneous and cesarean deliveries in CTG group (57.1% vs 52.3% and 23.2% vs 22.7%, respectively) and instrumental deliveries in ECG group (25% vs 19.6%). Indication for ending labor due to fetal distress was higher too in ECG group. The differences was not statistically significant. Blood gas values (pH and base deficit) in the umbilical cord artery and vein at birth was similar between CTG and ECG group. More newborn of ECG group were admitted in minimal neonatal care (29.5% vs 19.6%, no statistically significant). Days of neonatal and puerperal admission were similar in both groups. Conclusions: Preliminary results are not sufficient to demonstrate an improvement in pregnancy outcomes with the use of STAN. Keywords: Cardiotocography, STAN, fetal electrocardiography, intrapartum monitoring Presenter: A. Puertas Prieto

ID 123

HIGHER ORDER PREGNANCY FOLLOWING INTRAUTERINE INSEMINATION IN A STIMULATED CYCLE - A BOON OR A CATASTROPH M. Vijayasree Department of obg., Mamata medical college, Khammam., Andhra Pradesh Brief Introduction: Introduction: A combination of controlled ovarian hyper stimulation (COH) with intra uterine insemination (IUI) remains an important option available to an infertility specialist & is widely used treatment modality for many indications. Higher order pregnancies along with heterotropic pregnancies are quite common after COH and IUI.This study has been undertaken to know whether COH & IUI is a boon or a catastroph for the infertile couple. Materials & Methods: Aims and Objectives: To study the pregnancy outcome after IUI in a stimulated cycle & to know its adverse effects on the mother and fetus. Materials and Methods: It is a Prospective study done in a University-level tertiary care center.100 patients were selected for a period of one year.Ovarian stimulation with clomiphene citrate or gonadotrophins or in combination was initiated & a single IUI was performed 36 hours after ovulation.The result noted was clinical pregnancy & its outcome.Predictive factors like age, duration of infertility and Indication for IUI were noted. Clinical Cases or Summary Results: Results: Many pts. were more than 30 yrs of age and duration of infertility was more than 5–10 yrs. The cause for infertility was anovulation (50%), endometriosis (20%), male factor infertility(20%) and unexplained infertility in 10% patients. 50% had single live births,20% of them had multiple pregnancy, another 20% had miscarriages,6% of them had ectopic pregnancy and 4% of them had heterotropic pregnancy.The overall clinical pregnancy & live birth rates were satisfactory. Conclusions: Discussion:Our results indicate that COH/IUI is an effective option in couples with infertility. Prolonged duration of infertility is associated with decreased success & should be considered while planning treatment. Conclusion:Though we had miscarriages, multiple gestation, ectopic pregnancy and heterotropic pregnancies

266 in our study, IUI is still a boon for patients with infertility since it is cost effective when compared to IVF techniques. Keywords: infertility, iui, controlled ovarian stimulation, multiple gestation Presenter: Dr. M. Vijayasree

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ID 695

THE SEVERE COMPLICATIONS AND OUTCOMES OF 5 PREGNANCIES IN PATIENTS WITH CIRRHOTIC PORTAL HYPERTENSION A. Lupascu The Institute of Mother and Child Care, Chishinau, Republic of Moldova. Brief Introduction: Pregnancy is a rare event in patients with cirrhotic portal hypertension (CPH), but in cases when this occure, it can cause a great number of severe complications. We report the management of variceal hemorrhage from esophageal varices (EV) during pregnancy and its outcomes. Materials & Methods: The subjects of the present report were five pregnant women (mean age-30.3 ± 1.4) with posthepatitis (HCV, HBV) liver cirrhosis and high-risk of EV. Two with bleeding varices and the other three with varices- grade II-III, with high risk for bleeding, who uderwent endoscopic band ligation (EBL), by applying of bands and complete EV eradication had been obtained. EBL has been carried out with MBL-6 or MBL-10(Wilson-CookÕ , Winston-Salem, NC, USA). EBL was performed at 27,6 ± 4,2 weeks gestation.The severity of liver disease was classified: A/B/C-1/3/1, the mean score on admission (functional liver class Child-Pugh) was 9,3. Clinical Cases or Summary Results: Characteristics of EBL were: total sessions-3, mean(s.d.) rubber band consumption-4.3(0.8). The complete EV eradication was obtained in all patients with zero episodes of EV bleeding. The patients underwent delivery by cesarean section in three cases (N = 3) and per vias naturalis in two cases (N = 2), with an elective-assisted second stage. There was 1 maternal death in the postpartum period due to fulminant hepatic failure.The mean weight of new born babies was 2386 ± 636g, the mean Apgar score was 7,8 ± 1,8. Conclusions: Treatment of EV during pregnancy is a rare and serios clinical dilemma especially in endemic zone. Initial experience demonstrated that EBL appears to be a useful treatment for pregnant women with EV. The mode of delivery is based on case-by-case principles. If eradication of varices is completed before term, may be allowed vaginal one, with an elective-assisted second stage, in apsence of obstetrical complications. For patients with high risk EV an elective cesarean section should be offered as a mode of delivery. In case of deterioration of hepatocellular function in pregnant women with PH, the outcomes may be catastrophic for mother and baby Keywords: cirrhotic portal hypertension, from esophageal varices, high risk pregnancy Presenter: Aliona Lupascu

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

ID 837

INTRAPARTUM ULTRASOUND ASSESSMENT OF FETAL SPINE IN POSTERIOR OCCIPUT POSITION CAN PREDICT THE OCCIPUT POSITION AT BIRTH AND IMPROVE THE MANAGEMENT OF DELIVERY? S. Gizzo, M. Noventa, S. Di Gangi, G. Burul, D.L. Righetto, C. De Santis, D. D’Antona, & E. Cosmi Department of Woman and Child Health, University of Padua, Padua, Italy. Brief Introduction: In obstetrical practice, pregnant women with OPP foetuses present prolonged second stages of labour, higher rates of episiotomy and severe perineal lacerations, mainly owing to the higher rates of instrumental delivery and increased risks of Caesarean section (CS) by nearly 4-fold. Aim of the study was to investigate the role of foetal-spineposition in the first and second labour stages to determine the probability of OPP detection at birth and the related obstetrical implications. Materials & Methods: We conducted an observational-longitudinalcohort-study (December-2011/August-2013) on uncomplicatedcephalic-single foetus-pregnant women at term. We considered as main-outcome-measures: accuracy of ultrasound in predicting occiput-position at birth, influence of fetal spine in occiput-position during labour, labour trend, epidural analgesia request, type of delivery and indication to caesarean section (CS). Clinical Cases or Summary Results: The accuracy of the foetal-spinalposition to predict the occiput-position at birth was high at the firststage of labour. At the second-stage of labour, caesarean-sections (40.3%) and operative-vaginal-deliveries (23.9%) occurred more frequently in OPP than in occiput-anterior-position (OAP) (7% and 15.2% respectively), especially in cases of the posterior-spine. In concordant-posterior-positions labour length was greater than other ones, analgesia request rate was 64.1% versus 14.7% for all the others. Conclusions: The assessment of spinal-position could be useful in obstetrical management and counselling, both before and during labour. The detection of spinal-position, more than OPP, is predictive of successful delivery. In case of posterior-concordant spine and occiput, the labour-length as well as the rate of analgesia-request, operative-delivery and caesarean-section are higher than in the other combination. Keywords: Foetal occiput position, foetal spinal position, intrapartum ultrasound investigation, labour management, obstetrical practice, labour complications. Presenter: Salvatore Gizzo

ID 603

PREGNANCY OUTCOME OF MOTHERS WITH DIABETIC NEPHROPATHY M. Herman, J. Djelmis, M. Ivanisevic, J. Blajic, & V. Starcevic Department of Obstetrics and Gynecology, Clinical Hospital Center Zagreb, Zagreb, Croatia

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DOI: 10.3109/14767058.2014.924236

Brief Introduction: Diabetic nephropathy increases the risk of developing hypertension/preeclampsia in diabetic mothers. It is also closely associated with higher perinatal morbidity and mortality rate. The aim of the study was to investigate: (1) incidence of diabetic nephropathy in pregnant women with type-1 diabetes mellitus, (2) frequency of hypertension/preeclampsia in mothers with diabetic nephropathy, (3) perinatal outcome in mothers with diabetic nephropathy. Materials & Methods: During the period 2004 to 2011 retrospective analyses of 396 pregnant women with type-1 DM was performed. All patients were divided in five groups: I. pregnancies with type-1 DM without complications (309; 78%), II. pregnancies with type-1 DM and non proliferative retinopathy (n = 29; 7.3%), III. pregnancies with type1 DM and proliferative retinopathy (n = 23; 5.8%), IV. pregnancies with type-1 DM and peripheral neuropathy (n = 5; 1.3%), and V. pregnancies with type-1 DM and diabetic nephropathy (n = 30; 7.6%). Clinical Cases or Summary Results: Incidence of diabetic nephropathy was 7.6%. Hypertension/preeclampsia was developed in 14 (47%) of all pregnant type-1 DM patients with diabetic nephropathy, and only in 12% of type-1 DM patients without any complications of diabetes. When the groups were compared for age, height, body weight, gained weight during pregnancy, body mass index, HbA1c values and acid base status of umbilical vein after statistical analyses was found no significant difference. The significant statistical difference was found among diabetic mothers without complications of diabetes and those with diabetic nephropathy when compared to gestational age at delivery, new borns weight and ponderal index. In the group of mothers with diabetic nephropathy preterm delivery rate was significantly higher than in mothers without complications of type-1 DM (p = 9.035). Among the mothers with type-1 DM without complications perinatal mortality was 2.8%, and in type-1 DM mothers with diabetic nephropathy perinatal mortality was 0%. Conclusions: Diabetic nephropathy is a serious complication of DM and pregnancies of mothers with such complications have to be closely monitored in order to achieve such good perinatal outcome. Keywords: type-1 diabetes mellitus, diabetic nephropathy, hypertension, preeclampsia, perinatal outcome Presenter: Mislav Herman

ID 782

IMPROVING USE OF OXYTOCIN DURING THE THIRD STAGE OF LABOUR: DATA ON FEASIBILITY AND ACCEPTABILITY OF USING OXYTOCIN IN THE UNJECT DEVICE FROM STAKEHOLDERS IN GHANA S. Khan1, P. Cofie2, C. Tawaiah3, & S. Chritz1 1

Maternal Child Health and Nutrition Program, PATH, Seattle, U.S.A, 2PATH Ghana, Accra, Ghana, and 3Kintampo Health Research Center, Kintampo, Ghana Brief Introduction: Postpartum hemorrhage (PPH) is a major contributor to maternal mortality and morbidity in low resource settings. Uterotonics during the third stage of labour can prevent up to 60% of all PPH cases. To date, the World Health Organization continues to recommend oxytocin as the drug of choice for PPH prevention. However its heat sensitivity and route of administration often serve as a barrier in low resource settings. Oxytocin in the Uniject (TM) device with a Time Temperature Indicator (TTI) circumvents some of these issues. It is a single use, pre-filled auto-disable device which can be administered by minimally trained providers. The TTI changes colour upon cumulative exposure to heat and light, indicating that the drug can no longer be used.

Materials & Methods: This paper presents results from a qualitative research study nested in a trial assessing the acceptability and feasibility of Oxytocin in the Uniject (TM)- (OiU) device in Ghana. In-depth interviews and focus group discussions were conducted with providers and administrative managers to assess their views on benefits, barriers, and challenges to the use of OiU. We also assessed feasibility of OiU use in terms of human resources, health system, and logistic requirements and the ‘‘fit’’ of the product in current systems. We interviewed 40 providers and 14 district managers who were part of the study. Focus group discussions were also conducted with women who received OiU regarding their experience. Data were transcribed and analyzed by themes corresponding to study objectives. Clinical Cases or Summary Results: Providers mentioned ease of use, time savings and safety as some of the major benefits of Oxytocin in Uniject (TM). They felt that it improved the quality of intrapartum care provided and was particularly beneficial in delivery settings where a single provider attended to both mother and newborn. Facility managers mentioned reduction in volumes of waste generated and safety as some of the key benefits of OiU. Both providers and managers in both settings saw major benefits to scaling up use of device in their countries. Women in the study saw clear benefits in termed of improved intrapartum surveillance Conclusions: Oxytocin in the Uniject (TM) device has significant potential to improve prophylactic uterotonic coverage, especially at home births. It was found to address many of the concerns around use of oxytocin in the periphery and was acceptable to providers and women in this setting and viewed by managerial staff as being amenable to inclusion in current systems and procedures. Keywords: Postpartum hemorrhage, Oxytocin, third stage of labour, Prophylactic uterotonic Presenter: Sadaf Khan

ID 564

PUERPERAL UTERINE INVERSION: EXPERIENCE IN OUR CENTRE R.I. Monfort, T. Lozoya, L. Rubert, J. Renard, V.J. Diago, & A.J. Perales HUP La Fe, Valencia, Spain Brief Introduction: Puerperal uterine inversion is a severe and infrequent complication whose incidence, pathogenesis and recurrence are not well defined. Its early diagnosis and management are decisive, and it can have complications such as hypovolemic and/or neurogenic shock and death. Our objective was to assess the incidence, evolution and risk of recurrence in cases of puerperal uterine inversion in our hospital. Materials & Methods: Retrospective study. We have had 22 cases of puerperal uterine inversion from January 1993 to December 2013 (incidence 0.03%) in our hospital. We analyze the different risks. Clinical Cases or Summary Results: Patients: Medium age: 28,8 years (18–41). 19 nulliparous (86%). 3 previous cesarean sections, 1 previous miomectomy. 1 case of arcuate uterus. Labour: 5 elective cesarean sections (23%), 8 spontaneous deliveries (36%) and 8 instrumented deliveries (36%), 1 cesarean because of failed induction. Medium weight of newborns: 3111 grams (2130– 3950). 8 cases of placenta accreta (36.4%) and 3 patients with uterine atony (13.6%). Uterine inversion: 100% acute. Grade 2: 11 cases (50%); grade 3: 11 cases (50%). Complications and management: Hemorrhage in 7 patients, which needed blood transfusion. Initial management: Johnson procedure and coloides; 8 patients required myorelaxants. 2 hysterectomies (9%). There were no deaths.

268 Recurrence: 4 patients had another pregnancy, no recurrences. Gestations with normal course and delivery. Conclusions: Main risk factors in our study: nulliparity and placenta accreta (as some authors say). There were no cases of cord traction and short cord (a potent risk factor in the literature). The was 1 case of arcuate uterus, suggesting that mullerian malformations could be a risk factor. Earliness in diagnosis and treatment is very important. 91% of patients were resolved through initial procedures +/ uterine relaxants. Surgery should be the last option in cases of persistent hemorrhage. In our patients, the risk of recurrence was not increased in subsequent pregnancies. Keywords: hemorrhage, puerperal uterine inversion, Jonhson procedure

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Presenter: Vicente Jose´ Diago Almela

ID 053

CONGENITAL ABNORMALITIES IN NEWBORN OF WOMEN WITH PRE-GESTATIONAL DIABETES M.M. Agha, R.H. Glazier, R. Moineddin, A.M. Moore, & A. Guttmann

Brief Introduction: Pregnancy in women with diabetes mellitus is associated with an increased risk of congenital malformations. More than 20 years ago, Europe countries signed a declaration agreed on a goal ‘‘Achieve pregnancy outcome in the diabetic woman that approximates that of the non-diabetic. The objective of the current study is to compare the trend over time of prevalence of congenital abnormalities among women with and without diabetes, and to explore the impact of food fortification in Ontario on the rate of congenital abnormalities in general and NTD and congenital heart defects in specific, among pregnancies in women with diabetes. Materials & Methods: This study was based on the follow-up of all children born in hospital in Ontario, Canada during 1994–2007. Children unique identifier were linked back to their hospitalizations during their first year of life and those who had diagnosis of Congenital Anomalies were identified. Mothers’ health card numbers were also linked to Ontario Diabetes Data set in order to identify the date of diagnosis of pre-gestational diabetes in mothers. Clinical Cases or Summary Results: The birth prevalence of all anomalies combined is about 44% higher among children born to mothers with diabetes, this ratio observed minor fluctuation during the study period. While the gap between two groups of mothers remained unchanged for heart defects, the prevalence of brain defects among children born to mothers with diabetes observed a sharp decline. In spite of increase in the number of children born to mothers with diabetes, the relative risk for having a child with birth defect remained stable during the study period. We observed a sharper decline in the prevalence of congenital abnormalities among children born to mothers with diabetes after 1999 (when food fortification started in Ontario) For NTD, the declined we observed among diabetic pregnancies was considerably sharper than non-diabetic births, (70% vs. 40% after 1999). Conclusions: Result of this study indicates that, due to increasing trend in the incidence of diabetes, we need to be more active and aggressive in implementing preventive measures, including developing and implementing a national diabetes plan in each country (ref) or the proposed universal policy of supra-dietary folic acid supplementation (ref) for women with diabetes who are of reproductive age.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Keywords: Presenter: M. M. Agha

ID 190

AN AUDIT TO INVESTIGATE THE NUMBER OF CUT UMBILICAL CORD LENGTHS OF TERM NEONATES ON A TYPICAL POSTNATAL WARD THAT WOULD BE SUITABLE FOR CATHETERISATION R. Hayward Neonatal Unit, Royal Gwent Hospital, Newport, South Wales, UK Brief Introduction: The potential need for resuscitation in neonates delivered in good condition and transferred to the postnatal ward is unpredictable. A recent publication reports that 38% of NNU admissions over 12 months were term infants (11% requiring intensive care) [1]. Currently there are no midwifery or obstetric guidelines on the length umbilical cords should be clamped and cut at delivery. In seemingly healthy (term) babies who become acutely unwell on the postnatal ward, inadequate cord lengths may limit the options available for central access and delay resuscitation. In Neonatal practice, APLS guidelines advise trimming umbilical cords to 1–2 cm before insertion of an umbilical catheter [2]. This requires the provision of a clamped cord length of greater than 2 cm following delivery. Materials & Methods: This audit aimed to determine the number of cut umbilical cord lengths on a typical postnatal ward that would be suitable for umbilical catheterisation (in accordance with APLS guidelines). 100 cut cord lengths were measured (from skin to the base of the cord clamp) during routine examinations conducted on term infants on the postnatal ward. Clinical Cases or Summary Results: The mean gestational age of neonates examined was 40 + 1 weeks with a mean weight of 3.46 kg. The average cut cord length was 1.56cm. 46% of neonates on the postnatal ward had cut umbilical cord lengths suitable for catheterisation following APLS guidelines. However, this result assumes that catheterisation is uncomplicated and is successful at the first attempt. Only 26% of neonates had cut cord lengths that would enable further attempts and more complex ‘cut-down’ procedures. Conclusions: Whilst it is hoped that neonates delivered in good condition and transferred to the postnatal ward will not become compromised, the potential need for resuscitation is unpredictable. Considering the increased number of term neonates being admitted to neonatal units each year, it is proposed that a minimum standard cut umbilical cord length (of at least 2.5cm) is agreed with Obstetric and Midwifery professional bodies. This would ensure provision of an adequate cord length for central access, monitoring and/or sampling by the neonatal team in compromised term neonates and optimise successful catheterisation at the first attempt during resuscitation. Keywords: term infant, cord length, resuscitation, umbilical catheterisation Presenter: R. Hayward

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ID 743

EXPERIENCE OF RECOMBINANT HUMAN SOLUBLE THROMBOMODULIN MONOTHERAPY IN OBSTETRICAL DISSEMINATED INTRAVASCULAR COAGULATION Y. Nakajima & N. Masaoka

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Department of Obstetrics and Gynecology, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba, Japan. Brief Introduction: OBJECTIVE: To investigate the efficacy of recombinant human soluble thrombomodulin (rTM) monotherapy in obstetrical disseminated intravascular coagulation (DIC). Materials & Methods: PATIENTS AND METHODS: We conducted a retrospective review of 22 patients with obstetrical DIC. The first 12 patients were treated gabexate mesilate (FOY) monotherapy without rTM (control group), and the next 10 consecutive patients were treated with rTM monotherapy. Clinical parameters including bleeding symptoms and coagulation indices were evaluated. Blood transfusion therapy including FFP, RCC and platelet concentrate were included, however, AT (antithrombin) concentrate therapy was excluded from the subjects. Clinical Cases or Summary Results: RESULTS: Baseline characteristics and total blood loss were similar between the two groups. The levels of D-dimer and fibrinogen degradation product (FDP) were significantly higher in the rTM group than in the FOY group. During and after the treatment, the changes in platelet, D-dimer, FDP, fibrinogen, and AT activity were significantly improved in both groups. These hematological findings were not significantly different between the 2 groups. No adverse events were observed in the both groups. Conclusions: CONCLUSION: Recombinant human thrombomodulin monotherapy may be an effective adjunctive therapy in the management of obstetrical women with DIC. Keywords: human soluble thrombomodulin, obstetrical DIC Presenter: Y. Nakajima

ID 560

RISK FACTORS OF DISCONTINUE BREASTFEEDING OF HELTHY TERM INFANTS B. Krolak-Olejnik1 & G. Bogdał2 1

Neonatology Dept. University Hospital Wrocł aw, and Regional Hospital Zawiercie, Poland

2

Brief Introduction: The breastfeeding is the newborns’ and infants’ optional method of nutrition recommended by WHO, AAP and ESPGHAN. Improving breastfeeding rates is an important part of global health policy and also in Polish legislation. The strategy is achieved through implementation of practices encouraging lactation in maternity hospitals and through various forms of support for breastfeeding mothers at home. Materials & Methods: The aim of the study is a multiple factor analysis of: – the method of newborns and infants nutrition in the first half-year period of living,

– discontinue breastfeeding by women, taking into account maternity factors Clinical Cases or Summary Results: A half-year observation of nutrition methods (natural, mixed, artificial) of newborns showed a serious decrease a proportion of mothers who exclusively breastfeed their babies (from 61.2% in the ward to 19.4% in the 5–6th months to live. Women delivered vaginally more often (68.7%) exclusively breastfed their baby than women delivered to caesarean section (51%) during hospitalization at maternity unit – OR 2,1 95% Cl(1,3–3,4). Multiparous women breastfed longer than primipara ones - OR 2,0 95% Cl(1,1–3,5). Newborn birth weight had a statistically significant influence on the type of feeding. Mothers who gave birth before time had almost 2 fold less breastfed than mothers with ‘‘in time’’ delivery not only in the ward but also in the next months. Mother’s age had statistically radical influence on breastfeeding and mixed feeding only in the ward. Conclusions: In the study population 97.8% infants was breastfed but 36.2% of mothers supplemented the baby with formula in maternity unit, and up to 6 months 56.8% mothers breastfed, but up 37.2% of them used mixed feeding (breastfeeding and formula). Cesarean section, preterm delivery, primipara and young maternal age, were the risk factors of discontinue of breastfeeding. Initiation and maintain of breastfeeding depends on a number of determinants some of which may be modifiable but we must know and remember them. Keywords: breastfeeding, risk factors, newborn infants Presenter: Barbara Krolak-Olejnik

ID 878

PREGNANCY IN WOMEN WITH MULTIPLE SCLEROSIS G. Daskalakis, N. Papantoniou, E. Domali, M. Theodora, P. Antsaklis, M. Sindos, S. Mesogitis, & D. Loutradis 1st Department of Obstetrics and Gynecology, Athens University, Athens, Greece Brief Introduction: Multiple sclerosis (MS) is an inflammatory disease of the central nervous system which leads to demyelination and axon degeneration. The disease is more common in women and its onset is usually in the young age, with an occurrence of about 2–150 per 100,000. During pregnancy the symptoms usually remain stable or improve, with a higher relapse rate in the post-partum period. Materials & Methods: During the last 2-year period we managed 9 cases of pregnancy in women with MS. Clinical Cases or Summary Results: The mean maternal age was 30 years and five of them were nulliparas. In all cases the disease was at remission before pregnancy. One woman received steroid treatment due to relapse of symptoms at 28 weeks, while another terminated her pregnancy at 15 weeks due to severe neurologic disability with dissemination of thoracic muscles. All women delivered at term, normally grown infants. Four of them gave birth vaginally, while the 5 others with an elective cesarean section. In all but one cases immunoglobulin treatment was given for 2 to five days in the immediate post-partum period. Conclusions: Our results are in accordance to that of the literature and showed that uncomplicated MS cases have no adverse effect during pregnancy in the vast majority of cases. However, women with MS should be informed about the need to complete their family the sooner they can because of the progressive nature of the disease. Keywords: pregnancy, multiple sclerosis, outcome Presenter: G. Daskalakis

270

ID 082

SELF-INSTRUCTIONAL INFANT CPR TRAINING FOR EXPECTANT WOMEN AND THEIR PARTNERS: AN EVALUATION M. Barry

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Dept. of Nursing and Midwifery, University of Limerick, Limerick, Ireland Brief Introduction: In Ireland as in other parts of Europe infant CPR training is not provided routinely to expectant and new parents of term infants. Training those most likely to encounter an infant increases the possibility of survival.Objectives: Assess parents’ knowledge of infant CPR prior to, and on completion of, skills training. Assess parents use and satisfaction with the self-instruction kit Infant CPR Anytime. Evaluate the medium term impact of infant CPR skills training on parents’ knowledge. Materials & Methods: A survey design was used to evaluate expectant parents’ knowledge, satisfaction and use of the self-instruction kit Infant CPR Anytime prior to, and immediately following, and six months after infant CPR training. The 22 minute self- instruction DVD and infant manikin was developed by Laerdal Medical and American Heart Association 2011. Inferential statistics were used to determine difference in knowledge at the 3 time-points. Attendees at antenatal classes were recruited from one maternity service in Ireland. Participants included women who were 32 weeks gestation or greater with their partner or support person. Clinical Cases or Summary Results: 42 women expecting their first baby with 33 partners and 2 support persons took part in the study. 33 women and 25 partners returned questionnaires at 6 months indicating a response rate of 70%. Findings indicated a significant difference with knowledge scores pre and post training (z = -7.604 p =50.0001) Pre training and Follow on (z = -5.781 p =50.0001) post training and follow on (z = -5.874 p =50.0001). Effects of training on confidence in giving Infant CPR was 84% at average confidence or above at 6 months. 37.9% of participants reported that others had used their kit. 98.3% recommended that the maternity service should facilitate infant CPR anytime training for expectant women and their partners. Conclusions: Infant CPR training should be facilitated for expectant women and their partners within the Maternity Service. Keywords: Expectant women Infant CPR training Partners Presenter: Maebh Barry

ID 540

THE ASSOCIATION BETWEEN PREGNANCY-RELATED DISCOMFORTS AND PREPREGNANCY BODY MASS INDEX

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Research indicates that a woman’s body mass index (BMI) before pregnancy is important for predicting the occurrence of conditions such as gestational diabetes and thus improve pregnancy outcomes, but the relationship between BMI and pregnancy-related discomforts is not well known. This study aimed to investigate the association between pregnancy-related discomforts and pre-pregnancy BMI. Materials & Methods: We collected the personal information (i.e., age, height, and pre-pregnancy weight) of pregnant women using a questionnaire. We investigated the prevalence of pregnancy-related discomforts experienced during the second and third trimesters. According to their pre-pregnancy BMI, participants were divided into three groups: low BMI group, normal BMI group, and high BMI group. We used a binomial logistic regression analysis to examine the association between each discomfort and the participant’s prepregnancy BMI for each trimester. The presence of each discomfort was a dependent variable, whereas age, low BMI, and high BMI were independent variables, with normal BMI as a reference. Clinical Cases or Summary Results: We included information from 355 women (31.14 ± 4.05 years, pre-pregnancy BMI = 20.34 ± 2.13 kg/m2) between 16 and 40 weeks of gestation. We assigned 37 women to the low BMI group, 246 to the normal BMI group, and 72 to the high BMI group (BMI = 17.4 ± 0.6, 19.8 ± 1.0, and 23.5 ± 1.8 kg/m2, respectively). Based on multivariate analysis, pre-pregnancy BMI was significantly correlated to some discomforts. The prevalence of pain at the hip joint and pubis was significantly higher in the high BMI group than in the normal BMI group during the second trimester(odds ratio/95% confidence interval = 2.38/0.41–3.94).The prevalence of sleeping difficulty (2.00/1.08–4.82), stiffness in the hand or finger (3.00/0.51– 5.09), leg cramps (2.29/0.50–2.40), low back pain (2.20/0.99–3.98), pain at the hip joint and pubis (2.14/0.94–4.03), and shoulder stiffness or headache (2.01/0.69–3.86) were significantly higher in the high BMI group than in the normal BMI group during the third trimester (p50.05).The prevalence of shoulder stiffness or headache was significantly higher in the low BMI group than in the normal BMI group during the second trimester (odds ratio/95% confidence interval = 2.84/1.35–5.96).The presence of constipation was significantly higher in the low BMI group than in the normal BMI group during the third trimester (2.28/1.08–4.82) (p50.05). Conclusions: In this study, we found that pre-pregnancy BMI was related to some pregnancy-related discomforts. Most pregnant women are either prohibited from or avoid taking non-prescribed medicines because of potential adverse effects on the developing fetus. Therefore, preventing potential discomforts before pregnancy is necessary. It is important for women to maintain an appropriate BMI before pregnancy to prevent various pregnancy-related discomforts. Keywords: pregnancy, discomforts, body mass index Presenter: Saori Morino

ID 717

PREGNANCY AND MULTIPLE SCLEROSIS I. Rato, D. Pereira, C. Arau´jo, M. Centeno, L. Pinto, L. Grac¸a 1

1

Obstetrics Dept., CHLN-Hospital de Santa Maria, Lisbon, Portugal, 2Obstetrics Dept., Centro Hospitalar Barreiro Montijo, Barreiro, Portugal, and 3Faculdade de Medicina da Universidade de Lisboa, Obstetrics Dept., CHLN-Hospital de Santa Maria, Lisbon, Por

Brief Introduction: During pregnancy, various discomforts can have adverse effects on a pregnant woman’s quality of life.

Brief Introduction: Multiple sclerosis (MS) is a central nervous system inflammatory demyelinating disease causing disability in young adults. The majority of patients are women of childbearing age, making pregnancy-related issues a key concern. OBJECTIVE To analyze obstetrical outcomes and the influence of pregnancy on the progression of the disease in women with multiple sclerosis.

S. Morino1, M. Ishihara2, M. Yamada3, M. Yamashita2, & T. Aoyama1 Department of Physical Therapy, Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan, 2 Kishokai Medical Corporation, Nagoya, Japan, and 3 Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan

271

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DOI: 10.3109/14767058.2014.924236

Materials & Methods: Retrospective study of pregnant women with MS surveilled at our Maternal Fetal Unit in the years of 2012 and 2013. Data were obtained by consulting clinical records. In order to assess the influence of pregnancy on the activity of the disease we evaluated disability progression and the occurrence of post-partum relapse. We also evaluated pregnancy complications, mode of delivery, analgesia during labor, perinatal outcomes and breastfeeding. Clinical Cases or Summary Results: 10 pregnant women were included in our study: one woman asked for medical termination of pregnancy because of the agressive evolution of the disease. Six women were medicated with immunomodulatory therapy which was discontinued before pregnancy. Three patients were not submitted to any medication during pregnancy; around 35th week of gestation, 4 women started glatiramer acetate, 1 started Fingolimod and 1 intravenous immunoglobulin. Relapse during pregnancy occurred in 1 woman without medication. Eight women had a vaginal delivery (6 spontaneous vaginal deliveries, 2 instrumental vaginal deliveries) under epidural analgesia, and 1 had a cesarian section due to obstetrical reason (placenta previa)under general anesthesia. There were no neonatal complications registered. All of the women breastfed. One woman - who was under treatment with Immunoglobulin and who was submitted to a C-section – experienced a post partum relapse in the first six months after delivery. Conclusions: Our results are concordant with the literature in that pregnancy does not seem to worsen the natural history of MS. Although puerperium is described as the period of higher risk for disease exacerbation, in our small series the rate of relapse during pregnancy and in the post-partum were similar. Keywords: Multiple sclerosis Presenter: I. Rato

FGFR1 and moderate number of bFGF positive cells in embryonic tissue. Despite cartilage proliferation zone, ossification centres and chondrocytes, numerous or moderate number of NGF positive structures were found in all embryonic tissue. NGFRp75 was abundant on nerve fibres, muscle fibres and endotheliocyte plasmatic membranes. We found IGF-1 and IGF-1R positive cells in all human embryo tissues. HGF was widely distributed in embryonic epithelium, mesenchyma and nerve system. We found numerous synaptophysin positive cells in embryonic nerve system, spinal ganglia and in some blood vessels surrounding connective tissue cells. Chromogranins A and B containing granules were found in cytoplasma of spinal ganglionar cells of 5–12 gestation weeks embryos. We found GFAP positive cells to be localised in spinal ganglia, nerve tube ependimal and mantle layer and in motor neurones. Embryonic stratified epithelium expressed CK 5 and CK 13. Apoptotic cells were found in all embryonic tissue. Apoptotic index in skin, kidney, digestive and respiratory epithelium was 78%. Moderate apoptotic cells number was discovered in embryonic liver and in internal organ differentiating mesenchyma, meninges, perichondrium, ossification centres. Extraembryonal mesenchyma demonstrated a moderate number of apoptotic cells. Conclusions: TGF beta 1, IGF-1, IGF-1R, bFGF, FGFR1, NGF, NGFRp75, HGF, are widespread in human embryo tissue from 5/6 to 12 embryonic development week and take part in embryogenesis. Apoptosis is a widespread process, distributed in 5/6–12 gestation weeks old embryo tissue, involved in tissue remodelling and differentiation. Human defensin beta 2 innate response starts at 5/6–12 gestation weeks. GFAP is a nerve tissue progenitor cells both glial and neurons marker, synaptophysin provides CNS cell contacts forming, but chromogranin A and B are involved in neiropeptide (synaptophysin) synthesis 5/6–12 gestation weeks. Human embryo stratified epithelia express CK 5 and CK 13, that testify early fenotyping of epithelial tissue.

ID 138

Keywords: embryo, growth factors

GROWTH FACTORS AND APOPTOSIS APPEARANCE IN HUMAN EMBRYO

Presenter: Miskova Anna

A. Miskova1, M. Pilmane2, & D. Rezeberga3

ACCURATE ULTRASOUND IMAGING OF THE SURFACE OF A FETUS USING A BROAD ULTRASOUND BEAM

1

ObGyn Dept., Riga Stradins University, Riga Maternity Hospital, Riga, Latvia, 2Morphology Dept., Anatomy and Anthropology Institute, Riga Stradins University, Riga, Latvia, and 3ObGyn Dept., Riga Stradins University, Riga Maternity Hospital, Riga, Latvia Brief Introduction: Embryo implantation is a complicated process involving mother and conceptus cells differentiation, proliferation and invasion that are essential for successful pregnancy. Growth factors control proliferation, migration and differentiation of cells, but appropriate gene expression regulates embryo development. There are lack of data on growth and transcriptional factors distribution in ectopic and uterine implantation tissue. Materials & Methods: Human embryo tissue were obtained from 10 patients who terminated unplanned pregnancy (5/6–12 gestation weeks) with informed consent. We used immunhistochemical method for determination of TGF beta1, IGF-1, IGF-1R, bFGF, FGFR1, NGF, NGFRp75, HGF, human defensin beta 2, caspase 6, CK 5 and CK 13. The TUNEL method was applied for determination of apoptotic cells. The distribution of these factors was detected semi quantitatively: 0/occasional positive structure in visual field, + few positive structures in visual field, ++ moderate number of positive structures in visual field, +++ numerous positive structures in visual field.The data were analysed by nonparametric rank analysis with SPSS Statistic 17 software. A Mann-Whitney U test was used as appropriate for evaluation of significant differences. A p value 50.05 was considered to be statistically significant. Clinical Cases or Summary Results: Embryonal tissue demonstrated abundant TGF beta 1 immunreactivity. We discovered numerous

ID 433

H. Taki, S. Tanimura, T. Sakamoto, T. Shiina, & T. Sato Kyoto University, Kyoto, Japan Brief Introduction: Three-dimensional (3-D) ultrasonography has a potential to examine fetal anatomy. In this study, we propose an ultrasound imaging method using a broad beam to depict the surface of a fetus accurately and safely. Materials & Methods: The proposed imaging method is based on Range Point Migration (RPM) method that has been reported to depict high spatial-resolution images in radar imaging. In this study, we used a broad ultrasound beam of a 10-degree beam width to improve the safety of the 3-D ultrasonography, where the center frequency was 2 MHz. We applied the proposed method to a fetal phantom, and compared the image of the fetal surface depicted by the proposed method and that depicted by a 3-D digitizer, where the 3-D digitizer can depict an accurate image of a target surface using an optical measurement technique. Clinical Cases or Summary Results: Fig. 1 shows the surface of a fetal phantom acquired by a 3-D digitizer. Red broken line shows the measurement plane depicted by the proposed method. Fig. 2 shows the image depicted by the proposed method in the measurement plane, where the red broken lines indicate the fetal surface depicted

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Table 1. Cytogenetic findings in individuals with a major chromosomal anomaly Chromosomal anomalies Reciprocal translocation

Fig. 1. Surface of a fetal phantom acquired by a 3-D digitizer. Red broken line shows the measurement plane depicted by the proposed ultrasound imaging method.

Robertsonian translocation

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Chromosomal inversion Gonosomal mosaicism

Female carriage

Male carriage

46,XX,t(4;12)(p14;q24.3)

46,XY,t(3;11)(q22;q22)

46,XX,t(9;16)(q22.1;p11.1) 46,XX,t(10;18)(q11;q11) 46,XX,t(5;8)(q15;q21.2) 46,XX,t(9;20)(q21;p11.2) 46,XX,t(1;14)(q21;q32) 45,XX,rob(13;14)(q10;q10)

46,XY,t(3;5)(q12;p12) 46,XY,t(3;11)(q21;q22) 46,XY,t(5;10)(q24;p15.3) 46,XY,t(8;22)(q22;q13) 45,XY,rob(13;14)(q10;q10)

45,XX,rob(13;14)(q10;q10) 45,XX,rob(13;14)(q10;q10) 46,XX,inv(12)(p11.2;q14) 46,XY,inv(12)(p11.2q13) 46,XX,inv(8)(p12q24) 47,XXX [3]/46,XX [47]

No male carrier

45,X[5]/46,XX[45] 45,X[5]/46,XX[45] 45,X[3]/46,XX[50] 45,X 3]/46,XX47] 47,XXX[4]/46,XX[46] 47,XXX[2]/46,XX[46] 45,X[3]/46,XX[47] 45,X[3]/46,XX[47] 45,X[3]/46,XX[47]

Fig. 2. Ultrasound image depicted by the proposed method. Red broken lines show the surface of a fetal phantom depicted using the data acquired by a 3-D digitizer.

using the data acquired by a 3-D digitizer. The root-mean-square distance of the surface depicted by the proposed method from the surface depicted by a 3-D digitizer was 0.062 mm. Conclusions: This study shows the high potential of the proposed method in depicting an accurate image of a fetal surface by using a broad ultrasound beam, indicating the possibility that the proposed method may improve the imaging performance and safety in 3-D ultrasonography.

Table 2. Distribution of chromosomal anomalies according to gender

Chromosomal anomalies Reciprocal translocation Robertsonian translocation Chromosomal inversion Gonosomal mosaicism Total

Female, n (%) 6 3 2 10 21

Male, n (%)

(21.43) (10.71) (7.14) (35.71) (75)

5 (17.86) 1 (3.57) 1 (3.57) – 7 (25)

Overall total, n (%) 11 4 3 10 28

(39.29) (14.29) (10.71) (35.71) (100)

Keywords: Three-dimensional ultrasonography, fetal imaging, fetal surface, range point migration

Table 3. Prevalence of polymorphic variants in heterochromatin and satellites in 136 couples with recurrent abortions

Presenter: Hirofumi Taki

Polymorphic variants in heterochromatin

No. Patient with CA (%)

1qh+ 9qh+ 16qh+ Yqh+ Inv (9) Total

30 16 23 14 18 101

ID 159

IS CYTOGENETIC SCREENING MANDATORY IN COUPLES WITH A HISTORY OF RECURRENT PREGNANCY LOSS? A. Incebiyik1, H. Akbas2, A. Camuzcuoglu1, N.G. Hilali1, H. Camuzcuoglu1, & M. Vural1 1

Harran University, Faculty of Medicine, Department of Gynecology and Obstetrics, Sanliurfa/Turkey, and 2Harran University, Faculty of Medicine, Department of Medical Biology, Sanliurfa, Turkey Brief Introduction: The aim of this study was to determine whether a parental chromosomal anomaly has an effect on recurrent pregnancy loss (RPL). Materials & Methods: This retrospective study included 720 couples who presented to our clinic with RPL and underwent cytogenetic screening in a 3-year period. Couples with other disorders that can

Polymorphic variants in satellite

(4.17) (2.22) (3.19) (1.94) (2.50) (14.03)

13ps+ 14ps+ 15ps+ 21ps+ 22ps+ Total

No. Patient with CA (%) 6 7 5 9 8 35

(0.83) (0.97) (0.69) (1.25) (1.11) (4.86)

Abrevation: CA: chromosomal aberrations cause RPL, such as uterine anomalies, endocrine diseases and antiphospholipid syndrome, were excluded. Peripheral lymphocyte cultures incubated for 72 hours were used for karyotype analysis via the Giemsa banding technique. Clinical Cases or Summary Results: Of the 720 couples included, a structural chromosome anomaly was detected in 28 (3.89%). Reciprocal translocation carriage (n = 11; 1.53%) was the most commonly detected structural anomaly, followed by X chromosome mosaicism. Chromosomal polymorphisms, which are considered minor chromosomal changes, were detected in 136 individuals (9.44%). Conclusions: These data indicate that cytogenetic screening is an appropriate approach to elucidate the aetiology of RPL. Data from cytogenetic screening can be used in guiding couples planning future

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pregnancies and in prenatal diagnosis of chromosomal anomalies in the foetus. Keywords: Recurrent pregnancy loss, cytogenetic analysis, chromosomal anomaly Presenter: A. Incebiyik

ID 247

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JAUNDICE IN THE NEWBORN – ACCURACY OF CLINICAL JUDGMENT AND THE EXPERIENCE OF A HOSPITAL UNIT J. Cotrim, J. Carvalho, & I. Soares Pediatric Dept, Vila Real Hospital, Portugal Brief Introduction: Hyperbilirubinemia occurs in the majority of newborns, but only 60% develop visible jaundice and approximately 10% require phototherapy. In most hospitals, the request for bilirubin value determinations is based on clinical findings by health professionals. The complete absence of jaundice, as assessed by visual judgement, can be used to predict accurately which infants will not develop pathological hyperbilirubinemia. However, this does not apply to the estimation of serum bilirubin levels in jaundiced newborns and several studies highlight the importance of inter-observer variability in the visual evaluation of jaundice. Materials & Methods: Our objective was to evaluate the accuracy of visual assessment of neonatal jaundice by the pediatrician. To describe admissions in a Newborn Hospital Unit due to jaundice in the newborn. We did a retrospective analysis of records of total serum bilirubin (TSB) measurements, requested by the pediatrician after clinical observation of newborns and we analysed variables related to neonatal jaundice. Clinical Cases or Summary Results: There were 632 TSB measurements requested in 583 newborns due to apparent clinical jaundice. Most TSB requests were made after observation of newborns in the obstetrics department, during hospitalization after birth, which ranged from two to three days. Of 632 requests, 18.8% resulted in hospitalization due to hyperbilirubinemia requiring phototherapy. The highest percentage of positive tests (TSB value requiring treatment) was observed in the emergency department. The majority of newborns admitted for phototherapy was 37 or more weeks of gestacional age and was admitted between the second and fourth days of life. All patients admitted in the first 24 hours of life had known risk factors for hyperbilirubinemia. The most frequent risk factor observed was hemolytic disease. There were no neurological complications of hyperbilirubinemia. Conclusions: Our results confirm that there are limitations of the human eye in assessing neonatal jaundice: visual judgment alone is a poor screening tool. This method resulted in overvaluation of jaundice with excessive TSB determinations, implying the need to collect blood samples and related considerable costs. Thus, predischarge evaluation of neonatal hyperbilirubinemia should result from a combination of assessment of clinical risk factors and noninvasive tools. Delaying hospital discharge may contribute to early detect and manage neonatal jaundice. Keywords: jaundice, newborn, visual assessment, phototherapy Presenter: Joana Cotrim

ID 321

HEREDITARY LONG QT SYNDROME IN PREGNANCY O. Villar, P. Barbero, P. Vallejo, D. Montan˜ez, L. Force´n, JC. Garcı´a, & A. Garcı´a Servicio de Ginecologı´a y Obstetricia, Unidad de Medicina Perinatal., Hospital 12 de Octubre, Madrid; Espan˜a Brief Introduction: Long QT syndrome (LQTS) is a rare but severe cardiac arrhythmia, characterized by prolonged ventricular repolarization and a variable clinical course with arrhythmia related recurrent syncope, aborted cardiac arrest and sudden death. The effect of pregnancy on these patients is not well characterized and the available information is limited to isolated case reports. The optimal medical management is currently unknown. Materials & Methods:. Clinical Cases or Summary Results: We present five pregnant women affected by LQTS. They attended the high risk obstetric consultation and also they were reviewed by a cardiologist. They were offered genetic counseling. All of them were treated with B-blockers (metoprolol 50–100 mg/24h) during pregnancy and puerperium and monitored with ultrasound for growth assessment and Doppler studies. We brought them a list of drugs that prolong the QT interval to avoid them. Three of them had an uncomplicated vaginal delivery and two had a cesarean section (one of them due to arrest of labour; the other cesarean was indicated by premature rupture of membranes without spontaneous labour start and unfavorable bishop score). Oxytocin is a drug that prolongs the QT interval. For this reason some obstetricians tend to perform elective cesarean section in these patients. Also, these patients should avoid the stain associated with labour which could cause arrhythmias. Our Center allows spontaneous vaginal delivery under epidural anesthesia, avoiding (or limiting under close supervision) the use of oxytocin (if high doses or for long periods are suspected to be needed, we usually perform cesarean section). The five pregnancies were successful for the mother and the fetus. Conclusions: A multidisciplinary approach and close obstetric surveillance are mandatory for a good maternal and perinatal outcome. Pregnant women with LQTS should be treated with B-blockers for primary prevention of cardiac arrhythmias. Labor and postpartum are critical periods, and they should continue prophylactic treatment under close supervision. Follow up of the neonate is equally important. Keywords: Long QT syndrome, pregnancy, B-blockers, arrhythmia Presenter: Olga Villar Ruiz

ID 221

ANALYZING THE TRANSCRIPTS PRESENT IN THE AMNIOTIC FLUID SUPERNATANT K.J. Lee, D.H. Cha, & S.W. Lyu Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Korea Brief Introduction: Amniotic fluid is a complex biological material that provides a unique window into the developing human. Residual amniotic fluid supernatant contains cell-free fetal RNA. Amniotic fluid is the only body fluid in direct contact with the the fetal oropharynx, lungs, gastrointestinal tract, skin, and urinary system. The aim of this study is to develop an understanding of AF cffRNA profile of normal fetuses in three different gestational periods, 16  17 weeks (group 1), 25  26 weeks (group 2), and 36  38 weeks (group 3).

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Figure 1. Heatmap showing hierachial clusturing of amniotic Fluid samples.

Table 1. Expression of genes in amniotic Fluid of the group 1 (16W  17W)

Materials & Methods: The total 13 AF samples, 5 of group 1, 4 of group 2 and 4 of group 3, were collected. Total RNA was extracted from 10 mL of the amniotic fluid supernatant using the QIAamp Circulating Nucleic Acid Kit. The extracted RNA was hybridized to GeneChipÕ PrimeViewä Human Gene Expression Array to compare gene expression in amniotic fluid supernatant samples. The data were analyzed with Robust Multi-array Analysis using Affymetrix default analysis settings and global scaling as normalization method.

The normalized, and log transformed intensity values were then analyzed using GeneSpring 12.5. Clinical Cases or Summary Results: In group 1, total 3289 transcripts were identified. We were confirmed 532 transcripts that have been known to be associated with fetal development through a search of pathway analysis software and Medline. We found 1,977 genes to be differentially expressed between group 1 and group 2. Among these genes, 27 genes increased and 1950 genes decreased

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Table 2. Summary of the results of microarray

in group 2. Also, we found 2,039 genes to be differentially expressed in group 3 compared to group 1. 48 out of 2,039 genes increased and 1475 genes decreased in group 3. Conclusions: Our result presented cffRNA profiles in amniotic fluids of pregnant women with normal fetal development in three different gestational periods. This study might contribute to the further studies for the discovery of biomarkers for abnormal fetal growth. Keywords: amniotic fluid, cell free fetal RNA Presenter: K.J. Lee

ID 083

IMMUNOHISTOCHEMICAL ANALYSIS OF NESTIN, CD34 AND TGFB3 IN CLEFT LIP AND PALATE

were detected semiquantitatively. The nonparametric Mann–Whitney test was used for statistical analysis (p  0.05). Clinical Cases or Summary Results: Moderate to abundance number of nestin immunoreactive structures were observed in the oral mucosa. CD34 antibodies labeled all endothelial cells in blood vessels in lamina propria of the CLP affected tissue, while TGFb3 marked rare positive cells scattered in the connective tissue. There was no significant difference in mean between the study groups. Conclusions: Prominent expression of nestin in complete unilateral and bilateral cleft lip and palate affected soft tissue indicates a possible increase of tissue regeneration. CD34 positive oral mucosa cells proves the increase of angiogenesis in CLP patients, while the sporadic expression of TGFb3 proves its role in the cleft morphopathogenesis. Keywords: Cleft lip and palate, CD34, nestin, transforming growth factor b3 Presenter: L. Smane

L. Smane1, M. Pilmane1, & I. Akota2 1

Riga Stradins University, Institute of Anatomy and Anthropology, Department of Morphology, Riga, Latvia, 2Riga Stradins University, Institute of Stomatology, Riga, Latvia Brief Introduction: Cleft lip and palate (CLP) is among the most common congenital anomaly that arises in the early development. It occurs in 1:600 children in the European population and correction involves prolonged treatment over many years (Mossey et al., 2012). Acute wound healing involves four phases including hemostasis, inflammation, proliferation, and remodeling (van Beurden et al., 2011). Owing to the fact that CD34, nestin and transforming growth factor b3 (TGFb3) molecules are essential for tissue regeneration process. The aim of this study was to evaluate the expression of nestin, CD34 and TGFb3 in facial tissue of children with complete unilateral and bilateral cleft lip and palate. Materials & Methods: Twenty nine cleft lip and palate patients before and during primary and mixed dentition age were involved in this study. Soft tissue samples were collected during the primary and repeated plastic surgery correction in cases when the parents had given their informed written consent. Nestin, CD34 and TGFb3 expressions were assessed by using immunohistochemical techniques. Distribution of nestin, CD34, TGFb3 immunoreactive structures

ID 858

PROFILE OF THE CEREBRAL METABOLITES IN THE NEWBORN – EVALUATION BY MAGNETIC RESONANCE SPECTROSCOPY L. Ples1, C. Scheau1, R.M. Sima1, M. Enyedi1, E. Tar¸ta-Arsene1, A.E. Ghergu¸s2, & I.A. Badarau1 1

University of Medicine and Pharmacy ‘‘Carol Davila’’, Bucharest, and 2Department of Radiology, Fundeni Clinical Institute, Bucharest Brief Introduction: Magnetic Resonance Spectroscopy (MRS) is a dedicated Magnetic Resonance modality which has the ability to demonstrate various metabolites’ absolute and relative concentrations in any region of the brain designated by a volume of interest called voxel. Applying MRS in the newborn is a challenge due to the relatively small brain size and the need of sedating the patients, but can prove necessary in certain clinical scenarios.

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276 Materials & Methods: Since the 1st of January 2013, twenty-six consecutive pediatric patients have been investigated by cerebral MRS in our center, with ages ranging from 2 weeks up to 3 years (out of which five were neonates). The MRS sequence employed had a short TE (30 ms), with voxel placement in both gray and white matter regions and a size of 3,375 cc. Patients with focal pathology had a voxel placed in the opposite hemisphere for reference. Morphologically normal patients had bilaterally symmetrical regions investigated by this method. Ethics committee approval was obtained. Clinical Cases or Summary Results: The metabolic profile of the brain changes with age, as the brain matures. N-Acetyl Aspartate is a neuronal marker, and its values increase relative to the speed and degree of the maturation process. Choline is a membrane marker, and while it is commonly found in high concentrations in adults with brain tumors or neurodegeneration, the neonates present normally increased Choline peaks due to rapid maturation and respective cell division. Various pathology such as hypoxic ischemic encephalopathy, Canavan disease, Niemann-Pick and others yield specific MRS profiles which set a clear diagnosis and can lead to a better management in these cases. Conclusions: MRS is an accessible, non-invasive functional imaging modality which can provide important complementary diagnostic information. A sound knowledge of the metabolic particularities in the newborn brain can represent the key to assessing its functional status and the means for integrating the physiopathological data in the clinical context in these patients. Keywords: new born, MRS, cerebral metabolites Presenter: R.M. Sima

ID 924

SHORT OUTCOME OF INFANTS WITH COARCTATION OF THE AORTA C. Cavalli1, A. Weiss1, M.A. Salvati2, C. Kaihura2, N. Carano1, B. Tchana1, G. Oppido3, T. Hassan3, L. Ragni3, G. Gargiulo3, C. Verrotti2, T. Frusca2, & A. Agnetti1

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

of repair, postoperative course, medications at follow-up, short term re-CoA). Clinical Cases or Summary Results: We report a series of 14 patients with CoA (patients’ general data, table 1). Of them 10/14 (71.4%) had received a prenatal diagnosis or a strong suspicion for that while in 4/14 (28.6%) the diagnosis was postnatal. The hemodynamic status presented with a ductal-dependent systemic circulation in 5 of the 10 subjects having a prenatal diagnosis and in 1/4 among the infants who were diagnosed post-natally (overall 6/14 = 42.9%). The former 5 newborns received PGE1 infusion soon after birth, while the other patient was put on PGE1 on the 2nd day of life after the clinical signs of CoA emerged rapidly. All of them continued PGE infuision until surgery. The 3 remnant infants presented with symptoms related to an unknown CoA between the 2nd and the 4th week of life. Overall, 9/14 (64.3%) newborns required surgery and most of them (7/9) were operated on within 10 days of life. The other 5 patients were sent to follow-up. In 2 of them the isthmic obstruction observed in the first weeks of life recovered spontaneously while three infants are being serially checked. One patient had a CoA inside a complex syndromic pattern and died in the early postoperative at 28 days of life because of refractory congestive heart failure and represents the only death in our series so far (survival index 92.9%). Conclusions: The management of CoA seems still a tough topic both for newborn and professionals. From our data we can confirm that a follow-up starting from pregnancy can offer the newborn and the family more opportunities in terms of efficacy and effectiveness in the management of the newborn since the very first hours of life. From another point of view it seems like the prenatal diagnosis could be influenced by the severity of the CoA as the amount of infants who need PGE1 in this group was definitely high. Nonetheless it was confirmed once more from our data that CoA can present up to the 4th week of life. This latter aspect remains a debate as two possibilities can influence this pattern. Either the ductus plays as a confounding factor in the very first days of life by mimicking a femural pulse or the isthmus progressively narrows in the first days of life thus coarctating the aorta later on after birth. The perinatal and neonatal management of the CoA remains a borderline topic which should be played together from a multilevel and multitasking group of profesisonals, namely the obstetrician, the neonatologist, the pediatric cardiologist and the family pediatrician. Keywords: coarctation of the aorta, perinatal morbidity, neonatal cardiac surgery Presenter: Claudio Cavalli

1

Unit of Pediatric Cardiology, Dept. of Maternal and Pediatric Health, 2Center of Prenatal Diagnosis, Unit of Obstetrics and Gynecology, Dept. of Maternal and Pediatric Health. Azienda Ospedaliero-Universitaria. Parma. Italy, and 3Unit of Pediatric Card Brief Introduction: Coarctation of the aorta (CoA) is one of the most common congenital heart defects (CHD), accounting for approximately 7% of all liveborn infants having a CHD. The prenatal diagnosis of CoA is still a challenge as it is affected by high false negative rates and fetal echocardiography shows poor specificity for this anomaly. Nevertheless the impact of a prenatal diagnosis of CoA is high because this anomaly is the most common ductal dependent CHD missed at the routine clinical check of the newborn. Thus the prenatal diagnosis influences morbidity and mortality. Materials & Methods: The aim of this retrospective observational study was to evaluate the impact of a CoA upon the perinatal course up to the first weeks of life, both with and without a prenatal diagnosis. Our analysis enrolled all the patients receiving a new diagnosis of native CoA at our center of Pediatric Cardiology between January 2010 and December 2013 regardless they were inborn or outborn. Patients’ data were collected as follows: demographics (gestational age, gender, birthweight, associated chromosomal anomalies); perinatal clinical data (delivery room resuscitation, associated other cardiac anomalies, prenatal/postnatal diagnosis, need for intensive care with or without ductal-dependency, timing of clinical presentation); need for cardiac surgery and follow-up (age at theater, type

ID 817

PERINATAL ASPHYXIA –RISK FACTORS AND NEONATAL OUTCOME IN PRETERM AND TERM NEWBORNS S. Latifi Hoxha, Sh. Lulaj, M. Hoxha, V. Ibishi, M. Morina, N. Spahija, & I. Gerbeshi Obstetrics and Gynecology Clinic, University Clinical Center of Kosova, Kosova Brief Introduction: Perinatal asphyxia is e serious clinical problem worldwide. Each year approximately four million babies are born asphyxiated.The aim of this study was to determine risk factors for perinatal asphyxia and to evaluate early neonatal outcome among preterm infants born between 28 to 37 weeks of gestation and among term infants born at 37 weeks who are born asphyxiated with Apgar score of less than 7 at five minute. Materials & Methods: This descriptive retrospective study was carried at the Obstetrics and Gynaecology Clinic of the University Clinical Centre of Kosova from January 1st till December 31st 2011.

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DOI: 10.3109/14767058.2014.924236

The database at the delivery yard is used for extracting maternal data and for the newborns included in this study data were obtained from the newborns history. For the purpose of analysis all the enrolled newborns were divided in two groups: first group preterm newborns born between 28 to 37 weeks of gestation and the second group term newborns born at 37 weeks of gestation. Clinical Cases or Summary Results: One hundred and sixty seven asphyxiated newborns were included in this study. Of those 85 were preterm infants (50.89%). There were differences of risk factors between two groups with high level significance. In preterm infants the identified risk factors for perinatal asphyxia were: nuliparity (RR 0.56), maternal age 435 years (RR 0.6), IUGR (RR 0.8), placental and cord related factors (RR 0.9), hypertensive disorders of pregnancy (RR 0.85) and multiple pregnancy (RR 0.08). In term infants the identified risk factor was meconium stained amniotic fluid (p50.0001). Neonatal outcome analysis showed that asphyctic preterm newborns are prone to: RD Sy (p50.001), pulmonary haemorrhage (p = 0.0006), intraventricular haemorrhage (p = 0.0001), early neonatal sepsis (p = 0.003), need for CPAP (p50.0001), need for IMV (p = 0.0003) and exitus letalis (p50.0001). Duration of hospital stay (p50.0001) was significantly longer in preterm infants group than in term newborns. Conclusions: Perinatal asphyxia continues to be a major problem in our settings and based in our study it is more related to prematurity. Identified risk factors are nuliparity, maternal age435 years, placental and cord related factors, hypertensive disorders of pregnancy and multiple pregnancy. Thus, our data suggest the need for improvement of antenatal care, infection prevention control and educational programs for medical staff including Effective Perinatal Care and Alarm International Training. Keywords: aphyxia, risk factors, neonatal outcome

Clinical Cases or Summary Results: 90% of respondents heard about the possibility of a childbirth in water, but only 49% were informed by gynecologist of this possibility. 79% of the surveyed women plan to have a child in the future. 220 of the respondents gave birth in the water, most of them had a higher education. Women who gave birth in the water felt significantly less pain in comparison to those who didn’t give birth in the water. 100% of women who gave birth in the water definitely recommended this method to the other women. Conclusions: Childbirth in water immersion, under appropriate conditions, can be an alternative to the classical obstetrics. Given the available data, there are no reasons to discourage women to choose a childbirth in water. However, the duty of an obstetrician that qualify for labour in water is to inform about both risks and benefits of this. Very important fact is that this type of labour is better tolerated by women giving birth in water in comparison to those giving traditional birth. Women giving birth in water feel more free and bear birth contractions more calmly. Keywords: birth; birth in water; water immersion Presenter: Joanna Marzec

ID 775

MASSIVE FETOMATERNAL HEMORRHAGE A. Alexaki, A. Moutafi, G. Kandili, A. Xaritou NICU REA Maternity Hospital, Athens, Greece

Presenter: Syheda Latifi Hoxha

ID 637

CHILDBIRTH IN WATER AND ADVANTAGES OF WATER IMMERSION – AWARENESS, KNOWLEDGE AND EXPERIENCE OF POLISH WOMEN J. Marzec, N. Banas´, K. Skrzyn´ska Gynaecology and Obstetrics Dept., Medical University of Silesia in Katowice, Poland Brief Introduction: Women giving birth in the water better endure the pain of a childbirth (much less ask for anesthesia) and experience greater satisfaction with a labour, which takes less time. Childbirth in water is also a benefit for the baby. The infant is born into the aquatic environment - the one without noise, light and changing temperatures, where newborn can adapt faster. The first aim of the study was to assess awareness, knowledge and experience of Polish women on giving a birth in water, and on water immersion. The second one was to assess a newborn baby and patient’s satisfaction after a childbirth. Materials & Methods: In order to collect the material, author conducted a survey on a group of 590 women of reproductive age in Poland. The first part was addressed to all women and was aimed both at gathering general data related to the respondents, and indicating a level of knowledge about a childbirth in water. The second part of the questionnaire was addressed to women who gave birth in water – in order to demonstrate their knowledge of the subject as well as the feelings resulting from the childbirth in water. The study was performed between July 2013 and Mai 2014. STATISTICA was used for statistical analysis of the results.

Brief Introduction: Leakage of fetal cells into the maternal circulation is common. Massive Fetomaternal Hemorrhage (FMH) involves volumes of blood greater than 30 ml. FMH resulting in profound anemia and shock is associated with high perinatal morbidity and mortality. The infant is pale, perhaps with gasping respirations and signs of circulatory shock. The diagnosis can be made with the Kleihauer- Betke test (KBTtest), by the demonstration of fetal red blood cells in the maternal circulation. Materials & Methods: Case report Clinical Cases or Summary Results: Eight infants (4 males and 4 females) were born in our hospital with FMH and hospitalized in NICU. The diagnosis was made by the KBT-test. Five of them were born with caesarean section because of pathological NST test. Their gestational age was 33 + 4 - 39 + 5 and birth weight was 2010–3260 gr. Three of the mothers reported decreased fetal movements. The average Haemoglobin was 4,6 g/dl in arterial blood sample. They all were transfused with 40 ml/kg packed red blood cells in the first day of life. They all were intubated supportively and inotropic agents were given. Only one infant had multiple infractions of the cerebral hemispheres by u/s. All the infants exited from NICU in a good condition and the neurological follow up is normal. Conclusions: FMH is fortunately rare and likely remains underreported and underrecognized. High index of suspicion has to be arised with decreased fetal movements. Additional studies are needed to identify these patients, the clinical presentation, the management strategies and the outcomes achieved. Keywords: fetomaternal, hemorrhage, FMH, Kleihauer- Betke test Presenter: A. Moutafi

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ID 543

CHILBEARING AFTER 40 YEARS – A CHALLENGE OF THE MODERN OBSTETRICS Rotar Ioana1,2#, Muresan Daniel1,2, Cotutiu Paul2, Giurgiu Cristina2, & Stamatian Florin1,2 1

University of Medicine and Pharmacy ‘‘Iuliu Hatieganu’’ Cluj Napoca, Romania, and 21st Clinic of Obstetrics and Gynecology, Cluj Napoca, Romania

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#corresponding author: Rotar Ioana Cristina, [email protected], 1st Clinic of Obstetrics and Gyneco Brief Introduction: The social trends point out that in nowadays an increasing category of women are delaying their childbearing which has lead to an important number of patients that deliver at the end of the fourth decade or even in the fifth decade. The obstetrician has to face in this particular population obstetrical complication throughout pregnancy and delivery and even postpartum period. The present study aim to analyze the maternal and fetal obstetrical complications in pregnant women aged forty or older. Materials & Methods: Materials and methods: The study was designed as retrospective. It was conducted in the 1‘st Clinic of Obstetrics and Gynecology Cluj Napoca, Romania. All deliveries that took place in 2012 in the above mentioned hospital have been analyzed (1873 patients). Forty four patient had been at the moment of delivery 40 years or older. The patients were spitted in two groups: cases patients over 40 years and controls. The delivery way, parturition parameters, maternal and fetal parameters were analyzed between the two groups. Clinical Cases or Summary Results: The frequency of deliveries after the age of forty represented 2.402% of all the (CS) deliveries. Both nuliparas and multiparas over forty had a significantly higher cesarean section rate; the percentage was higher in primiparas. CS indications differ between primiparas and multiparas with a raised later category of prior uterine incision. Maternal comorbidities were significantely more frequently encountered in the case group. The fetal weight was significantly bigger in multiparas than in primiparas in the CS group The Apgar score seems not affected neither by the delivery mode nor by parity in the both groups. Conclusions: Having a child after 40 years leads to an increased number of obstetric interventions and pregnancy complications. Keywords: older women, delivery, pregnancy related diseases Presenter: Rotar Ioana

ID 954

URINE NGAL, KIM -1 AND IL -18 AS BIOMARKERS OF ACUTE KIDNEY INJURY IN CRITICALLY ILL NEWBORN INFANTS M. Daminova1, A. Safina2, & M. Koporulina3 Kazan State Medical Academy, Kazan, Russia, 2Kazan State Medical Academy, Kazan, Russia, and 3Kazan State Medical Academy, Kazan, Russia. 1

Brief Introduction: Any pathological condition of the perinatal period have an effect on the kidneys. Diagnosing the onset of acute kidney injury often occurs delayed due to lack of sensitive diagnostic tests. Purpose of this study to examine the significance of determining the level of Neutrophil gelatinase-associated lipocalin (NGAL), Kidney

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

injury molecule-1 (KIM-1) and interleukin-18 (IL-18) in the urine as an early markers of kidney injury in critically ill neonates. Materials & Methods: A comprehensive survey of 113 full-term infants: 86 from the main group were in critically ill and 27 – relatively healthy infants, a group of control. Main group was divided into two subgroups - with AKI and without AKI. AKI was defined as the presence of elevated serum creatinine (SCr) 41,5 mg/dl. The survey included clinical observation, laboratory and instrumental methods. Assessment of renal function was performed twice: on 3–5 and 10–14 days of life (d.l.). The level of NGAL in urine was determined by enzyme immunoassay using Human Lipocalin-2/NGAL ELISA, the level of KIM-1 in urine was determined by enzyme immunoassay using Quantikine Human TIM-1 Immunoassay, the level of IL-18 in urine was determined by enzyme immunoassay using Bender Medsystems IL-18 human ELISA (M ± m, p50.01). Clinical Cases or Summary Results: At 3–5 d.l. in the group with AKI level of NGAL in the urine amounted to 147.78 ± 8.7 ng/mL (more than 7 times higher than in the control group, and slightly higher than the group without AKI (110.57 ± 2.04 ng/mL), to 10–14 d.l. in this groupe level of NGAL in the urine amounted to 112.32 ± 13.44 ng/mL (more than 5 times higher than in the control group, and slightly higher than the group without AKI (95.18 ± 2.3 ng/mL). At 3–5 d.l. in the group with AKI level of IL-18 in the urine amounted to 159.35 ± 19.83 pg/mL (more than 4 times higher than in the control group, and slightly higher than the group without AKI (111.22 ± 3.01 pg/mL), to 10–14 d.l. in this groupe level of IL-18 in the urine amounted to 146.02 ± 18.71 pg/mL (more than 4 times higher than in the control group, and slightly higher than the group without AKI (112.19 ± 2.71 pg/mL). At 3–5 d.l. in the group with AKI level of KIM-1 in the urine amounted to 0.35 ± 0.03 ng/mL (more than 2 times higher than in the control group, and in the group without AKI, to 10–14 d.l. in this groupe level of NGAL in the urine amounted to 0.36 ± 0.04 ng/mL (more than 3 times higher than in the control group and in the group without AKI). Conclusions: Newborn with AKI there is an increase in urine NGAL, KIM-1 and IL-18 at 3–5 d.l. and 10—14 d.l. NGAL, KIM-1 and IL-18 levels in urine may serve urine NGAL levels as an early marker of preclinical renal failure. Keywords: Acute Kidney Injury; biomarkers; NGAL; KIM-1; IL-18; newborns. Presenter: Maria Daminova

ID 539

PREVENTION OF RECURRENT THROMBOEMBOLIC AND PERINATAL COMPLICATIONS DURING PREGNANCY IN PATIENTS WITH THROMBOPHILIA S.V. Akinshina, A.D. Makatsaria, & V.O. Bitsadze Department of obstetrics and gynecology, I.M. Sechenov First Moscow State Medical University, Russia Brief Introduction: Despite intensive research, arterial and venous thromboembolism (VTE) still accounts for significant maternal mortality and morbidity. Our aim was to determine thrombophilia in patients with history of thrombosis and to evaluate the efficiency of antithrombotic prophylaxis. Materials & Methods: Group I: 57 (28,7 ± 4,2 years) women with history of VTE, group II: 59 (32 ± 5,5 years) women with history of stroke and 60 healthy pregnant women (controls) were screened for genetic thrombophilia and antiphospholipid antibodies (APA). Subgroup Ia (n = 20 with history of VTE) and subgroup IIa (n = 22 with history of

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DOI: 10.3109/14767058.2014.924236

stroke) received prophylaxis with low molecular weight heparin (LMWH) in preconception period, during pregnancy and at least 6 weeks postpartum. In 17 women with history of VTE (subgroup Ib) and 20 women with history of stroke (subgroup IIb) LMWH was started from II-III trimester. Clinical Cases or Summary Results: In group I 54.4% had family history of VTE and 68.4% had personal history of pregnancy complications (p50.05 vs. control). Stroke was associated with hypertension (27.1%), metabolic syndrome (37.3%), rheumatic diseases (16.7%), past history of thrombotic complications (21.7%), oral contraceptive use (3.4%) and history of placental obstetric complications (preeclampsia, placental abruption, intrauterine growth restriction) (38.7% vs 11.5%, p50.05).In the group I thrombophilia was detected in 94.1%: FV Leiden +/ (23.5%), prothrombin G20210A +/ (13.7%), multigenic fibrinolytic defects (64.7%); APA (49%), hyperhomocysteinemia (45%) (p50.001 vs. control). Thrombophilia was detected in 88.2% with history of stroke, including fibrinolysis defects (76.5%), FV Leiden +/ (21.6%), prothrombin G20210A +/ (11.7%), APA (41.2%; p50.001), hyperhomocysteinemia (19.6%; p50.05). In subgroup Ia and IIa no one had severe obstetric complications. All pts were delivered at term and all babies were alive. In subgroup Ib and IIb moderate to severe obstetrics complications were noted: preeclampsia, IUGR grade I-III, critical maternal-placental-fetal blood flow disturbances (43.7% and 47%) (p50.05 vs subgroup Ia and IIa). Conclusions: Thrombophilia might be the essential pathogenetic mechanism of thrombosis in women of childbirth age. LMWH was effective for prevention of recurrent thromboembolism and obstetric complications.Women with personal or family history of thromboembolism or with history of obstetric complications should be screened for thrombophilia. Keywords: Venous thromboembolism, stroke, pregnancy, thrombophilia, LMWH Presenter: S.V. Akinshina

ID 648

PREGNANCY OUTCOME IN LIBYAN POPULATION WITH ADVANCED MATERNAL AGE A. Elbareg1, I. Elarbah1, F. Essadi1, K. Anwar2 Misurata Teaching Hospital, Misurata, Libya, and 2Iben-Sina Teaching Hospital, Sirt, Libya 1

Brief Introduction: During past three decades, proportion of women in Libya who gave birth after age of 35 years for the first time increased significantly mainly due to late marriage, whereas in previous generations women might be having their last child in their forties. Because of that, there is growing interest in pregnancy-related complications and outcome of pregnant women at older age. Aim of this prospective controlled study which was carried out at Misurata & Iben-Sina Teaching Hospitals was to investigate the impact of advanced maternal age on obstetric outcomes in Libyan Population. Materials & Methods: study included all deliveries of 424 weeks of gestation at both hospitals between January 2009 and June 2013. The two hospitals serving middle and majority of western parts of the country. Women studied divided into 3 categories according to age: A-20–34 years at delivery as referent group, B-35–39 years, C- 40 years at the time of delivery. Pregnancies among women520 years of age and cases of multiple pregnancies were excluded. Data collected: parity, delivery gestational age, presence of infertility and ART if any, medical & obstetric histories, diabetes, hypertension or anemia, mode of delivery, birth weight, (44000g, 52500g &51500g), Apgar score,

admission to neonatal ICU, postpartum course. Outcomes were compared for both nulliparous and multiparous women. Statistical analysis performed using SPSS package. P-value considered to be significant if (50.05). Clinical Cases or Summary Results: Women included in the study were (6865). (68.4%) patients were between 20–34 years, (31.6%) were 35 years. Patients 40 years of age were (11.9%) Women giving birth at age 35 or older carried a 2.9-fold increased risk for pregnancy complications, and 3.5-fold increased risk for adverse perinatal outcomes. Women in B and C groups were at increased risk for pregnancyinduced hypertension, diabetes; significantly higher than A, (p50.0034), operative vaginal delivery, caesarean sections, (p50.01), preterm and early preterm (534 weeks) deliveries, low birth weight, still birth and neonatal death in nulliparous women, but only with preterm birth before 37 weeks and caesarean deliveries in multiparous women. Relative risk of stillbirth was 1.89 for group B and 2.8 for group C. These risks estimates were independent of women’s infertility treatment history. Conclusions: Advanced maternal age is significantly associated with specific adverse pregnancy outcomes. As the number of this group is increasing, every effort should be made to reduce associated morbidity. Keywords: Advanced maternal age, adverse pregnancy outcomes. Presenter: Aisha Elbareg

ID 815

UMBILICAL CORD BLOOD NGAL CONCENTRATION AS AN EARLY MARKER OF PERINATAL ASPHYXIA IN NEONATES P. Surmiak, M. Baumert, M. Fiala, & M. Paprotny Chair and Department of Neonatology, Medical University of SIlesia, School of Medicine, Katowice, Poland Brief Introduction: Recent reports have revealed increased concentration of neutrophil gelatinase-associated lipocalin (NGAL) in cardiovascular diseases and after episodes of hypoxia, and defined as an early marker of acute kidney injury (AKI) in asphyxiated newborns. We hypothesized that elevated umbilical plasma NGAL levels could be as a result of kidney tubular injury, post perinatal asphyxia. Materials & Methods: Ninety-three newborns with a gestational age 37 weeks were enrolled in the study. There were 32 newborns, that presented perinatal asphyxia, in the study group, and 61 healthy neonates formed the control group. Plasma NGAL, lactate and creatinine concentrations, acid-base balance, absolute neutrophil and white blood cell counts were determined in the umbilical cord blood. Clinical Cases or Summary Results: The absolute neutrophil count and NGAL concentration were elevated in asphyxiated newborns compared to healthy children. In case of 6 newborns from the asphyxiated group, in whom AKI was diagnosed, we also observed higher NGAL concentrations compared to asphyxiated infants without AKI. We noticed a correlation between the NGAL level and severity of metabolic acidosis in the newborn, as well as the neutrophil count. Conclusions: The measurement of NGAL in the umbilical blood can be a valuable biomarker of perinatal asphyxia in neonates. Keywords: NGAL, newborn, perinatal asphyxia Presenter: Piotr Surmiak

280

ID 642

DOES IT MAKE SENSE TO TALK ABOUT STEM CELLS FROM UMBILICAL CORD BLOOD? – AWARENESS AND KNOWLEDGE OF POLES ON STEM CELLS STORAGE FROM UMBILICAL CORD BLOOD J. Marzec, N. Banas´, & K. Skrzyn´ska

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Gynaecology and Obstetrics Dept., Medical University of Silesia in Katowice, Poland Brief Introduction: Stem cells (SC) are self-cell lines present in many tissues and organs. Their use of proliferative potential and ability to differentiate underlies huge advances in medicine. Thanks to them, it is possible to extend and enhance human life; they are an alternative for treatment. SC taken from umbilical cord blood are of special interest. Characterized by, among others, non-invasive, less controversial method of taking them, a low degree of orientation, negligible influence of environmental mutagens. The role they play in the field of hematology and oncology continues to grow. That is why the amount of umbilical cord blood banks grows constantly as well. The aim of the study is to assess the awareness and knowledge of Poles on SC storage from umbilical cord blood. Materials & Methods: In order to collect the material, the survey consisting of 23 detailed and general questions was conducted on a group of 750 people of reproductive age in Poland; 550 women and 200 men filled in the questionnaire. The first part was to gather general information on the respondents, the second to demonstrate

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

the level of knowledge on: SC, procedures of obtaining them, storing, limitations and advantages of SC storing, as well as the associated costs. The results were statistically analyzed using STATISTICA. Clinical Cases or Summary Results: 78% of people have heard about collecting SC, mainly in age groups 31–40 and 21–25, women significantly more often than men. Among the people having children 85% have heard about collecting SC and 78% about umbilical cord blood banks. 88% reported the correct definition of SC, only 43% of people know that this treatment is carried out in Poland. 93 people stored SC of their child. Conclusions: Awareness of the respondents concerning the newest medical achievements is low. The subject of SC is taken up, but the possibilities of using them are not sufficiently discussed. Taking into consideration valuable potential role of SC in therapies of different disorders, there is a need to carry out educational campaigns to broaden knowledge of people on umbilical cord blood storage. Keywords: stem cells; umbilical cord blood; storage Presenter: Joanna Marzec

ID 561

SAFETY OF AIR AND GROUND TRAVEL AFTER DIAGNOSTIC AMNIOCENTESIS K.E. Karasahin1, M. Ozturk1, H. C¸oksuer1, D. Torun2, & Y. Tunca2 1 2

Gu¨lhane Military Medical Academy Dept. Ob/Gyn, and Gu¨lhane Military Medical Academy Dept. Medical Genetics

Brief Introduction: Some patients may have to travel back and forth from their residences to a tertiary center in order to have an

281

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DOI: 10.3109/14767058.2014.924236

amniocentesis. They often ask about the risks of travelling after amniocentesis. We have come up with this study to be able to answer these questions. Amniocentesis is generally considered a safe operation. But the question "whether there is an increased risk associated with travelling" is more likely to be answered by past clinical experience only, since a Pubmed search using the words "travelling after amniocentesis" did not return any results,(until our study). Materials & Methods: Before the unification of military and civilian health care systems, military patients had to come to military tertiary hospitals for invasive prenatal diagnostic procedures in Turkey. We had a chance to study a total of 57 (initially 60 but 3 were lost to follow up) patients who had to travel either by ground or by air in order to have diagnostic amniocentesis for various indications. The patients who live within 50 km of our center were included in the control group during the study period. We arbitrarily defined 3 zones in Turkey, in which the travelled distances were Z1: 50–100, Z 2: 101–300 km and Z3: over 300 km (Fig 1). The same physician (K.E.Karasahin) and team members have performed all of the procedures with the same technique and using the same equipment. The patients with singleton pregnancies who had single needle insertion and no post procedural early complications between 16–20 weeks of pregnancy were included in the study. None had previous uterine surgery or anterior placenta. All of the participants included in the study were adviced to have a 12 hours rest period before they travelled back to their residences. The senior resident called up 57 patients and questioned them about any instances of bleeding, amniotic fluid leakage or disturbing uterine contractions during or after their travel. Clinical Cases or Summary Results: The Study and Control Groups were evaluated for adverse outcomes after amniocentesis. There was only one woman at 17 weeks of gestational age who experienced amniotic fluid leaking 48 hours after amniocentesis when she travelled back. She had travelled 70 km (within Zone 1) by bus, and later had spontaneous resealing after prolonged bed-rest. She went on to have an uncomplicated term delivery. None of the women who underwent amniocentesis had any pregnancy loss. None of the women reported vaginal bleeding, painful uterine cramping or amniorrhexis after travelling. All women delivered at term without further obstetric problems. Conclusions: We conclude that travelling does not seem to increase the risk of bleeding, vaginal amniotic fluid leakage or provoke uterine contractions after the amniocentesis procedure. The perinatal outcomes of the patients who had to travel did not seem to have been influenced by travelling. Reference 1) K.E. Kara¸sahin, M. Ozturk, H. C¸oksuer, D. Torun, Y. Tunca Departments of 1 Obstetrics and Gynecology and 2 Medical Genetics, Gulhane Military Medical Faculty, Ankara, TurkeyTravelling after amniocentesis: Answer to a frequent question" Journal of Obstetrics and Gynaecology, May 2013; 33: 343–345 Keywords: Presenter: K.E. Kara¸sahin

ID 246

PERINATAL OUTCOMES IN WOMEN WITH HISTORY OF VENOUS AND ARTERIAL THROMBOEMBOLIC COMPLICATIONS AND THROMBOPHILIA S. Akinshina, A. Makatsariya, V. Bitsadze, & S. Baimuradova

Department of obstetrics and gynecology, I.M. Sechenov First Moscow State Medical University, Russia Brief Introduction: Despite intensive research, arterial and venous thromboembolism (VTE) still accounts for significant maternal mortality and morbidity. Our aim was to determine thrombophilia in patients with history of thrombosis and to evaluate the efficiency of antithrombotic prophylaxis. Materials & Methods: Group I: 57 (28,7 ± 4,2 years) women with history of VTE, group II: 59 (32 ± 5,5 years) women with history of stroke and 60 healthy pregnant women (controls) were screened for genetic thrombophilia and antiphospholipid antibodies (APA). Subgroup Ia (n = 20 with history of VTE) and subgroup IIa (n = 22 with history of stroke) received prophylaxis with low molecular weight heparin (LMWH) in preconception period, during pregnancy and at least 6 weeks postpartum. In 17 women with history of VTE (subgroup Ib) and 20 women with history of stroke (subgroup IIb) LMWH was started from II-III trimester. Clinical Cases or Summary Results: In group I 54.4% had family history of VTE and 68.4% had personal history of pregnancy complications (p50.05 vs. control). Stroke was associated with hypertension (27.1%), metabolic syndrome (37.3%), rheumatic diseases (16.7%), past history of thrombotic complications (21.7%), oral contraceptive use (3.4%) and history of placental obstetric complications (preeclampsia, placental abruption, intrauterine growth restriction) (38.7% vs 11.5%, p50.05).In the group I thrombophilia was detected in 94.1%: FV Leiden +/ (23.5%), prothrombin G20210A +/ (13.7%), multigenic fibrinolytic defects (64.7%); APA (49%), hyperhomocysteinemia (45%) (p50.001 vs. control). Thrombophilia was detected in 88.2% with history of stroke, including fibrinolysis defects (76.5%), FV Leiden +/ (21.6%), prothrombin G20210A +/ (11.7%), APA (41.2%; p50.001), hyperhomocysteinemia (19.6%; p50.05). In subgroup Ia and IIa no one had severe obstetric complications. All pts were delivered at term and all babies were alive. In subgroup Ib and IIb moderate to severe obstetrics complications were noted: preeclampsia, IUGR grade I-III, critical maternal-placental-fetal blood flow disturbances (43.7% and 47%) (p50.05 vs subgroup Ia and IIa). Conclusions: Thrombophilia might be the essential pathogenetic mechanism of thrombosis in women of childbirth age. LMWH was effective for prevention of recurrent thromboembolism and obstetric complications.Women with personal or family history of thromboembolism or with history of obstetric complications should be screened for thrombophilia. Keywords: stroke, venous thromboembolism, antiphospholipid syndrome, thrombophilia, LMWH Presenter: A. Makatsariya

ID 357

ORIGIN OF PRENATAL ANEUPLOIDY IN MALE CARRIERS OF TRANSLOCATIONS: IS THERE ANY INTER CHROMOSOMAL EFFECT? . . . A. Hajlaoui1, M. Kammoun1, S. Meddeb1, I. Zidi-Jrah1, M. Fekih1, M. Ajina1, S. Ibala-Romdhane1, M. Bibi1, A. Saad1, & S. Mougou-Zerelli1 1

Departments of Cytogenetics and Reproductive Biology, Farhat Hached University Teaching Hospital, Sousse, Tunisia Brief Introduction: Balanced structural anomalies represent one of the most common forms of genetic abnormality affecting approximately 1/500 (0.2%) individuals. Recently, it has been suggested that structural reorganization carriers can also produce increased number

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282 of unbalanced gametes with numerical abnormalities for chromosomes not related to the rearrangement. This phenomenon is called inter- chromosomal effect (ICE). Many researchers have sort to investigate this phenomenon, but the limitations of the available cytogenetic technologies has meant that the existence of an ICE remains a subject of debate. Hence, the aim of this study was to determine whether an ICE truly exists and could be considered as an origin of prenatal aneuploidy in male carriers. Materials & Methods: Five male carriers of translocations (3 reciprocal and two Robertsonian), received in our laboratory of Cytogenetic and Reproductive Biology, Farhat Hached University Teaching Hospital, were included in this study. In addition 7 fertile men with normal 46, XY karyotypes and normal sperm characteristics were recruited as a control group for the analysis of the ICE of chromosomes X, Y, 18, 21 and 22. Mann-Whitney U-test was used to compare the aneuploidy rates between patients and controls. Clinical Cases or Summary Results: In the ICE evaluation, all translocation carriers (both Robertsonian and reciprocal translocation carriers) showed significantly increased frequencies of disomy of all investigated chromosomes, and diploid gametes compared with the control group (p0.05). We also observed a considerable interindividual variability in disomy and diploidy rates observed in our group of translocation carriers. Conclusions: Our results lead to the conclusion that the ICE affecting male carriers of translocations may contribute to higher rates of abnormal prenatal aneuploidy, resulting in a small increase in the risk of miscarriage and birth of children with congenital abnormalities and a potential reduction in fertility. Keywords: prenatal aneuploidy, male carriers, inter- chromosomal effect Presenter: Saoussen Meddeb

ID 450

INTRAMUSCULAR CARBETOCIN TO PREVENT POSTPARTUM HEMORRHAGE A. Carballo Garcı´a, J. Hijona Elo´segui, & M. Vega Sa´nchez Complejo Hospitalario de Jae´n, Jae´n, Spain Brief Introduction: Postpartum Hemorrhage (PPH) is the leading cause of maternal mortality in the world. Able to affect up to 15% of births, is usually due to a low uterine tone. Regardless of etiology, is a true obstetric emergency that requires rapid and vigorous treatment and the implementation of preventive strategies interventionist, because between 8 and 9 out of 10 would be avoidable. Materials & Methods: The target is to determine the clinical effect and side effect profile of the use of 100 micrograms intramuscular Carbetocin within a strategy of active management of the third stage of labor. Clinical Cases or Summary Results: The sample had 54 patients at term with at least three risk factors for the condition of HPP and were attended our hospital for a vaginal labour, who voluntarily agreed to participate in the proposed research. Half the patients lightened before the 69 seconds and 92.6% before 116 seconds. The estimated mean blood loss was between 153 and 757 cc, with an average of 276.85 cc. Only two patients exceeded 500 cc bleeding (two had lesions in the soft birth canal). There were no cases of major bleeding to 1000 cc. 90.7% of patients bled less than 359 cc during delivery and 96.3% less than 496 cc. Was low rate of patients who required additional uterotonic administration (5.6%), being somewhat higher proportion of patients who required uterine massage to treat uterine hypotonia. In terms of tolerability profile was favorable (secondaries rate 10%).

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Conclusions: Although the experience to date is limited, could be an uterotonic carbetocin option in the active management of the third stage of labor in patients at high risk of bleeding and vaginal delivery. Keywords: Carbetocin, intramuscular, postpartum hemorrhage Presenter: A. Carballo Garcı´a

ID 683

OF EPIDURAL ANALGESIA ON SOME ASPECTS OF LABOR – PROGRESS OT THIRD AND EARLY PUERPERAL PERIOD, FETAL AND NEWBORN WELLBEING M. Atanasova, A. Nikolov, S. Nashar, N. Yarakova, & D. Boyadgiev Medical University – Sofia, Bulgaria, Department of Obstetrics and GynecologyState University Hospital ‘‘Maichin Dom’’ – Delivery room, Sofia Brief Introduction: Epidural anaesthesia (EA) is the most efficient method of pain reduction and its total elimination during delivery. The aim of this study was to establish an influence of EA on placental and early puerperal period of delivery, and the effects of EA on fetus and newborn. Materials & Methods: A study is prospective since 2009 – 03.2013,, included 1 049 patients, divided in two groups, according to method of analgesia – 698 with epidural analgesia and 351 with parenteral drugs (control group). Patients met the following criteria: (1) single birth; (2) gestational period 436 weeks; (3) live births; (4) occipital position of fetus; 5) vaginal delivery. Excluding criteria are: (1) Caesarian section. In both groups we applicate 10 UI Oxytocin i.v., after birth of fetus. In all patients we measure duration of third period, as like as the time for inspection and repairing lacerations of cervix, vagina or/and perineum in minutes. The bleeding is estimated by subjective and objective methods – the number of used gauzes and laboratory study. The conditions of newborn is evaluated in all infants by Apgar score on 1 and 5 minutes and in 556 newborn were investigate umbilical artery blood gases. Clinical Cases or Summary Results:: The mean duration of third period of labor was 3.25 min in control group and 3.15 min in group with epidural analgesia (p40.05). The average blood loose was 272.2 ml. in controls versus 252.11 ml in epidural group, the difference between group is significant (p50.05). We established that mean duration for inspection and repairing lacer rations was longer in control group (12.19 min.), than group with epidural anesthesia 7.18 min., p50.05) and that the rate of laceretions of vagina and cervix were more in control group. Different kind of changes in cardiotocograph tracing was observed in 17.03% in epidural group and in 21.67% control group. There are no significant differences between groups in frequency of early, late or variable decelerations. 34.9% of cardiotocograph trasing with changes in epidural group were bradycardia, 6.34% tachycardia and 11.9% low variability of fetal heart rate. In control group predominate changes ware – low variability (23,07%) and tachycardia (21.79%), bradycardia in 12.82%. Apgar score on 1 minute was significantly higher in group with epidural analgesia 7.42, vs. 6.87 in controls (p50.05). However, there was no significant deference between avarage Apgar score on 5 - the minute (9.01 vs. 8.92) and pH (7.29 vs. 7.27) of newborns of patients with EA and that of newborns of patients without EA. The need of first reanimation of newborn was significant higher in control group (14.32%), than group with epidural anesthesia (12.24%). Conclusions: Application of EA dose not affect duration of placental period, but increase the rate of instrumental inspection of uterine cavity. The average blood lose in group with epidural anesthesia is

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significant low. Epidural anesthesia could cause fetal bradycardia but the state is reversible and there are no effects of newborn wellbeing. Epidural analgesia does not affect newborn wellbeing and adaptation. Keywords: epidural anaesthesia, labor, delivery, fetus, newborn Presenter: N. Yarukova

ID 664

PROPHYLAXIS OF RECURRENT ANTENATAL FETAL DEATH AND HYPERGOMOCYSTEINEMIA J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

V. Bitsadze, N. Makatsaria, & R. Abramian I.M. Sechenov First Moscow State Medical University, Department of Obstetrics and Gynecology, Moscow, Russian Federation Brief Introduction: We included 200 married couples in research for evaluation of the role of folates and homocysteine in pathogenesis of abnormalities in fetus, antenatal death and the possibility of prevention of these complications. In all women in anamnesis there was antenatal fetal death; at the time of study the gestational age was 28 to 38 weeks. In the control group there were included 100 healthy women. Materials & Methods: Patients underwent though hemostasiological examination, checked genetical forms of thrombophilia, APA, defects of a folate cycle and level of homocystein. During fertile cycle and pregnancy women took folic acid, group B vitamins, antioxidants, aspirin, micronized progesterone and low-molecular heparins with the control of hemostasic system. For men (fathers) with a hyperhomocysteinemia and/or genetic defects of a folate cycle it was offered to use folic acid and group B vitamins at the time of preparation for pregnancy. Clinical Cases or Summary Results: In those couples with anamnesis of antenatal fetal death hyperhomocysteinemia was found in 75% of cases in mothers, in 50% in fathers and in 46% of cases in both. APA were diagnosed in 41.2% of patients, FV Leiden mutation in 8.4%, prothrombin G20210A mutation in 5.9%, MTHFR - 46.2%, a polygenic thrombophilia was found in 75.6% of patients (p  0.05). In 70% of cases in patients with hyperhomocysteinemia we detected congenital fetal abnormalities (defects of a nervous tube (23%), urogenital system (22%), cardiovascular system (28%), Down syndrome (1%)). In 100% of cases using prophylaxis it was possible to avoid severe pregnancy complications, congenital fetal abnormalities, antenatal fetal death and thrombotic complications. Conclusions: In patients with antenatal fetal death and other severe pregnancy complications we recommend screening for genetic thrombophilia, detection of homocysteine level and APA. Treatment started in fertile cycle allows to suppress pathological effects of hyperhomocysteinemia and to reduce endothelial dysfunction. Keywords: Antenatal thrombophilia Presenter: V. Bitsadze

fetal

death,

hyperhomocysteinemia,

ID 277

MAJOR BIRTH DEFECTS RELATED TO PERINATAL DEATHS SUBJECTED TO AUTOPSY. ASSESSMENT IN THE PERIOD 1992–2012 J.R. Cervilla, A. Perez-Mun˜uzuri, P. Lopez Perez, N. Mandı´a Rodriguez, A. Alshweki, & M.L. Couce Pico Neonatal Unit. Pediatric Assistance Area. Hospital Clinico Universitario (CHUS) Santiago de Compostela (SPAIN) Brief Introduction: Major Birth Defects (MBD) are considered recently a new marker of medical care, developed by EUROCAT (European Registration of Congenital Anomalies and Twins), due to the important impact they have in Public Health. EUROCAT reported a prevalence of MBD in 2006 of 23.9% live births (LB). Neonatal autopsy rates (NAR) have been falling down steadily in the last 20 years, however up to 25% of cases will reveal new or important information. Our goal in this study have been to assess the prevalence and sort of MBD directly causing perinatal death (MBDPD), and the autopsies performed in some live births (LB) whose dead were due to MBD during the last 21 years in our Maternity – Neonatal Units. Materials & Methods: We have reviewed our data records from 1992 to 2012 regarding MBDPD yearly and made a revision of the trend, type and ranking of MBDPD through this 21 consecutive year period. Overall there were 55.140 LB, 855 of them was affected by MBD of whom 57 died due to serious malformation in the perinatal period. Clinical Cases or Summary Results: We have found a prevalence of MBD in the 21 year period of 15.5% LB (855 infants with MBD in 55.140 LB). There were 57 infants with MBD who died in perinatal period (rate of 6.6%). The median rate per year of MBDPD in that 21 year was 1.0 % of all LB (ranged 3.0% in 1992 to 1.0% in 2011) a decline of 61.6 percent. The autopsy rate was 35% (20 autopsies from 57 LB with MBDPD). In decreasing order we found: 1st gross CNS malformations and myopathies 7 cases, 2nd Polycystic kidneys 3 cases, bilateral kidney dysplasia and bladder exstrophy 1 case each; 3rd diaphragmatic hernia 2 cases, duodenal atresia and pulmonary lymphangiectasia 1 case each; 4th: chromosomal abnormalities 2 cases: translocation 7:9 monosomy and Patau (trisomy 13–15); 5th with one case each: coartation of aorta and congenital hemochromatosis. The average day of life at death was 7.8 (range 1–26 days). There was no death due to MBD in 2012. Conclusions: Our overall prevalence of MBD 15.5% LB is much lower than the reported 23.9% by EUROCAT. Our rate of MBDPD 6.6 percent through this 21 year period, is higher than 2.5 percent reported by EUROCAT, but just taking account the first week of life. The main MBD as a cause of death were gross CNS anomalies, Kidney and Urinary tract serious dysplasias, gastrointestinal and chromosomal anomalies in that order. A remarkable decreasing trend in MBDPD have occurred through these years. The early prenatal diagnosis provided nowadays and the termination of pregnancy that follow this diagnosis, is the most probable explanation. Keywords: Presenter: J.R. Cervilla

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ID 442

THE -323P0/P10 FACTOR VII GENE POLYMORPHISM AND THE RISK OF RECURRENT MISCARRIAGES K. Drews1,2, M. Barlik1,2, A. Seremak-Mrozikiewicz1,2, H. Wolski1, A. Bogacz3,4, P.M. Mrozikiewicz3,4, & B. Czerny3,4

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

1

Department of Perinatology and Women’s Diseases, University of Medical Sciences, Poznan, Poland, 2Laboratory of Molecular Biology in Division of Perinatology and Women’s Diseases, Poznan University of Medical Sciences, and 3 Laboratory of Experimental Pharmacogenetics, Department of Clinical Pharmacy and Biopharmacy, University of Medical Sciences, Poznan, Poland, and 4Department of Quality Control of Medicinal Products and Dietary Supplements, Institute of Natural Fibres and Medicinal Plants, Poznan, Poland Brief Introduction: Genetically determined activity disturbances of coagulation factor VII may lead to obstetrical complications. The aim of the study was to evaluate the correlation between -323P0/P10 factor VII gene polymorphism and the risk of recurrent miscarriages. Materials & Methods: Study group consisted of 152 women with a history of 2 miscarriages. To the control group 180 women (1 pregnancy ended with the delivery of the healthy newborn at term and a negative history of miscarriage) were enrolled. The study group was divided twice into two subgroups (114 patients with the history of 2 miscarriages and 38 with a history of 3 miscarriages, 123 patients with miscarriages 513 gw. and 29 with miscarriages 521 gw.). Genetic analysis was performed with the use of PCR/RFLP method. Clinical Cases or Summary Results: Overrepresentation of P0/P0 genotype and lower frequency of P0/P10 genotype in the study group in comparison to controls was noted (P0/P0: 80,26 vs. 76,67%, p = 0.25; P0/P10: 18,42 vs. 22,78%, p = 0.20). In the subgroup of women with 3 miscarriages higher presentation of P0/P0 genotype and P0 allele, lower frequency of P0/P10 genotype and P10 allele in comparison to controls was observed (P0/P0: 86,84 vs. 76,67%, p = 0.12; P0: 93,42 vs. 88,06%, p = 0.12; P0/P10:13,16 vs. 22,78%, p = 0.13; P10: 11,94 vs. 6,58%, p = 0.12). Conclusions: Obtained results suggest a probable protective role of -323P10 allele as to the risk of miscarriages in women with 3 or more recurrent pregnancy losses.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437 2

Urogynecology Department. Hospital Clı´nic de Barcelona, Barcelona, Spain.

Brief Introduction: To evaluate the assessment of women with obstetric anal sphincter injuries (OASIS) with a 2D-transperineal ultrasound in a maternal fetal medicine clinic. Materials & Methods: Cohort study from January 2011 to December 2013 including all women with identified and repaired OASIS from Hospital Clinic, Barcelona. A 2D-translabial ultrasound was performed at 6–12 months after delivery, using an endovaginal probe (Siemens Antares) located in the vaginal introitus perpendicular to the anal canal and in the tranversal plane. Both external and internal anal sphincters (EAS and IAS, respectively) were evaluated. All examinations were performed by a maternal fetal medicine specialist. Symptoms of anal incontinence were evaluated using validated questionnaires. Clinical Cases or Summary Results: A total of 118 women were evaluated. Median maternal age was 32 years (range 18–42 years). More than half of the women with OASIS had a spontaneous vaginal delivery (65/118; 55.1%). Operative vaginal delivery include forceps Naegele (n = 21; 17.8%), forceps Kjelland (n = 18; 15.3%), vacuum extractor (n = 9; 7.6%) and spatula (n = 5; 4.2%). A 51.9% of operative vaginal deliveries were rotational forceps of 45 or more. The grade of OASIS was as follows: 49.2% grade 3a, 40.7% grade 3b, 5.9% grade 3c, 2.5% grade 4, and 2 women (1.7%) had isolated anal mucosa injury without anal sphincter injury. Postpartum evaluation of OASIS was performed at a median of 7.6 weeks after delivery (range 3.1–18.3). Symptoms of anal incontinence were reported in 24 cases (20.3%). Normal ultrasound was observed in 75 patients (63.6%) for both EAS and IAS. In 16 cases (13.6%) a residual defect was detected (11 in EAS and 5 in both EAS and IAS). A defect was suspected but not confirmed due to healing process in 27 women (22.9%) and required a 2nd ultrasound which was performed in 17 women at a median of 31.6 weeks after delivery (range 5.1–35.9). Eight women were asymptomatic and had a normal subsequent ultrasound. In 6 cases, a residual defect (5 in EAS, 1 in both EAS and IAS) was confirmed, and in 3 cases a defect could still not be confirmed. Overall, 19 women (16.1%) were referred to urogynecology or proctology specialist for occult lesion in 2D transperineal ultrasound or because of symptoms of anal incontinence. Conclusions: 2D transperineal ultrasound and detection of symptoms of anal incontinence could be used as a first step in maternal fetal medicine units to address adequate follow-up of OASIS in specialized units. Keywords: Presenter: M. Lopez

Keywords: recurrent miscarriages, coagulation factor VII, genetic polymorphism Presenter: K. Drews

ID 242

ID 697

CAUSES OF STILLBIRTH DIFFERENTIATED BY GESTATIONAL AGE

2D-TRANSPERINEAL ULTRASOUND FOR OBSTETRIC ANAL SPHINCTER INJURIES ASSESSMENT IN A MATERNAL FETAL MEDICINE DEPARTMENT M. Lopez1, D. Castellvı´1, C. Ros2, N. Elias1, M. Espun˜a2, F. Figueras1, E. Gratacos1, & M. Palacio1 1

BCNatal, Barcelona Center for Maternal Fetal and Neonatal Medicine. Hospital Clı´nic and Hospital Sant Joan de De´u, Universitat de Barcelona, Barcelona, Spain, and

N. Lorente1, C. Rovira2, L. Guirado1, D. Rodrı´guez1, S. Herrero1, E. Segura1, & M.D. Go´mez1 1

BCNatal. Barcelona Center for Maternal Fetal and Neonatal Medicine. Hospital Sant Joan de De´u and Hospital Clı´nic, Universitat de Barcelona, Barcelona, Spain, and 2Pathology Dept., Hospital Sant Joan de De´u, Universitat de Barcelona, Barcelona, Spain Brief Introduction: To compare the most common causes of stillbirth in singleton pregnancies depending on the gestational age in Hospital Sant Joan de De´u. Materials & Methods: A retrospective study of stillbirths was developed from 1993 to 2012 who delived in our hospital. Only singleton pregnancies between 22 and 42 weeks were included.

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Stillbirth were divided in four groups: limit of viability (524 weeks), preterm (24–36,6 weeks), term (37–40,6 weeks) and post-term (41 weeks) and we analyzed the main causes contrasting them with the bibliography. Clinical Cases or Summary Results: There were 144 stillbirths during 10 years, and the unknown cause (29,16%) was the most frequent, followed by placental one (27%). If we divided according to the gestational age, in the group of 524weeks the most common cause would be the infection (40%); in fetuses between 24–36,6 weeks the demise was due to placental alterations (29%) like placental insufficiency, abruptio placenta or primary placental alterations. Between 37 and 40,6 weeks and the post-term group (41 weeks) the most important cause is the unexplained with 31% and 57% respectively. Conclusions: In our study we were able to identify the main causes of stillbirth that are associated with a period during pregnancy. Therefore, it allows us to take care of the gestational monitoring and to predict what risks might be for future pregnancies. Keywords: stillbirth, gestational age, infection, placental alterations, unknown cause Presenter: Nuria Lorente

ID 476

DETECTED INBORN ERRORS OF METABOLISM BY NEONATAL SCREENING TEST. A 5-YEAR PREVALENCE STUDY IN PATIENTS BORN IN A MONTERREY, MEXICO POPULATION

J. Jua´rez Rodrı´guez1, C. Cantu´ Reyna2, & C. Diaz Olachea2 1

Pediatric Dept., San Jose´-Tec de Monterrey Hospital, Monterrey, Me´xico, 2Department of Basic Medical Sciencies, Monterrey Institute of Technology and Higher Education, College of Medicine ‘‘Ignacio Santos’’ Monterrey, Me´xico, and 3 Department of Clinical Pa Brief Introduction: Most inborn errors of metabolism (IEM) are due to a defect in an enzyme or transport protein, which results in a block in a metabolic pathway.The optimal development of a patient with an IEM, depends on the early diagnosis and treatment. Delay in its treatment should result in acute metabolic decompensation, progressive neurological damage or death. The use of Mass Spectometry Tandem in the newborn, makes it possible to screen a great variety of IEM in a single study. The disorders identified include aminoacidopathies, organic acidopathies and fatty acid oxidation defects. The neonatal screening test (NST) for the detection of IEM is a measure of public health directed to identify disorders with fatal consequences to the newborn. Materials & Methods: Retrospective data to determine how many newborns with IEM were born during the period from 2007 to 2012 at San Jose´ Tec de Monterrey Hospital, in Monterrey, Mexico were examined. Data from all patients born at this period of time were collected and analyzed. Clinical Cases or Summary Results: 5576 newborns were screened, 3 patients were confirmed for aminoacidopathies; 13 patients confirmed for glucose-6-phosphate-dehydrogenase deficiency and 1 as carrier; 13 patients carriers of hemoglobinopathies; 1 patient was confirmed for cystic fibrosis and 1 as carrier; 8 patients were confirmed for congenital hypothyroidism. Conclusions: The overall birth prevalence of IEM was 4.5 in 1000 live births (0.45%), prevalence of carriers, was 6.8 in 1000 live births (0.68%). These results are similar to those in other published studies. This study provides useful epidemiological information for those

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planning and providing services for patients with IEMs, including newborn screening, in Me´xico and similar populations. Keywords: Presenter: Juan Carlos Jua´rez Rodrı´guez

ID 086

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

STUDY ON THE FETUS HEAD MOLDING DURING VAGINAL DELIVERY AND THE BIOMECHANICAL BEHAVIOR OF THE PELVIC FLOOR MUSCLES M. Parente1, E. Silva1, R.M. Natal Jorge1, & T. Mascarenhas2

same simulation was repeated with two different models for the fetus skull, one being considered rigid and a second one being considered deformable (Figure 1b). Clinical Cases or Summary Results: The sum of the forces opposing the fetus descent, caused by the pelvic floor due to the passage of the fetus are different if the fetus skull is considered rigid or deformable. A difference of 23% was observed on the results, form a maximum of 235N when the fetus skull is considered rigid to a maximum of 182N when the fetus skull is considered deformable. Conclusions: The present numerical simulation shows that the inclusion of the fetus head molding effect is an important aspect, in order to correctly simulate a vaginal delivery. The fetus head molding effect contributes to lower the efforts on the pelvic floor muscles. The present work constitutes a non-invasive procedure that can be used in the future to estimate the damage that a vaginal delivery can induce on a specific pelvic floor. Keywords: numerical simulation, molding, pelvic floor Presenter: T. Mascarenhas

1

IDMEC, Institute of Mechanical Engineering, Faculty of Engineering, University of Porto, Portugal, and 2Dept. of Obstetrics and Gynecology, Faculty of Medicine, University of Porto, Portugal. Brief Introduction: Pelvic floor dysfunction is a hidden problem with a magnitude unknown to many. Statistics show that 1 in every 10 women will have pelvic floor dysfunction so severe that it will require surgery [1]. Several studies have shown that pelvic floor injuries during a vaginal delivery can be considered a significant factor in the development of urinary incontinence, fecal incontinence and pelvic organ prolapse. The objective of the present work is to contribute to the clarification of the mechanisms behind pelvic floor disorders related to a vaginal delivery. The Finite Element Model used intends to represent the effects that the passage of a fetal head can induce on the muscles a specific pelvic floor, from a mechanical point of view. Materials & Methods: The numerical model used in this work was constructed using the geometrical point data obtained from cadaver measurements. All the measurements were performed on one embalmed 72-year-old female cadaver obtained for scientific research [2]. To obtain a 3D model for the fetal skull, a dataset of images obtained by computed tomography was used. The images were supplied by the Pennsylvania Open Research Scan Archive (ORSA) [3]. In this work the movements of the fetus during birth, in the vertex position were simulated using the software ABAQUS. In order to study the influence of the fetus head molding during vaginal delivery, the

ID 692

POST PARTUM URINARY RETENTION IN A SOUTH INDIAN POPULATION A. Pramanick1, N. Kekre2, & A. Kekre3 1

Department of Obstetrics and Gynecology, KK Women’s and Children’s Hospital, Singapore, 2Department of Urology, Christian Medical College and Hospital, Vellore, India, and 3 Depatment of Obstetrics and Gynecology, Christian Medical College and Hospital, Brief Introduction: The incidence of urinary retention in the postpartum period ranges from 1.5–17.9%. Various factors like epidural analgesia, perineal trauma, fetal size, prolonged second stage have been found to have to increase the risk of post-partum urinary retention. Undiagnosed urinary retention leads to bladder over distention which may lead to ischemic damage to the parasympathetic nerve fibers and detrusor syncytium. Neglected cases of urinary retention may lead to long term voiding dysfunction and also bladder rupture. Therefore, early detection and management of post partum urinary retention (PPUR) is of paramount importance.

Figure 1. Computational model. (a) bones structure and pelvic musculature; (b) Fetal skull with cranial sutures.

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DOI: 10.3109/14767058.2014.924236

Materials & Methods: This prospective observational study was carried out in the department of Obstetrics and Gynecology, at Christian medical College and Hospital, Vellore, a tertiary referral center in South India. Inclusion criteria were normal or instrumental vaginal delivery. Women who delivered by Cesarean section or required catheterization for reasons other than urinary retention were excluded. A total of 5791 women were included in this study. Post-nataly, urinary frequency and volume was measured for all patients. The patient was clinically diagnosed to have overt PPUR if she was unable to void spontaneously 6 hours after delivery or if she had increased frequency with small volumes of urine; and on post void catheterization the urine volume was 4150ml. A self-retaining transurethral bladder catheter was left in situ for 48 hours. After 48 hours the catheter was removed and urinary frequency, volume monitored. Those who were able to void spontaneously were discharged with instruction to monitor for urinary symptoms and report back if voiding difficulties occurred. If the patient was unable to void spontaneously or he had a post void residual urine 4150 ml then indwelling transurethral bladder catheter was left in situ for 7 days followed by trial off catheter. Resolution of urinary retention was defined as ability to void naturally and low post void residual urine volume. All patients were followed up 6 weeks postnataly and bladder symptoms reviewed Clinical Cases or Summary Results: There were 41 csaes of PPUR among 5791 patients who had delivered vaginally (incidence of 0.70%). There was no significant difference in age, parity, BMI, duration of first and second stage of labour, birth weight of baby or perineal trauma among the two groups. Those who required instrument assisted delivery were at a significantly higher risk of developing PUR (48.7 vs. 24.3%, p = 0.022). Women who were unable to void spontaneously during the intra-partum period and had required intermittent catheterization in labor were at a significantly higher risk of developing retention in the postnatal period (65% vs 36%, p = 0.008). 2 patients had PPUR following their previous vaginal deliveries (previous two and previous one vaginal delivery). Both these patients developed PUR, were able to void normally after 48 hours of bladder drainage. There were 2 sets of twins in the PPUR group and one pair of twins in the control group with one twin requiring vaginal breech delivery in each group. 37(90.2%) of cases manifested retention of urine during the immediate post partum period (within 6 hours).The other 4 were initially able to micturate satisfactorily but later (2–6 days) manifested retention of urine. The mean bladder urine volume for the 41 women with urinary retention was 824ml (range 150 – 2000ml). After 48 hours, 34(82.9%) women were able to void normally after trial off catheter, had low residual urine volume and normal urine frequency volume charting. 7(17.1%) women required longer catheterization and were discharged home on the catheter. 1 was able to void normally after 1 week, 1 after 2 weeks, 2 after 3 weeks, 2 after 4 weeks and 1 after 40 days of continuous transurethral bladder catheter. The 3 patients (0.05% incidence for prolonged PPUR) who required catheter for more than 4 weeks underwent urological evaluation and continued follow up with urology. All three had resolution of their voiding dysfunction by the 40th post partum day. 5 women in the PPUR group and 2 women in the control group had significant growth of pathogens on urine culture (no significant difference). E coli was the commonest organism in these 7 cases. All culture positive cases were treated with antibiotics according to the sensitivity report. The patients with sterile urine cultures did not receive any antibiotics. Conclusions: Women who undergo instrument assisted delivery or are unable to void naturally during labor are at a higher risk of developing urinary retention in the postpartum period. Most of the women recover within 48 hours and only 0.05% has prolonged voiding dysfunction. PPUR tends to recur in subsequent pregnancies and those with history of previous PPUR require close monitoring in the post partum period. Following early and appropriate

management post-partum urinary retention does not lead to long term voiding dysfunction. All women should be monitored in the post-partum period to detect and relieve urinary retention with an aim to prevent bladder injury and voiding dysfunction. Keywords: post partum urinary retention Presenter: A. Pramanick

ID 430

IS DEPRESSION A BARRIER OR OPENING FOR MAMMOGRAPHY? A CANADIAN COMMUNITY HEALTH SURVEY S. Jahanfar School of Population and Public Health, University of British Columbia Brief Introduction: Depression is reported as a risk factor for lack of mammography screening. Current study aims at investigating an association between depression and use of mammogram screening among elderly Canadian women. Materials & Methods: This population-based, cross-sectional study utilized the Canadian Community Health Database (CCHS). The samples were from 12 provinces across Canada including 22,662 women of aged 40 and above who answered questions on depression, mammography, socio-demographic status, and healthcare utilization. Short-Form of Composite International Diagnostic Interview identified women with depression; and depressed women were defined as those with score 5. Clinical Cases or Summary Results: Following adjustment for confounders, the odds of reported mammogram was 1.3 (95%CI 1.2–1.5) for depressed compared to non-depressed women. Age was an effect modifier in this relationship between utilizing mammography screening and depression. Moreover, the odds of reported mammography were the highest for 60–69 years old depressed women (AOR 2.9, 95%CI 0.9–8.6), compared with their counterparts in the youngest age group (40–49 years) adjusting for potential confounders. Having a regular family doctor was strongly associated with reported mammography (OR 2.2 95%CI 1.9–2.5). Conclusions: Depression among elderly women is positively associated with utilization of mammography screening. Longitudinal studies are needed to explore the effect of age as an effect modifier. Further studies can investigate the impact of other competing factors such as anxiety. Reasons for increased utilization of mammography screening among elderly should further be explored. Keywords: Depression, Mammography, Health Survey Presenter: S. Jahanfar

ID 244

PREVENTION OF RECURRENT FETAL LOSS SYNDROME IN PATIENTS WITH THROMBOPHILIA V. Bitsadze, A. Makatsariya, & D. Kapanadze Department of obstetrics and gynecology, I.M. Sechenov First Moscow State Medical University, Russia Brief Introduction: Our aim was to evaluate the preconception treatment efficiency in women with fetal loss syndrome.

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

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Materials & Methods: We studied 130 patients: group I - 49 patients with recurrent fetal loss syndrome and trombophilia, group II - 16 patients with confirmed trombophilia without history of fetal loss and 65 healthy pregnant women (control group) were evaluated to have antiphospholipid antibodies (APA) and genetic thrombophilia. 65 patients (49 in group I and 8 in group II) received prophylactic therapy during pregnancy: LMWH guided by D-dimer, omega-3 acids, vitamins of B group, folic acid, patients with APA - aspirin (50–100 mg/day) and natural progesterone. Clinical Cases or Summary Results: 34% and 12.3% patients had family and personal history of thrombotic complications respectively. APA were detected in 8%, multigenic thrombophilia - in 27%, hypergomocysteinemia – in 3%, FV Leiden – in 20%, prothrombin G20210A – in 9% (p = 0.002 vs controls). Preconception therapy allowed preventing fetal loss in 98% patients. 1 fetal loss was due to cervical insufficiency. 95% were delivered after 37 weeks, babies were alive in 100%. Conclusions: Antiphospholipid syndrome and genetic thrombophilia might be the main pathogenetic mechanism of recurrent pregnancy losses. Due to thrombophilia involvement in trophoblast invasion and placentation, early treatment is essential. Preconception treatment with LMWH, aspirin, progesterone and vitamins allows preventing recurrent pregnancy losses in most cases.

neurology tests and help in the detection of various hearing, verbal and behavioral problems in an early childhood and start with exact therapy as soon as it is possible to earn better results.

Keywords: recurrent fetal loss syndrome, trombophilia, antiphospholipid syndrome

Brief Introduction: The pregnant patients with metabolic syndrome are at higher risk of developing fetal loss syndrome, intrauterine growth retardation, preeclampsia and other obstetric complications. High incidence of labor complications occurs in patients with metabolic syndrome. Metabolic syndrome is also associated with at higher risk of developing thrombosis and thromboembolism. Prothrombotic states due to be considered as essential components of metabolic syndrome. Thrombophilia plays an important role in impaired invasion cytotrophoblast and impaired placental development. Materials & Methods: Subject: 29 years old woman with metabolic syndrome. Weight – 106 kg, height- 168 cm. IBM –37,6 kg/cm2. Clinical Cases or Summary Results: Subject: 29 years old woman with metabolic syndrome. Weight – 106 kg, height- 168 cm. IBM –37,6 kg/ cm2. Burdened familial history:patient’s mother is 49 years old with obesity, hypertension, varicose veins of the lower limbs. Patient’s father is 51 years old with obesity.Obstetric history:I pregnancy ended in miscarriage on 8–9 weeks of gestation; II pregnancy ended in miscarriage on 5 weeks of gestation; III pregnancy ended in antenatal fetal death on 28–29 weeks of gestation. Stillborn child was born through maternal passages; IV pregnancy is present. The patient was examined on 19 weeks of gestation. It was found negative lupus test, homozygous form of polymorphism the 4G/4G phenotype of the gene PAI-1, heterozygous form of fibrinogen gene 455G/A polymorphism, heterozygous form of polymorphism in the angiotensin-converting enzyme (ACE) gene I/D, heterozygous form of polymorphism in the tissue- type plasminogen activator (t-PA) gene I/ D, highly increased levels of D-dimer, increased platelet activation. Antithrombotic therapy which involved low molecular-weight heparin, vitamins B, folic acid, antioxidants used during pregnancy and postpartum period. Outcome of pregnancy: signs of fetal hypoxia at 37 weeks, cesarean delivery at 38 weeks. The alive child was born, cried at once, breathed himself, weight 3150, height 51 cm, evaluation on Apgar scale – 8–9 points. Conclusions: Fetal loss and other obstetric complications during previous pregnancy especially in women with metabolic syndrome is an indication to check acquired and inherited thrombophilia. The genetic assay demonstrates the presence of hypofibrinolysis genetic form in patient with metabolic syndrome. We suggest that prothrombotic state may play an important role in impaired invasion cytotrophoblast and impaired placental development in women with metabolic syndrome. Antithrombotic therapy during pregnancy and postpartum period is a key of successful and safe outcome of pregnancy. The earlier the differential therapy was begun, the more successful the results of treatment were.

Presenter: V. Bitsadze

ID 355

FETAL MIDDLE CEREBRAL ARTERY CIRCULATION AFTER PRENATAL AUDITORY STIMULATION S. Jankovic-Raznatovic1,2, S. Rakic1,2, A. Curkovic1, J. Stankovic1, Dj. Cecez1, Lj. Srbinovic1, & A. Dobrosavljevic1 1

Department of Obstetrics and Gynecology ‘‘Narodni front’’, Belgrade, Serbia, and 2Belgrade University Medical School, Belgrade, Serbia Brief Introduction: Background. Our study evaluates variations of fetal middle cerebral artery (MCA) circulation after the defined prenatal acoustical stimulation (PAS). Prenatal auditory stimulation (PAS) is a method of early detection of development of fetal auditory and behavioral function. It is based on a method of detecting fetal reactions on the defined sound stimulation. Materials & Methods: Materials and Methods. Our study included 268 pregnant women without complications of any kind. Our examination was performed in period from 28 to 41 weeks of gestational age. Gestational age was determined in relation to last menstruation and estimated by ultrasound examination. Experimental study has been organized as a part of multicentric prospective clinical trial under the supervision of Ministry of Health and Education of Republic of Serbia, (2011–2014. We analyzed fetal midlle cerebral artery (MCA) circulation using Toshiba Nemio with Doppler and color-Doppler convex sectorprobe 3.5 MHz, before and after PAS. Clinical Cases or Summary Results: Results. Analysis of the Pulsatility index basic (PIB), before PAS and Pulsatility index reactive after (PIR), shows no statistical difference (p40.05). We can notice that the percentage of fetuses with increased middle cerebral artery circulation after the sound stimulation is higher than number of fetus with decreased cerebral circulation. Conclusions: Conclusion. Our results studied influence of sound stimulation on fetal brain circulation. However, bearing in mind that PI values are not strictly defined and vary in the relation to gestational week of pregnancy, we can conclude that the increase in the number of cases probably got a different result. Our work will introduce the second stage of investigation correlated with postnatal hearing and

Keywords: fetus, sound stimulation, prenatal acoustical screening, fetal cerebral circulation. Presenter: S. Jankovic-Raznatovic

ID 758

PROPHYLAXIS OF RECCURENT FETAL LOSS IN A PATIENT WITH METABOLIC SYNDROME AND MULTIGENIC THROMBOPHILIA A. Makatsariya, E. Perederyaeva, & T. Pshenichnikova I.M. Sechenov First Moscow State Medical University, Moscow, Russia

Keywords: metabolic syndrome, fetal loss, thrombophilia Presenter: A. Makatsariya

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ID 288

3D/4D ULTRASOUND SCANNING AS A PREDICTOR OF EMBRIONAL/ FETAL BEHAVIOR (OUR EXPERIENCE) A. Curkovic1, D. Sokolovic Curkovic2, S. Babic1, N. Karadzov Orlic1, S. Jankovic Raznatovic1, S. Rakic1, M. Djukic1, A. Jurisˇic´1, V. Zivanic3, L.J. Mirkovic4, N. Zecevic1, S. Stanimirovic1, & A. Stanimirovic1 Ob/Gyn Clinic Narodni Front Belgrade Serbia, 2EUROMEDIK, Belgrade, Srbia, 3Ana Life Hospital, Belgrade, Serbia, and 4O/B Clinic Clinical Center of Serbia, Belgrade J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

1

Brief Introduction: 3D/4D ultrasonography made the revolution in examination of fetal myoneurological development. This examination is important for the study of fetal vitality/activity, growth and myoneurological status. Most important are: major fetal movements – MFM measure of myoneurological maturation. First trimester observation: first reflex seen - the simple grasp detected in 12th GW, and group of pre/para movements: parabreathing, presuckling, hand/leg/body movements - proper frequency and incidence. Second trimester: grasp - same incidence and frequency as before. Two main groups of movements are discovered: MFM and fetal facial expressions (FFE), two movements: suckling and eye opening. Third trimester: MFM and FFE. Reflexes from the two previous trimesters are still present. Materials & Methods: Two groups: The control group - 50 physiological pregnancies 28–40 GW, randomly chosen during the period of 12 months, in year 2012. Test group - 80 pregnancies with pPROM, diabetes mellitus and epilepsy in mothers. We examined the reflexes, MFM, FFE, differences between groups, during the same period. The result that were acquired were compared with those of the same origin, but gathered a year earlier, and they were both statistically tested. The comparison was also made with the results in up to date literature. Clinical Cases or Summary Results: Epilepsy during the first trimester: fetal movements occurred later in average 9.17days. During the second trimester - frequency and incidence decrease significantly. Third trimester: frequency of fetal movements was lower, unless the mono or poly therapy, for the basic failure (epilepsy) is introduced. Reduction mostly of MFM, not FFE, is present in patients with pPROM, but infection was not excluded in the most of cases whether it was apparent or unapparent. Diabetes mellitus has significantly higher frequency of MFM, body/ respiratory movements, especially in a combination with pPROM, or some system diseases (SLE, Sjogren Sy, Sclerodermia). Second and third trimester primarily show a huge increase in them (over 75% in total) especially if the status is followed by high temperatures. Conclusions: Results correlate with most of the other authors, as well as with the results acquired during the previous year. It has been established that there are some differences in regional expression, probably due to genetic and fenotipic properties, but they were so small, that statistically were not tested. Group with pPROM had case of after birth proven cerebral palsy, the same as the previous year, but the gestation of the pPROM was much earlier, in 24 GW. Chronic fetal hypoxia in oligoamnions and infections during not only organogenesis may or may not be considered a cause. No significant and scientifically proven ultrasound markers for the prenatal diagnosis were found, yet. Introducing a high power multislice combined ultrasound 3D/4D and CT simultaneous exam, with low range X ray tissue destruction, might bring a new light concerning these problems. This is expected

to be in a very near future, combined with nano technology contrast dispersion, as well as nano dispersion of medicamentation in fetal or early neonatal period. Keywords: Presenter: Aleksandar Curkovic

ID 230

LOW-DOSE EPIDURAL ANALGESIA AND LABOR DURATION, DYSTOCIA AND OXYTOCIN AUGMENTATION IN PRIMIPAROUS AND MULTIPAROUS O. Kozlova, O. Baev, S. Rubtsova, O. Eremina, V. Rumyantseva, & A. Pyregov Federal State Budget Institution ‘‘Research Center for Obstetrics, Gynecology and Perinatology’’ Ministry of Healthcare of the Russian Federation. Moscow, Russian Federation Brief Introduction: There is no clear evidence, that nowadays low dose epidural analgesia (EA) has been associated with prolonged labour, use of oxytocin augmentation and increased incidence of instrumental vaginal delivery. The aim of our study is to determine whether in our clinic epidural analgesia in labor is associated with changes of labor duration, dystocia of labor and oxytocin augmentation. Materials & Methods: 180 women were included in the study (129 primiparous and 51 multiparous women). All women were divided into two groups: 75 women without analgesia during labor (first group) and 105 women who have undergone low-dose epidural analgesia (second). Inclusion criteria: spontaneous singleton pregnancy, fetus in vertex presentation, term labor. Exclusion criteria: chronic disease and severe pregnancy complications. There were no cases of poor maternal or perinatal primary outcomes. This study protocol was approved by the local ethics committee. Clinical Cases or Summary Results: Mean duration of labor without analgesia was 473,22 ± 197,75 min (M ± SD), with epidural analgesia – 613,62 ± 180,54 min (p50.0001). Mean duration of the first stage of labor was 406,81 ± 167,06 min and 524,41 ± 165,26 min, respectively (p50.0001). The second stage of labor lasted on average 59,81 ± 39,31 min (no analgesia) and 86,84 ± 50,54 (with epidural analgesia), p50.0001. Cesarean section rate was similar. Oxytocin augmentation in labor has been used in 26.6% of women in the first group, and in 53.3% of the second (p = 0.0006). The rate of labor dystocia was 13.3% and 32.4%, respectively (p = 0.0059). The duration of labor in primiparous women in the epidural analgesia group was longer than no-analgesia group. Mean duration of labor in the epidural analgesia group without labor augmentation was 596,6 ± 155,3 min: first stage – 509,4 ± 150,1, second stage – 81,6 ± 38,8 min. Whereas the duration of no-analgesia labor was 526,5 ± 127,3 min (p = 0.09): the first stage – 466,5 ± 120,4, the second stage – 53.3 ± 25,1 min (p = 0.007). The rate of oxytocin augmentation was significantly lower in primiparous women of no-analgesia group than in the epidural analgesia group (40% and 56.2%, p = 0.02). The same trend was observed in the rate of labor augmentation in multiparous women – 11,45% and 37.5%, respectively (p = 0.005). But there were no significant differences in duration of labor in multiparous women of the first and second groups. Conclusions: Women to whom epidural analgesia is applied are at increased risk of labor dystocia and oxytocin augmentation. Additionally primiparous are at increased risk of prolonged labor.

290 No differences between epidural analgesia and no-analgesia group were registered for need for cesarean section. Keywords: Labor duration, dystocia, epidural analgesia. Presenter: O. Baev

ID 885

RADIOIMAGING IN GASTROINTESTINAL OBSTRUCTION WITH YELLOW VOMIT IN NEWBORN INFANTS J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

V. Stefanescu, A.M. Pelin, & M. Dobre ‘‘Dunarea de Jos’’ University, Faculty of Medicine and Pharmacy, Galati, Romania Brief Introduction: Newborns often experience vomiting. It is well known that the color of vomit (yellow, green, red or brown) is a landmark for diagnostic guidance, the yellow or green color being due to the presence of bile, which may occur regardless of gastrointestinal obstruction. This study shows the contribution of radioimaging to the diagnosis of 7 newborns with various cases of gastrointestinal obstruction with yellow vomit.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Materials & Methods: All patients (aged 7 hours to 10 days) showed common symptoms: repeated vomiting accompanied by dehydration, electrolyte imbalance (alkalosis, hypochloremia) and abdominal distension. As clinical signs were suggestive of obstructions within the digestive tract, the infants were investigated via radiography (with or without contrast substances) and ultrasound. Clinical Cases or Summary Results: Case 1: Newborn (4 days old) with multiple malformations and Down syndrome, displaying yellow vomit and a distended abdomen. Contrasted gastric X-ray (contrast substance: Gastrografin) showed duodenal stenosis due to peritoneal bands (Ladd’s bands) and common mesentery (Fig. 1). Case 2: Newborn (2 days old) with a distended abdomen, no meconium elimination. Irigography showed microcolon (Fig. 2). Eso-gastro-duodenal barium contrast radioscopy showed a dilated stomach and duodenum, residual contrast substance pockets in the colon and a lack of pneumatic compression of the small intestinal folds. Surgery helped determine the final diagnosis of marked jejunal atresia and minor ileal atresia. Case 3: Newborn initially presented with yellow vomit and reduced meconium elimination. The patient’s general state deteriorated between age 5 and 9 days, with the onset of dyspnea and abdominal meteorism, followed by bronchopneumonia, reduced vomiting and a complete absence of defecation. A diagnosis of pneumoperitoneum was established via abdominal contrasted X-ray (Fig. 3). Case 4: Newborn male exhibiting yellow vomit, no meconium elimination and distended abdomen. An abdominal X-ray revealed hydroaeric levels and no pneumatic compression in the lower

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DOI: 10.3109/14767058.2014.924236

Keywords: gastrointestinal obstructions, bilious vomiting, newborn infant Presenter: V. Stefanescu

ID 404

SEVERE NEONATAL HYPERCALCEMIA SECONDARY TO SUBCUTANEOUS FAT NECROSIS V. Mugarab-Samedi & E. Al Awad

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Neonatal Intensive Care Unit, Peter Lougheed Hospital, Calgary, Canada abdominal cavity. When investigating the digestive tube with a nonionic substance, 24h after the X-ray, the contrast substance was found to have been blocked in the stomach (Fig.4). Case 5: Newborn female (3 days old) with distended abdomen, vomiting and no meconium elimination. An irigography revealed a normal rectal ampulla but a sigmoid and lower colon hypoplasia, which was stopping the progress of the contrast marker (Fig.5). Surgery confirmed a diagnosis of descending microcolon and ileocolonic atresia. Case 6: Patient presented without meconium elimination and distended abdomen. Abdominal X-ray revealed hydroaeric levels and an absence of pneumatic compression in the lower abdominal half. An X-ray performed with the patient placed upside down and using a coin to mark the anus revealed an absence of air through the distal digestive tube, and helped establish a diagnosis of sigmoid atresia and anal imperforation (Fig.6). Case 7: Newborn (7 hours old), exhibiting a distended abdomen and vomiting. Abdominal X-ray reveals massive pneumoperitoneum. Surgery reveals anterior gastric perforation and intestinal atresia (Fig. 7). Conclusions: Obstructive gastrointestinal malformations represent an important cause of yellow vomit in newborn infants. Radiologic investigations, performed with or without a contrast substance, is a simple, necessary and often sufficient instrument to reveal digestive tube malformations which cause bilious vomiting.

Brief Introduction: Subcutaneous fat necrosis (SCFN) is an inflammatory disorder of adipose tissue triggered by different types of perinatal distress. With increasing use of therapeutic hypothermia for management of hypoxic -ischemic encephalopaty (HIE), SCFN became one of potential complication of this medical intervention. SCFN is a self-limiting condition that could be associated with metabolic abnormalities, as thrombocytopenia, hypoglycemia, hypertriglyceridemia and hypercalcemia. Pamidronate inhibits the activity of osteoclasts and blocks dissolution of bone calcium phosphate (hydroxyapatite) crystals. We report a case of severe hypercalcemia complicating SCFN secondary to therapeutic cooling treated in term infant successfully treated with pamidronate Materials & Methods: Two main theories explain mechanism of Hypercalcemia: i) granulomas secrete high levels of 1,25-dihydroxyvitamin D3 that increases intestinal calcium uptake ii) inflammatory mediators(prostaglandins) activate osteoclasts and calcium release from necrotic fat cells Laboratory investigations: Serial Ca levels (total and ionised) Phosphate level -1.92 (normal) Alkaline Phosphatase - 172 units/L 25-hydroxy vitamin D level - 100 nmol/L (normal) PTH level was less than 4 mg/L (13–54) Endocrinology consultation

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Conclusions: Pamidronate is an effective alternative to steroid therapy in complex management of hypercalcemia; it is faster acting and well tolerated medication. Literature suggests three to four doses of pamidronate 0.25– 0.5 mg/kg/daily for treatment of hypercalcemia G. Lombardi at al (2009) Effectiveness of pamidronate in severe neonatal hypercalcemia caused by subcutaneous fat necrosis.Eur Jour of Pediatr Alos N et al (2006) Pamidronate: treatment for severe hypercalcemia in neonatal subcutaneous fat necrosis. Horm Res 65:289–294 Keywords: Hypercalcemia, subcutaneous fat necrosis, pamidronate

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Presenter: V. Mugarab-Samedi

ID 803

A CASE OF SOS1-ASSOCIATED NOONAN SYNDROME IN A HIGH FAMILIAR EXPRESSIVITY PATTERN FOR SYNDROME RELATED PULMONARY VALVE STENOSIS N. Todisco, V. Della Monica, M. Visconti, A. Ciccullo, A. Frascogna, M. Corbo, & A. Criscuolo Division of Neonatology and NICU, University Hospital ‘‘San Giovanni di Dio e Ruggi d’Aragona’’ of Salerno, Salerno, Italy

Therapeutic interventions: hyper-hydration, pamidronate administration. Clinical Cases or Summary Results: The patient was a term female infant, delivered via cesarean section due to fetal heart abnormalities. Her Apgars scores were 1, 6 and 8 on 1st, 5th and 10th minutes of life; cord pH was 6.85 and BE was -17. Baby had complex course at Level III, part of which was Hypoxic Ischemic Encephalopathy required cooling for 72 Hrs, as well as sedation and relaxants (fentanyl, rocuronium). At the age of 25 days CGA 44 + 3/7 weeks baby was transferred to level II care with nodular indurated erythematous lesions on the right shoulder and inter-scapular space on the back. On day 26 of life total calcium found to be 4.15 mmol/L with ionized calcium of 1.86 mmol/L. Vitamin D was immediately stopped, baby was kept NPO, started with IV hyperhydration and diuretics (furosemide 1 mg/kg per dose every 12 hours) As repeated Calcium levels didn’t show significant improvement(calcium prior to infusion was 3.56), initial infusion of Pamidronate was given on at 0.25 mg/kg, and level of total Calcium post-infusion was 3.5 and ionized calcium 1.5. Decision to use higher dose of 0.5 mg/kg on 3 consecutive days starting on day 28 resulted in normalization of calcium level. No side effects were observed during treatment. Total calcium prior to discharge home on January 2, 2014 was 2.94 and ionized calcium was 1.6 Baby continue to gain weight on exclusive breastfeeding Calcium level in 2 weeks post-discharge was 2.65 and Phosphate was 1.79 The follow-up of serum calcium level will be continued for next six months Vitamin D is on hold at least for next 2–3 months

Brief Introduction: Noonan Syndrome (NS) consists in a congenital genetic disorder characterized by many clinical findings of facial and musculoskeletal altered aspects with appearance is most characteristic in infancy from newborn period until early-to-middle childhood, becoming more subtle in adulthood. Principal phenotypic features (large head, wide-spaced eyes with epicanthal folds, ptosis and downslanting palpebral fissures, short nose, low-set and posteriorly rotated ears, neck and chest deformity, short stature, possible hematologic disorders) must accompain congenital heart defects (in more than 80% of all cases; dysplastic pulmonary valve alone in 25–35% of all cases) in according with description made by Dr. Jacqueline Noonan in 1968. Materials & Methods: NS consists in an autosomal dominant disorder with complete penetrance and variable expressivity; its estimated prevalence is 1:1000 – 2500 live births. From recent understanding of underlying genetic disorders (mutations in gene of the Ras/MAPK pathway) and its genetic heterogeneity was hypothesized that Pulmonary valve stenosis (PSV), as prominent feature of NS, is the product of a particular genotype/ phenotype correlating pathway recognized as SOS1 mutation. Clinical Cases or Summary Results: We describe the case of an inborn preterm (30 wks; birth weight 1490 gr.) male newborn requiring at birth rescue respiratory assistance who presented an early-onset significant systolic murmur (24 hours later) and an abnormal pulmonary-valve shape. Successive cardiac ultrasonography scan confirmed PSV with progressive enhancement of the valvulat pressure gradient. SOS1 gene mutation R552S (c.1656 G4C) was detected during fetal period by amiotic fluid cells. Pathologic anamnesis reveals high recurrence of Noonan syndrome in the family on the maternal line (mother; mother’s sister; mother’s father). Major patient’s brother (4 years) resulted moreover be affected by SOS1 mutation (c.1656 G4C) NS with clinical finding of mild stenosis associated-PSV (max pressure gradient 25 mmHg). Patient’s prognosis result at the moment be poor because mildsevere PSV (max pressure gradient 35–40 mmHg) and necessity of mechanical assisted ventilation (n-SIMV) although needing low FiO2 level.

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DOI: 10.3109/14767058.2014.924236

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Conclusions: Our case may open some orders of considerations: first, clinical management of severe PSV; second, genotype/phenotype correlations in NS; then, necessity of genetic counseling. Patients having clinically significant PSV need periodic reevaluation by cardiologist and require pulmonary ballon valvuloplasty as initial treatment, then, if it may results unsuccessful, pulmonary valvectomy may be needed in childhood. Genetic and epigenetic factors seem to influence both penetrance and expressivity thus genotype/phenotype correlations may be useful only for clinicians and aren’t phenotypic features exclusive to a specific genotype, whereas significant differences in the risk of various NS manifestations are based on the causative gene (SOS1 mutation more likely appears to cause PSV). Before child is born, consultations with parents may explain mechanisms for occurrence or recurrence of NS in the fetus and the recurrence risk in the family (in some cases an affected person inherits the mutation from one affected parent). Keywords: Noonan Syndrome; SOS1; Pulmonary Valve Stenosis; RDS Presenter: N. Todisco

ID 534

MANAGEMENT AND OUTCOME OF PREGNANT WOMEN WITH HIV ACQUIRED BY VERTICAL TRANSMISSION V. Serrano-dela Cruz, A. Martı´nez, M.J. Nu´n˜ez, V. Maiques, V. Diago, & A. Perales Department of Obstetrics and Gynecology, La Fe University Hospital, University of Valencia, Valencia, Spain. Brief Introduction: Combined antiretroviral therapy for perinatally HIVacquiredchildren has prolonged their survival. The first case of pregnancy in an adolescent with perinatally acquiredhuman immunodeficiency virus was published in 1998. Nowadays, the number of cases of these patients are increasing, so the control of these pregnancies is a new achievement for obstetricians. We don’t know the perinatal and long-termmaternal outcomes, because the number of cases is still not enough. Materials & Methods: We report eight patients (nine pregnancies) with HIV acquired by vertical transmission, whose pregnancies were controlled in our tertiary Hospital. They delivered a total of nine newborns between 2004 and 2011. Clinical Cases or Summary Results: The average age of women was 20 years (range 16–26). Seven patients were in their first pregnancy (87.5%). Only one was her second pregnancy. Seven pregnancies were single and one was twin. One suffered an miscarring and one a volunteer pregnancy interruption. All patientstook the treatment during pregnancy, at least at the end of it. One pregnant underwent a pneumonia, which was successfully solved. One pregnancy was a dichorionic twin with small for gestational age fetuses, the remainder were uncomplicated pregnancies. At 36 weeks of gestation, 4 cases had viral load 51000 copies/ml (50%) and the other pregnant had a viral load 41000 copies/ml.All pregnancies were delivered by cesarean section and only two of them were urgent. The average of term was 36 weeks (33 + 3;38 + 2), 4 of them were before 37 weeks (40%) and the average weight was 2212,777 gr (1820;3325). In any case mother-to-child transmission was reported (We lack the viral load of the last two infants). Conclusions: The management of pregnant women with HIV acquired by vertical transmission is difficult, because these women are teenager and young. In addition, combined antiretroviral therapy

during pregnancy should be a strict treatment in order to achieve the maximal viral suppressionat the moment of the delivery, and the most cases, the compliance of the treatment use to be poor (In our experience, the 50%). Keywords: VIH, mother-to-child transmission Presenter: Vicente Diago Alamela

ID 676

MAKING THE FIRST DAYS OF LIFE SAFER: TIME FOR A NEW PROTOCOL TO PREVENT SUDDEN UNEXPECTED POSTNATAL COLLAPSE R. Davanzo, MD, PhD, S. Demarini, MD, L. Travan, MD, G. Verardi, CNM, A. De Cunto, MD, & G. Paviotti, MD Perinatal Medicine, Institute for Maternal and Child Health IRCCS ‘‘Burlo Garofolo’’, Trieste, Italy Brief Introduction: Early and prolonged skin-to-skin contact (SSC) after birth between a mother and her newborn has been shown to generate beneficial effects on mother-infant relationship and breastfeeding. SSC may ease the infant’s transition to extra-uterine life and helps to regulate the infant’s body temperature and nursing behavior. However, reports of sudden unexpected postnatal collapse (SUPC) soon after birth, in healthy term neonates, in association with skin-to-skin contact, have raised concerns about the safety of this practice. Materials & Methods: Based on the available evidence, the working group on breastfeeding of the Maternal and Child Health Institute of Trieste (Italy) developed a surveillance protocol to be implemented in the Delivery Room and Postnatal Ward. The aim of our protocol is: (1) promoting safe mother- infant bonding (2) establishing successful early breastfeeding and (3) correcting the risk factors for sudden unexpected postnatal collapse (SUPC). This protocol is especially focused on the first 2 hours of life, when about 1/3 of SUPC occur, but extends to the whole duration of the infant stay in the maternity ward. Clinical Cases or Summary Results: The following interventions will be undertaken: 1. antenatal and early postnatal oral and written information to parents about: (a) the risk of bed-sharing (b) avoidance potentially suffocating infant positions (i.e. mouth/nose obstruction) (c) the need of an adequate supervision of the infant in the first hours/days after birth 2. periodical assessment (position, colour, breathing) of the infant (at 10, 30, 60, 90 and 120 minutes of life) by midwifes in the delivery room 3. discouragement of bed-sharing 4. encouragement of skin-to-skin contact only when mothers are fully awake 5. avoidance of mothers left alone with the baby in the first hours after birth particularly during skin-to-skin contact and first breastfeeding attempts Conclusions: As there is no evidence of effective interventions to prevent SUPC, our protocol has been written as a potential best practice. Evidence of its clinical effectiveness is obviously needed. Keywords: postnatal collapse, skin-to-skin contact, protocol Presenter: R. Davanzo

294

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ID 711

PERSISTENT CONGENITAL HYPERINSULINISM: SURGICAL TREATMENT OF LESIONS (ABOUT FIVE CASES) A. ksia1, F.Z. chioukh2, J. chahed1, H. Ben Hamida2, L. sahnoun1, I. Krichene1, M. Mekki1, M. Belghith1, K. Monastiri2, & A. nouri1 1

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Department of Pediatric Surgery, Teaching Hospital of Monastir, and 2Department of Intensive care and Neonatal Medicine, Faculty of Medicine of Monastir, Tunisia Brief Introduction: The congenital hyperinsulinism is a rare cause of hypoglycemia in neonates and infants. It is due to genetic mutations that induce hypersecretion of insulin by pancreatic cells. The aim of this work is to study the epidemiological, ethiopathogenic, clinical features of the congenital hyperinsulinism, and to assess the prognosis after surgical treatment. Materials & Methods: Our study is retrospective, covering five cases of congenital hyperinsulinism collected at the pediatric surgery department of Monastir on a 8-year period study from 2005 to 2012. Clinical Cases or Summary Results: The reported cases are neonatal forms. Surgery was indicated for all patients because of a resistance to medical treatment. The first patient had a pancreatectomy at 90%. The anatomopathologic study showed an atypical form. He had a psychomotor deficiency and epilepsy. The second patients had a 95% pancreatectomy. The anatomopathologic study showed a diffuse form. After that, he developed a diabetes mellitus. The third patient had a pancreatectomy at 70%, but the persistence of hypoglycemia indicates a pancreatectomy at 95%. The anatompathologic examination found a focal form. The fourth patient had a 95% pancreatectomy and no endocrine hyperplasia was found. The last patient had a pancreatectomy at 90% and the anatomopathologic study showed a diffuse form. Conclusions: The postoperative results are influenced by the risk of diabetes mellitus, Also the delay of treatment of the hypoglycemia can be the cause of neurological sequels such psychomotor deficiency and epilepsy. Keywords: congenital pancreatectomy-

hyperinsulinism-neonatal

hypoglycemia-

Department of Pediatrics, Medically University - Pleven, Pleven, Bulgaria, 2Department of ‘‘Chemistry and Biochemistry & Biophysics and Physics’’, Medical University Pleven, Pleven, Bulgaria, and 3Department of Cardiology, Pulmonology, Endocrinology, Medical University Pleven, Pleven, Bulgaria, 4National Heart Hospital – Sofia, Sofia, Bulgaria, and 5UMHAT ‘’ George Stranski’’ - Pleven, Pleven, Bulgaria Brief Introduction: Primary hypertension frequency in children is determined by cardiovascular risk factors such as obesity, smoking and inappropriate diet. The success of strategies for its prevention is dependent on a plurality of perinatal and postnatal risk factors.The aim of this study was to investigate the influence of potential risk factors like maternal smoking during pregnancy and the diet throughout the first year of the child for primary hypertension occurrence and the level of certain trace elements in children with primary hypertension. Materials & Methods: The study was conducted among 61 students aged 10–17 years with hypertension and a control group of 20 normotensive children. Maternal smoking during pregnancy and the diet of the infant were determined and studied by conducting a survey. Spectrophotometric methods were used to determine the serum levels of the trace elements Zn, Cu, Cr. The data was processed statistically using Statgraphics. Clinical Cases or Summary Results: We found that 47.5% of the mothers of children with hypertension had smoked during pregnancy. 80.4% of children with hypertension were formula fed and only 19.6% of them were breast-fed. Significantly lower levels of serum zinc (9,90 ± 1,63 mmol/l) were found in 66.6% of the children with hypertension. Serum copper levels were statistically significantly lower in 50% of the children (6,76 ± 2,96 mmol/l). All patients with hypertension had significantly lower chromium (0,68 ± 0.26 mmol/l). Conclusions: Smoking mother during pregnancy and formula feeding during the first year of life can probably be considered risk factors for early hypertension manifestation. The status of trace elements Zn, Cu, Cr showed a deficit in children with hypertension. Given the role of these micronutrients in cholesterol metabolism, their low serum levels may lead to early, preclinical vascular changes. These results require more in-depth study of the causes of hypertension. Keywords: trace elements, primary hypertension, perinatal, postnatal, risk factors Presenter: Nadia Kolarova-Yaneva

Presenter: F.Z. Chioukh

ID 901 ID 805

PERI AND POSTNATAL RISK FACTORS, TRACE ELEMEPRIMARY HYPERTENSION FREQUENCY IN CHILDREN IS DETERMINED BY CARDIOVASCULAR RISK FACTORS SUCH AS OBESITY, SMOKING AND INAPPROPRIATE DIET. THE SUCCESS OF STRATEGIES FOR ITS PREVENTION IS DEPENDENT ON A PLURALITY O N. Kolarova - Yaneva1, M. Angelova2, V. Nedkova1, A. Bozhinova2, K. Gospodinov3, P. Kolarov5, S. Tisheva3, & M. Tzonzarova4

PRENATAL DIAGNOSIS AND CHARACTERIZATION OF A SUPERNUMERARY MARKER CHROMOSOME 20 (SSMC) WITH APPARENTLY NORMAL PHENOTYPE Slimani Wafa1, Kammoun Molka1, Meddeb Saousen2, Jihen Mathlouthi3, Saad Ali1, & Mougou-Zerelli Soumaya1 1

Laboratory of Human cytogenetics, Molecular Genetics and Biology of Reproduction, Farhat Hached University Teaching Hospital, Sousse, Tunisia, 2Department of Gynecology and Obstetrics, Farhat Hached University Teaching Hospital, Sousse, Tunisia, and 3Department of neonatology, Farhat Hached University Teaching Hospital, Sousse, Tunisia Brief Introduction: Small supernumerary marker chromosomes (sSMC) are ‘‘structurally abnormal chromosomes that cannot be identified or

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DOI: 10.3109/14767058.2014.924236

characterized unambiguously by conventional banding cytogenetic alone, and generally are equal in size or smaller than a chromosome 20 of the same metaphase spread’’ (Liehr et al). SMC can have many shapes: inverted duplicated (inv dup), centric minute (min) and ring chromosomes (r), which make of them a considerable problem in cytogenetic diagnostics and genetic counseling. Most of the SMC are derivatives of acrocentric chromosomes especially from chromosome 15 (50%), but it was shown that they may originate from all human chromosomes. They are found in nearly 0.044% of live births and 0.075% prenatal cases and are seven times more prevalent in mentally retarded patients. Materials & Methods: Approximately 77% of SMCs are de novo and 23% are inherited, either from the mother (16%) or the father (7%). SMC carriers, are clinically highly variable, Clinical manifestations of might be affected by the many conditions such as chromosomal origin, amount of euchromatin, degree of mosaicism, uniparental disomy, and the chromosomal locus or genes present on the marker chromosome. In fact, 70% of non-acrocentric sSMC do not have phenotypic consequences, while the other 30% have various clinical manifestations. Supernumerary marker chromosomes derived from certain human chromosomes are rare and still need to be characterized further such as supernumerary marker chromosomes originated from chromosome 20. Observation of these marker chromosomes especially during prenatal diagnosis makes of them a major problem in predicting possible clinical outcome and giving genetic counseling to families. Therefore quick and clear characterization of such markers is indispensable. Here we report an additional de novo chromosome 20 prenatally diagnosed resulting in normal pregnancy outcome. A 39 year old pregnant woman was referred for amniocentesis at 17 weeks of gestation due to advanced maternal age. Parental karyotypes were normal. R-banding analysis on amniotic cells has shown a supernumerary marker chromosome present in mosaic and suspected to be a chromosome 20. FISH analysis with telomeres 20 probes was used to confirm the origin of the SMC. Clinical Cases or Summary Results: Here we report an additional de novo chromosome 20 prenatally diagnosed resulting in normal pregnancy outcome. A 39 year old pregnant woman was referred for amniocentesis at 17 weeks of gestation due to advanced maternal age. Parental karyotypes were normal. R-banding analysis on amniotic cells has shown a supernumerary marker chromosome present in mosaic and suspected to be a chromosome 20. FISH analysis with telomeres 20 probes was used to confirm the origin of the SMC. Genetic counseling was given to parents who decided to continue the pregnancy to term. Conclusions: The SMC was found to be a de novo chromosome 20 resulting in a chromosomal mosaicism that did not appear to affect the phenotype of the child. Keywords: prenatal diagnosis, Marker chromosome, FISH, chromosome 20, mosaicism Presenter: Meddeb Saousen

ID 941

HYSTEROSCOPY FINDINGS IN FAILED IVF AND THEIR INFLUENCE ON PREGNANCY OUTCOME Ziad Al-Shraideh, Ahmed Al-Zboone, & Mahmoud Alkhateeb Specialist, Department of obstetric and gynecology, Royal Medical Services - Jordan

Brief Introduction: To identify and analyze the abnormal hysteroscopic findings in women with failed IVF, and their effect on pregnancy outcome. Materials & Methods: A simple, descriptive, non -randomized study of 245 patients was conducted at King Hussein medical center. All patients with failed IVF were referred to routine hysteroscopy in our hysteroscopic unit. The hysteroscopic find˜ing was identified and recorded. The patients’ ages ranged from 20 to 38 years and duration of infertility ranged from 5–10 years. Clinical Cases or Summary Results: Uterine cavity was normal in 75% of the cases, while sixty one (25%) patients showed abnormal hysteroscopic findings of the cervical canal and uterine cavity (endometrium). The ab˜normal hysteroscopic findings seen were: intra˜mural myoma: 26 cases, endometrial polyp: 19 cases, isthmic abnormalities were present in 8% (5 cases), endometrial hyperplasia in 3 cases, intrau˜terine adhesion (synechiae): 4 cases, and septate uterus in 4 cases. Conclusions: Patients with recurrent IVF embryo transfer failures should be reevaluated using hys˜teroscopy prior to further commencing IVF-em-bryo transfer cycles. Hysteroscopy is part of first-line exams in infertile woman regardless of age. Keywords: Presenter: Ziad Al-Shraideh

ID 627

THE INFLUENCE OF PREPARTAL ACUPUNCTURE ON THE BICHOP SCORE AND THE DURATION OF DELIVERY N. Bilic1, I. Djakovic2, & K. Klican-Jaic3 1 University Hospital Center "Sestre Milosrdnice", Department of Anesthesiology, Zagreb, Croatia, 2University Hospital Center "Sestre Milosrdnice", Department of Obstetrics and Gynecology, Zagreb, Croatia, and 3University Hospital Center "Sestre Milosrdni

Brief Introduction: It is believed that prepartal acupuncture positively influences the infant, alleviates pain and shortens the duration of the delivery. At the University Hospital Center ‘‘Sestre Milosrdnice’’, Department of Obstetrics and Gynecology we have analysed the influence of prepartal acupuncture (PPAK) on the Bishop score and the duration of the delivery. Materials & Methods: We have compared two groups of 30 pregnant women, primiparas with uncomplicated pregnancies. The PPAK according to the Mannheim acupuncture scheme following Roemer was applied onto the first group, while the control group was represented by healthy pregnant women from the obstetrics infirmary. Clinical Cases or Summary Results: The application of the PPAK did not result in a statistically significant difference in the Bishop score between the test and control groups in the 36th, 38th and 39th week of pregnancy, but in the 40th week the Bishop score was statistically significantly higher with the pregnant women that received the PPAK (t = 3.30; df = 58; p50.05). A statistically significantly shorter duration of delivery was noticed with the pregnant women that received the PPAK in comparison to the control group (t = 3.08; df = 58; p50.05). Conclusions: The PPAK is recommended for a faster and easier delivery. Keywords: acupuncture, Bishop score, delivery duration Presenter: I. Djakovic

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ID 829

PULMONARY HYPERTENSION AND PREGNANCY. OBSTETRIC MANAGEMENT M.D. Monta´n˜ez-Quero, P. Barbero-Casado, C. Martı´nez-Go´mez, I. Caman˜o-Gutie´rrez, P. Vallejo Pe´rez, & O.P. Villar Ruiz

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Department of Obstetrics and Gynecology, Hospital Universitario 12 de Octubre, Madrid, Espan˜a Brief Introduction: Pulmonary hypertension (PH) is a syndrome that includes primary HP, a rare disease without cardiac damage that suffers fertile young women in which pulmonary arteriolar pressure rises, and secondary HP, where clinical situation is result of a heart injury, such as mitral stenosis and many congenital heart disease. Pregnancy in this patients has high maternal an fetal mortality rates (30%-50%). Present guidelines advise against pregnancy, however, development of new drugs for this disease has improve survival of patients (16%) Materials & Methods: The aim of this review it is to describe the actual risk, the algorithm to diagnose, drug treatment during pregnancy and specific advises for parturitium and puerperium in this disorder. We explain our obstetric protocol in patients affected by pulmonary hypertension, followed successfully in our hospital between 2011–2013 Clinical Cases or Summary Results: In this pregnant women, the increase of cardiac output and vascular volume during gestation, specifically in labor, when compensation can not be happen due to fix and high vascular resistance, could create an accute critical situation and get involved a right failure and a decompensated cardiac insufficiency.

Table 1. Asymptomatic patients in I class well-responder to calcium cannel blockers, did not need diuretics of sildenafil and a term cesarean section was programmed. Patients which required sildenafil was well tolerated in patients who required it, and habitual dose was 40 mg/8 hours.

Table 2. Obstetrical outcomes.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

This is the reason that obligates to follow the pregnancy by a team integrated with obstetrics, anesthesics and experienced cardiologists in PH. Cardiologic controls are made each 15 days from the beginning of second until the last trimester, when they become more often depending of clinical symptoms (once or twice each two weeks). At last trimester, they are examined weekly Echocardiogram and effort tests are made monthly. We recommend to reduce physical activity and to avoid low oxygen situations, even if necessary, oxygen theraphy is prescribed. The treatment begins as soon as possible, in order to avoid a right heart failure and control of symptoms. There are no clinical trials with drugs, but some of them have been used successfully. We talk about prostacyclins (Epoprostenol, Treprosinil and Iloprost), sildenafil, and calcium channel blockers, (nifedipine and diltiazem are safe during pregnancy). Diuretics, if necessary, should be used with caution, as glomerular filtration rate is higher, so they could have a big reponse to low diuretic dose. We recommend to begin with 10 mg of furosemide, and adjust dose depending of reponse, thus in our patients there have not been necesary. Adequate medical treatment is provided depending of clinical symptoms and functional class. All patients must be anticoagulated with profilactic low molecular weight heparin until 12 hours before to delibery, and no thrombo-embolic complications have been reported when arrested. Ambulatory obstetric and cardiologyc controls are followed according to hig risk protocol. Blood tests in first, second and third trimester do not change As was said above, hipoxemia situations should be avoided, and in case of anemia, promptly, iron supplements must be established Ultrasound examinations during pregnancy are closer due to increment in prevalence of intrauterine growth restriction, so we perform them at 12, 16 (early echocardiography) 20, 28 and 33 weeks. In case of preterm labor, hospital admission is indicated under rest, and if necessary, tocolysis with indomethacin will be dispesed, because ritodrine is contraindicated and there is no experience with atosiban. Corticoids for accelerating fetal lung maturation can be used By 32–34 weeks, a cesarean section is programmed, in order to prevent unexpected births, and once fetal maturity is adquired. Thus we individualize each woman, the elective way of delivery often is cesarean section as uterine contractions could increase suddenly vascular lung resistances and result in heart failure. On the other hand, a vaginal birth has less risk of hemorrhage, infection or thromboembolism. Respecting to anesthesia, the locoregional with progressive dose is preferred to general When got time to delivery, the woman will stay at the hospital 24– 48 h before de surgery, to monitoring blood pressure, EKG and oxygen saturation, central venous pressure, pulmonary artery catheterization. As for surgical technique, there is nothing special and tubal ligation should be recommended. In case of unstable patients we change the place and we operate in cardiac surgery operating theater Use of antibiotic prophylaxis for bacterial endocarditis, minimal dose of oxytocin and as short as possible, must be taken into account. During the postpartum period, before moving to hospitalization floor, the pacient will be stay in intensive care unit at leats 72 hours under the same monitoring, and administering again low molecular weight heparin. Below we expose the features and obstetrics results of 5 pregnant women diagnosed of arterial pulmonary hipertension between 2011– 2013 in our hospital. Conclusions: Thus Pulmonary hypertension is a high risk pregnancy, current treatments allow get a successful pregnagncy if a well obstetric and cardiological following are made, and this pathology is no more an absolute contraindication to get pregnant. Keywords: Pulmonary hypertension, pregnancy Presenter: P. Barbero-Casado

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DOI: 10.3109/14767058.2014.924236

1

ID 236

Department of Obstetrics and Gynecology, Xiang-Ya Hospital, Central South University, Hunan, Changsha 410008, China, and 2Department of Clinical Medicine, Undergradua

Acute Fatty Liver of Pregnancy: The Screening Time and Program for Outpatients

Brief Introduction: Acute fatty liver of pregnancy (AFLP) is an uncommon but potentially life-threatening perinatal complication. AFLP is associated with low morbidity but considerable mortality. Although mortality due to AFLP has declined in recent years, it is important to further lower the mortality rate by early diagnosis of this disease.

Te-Xuan Zhu1, Qi Li2, Wei-She Zhang1, Yue-Lan Liu1, Fang Xu1, Wei-Nan Wang1, & Xin-Hua Wu1

Table 1 Clinical and laboratory features of acute fatty liver of pregnancy Hunan

USA

UK

India

MA

Jiangsu

Guangdong

Guangxi

(n=44)

(n =51)

(n=57)

(n=24)

(n=28)

(n=20)

(n=26)

(n=27)

Laboratory features Elevated bilirubin

100%)

100%

100%

100%

100%

100%

80.8%

100%

Elevated transaminases

97.7%

100%

100%

95.8%

96.4%

100%

100%

100%

Coagulopathy

90.9%

60.0%

87.0%

95.8%

100%

100%

100%

100%

Leucocytosis

90.7%

98.0%

98.0%

87.0%

78.6%

95.0%

42.3%

100%

Ascites or bright liver on ultrasound scan

86.1%

27.0%

27.0%

72.7%

--

90.0%

50.0%

55.6%

Renal impairment

77.3%

96.0%

58.0%

70.8%

100%

90.0%

73.1%

59.3%

Elevated urate

77.3%

--

--

80.0%

100%

--

92.3%

66.7%

Elevated ammonia

35.3%

--

2/4

2/2

--

--

23.1%

37.0%

Hypoglycaemia

34.1%

18.0%

78%

33.3%

17.9%

35.0%

34.6%

74.1%

Jaundice

88.6%

33.0%

--

--

28.6%

--

73.1%

--

Nausea or vomiting

63.6%

57.0%

60%

52.4%

71.4%

95.0%

80.8%

100%

Encephalopathy

36.4%

16.0%

9.0%

37.5%

--

45.0%

23.1%

33.3%

Polydipsia/polyuria

34.1%

--

12.0%

1/1

--

25.0%

--

--

Abdominal pain

22.7%

53.0%

56.0%

21.4%

50.0%

30.0%

38.5%

--

Clinical manifestation

Notes USA:the United States of America. UK: United Kingdom.MA: Massachusetts. Hunan, Jiangsu, Guangdong, Guangxi: provinces of China. Red:positive rate≥80%,Orange: positive rate 50∼79%,Blue: positive rate 30∼50%,Green: positive rate<30%;☆:the blood glucose is beyond the normal range。

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298 Materials & Methods: This retrospective study included 44 AFLP patients admitted to Xiangya Hospital, Central South University, Hunan, China between November 2006 and December 2013. The 44 patients fulfilled both the clinical and laboratory criteria and the Swansea criteria for the diagnosis of AFLP. Clinical and laboratory data obtained on admission were used for analysis. Contrastive analysis was conducted within Xiangya Hospital and other large medical centers or general hospitals. Clinical Cases or Summary Results: There is no statistically significant difference between clinical and laboratory criteria and Swansea criteria in diagnosing AFLP patients included in our study (P40.05). The maternal mortality was 11.36% (5/44) and perinatal mortality was 27.27%.The women were delivered 35.98 average gestation weeks. According to the sequence based on the positive rate of clinical and laboratory data obtained on admission from high to low, more than 80% of AFLP patients have abnormal levels of transaminase, bilirubin, white blood cells and coagulation function. Gastrointestinal symptoms (abdominal pain, vomiting), jaundice, renal impairment and ascites or bright liver on ultrasound scan occur in 50% 80% of the patients. Less than 50% of the patients suffer from low blood sugar, high blood ammonia and hepatic encephalopathy. Conclusions: The screening time of AFLP for outpatients should be 34 gestation weeks. Gastrointestinal symptoms, blood routine, liver function and coagulant function tests have be recommended as first grade screening indicators. Then, renal function, blood sugar test and abdominal ultrasound could be the second grade screening indicators for AFLP out-patient. Keywords: Acute fatty liver of pregnancy; clinical features;screening time; screening program Presenter: Wei-She ZHANG

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

ID 438

THE PELVIC FLOOR INJURY AFTER VAGINAL DELIVERY I. Michalec, M. Navratilova, M. Tomanova, & O. Simetka The Department of Obstetrics and Gynaecology, University Hospital of Ostrava Brief Introduction: The evaluation of the frequency of levator ani avulsion within a group of women delivering vaginally in comparison to a group of women delivering with the help of vacuum extraction. Materials & Methods: Twenty primiparas were organized into two reference groups: group A – vaginal delivery and group B –vacuum extraction With the use of a GE E8 device, both groups underwent an ultrasonic transperineal examination focused on m. levator ani in axial plane with the smallest area of urogenital hiatus. Levator ani avulsion injury is indicated, if the distance between levator insertion to pubis and the middle of urethera (LUG) is greater than 25 mm (sensitivity 64%, specificity 94%). The presumptive prevalence of levator ani avulsion injury after vaginal delivery is around 15–20%. Clinical Cases or Summary Results: Up to the present time, the measurements have been carried out in 20 primiparas. In group A (10 patients), we could not see LUG greater than 25 mm in any of the studied planes. The average distance to the left was 20 mm (range 17–23 mm), right 22 mm (range 18–24 mm). In group B (10 patients), LUG was greater than 25 mm in one patient (on the right side of 32 mm). The average distance to the left was 21 mm (range 17–23 mm), right 24 mm (range 15–32 mm). Conclusions: The ultrasound finding of avulsion ani injury was noted in one patient in the group B. By extending the number of the examined sample of patients we will be able to prove statistically if there is a link between the use of vacuum extraction and the risk of m. levator ani injury. Keywords: avulsion, m. levator ani, injury, delivery Presenter: I. Michalec

ID 519

IVF, GENETIC AND ACQUIRED THROMBOPHILIA J. Khizroeva, & V. Bitsadze 1 2

First IM Sechenov Moscow State Medical University, and First IM Sechenov Moscow State Medical University

Brief Introduction: IVF failure has recently been associated not only with embryo quality or endometrial receptivity but with thrombophilia. Materials & Methods: we examined 75 patients after IVF failure. Among them – 55 after repeated IVF, and 20 pregnant women after IVF who received anticoagulant therapy before pregnancy at the period of planning of pregnancy. All of them had complicated obstetric history (fetal loss syndrome, pre-eclampsia, abruptio placenta, IVF failure, IUGR, antenatal fetal death, thrombosis in personal and family history) and venous thrombosis. Control group consisted of 75 healthy pregnant women. All patients were tested for acquired and inherited thrombophilia and hemostasis parameters (D-dimer, thromboelastography, platelet aggregation, fibrinogen level, AT III, protein C function). Criteria of thrombophilia were: mutation of the factor V Leiden, mutations of prothrombin G20210A, antithrombin III deficiency, protein C deficiency, 3 homozygous thrombophilic polymorphisms, or 5 heterozygotic polymorphisms, moderate or heavy hyperhomocysteinemia and antiphospholipid syndrome. Clinical Cases or Summary Results: the prevalence of thrombophilia was found in all 75 patients with IVF failure and consisted 90%. The

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incidence of genetic thrombophilia was 44.4%. MTHFR mutation was found in 41%, prothrombin gene mutation – 9%, Factor V Leiden mutation – 8%, PAI-I gene polymorphism – 69%, t-PA – 34%. 42.1% had circulation of antiphospholipid antibodies, 47% - anti-b2-GP I antibodies, 24% - anti-annexin V antibodies, and 8% - antibodies to prothrombin. Hyperhomocysteinemia was found in 54%. Multigenic thrombophilia was revealed in 74.6%, combination of genetic thrombophilic mutations and circulation of APA was identified in 57%. All women with pregnancy after IVF who received therapy from the fertile cycle and during all pregnancy (LMWH, antioxidants, aspirin, folic acid, natural progesterone, vitamins group B) were delivered with healthy newborn. Conclusions: these data suggest that thrombophilia may play a role in the genesis of IVF failure, especially in cases of multigenic and combined thrombophilia. Since thrombophilia has been diagnosed antithrombotic therapy should be evaluated in patients with thrombophilia and IVF failure. Keywords: IVF, thrombophilia, antiphospholipid antibodies Presenter: J. Khizroeva

ID 455

HORNER’S SYNDROME SECONDARY TO INTERNAL JUGULAR VENOUS CANNULATION

the cervical hematoma. The clinical signs of Horner’s syndrome resolved completely after 4 months. Case 2. A 4-months-old boy, a former 33 wg premature, was admitted to the ICU showing signs of acute intestinal occlusion related to previous necrotizing enterocolitis in the neonatal period. He required a central venous access for parenteral nutrition. Several attempts to place a catheter in the IJV, under mild sedation and local anesthesia and without ultrasound guidance, were unsuccessful. The left carotid artery was accidentally punctured. Then, a left subclavian venous 4,5F catheter was placed using the Seldinger technique without evidence of complications during the procedure. Four hours after, mild left-sided ptosis and miosis were noticed with slow lefteye-light reaction. No other neurological symptoms were observed. The clinical signs of Horner’s syndrome resolved completely after 6 months. Conclusions: Horner’s syndrome secondary to IJV cannulation is a rare but recognized complication in children and adults. Seven pediatric cases have been previously reported, with an age range between 6 months and 6 years, none in the neonatal period. It is more likely to occur if the carotid artery is accidentaly punctured, as the postganglionic fibers of the sympathetic nervous supply run in a plexus along the internal carotid artery. Damage to the nerve can be due to direct trauma to the nerve or by compression secondary to hematoma. The ultrasound guidance decreases but doesn’t eliminate the risk of this complication. Most of the reported cases have had a favorable outcome, with complete resolution before 6 months.

R. Porta1, E. Capdevila2, M. Vin˜as3, J. Cubells4, D. Gispets5, & N. Martı´n-Begue´6 1

Neonatal Unit, Pediatric Department, Institut Universitari Dexeus, Barcelona, Spain, 2Neonatal Unit, Pediatric Department, Institut Universitari Dexeus, Barcelona, and 3 Intenisve Care Unit, Pediatric Department, Institut Universitari Dexeus, Barcelona, Spain, 4Pediatric Department, Institut Universitari Dexeus, Barcelona, Spain, 5Anesthesiology Department, Institut Universitari Dexeus, Barcelona, Spain, and 6Institut Oftalmolo`gic del Pilar, Paediatric Ophtalmology Unit, Hospital Universitari Vall d’Hebron, Barcelona, Spain Brief Introduction: Horner’s syndrome is a defined by an ipsilateral ptosis and miosis. It results from functional interruption of the oculosympathetic innervation. A few cases have been previously reported in adults and children after internal jugular venous (IJV) cannulation, any of them in neonates. Materials & Methods: 2 cases of Horner’s syndrome ocurred in last 3 years after IJV cannulation are presented. The clinical information and results from complemetary exams (ultrasound) were obtained from clinical charts during admission and follow up. Informed written parental consent was obtained in both cases. Clinical Cases or Summary Results: Case 1. A 72 hours–old male newborn, born at 40 weeks of gestation (wg), was admitted to the neonatal intensive care unit (NICU) with signs of bowel occlusion. His birthweight was 3610g. On the 2nd day of admission, the abdominal distension and bilious drainage throught the nasogastric tube persisted, and a parenteral nutrition was ordered. Several attempts to cannulate a peripherically inserted central line were unsuccesful. After induction of anesthesia, cannulation of the right IJV was attempted under ultrasound guidance. The procedure was unsuccesful again, and the ultrasound showed and hematoma surrounding the carotid and IJV. Finally, a 4F 2 lumen catheter was inserted in the right femoral vein. Two days after, the patient’s parents noticed that the right eye and pupil were ‘smaller’ than the left. He showed signs of rigth Horner’s syndrome, with ptosis and miosis. The final diagnostic suspiction of the underlying condition was Hirschprung disease, and he did well with conservative management. The central line could be removed 3 days after, with full enteral feeds introduced. A cervical ultrasound performed 3 weeks later showed complete resolution of

Keywords: Internal jugular vein, Horner’s syndrome, neonate Presenter: Roser Porta

ID 397

NEONATAL LEUKAEMIA IN A TERTIARY CHILDREN’S HOSPITAL (2001–2013) L. Herrera1, C. Garcia-Maurin˜o1, L. Lecina1, C. Lazaro1, C. Garcia1, & A. Sanchez2 1 Paediatric Dept., Hospital Universitario La Paz, Madrid, Spain, and 2Neonatology Dept. Hospital Universitario La Paz, Madrid, Spain.

Brief Introduction: Neonatal leukaemia is a rare but important disorder, being the second cause of malignancy in this period of life. It can be classified as: Acute Myeloid Leukaemia (AML), Acute Lymphoblastic Leukaemia (ALL), and Transient Leukaemia Disorder (TLD). Materials & Methods: A retrospective chart-review study was performed. Patients with leukaemia during the neonatal period between 2001–2013 were included. Patients with leukemoid reaction due to congenital infection, sepsis, haemolytic disease and hypoxia were excluded. Clinical Cases or Summary Results: 6 patients with Neonatal Leukaemia were found. Trisomy 21 was confirmed in 4 (67%) with 50% of mosaicism. All four patients were finally diagnosed of TMD. The other two patients with normal karyotype were diagnosed of AML and ALL. Median WBC count was 71000(7100–252000) leukocytes/mm3. Median blast percentage in peripheral blood was 58% (20–83) and

300 in bone marrow 35%(8–66). They associated anaemia or low platelet count (67%), organomegaly (67%), dermatological manifestations (67%). Two of the patients with TMD presented spontaneous resolution (50%), one went on to early death and the last one developed an acute megakaryoblastic leukaemia. The patient with normal karyotype and ALL had a fatal outcome while the one with AML had a good response to specific treatment. Conclusions: Acute leukaemia has to be distinguished from TMD because of the different prognosis. TMD is linked with trisomy 21; Down syndrome may not always be obvious (mosaicism). TMD remits spontaneously in most patients, with a small percentage developing true leukaemia. Children with normal karyotype with acute leukaemia have a high mortality rate and they will need an intensive chemotherapeutic approach.

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Keywords: Neonatal Leukaemia, Trisomy 21, Acute Myeloid Leukaemia, Acute Lymphoblastic Leukaemia, and Transient Leukaemia Disorder Presenter: L. Herrera

ID 911

FATAL FAMILIAL HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS TYPE 2: A CASE REPORT R. Jordan1, F. Camba1, E. Clots1, E. Berber1, & J.L. Dapena2 1

Neonatal Unit, University Hospital Vall d’Hebron, Barcelona, Spain, 2Hematolgy and Oncology Dept., University Hospital Vall d’Hebron, Barcelona, Spain. Brief Introduction: Familial Hemophagocytic Lymphohistiocytosis (FLH) is a potentially fatal syndrome characterized by uncontrolled hyperinflammation with impaired function of natural killer (NK) cells and cytotoxic T-cells. It’s a genetic heterogenous autosomal recessive disorder. The presentation in the neonatal period is rare and the outcome is poor. Materials & Methods: We report a fatal case of FHL in a newborn, who presented hepatoesplenomegaly prenatally and multiorgan failure at birth with a fulminant clinical course. Clinical Cases or Summary Results: Male neonate born at 33 2/7 weeks of gestation. Hepatosplenomegaly detected in the last prenatal ultrasound examination. He was the fourth child of parents from North African, not consanguineous. Family history included a deceased brother on the third day of life with the diagnosis of fetal hydrops, liver and multiorgan failure. Our patient presented at birth liver failure with severe cholestasis, pancytopenia and coagulopathy. Blood tests showed hyperferritinaemia (410,000 mcg/L), coagulopathy with hypofibrinogenaemia, absent NK-cell activity and CD25 levels increased in serum. Haemophagocytosis was found in bone marrow aspirate. The diagnostic of Hemophagocytic lymphohistiocytosis (HLH) was established based on these findings, and due to the severity of the condition, HLH-2004 treatment protocol with cyclosporin A and dexamethasone was started. He presented hypertensive emergency with severe myocardial hypertrophy and CNS hemorrhage as a side effect of cyclosporine A, that forced its discontinuation. A dose of etoposide was administered but there was no clinical response to immunochemoterapy treatment. The patient died as a result of pulmonary hemorrhage with multiorgan failure despite intensive vital support. The genetic study showed heterozygous mutation in the perforin gene (PRF1, 10q21–22) (FLH type 2). Conclusions: FLH is a rare entity in the neonatal period, with a poor prognosis, especially in cases of prenatal presentation as our patient. The features of severe neonatal acute liver failure with hepatoesplenomegaly, pancytopenia, hipofibrinogenemia and high levels of

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

tryglicerides and ferritin should arouse suspicion of the possibility of HLH. Clinical suspicion for FHL is critical for timely diagnosis and proper management to improve the prognosis of the disease. Keywords: Familial Hemophagocytic Lymphohistiocytosis Presenter: Raquel Jordan

ID 745

ENTIRE – CUTANEOUS FISTULA DURING PREGNAN; BY THE WAY A CLINICAL CASE M. Valverde, J.C. Marin˜o, M. Reyes, E. Iniesta, M. Martı´n, & R. Martı´nez de la Ossa Servicio de Obstetricia y Ginecologı´a. A´rea de Gestio´n Sanitaria Sur de Granada. Motril. Granada. Espan˜a, 2Servicio de Obstetricia y Ginecologı´a. A´rea de Gestio´n Sanitaria Sur de Granada. Motril. Granada. Espan˜a, 3Servicio de Cirugı´a General. A´rea de Gestio´n Sanitaria Sur de Granada. Motril. Granada. Espan˜a, 4Servicio de Obstetricia y Ginecologı´a. A´rea de Gestio´n Sanitaria Sur de Granada. Motril. Granada. Espan˜a, 5Servicio de Cirugı´a General. A´rea de Gestio´n Sanitaria Sur de Granada. Motril. Granada. Espan˜a, and 6 Servicio de Obstetricia y Ginecologı´a. A´rea de Gestio´n Sanitaria Sur de Granada. Motril. Granada. Espan˜a 1

Brief Introduction: Fistulas are not much frequent complications that are in the habit of being related to previous surgeries, radioterapic treatments or inflammatory intestinal disease of the type of Crohn’s disease. In obstetrics, the most frequent fistulas are in the habit of being the happened ones as consequence of the childbirth be vaginal or by means of Caesarean for anomalous communication between bladder and vagina or rectum and vagina. Materials & Methods: We analized a clinical case report: Clinical Cases or Summary Results: Is a pregman woman of 38 years old with a gestation of normal course that she presents as personal precedents a surgery in the infancy of reimplantation ureteral bilateral for reflux and duplicity pielouretral left 2 years after age, which was complicated by a perforation of sigma and an abscess intraabdominal later, this complication needed a transverse colostomı´a with closing of the same one to two months of the surgery. These surgeries leave an abdomen with multitude of scars queloideas and retractable in some of his sections. This woman consults to 33 weeks of gestation for sharp pain in the zone of the scar of laparotomia ancient average and presentation of a nodule to this level. A puncture - aspiration of saying is realized by the nodule and drained too much purulent material, which agrees with the analytical suggestive one of systemic infection; leucocitosis with left diversion and increase of the PCR. Local priests and antibiotic treatment are indicated. At 72 hours the patient consults for the continuous drainage of purulent material and also of gas. Abdominal ultrasound scan is realized and it demonstrated a fistulous way supraumbilical by an underlying collection of 15 mm. The obstetric exploration is totally normal; so, they decided wait and continue with the antibiotic treatment. The childbirth does not free itself for what indicates an induction of the childbirth to itself for pregnancy in routes of prolongation in the week 41 and 3 days that it finishes in Caesarean for the failure of the above mentioned induction. The boarding in the course of the Caesarean is across Pfannestiel’s incision and since it had been decided not to approach the fistula at this moment there was not realized exploration of top hemi-abdomen and limited itself to the Caesarean. The immediate puerperium is adapted and after this one is confirmed the diagnosis of entire - cutaneous fistula by a fistulografia and provided that it has not disappeared spontaneously in spite of having a due minimum it is decided to realize the surgical

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DOI: 10.3109/14767058.2014.924236

correction of the same one. Nowadays the patient is in wait of this surgery. Conclusions: The entire - cutaneous late fistula is a very rare affection and has not described in the literature any case where the trigger one of his appearance has been the uterine growth for the gestation. Keywords: entire-cutaneous fistula, gestation, complication surgery Presenter: Mercedes Valverde Pareja

ID 174

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IDENTIFICATION OF HIGH RISK CLINICAL PARAMETERS FOR PREDICTING SURVIVAL OF HOSPITALIZED NEONATES H. Singh1, R.K. Soni2, & G. Singla3 1

Pediatric Department, Dayanand Medical College and Hospital, Ludhiana, India, 2Deptt of Community Medicine, Dayanand Medical College and Hospital, Ludhiana, India, 3 Pediatric Department, Dayanand Medical College and Hospital, Ludhiana, India Brief Introduction: Back ground and aims: The early identification of severity of illness is important for prioritizing treatment to reduce mortality and morbidity in neonates but it is sometimes difficult to assess. An overall subjective assessment of the severity of underlying illness is useful in final decision making. Most of the available neonatal scoring systems have certain limitations. None of the existing scoring systems can predict neonatal outcome by assessing only clinical parameters without including any laboratory investigations. Hence this study aimed to identify high risk clincial parameters helpful in Predicting outcome of hospitalized neonates.

Materials & Methods: Design & Setting: Prospective, Clinical, teaching hopital based observational study. Methods: All the 344 neonates at admission were assessed on the basis of various clinical parameters. Statistical analysis: Comparision between means by ANOVA. Odds ratio with 95% CI.Multiple logistic regression analysis, Positive and negative predictive values, sensitivity, specificity of each significant variable. significance level p50.05. Clinical Cases or Summary Results: Results: Variables significantly associated with mortality were: HR(OR3.27, CI-1.56–6.83, p-0.0016), RR(OR-5.61, CI-2.26–13.96, p-0.0002), SPO2 (OR-12.17, CI-4.60–32.72, p-50.0001), CFT (OR-24.31, CI-7.39– 79.94, p-50.0001), hypo/hyperthermia (OR-3.58, CI-1.66–7.70, p-0.001), birth weight (OR-2.13, CI-1.05–4.33, p-0.037), sensorium (OR-21.07, CI-8.30–53.48, p-0.0001), activity (OR-44.55, CI-6.01–330.26, p-0.0002), pallor(OR-0.15, CI-0.07–0.33,p-50.0001), cyanosis(OR-0.10, CI-0.04–0.25, p-0.0001), bleeding (OR-0.29, CI-0.10–0.80, p-0.016), dehydration(OR-4.70, CI-1.99–11.09, p-0.0004), respiratory distress (OR-2.43, CI-1.18–4.96, p-0.015), murmur (OR-0.25, CI-0.09–0.70, p-0.008), abdominal distension (OR-0.16, CI-0.07–0.33, p-50.0001), hepatomegaly (OR-0.07, CI-0.02–0.17, p-0.0001), tone (OR-37.12, CI8.66–158.99, p-0.0001)/(OR-18.2, CI-2.32–142.91, p-0.005), absent Moro’s (OR-14.43, CI-5.74–36.28, p-0.0001). Conclusions: Conclusions: Outcome of neonates can be predicted at the time of admission, using simple, easily assessed bedside clinical parameters. Keywords: Neonates, outcome, clinicap parameters Presenter: H. Singh

ID 099

CONGENITAL SOLITARY SELF-HEALING HISTIOCYTOSIS V. Mugarab-Samedi & A. Akierman

Statistically significant association of clinical parameters with mortality

Clinical variables Abnormal HR (4160/min or 5100/min) Abnormal RR (460/min or 530/min) Abnormal SpO2 (590%) Prolonged CFT (3sec) Moderate hypothermia/ hyperthermia Low birth weight (52500 gm) Decreased consciousness level Reduced/no activity Moderate/severe pallor Central cyanosis Bleeding Dehydration Chest recessions Respiratory distress Cardiac murmur Abdominal distension Significant hepatomegaly Hypotonia Hypertonia Incomplete/absent Moro’s reflex in term Absent/sluggish DTR’s Short hospital stay (7days)

95% Confidence interval Odds (CI) p Value ratio (OR) 3.27

1.56–6.83

0.0016

5.61

2.26–13.96

0.0002

12.17 24.31 3.58 2.13 21.07 44.55 0.15 0.10 0.29 4.70 0.05 2.43 0.25 0.16 0.07 37.12 18.2 17.25

4.60–32.72 7.39–79.94 1.66–7.70 1.05–4.33 8.30–53.48 6.01–330.26 0.07–0.33 0.04–0.25 0.10–0.80 1.99–11.09 0.01–0.23 1.18–4.96 0.09–0.70 0.07–0.33 0.02–0.17 8.66–158.99 2.32–142.91 4.88–60.97

50.0001 50.0001 0.001 0.037 50.0001 0.0002 50.0001 50.0001 0.016 0.0004 0.0001 0.015 0.008 50.0001 50.0001 50.0001 0.005 50.0001

14.43 15.08

5.74–36.28 50.0001 4.51–50.50 50.0001

Division of Neonatology, Peter Lougheed Hospital, Calgary, Canada Brief Introduction: Congenital Solitary Self-Healing Histiocytosis (SCSHH) was first reported in 1973 by Hashimoto and Pritzker as a rare variant of clonal proliferative disorder of Langerhans cells.Typical SCSHH lesions described as multiple papules or nodules that found scattered over the face, scalp and body, rarely present on mucosa. Normally, Langerhans cells arise from the bone marrow precursors and by 7 weeks of gestation they found in the epidermis. SCSHH lesions characterized by dermal and hypodermal infiltration of histiocytic cells. Lesions usually present at birth and self-resolve within first 3 months of life. Since first description about 35 cases of Solitary Self-Healing Histiocytosis were reported. Materials & Methods: Skin biopsy, electron microscopy, immunohistochemistry for S-100 and CD1a Clinical Cases or Summary Results: The patient was a premature male infant born on 34 weeks of gestational age (GA) with birth weight 2375 via cesarean section for fetal heart abnormalities. Pregnancy was complicated by maternal diabetes type 2 on insulin, last prenatal u/s at the day showed mild polyhydramnios (AFI 25.8). Upon admission to Neonatal Intensive Care Unit baby was noted to have solitary lesion over the left forearm. It was a papule 3 mm in diameter, initially red in color, within first hour of life became brownish. Papule has central ulceration with depth up to 1.5 mm covered with sero-sanguineous scab over. On palpation lesion seems to be painless and has induratation on the base. No other lesions were detected. Punch biopsy was done, material was sent for histology. Biopsy showed proliferation of histiocytic cells positive for S-100 and CD1a.

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often smoke tobacco, despite its negative impact on the mother and child. Smoking carries with it many risks, the consequences are serious for both mother and pregnant smokers present in the environment in which the tobacco smoke. The aim of the study was to show the smoking prevalence for women who are in the perinatal period. Materials & Methods: The study included 91 women in childbirth was staying at a branch of Obstetrics and Perinatology, University Hospital in Krakow. The study used a statistical method involving the quantitative recognition, social, psycho-social, measuring maternal beliefs about smoking cigarettes. Complement the results of a qualitative analysis of the respondents. Technique used in the study was a questionnaire addressed to the author’s maternal maternity ward in Krakow. Surveys were completed during the first days after the completion of the delivery. The respondents were given a questionnaire in the form of a written form. It was anonymous, and the study was voluntary. The data were collected in a spreadsheet and given the statistical analysis. The results were descriptively and statistically. Clinical Cases or Summary Results: In the study group, there were no statistically significant correlation between age, place of residence, professional activity, the number of births and smoking. Respondents with an increase in the level of education, religious belief, marital status and a better financial situation, rarely reached for the cigarettes. The study group, which is identified with cigarette smoking was often hospitalized. As the most common reason for hospitalization was given: threatening miscarriage, premature labor, vaginal bleeding, hypertension, infections of the genital tract. Based on our research, respondents showed that smoking had a negative impact on the conception, the time/date of birth, infant birth weight, Apgar scale. The study group was able to partially define the risk to the child resulting from cigarette smoking during pregnancy. According to the respondents the company is the main reason for resorting to tobacco. Other important causes are stress and addiction. Conclusions: During pregnancy and breastfeeding women surveyed had no effect on the decision to stop smoking. The level of knowledge about the risks of tobacco smoking for mother and baby is low, inadequate and requires the involvement of all resources, nursing - medical and social campaigns. Conclusions: Clinical examination, laboratory work up and diagnostic scan ruled out possibility of systemic involvement. Patient was diagnosed with Congenital Solitary Self-Healing Histiocytosis, lesion started to resolved from day 7, and completely resolved within 2 months of life; no lesion was detected during follow up visit at 40 weeks of GA. Baby will be monitored for the next 12 months to exclude possible relapse or progression of the disease by pediatrician. Keywords: Presenter: Veronica Mugarab-Samedi

ID 176

AWARENESS OF THE HEALTH CONSEQUENCES OF SMOKING DURING PREGNANCY AMONG PREGNANT WOMEN H. Huras, M. Radon´-Pokracka, M. Sajewicz, P. Ossowski, R. Rytlewski, A. Wo´jtowicz-Grzyb, & A. Reron´ Obstetrics and Perinatology Dept., Collegium Medium Jagiellonian University of Krako´w, Krakow, Poland Brief Introduction: Motherhood is a period in the life of a woman requiring the proper preparation and stopping or reducing drugs, which can be a major difficulty for the mother. Expectant mothers

Keywords: tobacco smoking, pregnancy Presenter: M. Radon´-Pokracka

ID 646

PREGNANCY IN A PATIENT WITH EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS (CHURG-STRAUSS SYNDROME) G. Daskalakis, I. Mole, A. Ntomali, N. Papantoniou, P. Antsaklis, & S. Mesogitis 1st Department of Obstetrics and Gynecology, Athens University, Athens, Greece Brief Introduction: Eosinophilic granulomatosis with polyangiitis (EGPA), previously called Churg-Strauss syndrome, or allergic granulomatosis and angiitis, is a non-inflammatory leukocytoclastic systemic vasculitis, which affects the lungs and many other tissues and organs. Pregnancy has rarely been reported in patients with EGPA, partly because its peak incidence occurs at a later age(fourth and fifth decades), in addition, there is a preponderance of male patients (male:female 1.4:1). We report a case of pregnancy in a patient with EGPA and we review the literature on this subject.

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DOI: 10.3109/14767058.2014.924236

Materials & Methods: A 39-year-old woman with EGPA was referred to our hospital at 26 weeks’ gestation due to exacerbation of the disease with a flare of bronchial asthma, difficulty in swallowing process and swollen neck lymph nodes. The diagnosis of the syndrome had been confirmed by a lung biopsy, two years ago. She had a positive history of chronic rhinitis since childhood and bronchial asthma since five years. Clinical Cases or Summary Results: On admission a chest radiograph showed multiple infiltrates at the bases of lungs as interstitial pneumonitis. Her blood pressure was 110/70 mmHg and her temperature was 36.8o C. The treatment remained the same as was from the beginning of the pregnancy: methylprednisolone 4mg twice daily, azathioprine 125 mg/day, salbutamol inhaler 200 mcg 3 times a day and fluticasone propionate inhaler 250 mcg twice per day. Moreover, nadroparin calcium 0.3 ml x 2/day was given. An ultrasound scan was also performed which revealed an appropriately grown fetus with normal amniotic fluid and normal Doppler indices. The next day her condition worsened with severe dyspnea, therefore the dose of methylprednisolone was increased to 8 mg twice daily, while IgG immunoglobulin was considered in case of further worsening of the symptoms. The following days she had a rapid recovery, so IgG immunoglobulin was not given. The patient left hospital sixteen days later with instructions for appropriate medication and frequent ultrasound monitoring. At 33 weeks of gestation she entered our clinic again because of intrauterine growth restriction. Her condition remained stable, while the ultrasound scan confirmed the diagnosis of a growth restricted fetus with reduced amniotic fluid. The patient had cardiotocographic assessment twice daily and ultrasonographic evaluation twice a week. She finally delivered after steroid preparation (two doses of 12 mg of betamethasone) at 34 + 3 weeks by an elective cesarean section because of a breech presentation a healthy female infant weighting 1910g. Her post-operative course was uneventful and she left the hospital five days later. Conclusions: A close collaboration of obstetricians and vasculitis specialists with aggressive management of active disease is need for a successful pregnancy outcome in pregnancies with EGPA. Keywords: eosinophylic granulomatosis with polyangiitis, pregnancy, Churg-Strauss Presenter: G. Daskalakis

to 12,000 births, while the colon is the least affected with an incidence of one in 40,000 live births. The most typical clinical feature is abdominal distension while vomiting begins in the first 24 to 48 hours after birth. Intestinal atresia can be detected by prenatal ultrasounds examination. Radiographic studies should be performed after birth to confirm the diagnosis. The treatment is surgical correction with a long-term survival that varies from 84–100%. Most of the mortality occurs in infants with associated medical conditions. Materials & Methods: A retrospective, descriptive study of case series of the patients with intestinal atresia attended in University Hospital ‘‘Nuestra Sen˜ora de Candelaria’’ since 2002, January to 2013, December. Clinical Cases or Summary Results: 7 patients included. 4 of them were premature infants. In 5 of them there was a prenatal suspicion. The most frequent clinical features were vomiting and abdominal distension. The radiographic studies were helpful in the 100% of patients. 1 case of colonic atresia. All the children were operated, and 3 of them more than once. We experienced 3 deaths. Conclusions: Intestinal atresia should be suspected in a newborn with abdominal distension, bilious vomiting and failure to pass meconium. We think we experienced a mayor rate of mortality than other series due to associated medical conditions and the complexity of the lesions. Keywords: intestinal atresia Presenter: Cinzia Tripodi

ID 779

UTERINE ARTERY PSEUDOANEURYSM MANIFESTING AS DELAYED POSTPARTUM HEMORRHAGE AFTER PRECIPITOUS DELIVERY: THREE CASE REPORTS J.W. Kim, Y.H. Kim, & T.B. Song

ID 909

INTESTINAL ATRESIA AND PRENATAL FINDINGS IN OUR UNIT WITHIN THE LASTS TEN YEARS C. Tripodi1, C. Marrero2, R. Papoya´n3, P. Arango4, T. De Ganzo5, & L. Martı´n6 1

Neonatology Dept, University Hospital Nuestra Sen˜ora de Candelaria, Santa Cruz de Tenerife, Spain, 2Neonatology Dept, University Hospital Nuestra Sen˜ora de Candelaria, Santa Cruz de Tenerife, 3Neonatology Dept, University Hospital Nuestra Sen˜ora de Candelaria, Santa Cruz de Tenerife, 4 Neonatology Dept, University Hospital Nuestra Sen˜ora de Candelaria, Santa Cruz de Tenerife, 5Gynecology Dept, University Hospital Nuestra Sen˜ora de Candelaria, Santa Cruz de Tenerife, and 6Neonatology Dept, University Hospital Nuestra Sen˜ora de Candelaria, Santa Cruz de Tenerife Brief Introduction: An atresia is a complete congenital obstruction of the lumen of a hollow viscus. It is one of the most frequent causes of bowel obstruction in the newborn. The most common site is the small intestine (jejunum and ileum) with an incidence rate from one in 1500

Department of Obstetrics and Gynecology, Chonnam National University Medical School, Gwangju, Korea Brief Introduction: Precipitous delivery may lead to serious maternal and neonatal complications. Uterine artery pseudoaneurysm is one of the causes of delayed postpartum hemorrhage. Materials & Methods: We describe three cases of uterine artery pseudoaneurysm manifesting as delayed postpartum hemorrhage after precipitous delivery. Clinical Cases or Summary Results: Duration of second stage of labor in case 1, 2, and 3 was 15, 15, and 60 minutes, respectively. Excessive vaginal bleeding occurred 10, 9, and 31 days after delivery, respectively. Conclusions: Ultrasonogram and pelvic angiography revealed the uterine artery pseudoaneurysm in each case and uterine artery embolization was performed. Uterine artery pseudoaneurysm may be a complication of precipitous delivery. Keywords: Precipitous delivery, Uterine artery pseudoaneurysm, Delayed postpartum hemorrhage Presenter: JW Kim

304

ID 794

MASTALGIA AND GESTATION. AN UNUSUAL PRESENTATION OF RAYNAUD’S SYNDROME M. Navarro, O. Vaquerizo, AI. Escudero, & C. Ferna´ndez-Plaza

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Obstetrics and Gynecology Dept., University Hospital Central of Asturias, Oviedo, Asturias, Spain

Brief Introduction: Usually, monitoring of pregnant women with multiple pathologies is performed in High-Risk Obstetrics Units. These pregnant women present with very different symptoms we should pay attention to, but it can not be forgotten about those common symptoms to any pregnant women, which seem uninteresting, but could be part of systemic deseases with significant impact on the course of pregnancy and on the future of the patient. Materials & Methods: No Clinical Cases or Summary Results: 37 years old, second-gravidae, followed up in our High-Risk Obstetrics Unit. Obstetric history: normal pregnancy and childbirth in 2007, newborn weighting 3500 grams. She has multiple risk factors: chronic hypertension since 3 years ago treated with alpha- methyldopa, microprolactinoma untreated, supraventricular tachycardia treated with beta blockers, and colonic polyposis. In the last year, she was diagnosed of Mondor’s disease as a sequel of superficial phlebitis in both legs. She also is affected by discontinuous hemicranial headache, overweight (BMI = 38.9) and chronic constipation. During 14th week, she onset whith pain and discoloration on the nipples, especially when cold. Although initially it was thought as a symple mastalgia, due to the insistence of the patient, differential diagnosis with other processes was established, including those associated with pain in fingers and nails duringtemperature changes. The pregnant woman is referred to the Systemic Autoimmune Diseases Unit for screening of systemic processes, with a suggestive capillaroscopic study of systemic lupus or antiphospholipid syndrome, although immunological studies were negative. Finally, she was diagnosed of secondary Raynaud’s Syndrome whitout sclerodermyc pattern butwith capillaroscopic pattern of not defined systemic disease yet. The pregnancy was uneventful until 39 weeks. Delivery was induced because of her chronical hypertension and ended with eutocic childbirth of a 3450 grams male fetus. No incidences were recorded during postpartum and after hospital discharge, the Outpatiens Department resumed the studies about possible systemic autoimmune disease associated with Raynaud’s Syndrome. Conclusions: This is a pregnant women with multiple pathologies. During pregnancy some nonspecific symptoms presented as pain, cold and pale of both breasts’s nipples were shown. After they were successfully evaluated, she was diagnosed of Raynaud’s Syndrome and it was suspected systemic disease. It is very important to enable differential diagnosis of breast symptoms and signs during pregnancy, because in most cases these are only local entities as mastalgia or dermatological processes, but sometimes they may be the beginning of systemic diseases with great clinical impact. Keywords: mastalgia, Raynaud’s, gestation Presenter: M. Navarro

ID 389

SEX RATIO OF PERINATAL MORBIDITY AND MORTALITY. IS THE MALE SEX AN AGENT FOR

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

DIFFERENT OBSTETRIC INTERVENTION? C. Goudeli1, A. Kondi-Pafiti2, D. Botsis3, L. Aravantinos4, & G. Creatsas5 1

Department of Gynecology, St.Savvas Hospital, Athens, Greece, 2Department of Pathology, University of Athens, Aretaieion Hospital, Athens, Greece, 3,4,5Department of Obstetrics and Gynecology, University of Athens, Aretaieion Hospital, Athens, Greece Brief Introduction: Male sex has always been considered as the vulnerable sex concerning the sustainability and viability. We herein present a report, based on the findings of perinatal period-stillborns of the last twenty years, referring to the sex-ratio of morbidity and mortality. Materials & Methods: This retrospective study is based on the autopsy results of the last 20 years in a tertiary Greek hospital conducted by a pathologist specialized in perinatal medicine. We classified the sample according to the year and gestational age. The causes of death were divided based on the ReCoDe (2005) classification system and we excluded pharmaceutical abortions and those containing vague variables. Finally, we registered a sub-group of SGA (small for gestational age) fetuses. The counted population of births during the years 1993–2012 was 21.207. The sex ratio was 1,07, which agrees with the international SR of the literature. Our File included 405 stillborns, 21 of which were of indeterminate sex with extensive autolytic lesions and 127 were therapeutically expelled. Eventually our sample contained 134 male and 123 female stillborns to study (SR = 1,09). Clinical Cases or Summary Results: Overall, perinatal mortality was reduced during the 20 years (RR1993–1997 vs. RR2008–2012 = 2,7, 95% CI 1.94–3,94, p50.0001). Male fetuses had a higher perinatal mortality rate in total (6,3% vs. 5,8%). During those years males’ perinatal mortality halved, while females’ reduced 36%. Males excelled in the congenital anomalies, but also in the number of deaths caused by amniotic fluid pathology. Additionally, they overmatched between the perinatal infections, the small-for-thegestational-age fetuses and the induced abortions.

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DOI: 10.3109/14767058.2014.924236

Conclusions: During 20th century, and especially after the second half, medical changes were observed to influence the sex-ratio. Although males are more vulnerable to infections and conditions involving prematurity, further analysis of gender differences can reveal additional medical and environmental factors which influence not only perinatal, but also adult mortality. Keywords: perinatal mortality, sex ratio, vulnerable sex, Greek population Presenter: Christina Goudeli

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ID 917

COMPLEX CEREBRAL MALFORMATIONS CONSIDERATIONS ON SOME CASESES L. Blaga1, M. Matyas1, S. Barsan2, M. Popa1, C. Vidra3, M. Muresan3, & G. Zaharie1 1 Neonatology Dept., University of Medicine and Pharmacy ¨Iuliu Hatieganu" Cluj Napoca, 2Paediatric Surgery Dept., University of Medicine and Pharmacy ¨Iuliu Hatieganu" Cluj Napoca, and 3Neonatology Dept. "D. Stanca" Obstetric and Gynecology Hospital, Cluj Na

Brief Introduction: The pericallosal lipoma is a rare CNS anomaly founded in 1 of 2500 - 25000 postmortem examinations. The most frequent localization is around the corpus callosum and in the interhemispheric region. It may be accompanied by malformations of the corpus callosum. Antenatal diagnosis can be made at 18–20 week’s gestational age. Acalvaria is a congenital anomaly characterized by total or partial absence of the flat bones in the cranial vault, scalp and dura mater, with complete but abnormal development of the cerebral hemispheres and lethal evolution. The incidence of acrania without anencephaly is unknown, only a few cases being reported in the literature. Prenatal diagnosis is possible at 12 week’s gestational age, by vaginal ultrasound. Postnatal diagnosis is made by ultrasound and MRI. Materials & Methods: The authors present two cases: interhemispheric lipoma with corpus callosum agenesis, and acalvaria with corpus callosum hypoplasia Clinical Cases or Summary Results: The antenatal and postnatal diagnosis, treatment and evolution of the cases are evaluated. Conclusions: Conclusions: the low incidence of the two malformations makes their prenatal recognition sometimes difficult. Cranial ultrasound allows for their immediate identification postnatally, but the complete evaluation of the associated anomalies is only possible by MRI. Keywords: corpus callosum agenesia, acalvaria, cranial ultrasound, cerebral malformations Presenter: Ligia Blaga

ID 960

MALFORMATION OF THE DURAL VENOUS SINUS ASSOCIATED WITH AN OCCIPITAL MENINGOCELE. A CASE REPORT M. Collet, T. Hellel, P. Marcorelles, & L. Dessolle

Chru Brest, France Brief Introduction: The authors report a good prognosis case of dural venous sinus malformation in which the antenatal findings of an intracranial collection in the fetal occipital region had initially raised the diagnosis of a small meningocele. Materials & Methods: A case report Clinical Cases or Summary Results: A 25 year-old nullipara was referred at 22 weeks gestation to our prenatal diagnosis center for a suspected occipital meningocele. Ultrasound revealed an anechoic avascular occipital collection of 1.5  1 cm associated with a small occipital bone defect. The anatomy of the brain and cerebral Doppler were normal and there was no other suspected malformation. The fetus was found to be small for the date with an estimated weight 53rd percentile. The woman received genetic counselling. She refused amniocentesis. At 26 weeks gestation, the size of the collection was stable. Prenatal brain MRI was normal at 30 weeks An 1170g boy was delivered by cesarean section at 31.5 weeks due to severe preeclampsia. The APGAR score was 10 at 1 minute and 10 at 5 minutes. The newborn presented with a subcutaneous bluish occipital mass that was not pulsatile. Neurological examination was normal. Conclusions: Postnatal MRI confirmed the diagnosis of meningocele but revealed a malformation of the posterior part of the dural sinus. The was elevated. There was a malposition of the tentorium cerebelli, of the longitudinal sinus and of the torcular herophili in relation to the absence of the posterior part of the cerebral fax. There was also an occipital bone defect. There was no abnormality of the brain. A surgical treatment has been planned within the first year of life. Keywords: Postnatal MRI, venous sinus malformation Presenter: Michel Collet

ID 063

HYDROLAPAROSCOPY – AS AN ALTERNATIVE METHOD AFTER A FAILURE OF THE PHARMACOLOGICAL THERAPY FOR PCOS INDUCED INFERTILITY W. Pie˛ta1, A. Wilczyn´ska1, & S. Radowicki2 1

Mie˛dzyleski Hospital, Department of Gynecology and Obstetrics, Warsaw, Poland, and 2Warsaw Medical University, Clinical Hospital Anna Mazowiecka, Department of Gynecological Endocrinology, Warsaw, Poland Brief Introduction: To evaluate the effectivness of hydrolaparoscopy in the infertile women with a polycystic ovarian syndrome (PCOS) resistant to clomephine. Materials & Methods: Retrospective study including eighteen women with a resistant to clomiphene PCOS induced infertility who underwent hydrolaparoscopy including ovarian drilling with bipolar probe, hysteroscopy and chromopertubation. Mean age was 31.4 (6.5) years (95% CI: 28–34.6) and mean body mass index 26.6 (6.9) kg/m2 (95% CI: 22.3–30.6). Laparoscopic conversion was required in 3 cases (16.6%) due to a failure of entering Douglas cavity. Clinical Cases or Summary Results: Seventeen women (94%) had a positive chromopertubation and 2 women had uterine anomaly (n = 1 T-shaped uterine cavity, n = 1 endometrial polyp). THLOD resulted in the successful pregnancy in 10 cases (55.5%). In five cases (27%) pregnancy has occurred spontaneously, in the further four cases

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(22.2%) ovarian stimulation was required and in one case the patient underwent in-vitro fertilization. Conclusions: The ovarian drilling by hydrolaparoscopy is a minimally invasive method to treat clomiphene resistant PCOS infertility. In addition it allows to assess the anatomy of the reproductive organs. Keywords: induction

infertility,

policistic

ovaries,

pregnancy,

ovulation

Presenter: W. Pie˛ta

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ID 283

PULMONARY HYPERTENSION AND PREGNANCY. LAST OBSTETRIC OUTCOMES P. Barbero, P. Vallejo, O. P. Villar, M.D. Montan˜ez, C. Martinez, & L. Force´n University "12 de Octubre" Hospital, Madrid, Spain Brief Introduction: Pulmonary hypertension (PH) describes a group of diseases characterised by progressive obstructive vascular injury of the pulmonary vessels, which leads to rapid heart failure and dead if not detected and treated. Important changes in the treatment of PH have been introduced recently, that have improved the patient’s life quality and survival. Pregnancy has been clasically discouraged in PH patients, due to the high rates of maternal mortality. The reports published mortality rates from 36 to 56%. However, recent papers according to the updates in PH treatment, suggested better outcomes. We describe here the results of the PH pregnant patients controlled in our hospital from 2010 to 2013, relating our pregnancy and delivery management. Materials & Methods: Descriptive analysis of the pregnant women diagnosed of PH (during or before the pregnancy) controlled in high risk pregnancy consultation of our center (12 de Octubre University Hospital) from 2010 to 2013. With the results obtained, we try to update the preconception advice, pregnancy, delivery and postpartum management according the progresses in PH treatment. 5 pregnant women with PH were followed in our consultation (4 with previous diagnosis, 1 diagnosed during pregnancy). The evolution and outcomes are showed in the attached tables. Clinical Cases or Summary Results: Monthly control in Obstetric and Cardiology consultation until 28 weeks of gestational age (GA) were

performed, then biweekly until 32weeks GA and weekly until time of delivery. Last 2nd/early 3rd trimester are the riskiest moments due to the hemodynamic changes. Cardiologic check was performed through serial levels of Brain Natriuretic Peptide, 6-minute walk test and electrocardiogram. An echocardiography was realized in each pregnancy trimester. No particular obstetrical controls but an extra obstetric ultrasound at 28weeks GA for the screening of intrauterine growth restriction, were done. No IGR detected in our patients. All the patients were prophylactic anticoagulated. 2 were treated with CCB and 3 with PDE5-I. One of them needed introduction of nebulized PC due to worsening of her clinical status. The aim was reaching 34 weeks GA, whereas maternal condition allows it. 2 asymptomatic well controlled patients were suitable to reach 37 weeks. All the patients had an elective CS. Conclusions: Pregnancy in PH patients is a high risk situation with a maternal morbimortality described in the literature up to 50%. There are no standard protocols due to the limited number of cases. During the pregnancy, this patients should have a close multidisciplinary control (obstetricians, cardiologists, anaesthetists and neonatologists), to detect maternal complications as early as possible and to agree the time and mode of delivery. Mode of delivery is a controversial matter. Elective CS is preferable because of a better control of the situation, but vaginal birth, when starts spontaneously can be allowed. Immediate puerperium is also a critical period cause of the rapid establishment of the hemocynamic changes. PH patients who respond to calcium channel blockers (CCB) seem to be a group with a better evolution and prognosis, in which a pregnancy appears to be an assumable risk. Keywords: pulmonaty hipertension, pregnancy, maternal outcomes Presenter: P. Barbero

ID 594

SUCCESSFUL OUTCOME OF A PRETERM BABY WITH AN ‘‘APPLEPEEL’’ INTESTINAL ATRESIA L. Castells Vilella1, E. Guirado Sayago1, N. Pumares Parrilla1, F. Mun˜iz Llama1, M. Miranda Vega1, P. Ventosa Rosquelles1, & M. Xiberta Pons2 1

Neonatology Department, IDC Hospital General de Catalunya, Sant Cugat del Valle´s, Barcelona, Spain, and 2 Obstetrics Department, IDC Hospital General de Catalunya, Sant Cugat del Valle´s, Barcelona, Spain. Brief Introduction: Intestinal atresia is one of the major causes of neonatal intestinal obstruction. The most common types of intestinal atresia are those categorized as type I, II or IIIa. Complex intestinal atresia (type IIIb or apple peel jejuno-ileal atresia) and type IV (multiple intestinal atresia) are one of the rare and most severe forms, which are associated with higher morbidity and mortality rates. Apple peel atresia is a serious congenital anomaly that affects approximately 1–2:10.000 live births. It is, in most cases, caused by delayed mesenteric vascular catastrophes during embryonic development. Materials & Methods: (not needed because of Case report) Clinical Cases or Summary Results: We report the case of a 2,300 g preterm baby born at 33 weeks of gestation with prenatal suspicion of intestinal atresia. Prenatal ultrasound is performed at 31 weeks of gestation, which shows large gastric and small bowel dilatation, and posterior Fetal MRI, which confirmed the suspicion of intestinal atresia. At birth, diagnosis is confirmed by abdominal radiography and at 20 hours of life. Midline laparotomy was performed, demonstrating high jejunal atresia type IIIb with "apple-peel" in distal segment, with large

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atresia and the other complex atresia have a poor prognosis. Keywords: Apple-Peel, intestinal atresia Presenter: Laura Castells Vilella

ID 084

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MORPHOLOGICAL EXAMINATION OF THE MYOMETRIUM IN DIFFERENT PERIODS OF DEVELOPMENT AND MODIFICATION OF THE UTERUS P. Ovsyannikov1, P. Konovalov2, & L. Mitrofanova3 Almazov Federal Heart, Blood and Endocrinology Centre, Saint-Petersburg, Russia

caliber disproportion between proximal and distal segment, and irrigation of the entire small intestine by right colic artery. Modeling of the proximal end, prior to the end to end anastomosis, was performed, without need of placement of drains or catheters. Parenteral nutrition was requiered until 18th day of life, at initiation of intestinal peristalsis and disappearance of bilious gastric residuals. She mantains appropriate weight gain and proper bowel habits. She remained hemodynamically stable throughout hospitalization, without surgical complications. She was finally discharged at 29 days of age with a weight of 2,590 g. Further evolution is excellent, achieving therefore patient survival without complications. Conclusions: This type of atresia has difficult management, and needs a complete multidisciplinary equipment, in order to attain good results. Adequate prenatal diagnosis, the existence of neonatal intensive care and multidisciplinary support are the key to improving survival and quality of life of these patients. Despite technical advances, the risk of complications such as dysmotility, dilated proximal segment and short bowel is high. Although survival of patients with intestinal atresia is close to 100%, this type of intestinal

Group Fetus Newborn reproductive postmenopause Labor

Brief Introduction: The majority of morphological studies of the uterus is held in connection with the study of the endometrium and myometrium during benign, malignant tumors and hyperplastic processes. There are different controversial literary representations about histoarchitectonics of myometrium. Still no one explains if smooth muscle cells proliferates or not. Whether the area of vessels and fibrous tissue varies or not during the physiological remodeling in different stages of the life of women and childbirth. Materials & Methods: The material of the study were: (1) uterine fetuses (n = 10, 18 - 20 weeks of gestation), (2) newborns (n = 10) uterine retrieved at autopsy (3) the uterus of women of reproductive age (n = 10, 30 - 42 years); (4) postmenopausal women (n = 10, after 60 years) retrieved during surgical intervention, (5) fragments of myometrium taken during cesarean section (large fetus, fetus defects, narrow pelvis (n = 10). Clinical Cases or Summary Results: Our study showed that at 18–20 weeks of gestation fetuses has no clear distinction between inner and outer layers in myometrium. Single cells which start to form the inner layer express smooth muscle actin, while in the outer layer there are more cells with mark of this antigen. In newborns, we observed two layer of myometrium without third vascular, which was described in some editions

smooth muscle cells Number

Interstitium,% Length. Mkm

Vessels,% Diameter. Mkm

Square

Coll I

Coll III

Coll V

Fibronectin

Density

126 ± 27.4 108 ± 11.8 66 ± 5.5 145 ± 13.3 46 ± 4.6

20.5 ± 5 26 ± 7.5 29 ± 3.6 17.5 ± 3.9 104 ± 17.5

7.3 ± 1.3 6±1 7 ± 1.2 4.8 ± 0.9 13 ± 2.3

38.1 41.8 50.4 48.9 30.2

40.5 55.5 49.3 54.8 67.9

26.1 34.3 20.3 30.7 32.3

37.7 54.5 44.1 65 61.5

26.8 29.1 22.8 14.7 35.44

5.2 3.8 4 6.5 11.2

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We have not seen a clear distinction of myometrium on layers, among adult women and in labor. Accordingly to this, histological architectonics of myometrium depends on phase of its development. Our study also showed that the size of SMC from the birth until menopause was not significantly changing. Conclusions: 1. Histological architectonics of myometrium depends on it’s development stage: 2 -layer structure at the moment of birth due to the mesenchymal cells differentiation into pluripotent SMC. It transforms into a single layer in adult women. 2. Sizes of SMC from birth until menopause was not significantly changing. Atrophy of myocytes was noticed in postmenopausal women. 3. Proliferativ activity of SMC observed in all age periods, including menopause. It was almost 3 times higher in labor than in women of reproductive age. 4. Relative area of myometrium interstitium was not significantly differs from age. Ratio of expression area of collagen types I, III and V remains constant, in which the amount of collage type III is smaller than the others. 5. Increasing of vessels density in myometrium without increasing of relative area of interstitium fibrous tissue, collagen type I prevails, maximal level MMP- 1, MMP- 9 and TIMP1 expression is observed. Keywords: smooth muscle cells, age, proliferation, myometrium. Presenter: Philipp Ovsyannikov

ID 925

GIANT CONGENITAL MELANOCYTIC NEVI NOTED AT BIRTH: CASE REPORT-REVIEW OF LITERATURE E. Tsekoura1, E Kontaki1, E. Papadavid2, C. Chrelia, E. Trakakis3, & P. Mexi1 1

NICU 3rd Department of Pediatrics, Medical School National and Kapodistrian School of Athens, ‘‘Attikon’’ General University Hospital, Athens, Greece, and 22nd Department of Dermatology, Medical School National and Kapodistrian School of Athens, ‘‘Attikon’’ Ge

Brief Introduction: Congenital melanocytic nevi (CMN) are melanocytic skin lesions noted at birth, with an 1% estimated incidence of all newborns. They are classified by surface diameter as small (51.5 cm), intermediate (1.5–20 cm), and giant lesions (20 cm). Giant congenital melanocytic nevi (GCMN), are extremely rare, presenting in 51:20.000 newborns, whereas the variety ‘‘bathing trunk’’ is even scarcer, with an incidence 51:500.000. Although, GCMN are rare, they are important, since they increase the lifetime risk for malignant melanoma and leptomeningeal melanocytosis. GMCN require stage surgical treatment with the use of an intermediate thickness skin graft or removal of the superficial layers of the nevus.

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DOI: 10.3109/14767058.2014.924236

Materials & Methods: We report an extremely rare case of giant CMN noted at birth. Clinical Cases or Summary Results: Male infant born via cesarean section to a 30-year-old gravida 1, para 1 mother at 38 weeks GA, with BW = 3150gr. A giant hyperpigemented skin lesion of more than 20 cm in diameter was noted at birth, affecting his back, buttocks, abdomen and bilateral thighs. The lesion was characterized by variegated color and roughed surface with irregularly shaped nodules. Other smaller pigmented nevi were scattered over the torso and the scalp. No neurological abnormality was noted during physical examination, while fundal examination revealed no pathological signs. Magnetic resonance imaging (MRI) of the brain and spine was negative for melanosis or thickening of the leptomeninges. Surgical removal in the first week was considered not feasible in of lie in view of the big size of the lesion. Therefore the infant was referred to our pediatric outpatient clinic for regular dermatological and neurological follow up. Family history revealed that his mother and his first cousin had small isolated melanocytic lesions from birth which were both underestimated. Conclusions: Although melanocytic nevi are rare skin lesions they require close monitor since they can be complicated with melanoma early in life. In giant lesions management in early life can be proven extremely difficult. Keywords: congenital melanocytic nevi, skin lessions at birth Presenter: Effrossine Tsekoura

ID 133

IMMUNOLOGIC MECHANISMS OF FORMATION OF THE INFECTION INDUCED BY HERPES VIRUS OF TYPE 6 IN NEWBORNS

L. Kravchenko, A. Afonin, M. Levkovich, M. Demidova, & L. Zaurova Rostov Scientific-Research Institute of Obstetrics and Pediatrics, Rostov-on-Don, Russia Brief Introduction: The infection induced by herpes virus of type 6 (HHV-6) is one of the most important medical and social problems of contemporary perinatology; its importance is caused by the severity of the course of disease and by high incidence of the central nervous system damage. The apparent tropism of HHV-6 to lymphoid cells indicates its etiological significance in the induction of the immune response. Objective. To evaluate the content of specific G immunoglobulins and costimulation molecules in case of a severe infection induced by HHV-6 in newborns. Materials & Methods: We examined 32 full-term newborns with the infection induced by HHV-6. The control group was comprised of 15 healthy newborns. The content of sCD40 was determined by the immune-enzyme assay (eBioscience), the level of specific IgG to HHV6 was determined by the immune-enzyme assay (Biotrin). The Wilcoxon distribution free test was used to evaluate the statistical significance of differences between the compared groups. The median and the interquartile range were used to present the results. The differences of the compared values were accepted as statistically significant with the level of significance p50.05. Clinical Cases or Summary Results: Newborns with the severe infection induced by herpes virus of type 6 had a significant increase of the titer of specific immunoglobulins of class G to herpes virus of type 6 as compared with the control group [1.63 (1.2–2.06) and 1.16 (0.82– 1.58)] p50.04) and a significant increase of content of soluble costimulation molecules sCD40 up to 39.9 (16.5–54.3) pg/ml as compared with the control group [11.7 (6.6–19.9)] pg/ml, (p50.01). Conclusions: In case of the severe infection induced by herpes virus of type 6 we recorded a heightened titer of specific immunoglobulins of

310 class G to herpes virus of type 6 and a heightened level of soluble costimulation molecules sCD40, which participate as a cofactor at differentiation of V-lymphocytes, their maturation and transformation to plasma cells. These changes indicate the intensity of infection and the shift of the immune response to T-helpers of type 2 that does not ensure a sufficiently effective virus protection of a newborn organism in case of the infection induced by HHV-6. Keywords: Presenter: A. Afonin

ID 932

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PERINATAL OUTCOME OF FETAL BRADYARRHYTMIA - CASE REPORT Lj. Pejcic, M. Ratkovic Jankovic, & I. Nikolic Clinic for pediatric disease, Clinical Centre Nis Brief Introduction: Fetal bradyarrhythmia refers to an abnormally low fetal heart rate (less than 110 beats per minute) as well as being irregular, i.e irregular fetal bradycardia. Fetal bradyarrhythmias have various underlying mechanisms. Causes of sustained fetal bradycardia include sinus bradycardia, blocked premature atrial contractions (atrial bigeminy/trigeminy), variable second-degree atrioventricular block (AVB) and complete heart block. Fetal echocardiography provides a reasonable level of comfort when differentiating between these causes of bradycardia. As blocked premature atrial contractions generally resolves spontaneously, but incomplete AVB might respond to steroid treatment, correct diagnosis is of major importance. Materials & Methods: Case report Clinical Cases or Summary Results: Case report This report presents a case of fetal bradyarrhythmia discovered by antenatal auscultation and confirmed by external cardiotocography at gestanional age 36/37 weeks. The family history had a preterm delivery in early pregnancy (fetal cardiac arrest). Because of that delivery by urgent caesarean section was performed without previous fetal echocardiography. A male baby, weighing 3,000 g, Apgar score 9, oxygen sat. 95%, heart rate 75–115 bpm, was born and immediately transported to regional pediatric centre and pediatric cardiology. An ECG performed after hospitalisation revealed blocked supraventricular extrasystoles with a heart rate of 65–100 bpm (Fig 1). An echocardiography performed the same day showed a small patent FO with minimal left-to-right shunt and a trivial tricuspid regurgitation with an indirect estimate of pulmonary artery pressure of 32 mmHg. An ECG the day after revealed similar pattern (Fig 2), but in a few days an ECG showed a few atrial extrasystoles (Fig 3). Newborn baby was dismissed with regular sinus ritam. Currently, the little boy is healthy without any ritam disturbances. Conclusions: Atrial bigeminy, characterized by blocked premature atrial contractions (PASs) occurring in a bigeminal sequence, is a benign cause of neonatal bradycardia. In utero, frequent premature beats are associated with an approximately 1% risk of associated supraventricular tachycardia (SVT); postnatally, that risk may be even lower. In neonates, PACs may occur frequently but tend to decline in frequency within the first few postnatal weeks. Keywords: Presenter: Ljiljana Pejcic

ID 776

RIGHT OVARIAN CYST AUTOAMPUTATION

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

B. Anglim1, & G. von Bunau1 Coombe Women and Infants Hospital, Coombe, Dublin 8, Ireland Brief Introduction: Neonatal ovarian cysts occur due to the stimulus of chorionic gonadotrophin. Complications include intracystic haemorrhage, cystic rupture and ovarian torsion, with larger ovarian cysts possibly causing polyhydramnios, pulmonary hypoplasia and dystocia. Ovarian torsion is the most common complication and is related more to the length of the pedicle than cyst size. There is no guideline on the management of neonatal ovarian cysts, however evidence shows that conservative management with serial ultrasounds is suitable in simple ovarian cysts 54–5cm as they are likely to resolve. Lesions more than 5cm in diameter have a higher risk of complication, and cyst puncture with serial ultrasound monitoring should be performed, or surgical removal with an attempt to conserve ovarian tissue. Materials & Methods: A 32 year old lady, Para 1 was presented for a routine sonogram at 22 weeks gestation for fetal wellbeing. At this time a right sided cystic structure was diagnosed measuring 6 by 7 cm. No other anomalies were detected at this time. Mother’s antenatal course was uncomplicatied and she delivered a 3100 g female infant by spontaneous vaginal delivery at 39 weeks without any complications. No abdominal mass was palpable in the infant in the neonatal period. Serial ultrasound scans were performed in the postnatal period on a 4 monthly basis. Clinical Cases or Summary Results: At 19 months of life the child was admitted electively for a laparoscopic ovarian cystectomy +/ oopherectomy. At the time of surgery an autoamputated, necrotic appearing, right ovary and cyst were found to be free floating in the abdomen, with a blind ending right tube. Left ovary appeared normal. This was converted to a pfannenstiel incision in order to remove the cyst intact. The post-operative course was uneventful, and the child was discharged home on oral antibiotics. Histology of the specimen showed an infracted and calcified haemorrhagic cystic structure, benign in nature. Serum hCG was 50.1 IU/L and AFP was 10.5 IU/ml, both normal as infantile AFP levels do not drop to adult levels until around two years of life. Conclusions: Parents and child were seen at a 6 week follow up visit, and child is doing well. Earlier ovarian cystectomy may have prevented autoamputation and loss of right ovary and tube. Antenatal and postnatal counseling combining paediatric and obstetric input is essential. Keywords: Autoamputated cyst, antenatal ultrasound, neonatal ovarian cyst Presenter: Breffini Anglim

ID 926

SPONTANEOUS UTERINE RUPTURE IN THIRD TRIMESTER WITH FETAL DEMISE FOLLOWING MYOMECTOMY I. Djakovic, V. Kosec, S. Sabolovic-Rudman, & V. Gall Department of Obstetrics and Gynecology University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia Brief Introduction: Rupture of a gravid uterus is a surgical emergency, causing maternal and perinatal death. Risk of uterine rupture is associated with uterine scars caused by previous cesarean section, myomectomy, hysteroscopic procedures and curettage. Materials & Methods: Case report. Clinical Cases or Summary Results: A 40-year old woman (gravida 3, para 2) at 31 weeks gestation came into the ER of

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DOI: 10.3109/14767058.2014.924236

Conclusions: Uterine scars require vigilanse because even one successful vaginal birth after myomectomy is no guarantee for future pregnancies. Keywords: uterine rupture, myomectomy, pregnency Presenter: I. Djakovic

ID 134

THE ROLE OF INNATE IMMUNITY FACTORS IN THE FORMATION OF GENERALIZED HERPETIC INFECTION IN NEWBORN CHILDREN A. Afonin, A. Levkovich, M. Levkovich, & L. Kravchenko Rostov Scientific-Research Institute of Obstetrics and Pediatrics, Rostov-on-Don, Russia

Department of Obstetrics and Gynecology University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia, with abdominal pain, vomiting and pain in the right shoulder, lasting 12 hours back. The ultrasound showed a fetus in the abdomen and free fluid in abdominal cavity. This pregnancy was regularly controlled with anamnesis of placenta previa totalis. She had past history of one laparoscopic myomectomy. After myomectomy she had a vaginal delivery. An emergency laparotomy was done. The entire amniotic sac was found in the peritoneal cavity (Figure 1), a rupture of the uterine fundus (Figure 2) and completely exfoliated placenta (Figure 3). The male fetus weighed 2150 grams and was 44 cm long (Figure 4).

Brief Introduction: Herpetic infection (HSV 1, 2) is the major problem of the modern pediatrics. Taking into account the fact that realization of infection is determined by pathogenicity of infectious agents and efficiency of host defenses the important part is assigned to the immune system state. At that implementation of specificity of the innate immune system is born by the family of TLR-receptors, the binding of which by microbial products results in the production of cytokines, subsequently it determines the character, direction and intensity of the adaptive immune response. Objective: detection of the role of innate immunity factors in the development of the generalized herpetic infection in newborn children. Materials & Methods: We studied clinical laboratory findings of 48 newborns in the early neonatal period. 22 children (basic group) had generalized herpetic infection. The control group was comprised of 26 clinically healthy newborns from mothers with physiological pregnancy. The intrauterine herpetic infection was diagnosed on the basis of the clinical presentation of the disease, detection of DNA of HSV 1, 2 in blood and in urine, rising titers of specific IgG to HSV in dynamics, detection of IgM in the blood serum of a child. The expression of TLR-2(SD14+SD282+) on monocytes was determined by the method of laser flow cytofluorometry (Beckman Coulter). Polymorphism of allelic variants of TLR genes was studied by the PCR method. Clinical Cases or Summary Results: The clinical presentation in case of the generalized herpetic infection induced by HSV 1, 2 was characterized by meningoencephalitis – 4.6%, hemorrhagic syndrome – 9.1%, hepatitis – 13.6%, hypotrophy – 31.8%, pneumonia – 31.8%,

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312 central nervous system suppression syndrome – 45.5%, convulsive disorder – 40.9%. High frequency of hepatomegaly -77.3%, fever – 54.5% is also typical. The development of the generalized herpetic infection in the observed newborns was accompanied with significant changes in the immunological status. Thus, a definitive reduction of TLR-2 expression (CD14 + CD282+) on monocytes of the peripheral blood (43.8 ± 8.3% and 76.2 ± 5.6% correspondingly, p50.05) was detected in the basic group as compared with the control group. The study of occurrence of polymorphism of TLR-2 genes determined that the frequency of Arg753Gln genotype of TLR-2 gene was definitively higher in newborns with the generalized herpetic infection as compared with the control group (26.3% and 3.8% correspondingly, p50.05). Conclusions: In case of the generalized herpetic infection there is a reduction of TLR-2 expression on monocytes and it results in the reduction of the antivirus immune response. Allelic variants of TLR-2 gene in the points of Arg753Gln polymorphism may be genetic risk markers of the development of the generalized form of infection induced by HSV of type 1, 2 in newborns. The detected peculiarities of the innate immunity factors explain high sensitivity of newborns to herpetic infection and confirm their role in the development of the clinical presentation of the disease. Keywords: Presenter: A. Afonin

ID 889

ANENCEPHALY RELATED TO DRUG ABUSE IN A PREGNANCY WITHOUT PRENATAL– CASE REPORT L. Ples1,2, C Moisei2, & R.M. Sima1,2 1

Clinic of Obstetrics and Gynecology, ‘‘Bucur’’ Maternity, Bucharest, and 2‘‘Carol Davila’’, University of Medicine and Pharmacy, Bucharest Brief Introduction: The use and abuse of substances by pregnant patients was an unusual event in our country. Despite the ongoing efforts to educate the future mother concerning the benefits of prenatal care and the facile access to medical assistance about 40% of the births in our unit are neglected. Anencephaly is a neural tube defect caused by a failure of closure in the cranial neuropore between the third and fourth week of gestation, resulting in the absence of a major portion of the brain, skull, and scalp. Materials & Methods: We report a case of 34 years of age primigravida admitted in our clinic at term in the second stage of labour. The anamnesis revealed that she was a heroin long term user and she refused medical care during pregnancy. Clinical Cases or Summary Results: The prenatal ultrasound scans have a detection rate for anencephaly about 100% from the first trimester. In the case we report the patient didn’t ask any medical examination before this first visit at the hospital. Being during labour no ultrasound examination was performed before delivery. Clinical examination revealed cranial presentation of anencephalic fetus. The diagnosis was confirmed after the delivery of a 3500 g alive new born, with a rudimentary brain. He died 10 days later. Intra-uterine exposure to maternal drugs is known to adversely affect the developing central nervous system, our case being an example. Unappropiated prenatal care expose the patients to poor birth outcome as severe fetal malformation incompatible with extrauterine survival. Furthermore in the situation of drug abuse the incidence of severe malformation places patients in the high risk

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Conclusions: This case is related to the fact that this pregnancy with anencephalic fetus is discussed as the consequence of drug abuse and no prenatal care. Keywords: Presenter: RM Sima

ID 205

ANTITHROMBOTIC MEDICATION DURING PREGNANCY K. Neykova1, V. Dimitrova2, R. Dimitrov3, A. Savov4, L. Vakrilova5 1 Specialising in the Department of Fetal medicine, Maichin Dom University Hospital, Sofia, Bulgaria, 2Department of Fetal medicine, Maichin Dom Hospital, Sofia, Bulgaria, 3 Department of Gynecology, Maichin Dom University Hospital, Sofia, Bulgaria, 4Department of Genetics, Maichin Dom Hospital, Sofia, Bulgaria, and 5Paediatric Department, Maichin Dom University Hospital, Sofia, Bulgaria

Brief Introduction: Aim: To analyze the current practices of antithrombotic medication (AM) in pregnant women in our country. Materials & Methods: 84 pregnant women on AM were enrolled in the study. Part of them were admitted to the Fetal Medicine Clinic of the State University Hospital Maichin Dom, while others underwent routine Ist or IInd trimester ultrasound scan in Femina Medical Center. All they were on either low-dose aspirin (LDA) and/or low-molecularweight heparin (LMWH). Data about AM was obtained by the patients themselves. We analyzed the indications for antithrombotic prophylaxis (AP), as well as the types of medications used, the doses applied, and last but not least, the regimen of application. Descriptive analysis was performed. Clinical Cases or Summary Results: Results: 25/84 (29%) of the patients were carriers of PAI 4G/4G polymorphism, which is related to abnormal fibrinolytic activity, but not related to increased coagulability. 9/84 (10%) women carried 4G/5G polymorphism, which is considered normal for the Bulgarian population. 5/84 (6%) were heterozygous carriers of R506Q mutation in the gene, encoding the synthesis of factor V (FVL), and only one patient (1.2%) was homozygous carrier of the same gene mutation. 5/84 (6%) patients were carriers of the C677T mutation of the methylentetrahydrofolate reductase (MTHFR) gene, 1/84 (1.2%) was heterozygous carrier of G20210A mutation of factor II gene (PGM). 23/84 (27%) of the pregnant women did not have inherited thrombophilia (IT). 20/84 (23%) were not tested at all for IT. 2 (2.3%) patients had essential thrombocytemia, and one (1.2%) had a medical history of deep venous thrombosis. 25/84 (30%) of the patients were on LDA only, 19/84 (23%) were on LMWH alone, and 39/84 (46%) were both on LDA and LMH. In 12/ 64 (19%) of the pregnant women LDA was started before conception, in 32/64 (50%) it was started in the 1st trimester and in 6/64 (9%) - in the 2nd trimester. Regarding LMWH therapy, the corresponding figures were 5/58 (8%), 33/58 (57%), 5/58 (8%). In 5/64 patients (7.8%) on LDA, the therapy was applied every other day, and this was the same case with 7/58 (12%) patients on LMWH. Conclusions: Conclusions: The analysis showed that serious indications for AM were present in 18/84 (21.4%) cases. They include one of the following: history of venous thromboembolism, homozygocity for either PGM or FVL mutations, compound heterozygocity for FVL and PGM, or protein S deficiency. In other types of IT LDA/LMWH medication has not yet proven to be effective. The administration of LDA or LMWH at intervals greater than 24 hours is not justified from point of view of the pharmacokinetics of these preparations. Keywords: Presenter: Dr. Konstantsa Neykova

DOI: 10.3109/14767058.2014.924236

ID 243

AORTIC DISECTION DURING PREGNANCY P. Barbero, M.D. Montan˜ez, P. Vallejo, C. Martinez, O.P. Villar, & E. Tessier

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University "12 de Octubre" Hospital, Madrid, Spain Brief Introduction: Aortic dissection (AD) during pregnancy is an unusual event but represents a true surgical emergency and has a high rate of maternal and neonatal mortality. Literature shows no evidence about the handling or treatment of this entity, describing the most of the articles experiences based on a case report. Marfan syndrome patients are the most likely to develop this complication, being an aortic root diameter greater than 4cm before the pregnancy a high risk marker. Materials & Methods: We describe the case of a 25 weeks pregnant woman admitted at the ER with oppressive centrothoracic pain and sickness. Personal history: 39 years old patient, diagnosis of aortic aneurism before the current pregnancy with an aortic root diameter of 53mm. Gravida 2, para 1(CS) she had a deep vein thrombosis treated during the present pregnancy. She was diagnosed of an AD. We related the multidisciplinary approach (obstetricians, cardiothoracic surgeons, neonatologists and intensivists) management, the evolution and results. Clinical Cases or Summary Results: Chest X-ray and CT showed an aortic intramural haematoma and severe scoliosis which, with other clinical findings, leaded to suspect a Marfan syndrome. Surgical repair of AD going ahead with the pregnancy was planned, after the administration of corticosteroids for pulmonary maturity. Surgery was performed under extracorporeal circulation, normothermia and in high flow conditions. Complete rupture of the aortic intima up to the right coronary artery was revealed. The root and ascendant portion of the aorta were resected and replaced, preserving the patient’s valve (Modified David I procedure). Magnesium Sulfate as neuroprophylaxis, tocolysis with Tractocile and monitoring of fetal hearth rate supported fetus well-being. The onset of an acute respiratory failure 8 days after the primary surgery leaded to perform a CS to stabilize the patient. Female 1020g

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314 newborn was delivered. The patient was successfully discharged 21 days later. Mother and newborn posterior controls were good. Conclusions: Marfan syndrome-pregnant women with an aortic root diameter greater than 4cm are in high risk of developing an aortic dissection. Although been a rare condition, it establishes a true lifethreathening emergency with a high maternal and foetal mortality. Late 2nd thrimester and immediate puerperium are the riskiest periods due to hemodynamic changes. Carefully preconceptional advice should be given, considering pregestational surgical repair if the aortic dilatation exceeds 4.5cm. When aortic dissection occurs during pregnancy, approach depends on the gestational age. Before 30 weeks, surgery can be performed without ending the pregnancy; but after 30weeks delivery of the newborn should be carried out previously. Some technical modifications must be considered in case of performing the surgery before the delivery, to avoid uterine hypoperfusion and foetal hypoxia. Multidisciplinary approach is mandatory to achieve an optimal management and the best outcomes. Keywords: Aortic disection, Marfan syndrome Presenter: P. Barbero

ID 362

SPONTANEOUS HEMOPERITONEUM DUE TO RUPTURE OF SUPERFICIAL UTERINE VARICOSE VEINS DURING LABOR SUCCESSFULLY TREATED BY PERCUTANEOUS EMBOLIZATION R. Dı´az, P. Tobı´as, S. Lo´pez-Magallo´n, F. Magdaleno-Dans, & J.L. Bartha Obstetric Dept. University Hospital La Paz, Madrid, Spain Brief Introduction: Hemoperitoneum during pregnancy is a rare but potentially lethal clinical condition. In 1950, maternal mortality may reach until 49%. Improvements in antenatal and intrapartum care, especially in surgical and anesthetic techniques have reduced this until 3.4%; perinatal mortality remains very high (31%). Most of these cases occur antenatally (61%) especially during the third trimester. Early diagnosis is essential to prevent mortality. Classically, treatment is based on the systemic correction of hypovolemia and immediate surgery via laparotomy or laparoscopy in cases in the first trimester of pregnancy for hemostatic purposes. In cases at term usually Cesarean section is performed and in those cases in which the focus of the hemorrhage is not clear sometimes hysterectomy is needed. Materials & Methods: We report a case of spontaneous hemoperitoneum during labour due to ruptured uterine varicocele successfully treated with radiological embolization of both uterine arteries. Clinical Cases or Summary Results: A 35 years old Asiatic primigravid woman at 37 weeks’ gestation with otherwise uneventful pregnancy came to the Hospital referring abrupt-onset lumbar and abdominal pain. Cardiotocography showed a reassuring trace and the presence of low intensity uterine contractions. Ultrasound revealed a normal fetus in breech presentation, normal placenta and normal amniotic fluid volume. On examination the cervix was unchanged and there was no evidence of external bleeding. Maternal hemoglobin at admission was 11.5 g/dL and there were no signs of hypovolemia. The patient was admitted for observation. Subsequent cardiotocography showed a mild fetal tachycardia while uterine contractions

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

remained low frequency and intensity. However the distressing back pain continued increasing. It just partially ameliorated by sitting and worsened with recumbency. Because of breech presentation, the presence of symptoms and gestational age a Cesarean section was indicated. After laparotomy a moderate hemoperitoneum was seen in the abdominal cavity. No bleeding point was evident. After fetal extraction and deliver of the placenta, the uterus was exteriorized. A bleeding uterine superficial varicocele of about 7 cm was found on the left uterine horn. Uterine wall was extremely thin at this area. There were numerous and friable bleeding points connecting with the left broad ligament. After a detailed examination of the abdominal cavity no other hemorrhagic area was located. For treatment, local excision was not considered due to the extension of the injured area. Because of the patient was hemodynamically stable and considering primiparity, hysterectomy was not selected as the first therapeutical option. A procoagulant device (TachoSil Õ Nycomed Pharma) was placed on the bleeding area and interventional radiologic embolization of both uterine arteries was successfully performed. The access way for the embolization was both common femoral arteries. After selective catheterization of both uterine arteries, an uterus with prominent arteries was observed. The left horn was more vascularized, without signs of extravasation. It was proceeded to embolization with polyvinyl alcohol particles of 500–700 microns Posterior evolution of the patient was favorable. Conclusions: The main causes of spontaneous hemoperitoneum due to obstetric reasons include rupture of interstitial ectopic pregnancy, uterine rupture due to placental accreta, rupture of uterine vessels, or rupture of a rudimentary uterine horn. Among the non-obstetrics causes spontaneous rupture of umbilical maternal vein, rupture of splenic vein or arterial aneurysm, liver rupture (spontaneous hematoma, HELLP syndrome), rupture of hemangioma or liver metastases.

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DOI: 10.3109/14767058.2014.924236

The particular tortuous, non-valvular and thin walled uterine veins anatomy under the high pelvic vein pressure during pregnancy are the factors predisposing for rupture. However, considering the rarity of the condition it should be some additional factor involved in its pathogenesis. For example, it has been reported that the presence of endometriosis lesions, adhesions, vascular anomalies, previous uterine surgery, uterine fibroids and multiparity may be considered as risk factors. Similar cases of spontaneous hemoperitoneum during pregnancy have been previously reported associated to spontaneous rupture of uterine vessels (veins or arteries), uterine varices or uterine-ovarian vessels. The influence of uterine contrations on the rupture of these vessels is still unknown. It is possible that myometrial activity can lead to an increased pressure in the uterine vessels previously dilated due to the physiological increased pressure in the iliac and inferior vena cava area caused by hormonal and anatomical reasons. Concerning treatment, until now, the only possibility of improving the prognosis is to perform an urgent surgical procedure on the uterus or at least on the bleeding area. Percutaneous vascular embolization of the uterine arteries is an alternative and effective treatment for many obstetrical and gynecological causes of bleeding, such as uterine fibroids, adenomyosis, postpartum hemorrhage, abnormal placentation and even ectopic pregnancy. The main advantage of this technique is the low rate of serious complications and the preservation of reproductive function. In order to integrate this method into clinical practice, it is necessary to know indications, vascular anatomy, the technical procedure and the risks and benefits. To our knowledge, this is the first case of spontaneous intrapartum hemoperitoneum treated with this technique. For that, it is essential an early diagnosis and a rapid indication of this therapeutic option as hemodynamic stability is needed to decide this conservative management.

achieved with diet. A cesarean section was performed at 40 weeks due to failed induction of labor. The newborn weighted 3250g and had an Apgar Score of 9/10. The patient breastfed the neonate for two months, remaining clinically stable. The definitive diagnosis was made in the postpartum period. Growth hormone was not suppressed by a glucose tolerance test, in accordance with the diagnosis of acromegaly. Conclusions: As described in the literature, even with no therapy, pregnancy and lactation did not change the natural course of the disease. Due to the high risk of developing gestational diabetes and hypertension, it’s screening is crucial with a multidisciplinary team.acr

Keywords: hemoperitoneum, pregnancy, embolization

Brief Introduction: INTRODUCTION:PPH is a serious obstetric emergency & causes significant maternal mortality & morbidity. Active management of the 3rd stage by IM/IV oxytocics, Misoprostol were used to prevent PPH.Surgical prophylaxis like balloon occlusion or arterial embolisation, are used to reduce PPH.B-Lynch suture is used as conservative surgical approach in parturient for PPH. I would like to present patients with 3rd stage complications & their management admitted in mamata medical college, khammam. Materials & Methods: MATERIALS & METHODS: Women with 3rd stage complications were studied over a period of 2 years. (January 2012 to December 2013) in MGH.100 women were included in the study.These patients were studied with respect to causes of PPH & their management-medical,/conservative surgical/& definitive treatment.All the patients were having primary PPH. Clinical Cases or Summary Results: RESULTS: Atonic/traumatic PPH(68), Retained placenta(20), Adherent placenta(10) & Acute inversion of uterus(2). multiparous women(76), primiparas(24). vaginal delivery(70), LSCS(30).delivered in mgh (80) & referred from outside(20).The risk factors for PPH were multiparity, previousLSCS, instrumental delivery, macrosomia, induction of labour, multiple gestation, PIH, malpresentation, hydramnios. management:36 patients had B-lynch suture, 14 patients had vaginal, cervical lacerations & were sutured, 10 patients were treated with oxytoxics alone, 6 patients had balloon tamponade,2 patients with broad ligament heamatoma were evacuated on laparotomy. 14 cases manual removal of placenta done under GA.6 cases placenta removed piece meal.adherent placenta(10): 8 had subtotal hysterectomy & 2 patients placenta was left in situ & treated with methotrexate 50mg IM.Uterine inversion(2):repositioned immediately. All the patients were given additional medical management and blood transfusion. Conclusions: SUMMARY & CONCLUSION: active management of third stage, early identification of risk factors, prompt diagnosis & effective treatment will minimize the maternal morbidity & mortality. In our study we were able to manage all cases of PPH including the cases referred from outside.

Presenter: Rebeca Dı´az Murillo

ID 943

ACROMEGALY AND PREGNANCY – A CASE REPORT D. Pereira1, I. Rato2, M. Centeno2, S. Guerra2, & L. Pinto2 1

Servic¸o de Obstetrı´cia do Centro Hospitalar Barreiro-Montijo, Barreiro, Portugal, and 2Clı´nica Universita´ria de Obstetrı´cia e Ginecologia, CHLN-Hospital Universita´rio de Santa Maria, Faculdade de Medicina da Universidade de Lisboa, Centro Acade´mico de Medi Brief Introduction: Acromegaly is an uncommon clinical situation. It is rarely found in pregnancy due to a decrease in fertility observed in these women. Thus, limited data are available. In most cases described, there were no complications during pregnancy and lactation, most patients did not have an increase in tumor size and IGF-1 (Insulin-like growth factor 1) levels tended to be stable or even decreased. However, metabolic complications associated with insulin resistance, and thus an increased risk of gestational diabetes and hypertension, has been described. Neonatal outcome is generally unaffected. Materials & Methods:. Clinical Cases or Summary Results: 32-year-old woman, nulliparous, caucasian. The patient was referred to Department because of a pituitary adenoma (11.5  24.6  20mm), diagnosed by MRI (magnetic resonance imaging) two months before pregnancy. She presented enlarged facial features, increased size of the hands and developed soft tissues. Prolactin, ACTH and cortisol levels were within the normal range, IGF-1 levels were higher than normal. There was no quiasmatic/oculomotor dysfunction or alterations of visual fields. No therapy was instituted. The patient remained clinically stable with no clinical signs of tumor expansion. Gestational diabetes was diagnosed during the 1st trimester (fasting glucose - 103 mg/dL), and metabolic control was

Keywords: Acromegaly, Pregnancy, Lactation, Gestacional diabetes Presenter: D. Pereira, I. Rato

ID 122

A STUDY OF RECENT ADVANCES IN THE MANAGEMENT OF POSTPARTUM HEMORRHAGE AND RETAINED PLACENTA-A JOURNEY TOWARDS EXCELLENCE M. Vijayasree Department of Obg., Mamata Medical college., Khammam., Andhra Pradesh

Keywords: PPH, B-lynch, retained placenta, maternal morbidity Presenter: Dr. M. Vijayasree

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ID 945

PATENT OMPHALOMESENTERIC DUCT – CASE REPORT I. Periquito, T. Marques, S. Lima & M. Ferreira

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Neonatology Department, Hospital Prof. Doutor Fernando da Fonseca, Portugal Brief Introduction: The omphalomesenteric duct (OMD) is an embryologic structure that connects the mid gut to the yolk salc and normally regresses between the 5th and 9th weeks of fetal development. Remnants of the OMD may persist in approximately 2% of the population, the most common presentation being the Meckel’s diverticulum. Materials & Methods: Maternal and neonatal records were revised. Clinical Cases or Summary Results: We report the case of a male newborn, the second triplet of non-consanguineous healthy parents, born from a dichorionic triamniotic pregnancy with adequate prenatal care and normal ultrasounds. A cesarean section was performed at 32 weeks gestation. The Apgar score was 5/6/8, birth weight was 1395 g and no malformations were noted. After sectioning the umbilical cord to place a venous catheter, an abnormal bleeding structure with a fistula discharging watery liquid was noted (image 1). The ultrasound performed was normal, so a catheter was passed through the fistula and small bowel content was aspirated. The surgical correction took place in the 5th day of life, without complications (image 2). Histology revealed proximal intestinal

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

mucosa consistent with a patent omphalomesenteric duct. The newborn regained normal bowel function and resumed breastfeeding after 5 days. Conclusions: An accurate diagnosis and management of this condition is important as it may lead to invagination of the small bowel and intestinal obstruction, with a significant increase in mortality. Keywords: Patent omphalomesenteric duct Presenter: I Periquito

ID 630

BECKWITH-WIEDEMANN SYNDROME O. Szaka´ll1, M. Grasselly2, Zs. Kiss3, Cs. Nagy4, E. Ba´rdi5, P. Masa´t6, Gy. Laza´ry7, Gy. Oroszla´n8 Neonatology Dept., 3Genetics Dept, 4Radiology Dept., Paediatric Oncology Dept., 7Surgery Dept., and 8Paediatric Dept. Markusovszky University Teaching Hospital, Szombathely, Hungary 1,2

5,6

Brief Introduction: Beckwith-Wiedemann syndrome/BWS/is an overgrowth disorder characterized by macrosomia, macroglossia, visceromegaly, midline abdominal wall defects, neonatal hypoglycaemia and ear creases or pits. The diagnosis of BWS is based on physical signs and molecular/cytogenetic tests. The problem is on the short arm of chromosome 11 referred to as 11p15. Children with BWS are in an increased risk of cancer during early childhood. Materials & Methods: We present a premature boy, who was born in 35th gestational week with 4150 g birth weight and 52 cm birth length. Clinical Cases or Summary Results: He had an enormous tongue, hepatomegaly, nephromegaly on the both side, facial nevus flammeus, ear creases and neonatal hypoglycaemia.These signs raised the BWS. Cytogenetic tests verified maternal chromosomal rearrangements of 11p15. His growth rate was increased. He had tongue reduction operation because of macroglossia in 5th months age. Every three months we screend for embryonal tumors by abdominal ultrasound examination and serum alpha-fetoprotein concentration. We diagnosed Wilms tumor on the left kidney in 9th months age. We used standard pediatric oncology protocols. Nowadays he is 1,5 years old, he is well.His increased growth rate has slowed down. His intellectual and movement development is normal. Conclusions: Macroglossia, macrosomia, visceromegaly and neonatal hypoglycaemia are suspected of being BWS. The diagnosis is clinical and genetical.Screening for embryonal tumors is of crucial importance. Keywords: Presenter: Orsolya Szaka´ll

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DOI: 10.3109/14767058.2014.924236

ID 812

INTRAUTERINE RUPTURE OF SACROCOCCYGEAL TERATOMA A. Ksia1, F. Chiouck2, M. Ben Saad1, K. Ben Ameur2, S. Aloui1, L. Sahnoun1, I. Kricnene1, M. Mekki1, M. Belghith1, K. Monastiri2, & A. Nouri1

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1 Department of Pediatric Surgery, University Hospital of Monastir, and 2Department of Intensive care and Neonatal Medicine, Faculty of Medicine of Monastir, Tunisia.

Brief Introduction: Sacrococcygeal teratoma (SCT) is the most common congenital neoplasm. Intrauterine rupture of SCT has rarely been reported. Materials & Methods: A case report. Clinical Cases or Summary Results: We report a case of SCT’s rupture during labor. Prenatal sonographic was not performed because the mother did not attend antenatal care. An emergency Cesarean section was performed. Hemoglobin concentration of the neonate was 9 g/dL. The patient received a blood transfusion. Surgical resection of the tumor was performed on the second day of life.Posterior sacral approach was used for the excision of tumor. A wound infection complicated the postoperative course. Follow-up at one year revealed no evidence of recurrence. Conclusions: The cornerstone in the management of SCTs is prenatal diagnosis. Delay in diagnosis and treatment may lead to rupture, bleeding and infection.

Clinical Cases or Summary Results: The neonate was admitted in our NICU because of her prematurity. She presented transient tachypnea and neonatal jaundice. She had arachnodactyly and pectus carinatum but no myopia, megalocornea or ectopia lentis. Arterial pressure was 58/25 mmHg, normal for the age. The cardiac ultrasound showed an ascending aorta in the upper normal limits for the age and weight. Both the mother’s and daughter’s genotype showed the familial, heterozygous variant FBN1:c.7656 C4G, located in exon 62, with unknown significance. Regular blood pressure measurement, ophthalmologic follow-up, and annual cardiac ultrasound were recommended. The girl’s prognosis mainly depends on the aortic root Z-score, which identifies the progressive aortic root dilatation, the latter potentially resulting in dissection and rupture if left untreated. Prophylactic aortic root surgical repair has been found to raise life expectancy to 30 years of age. In this case, all affected family members have surpassed typical life expectancy, with some individuals reaching 40 to 60 years. Analysis of siblings and other maternal family members could help to clarify the significance of the FBN1:c.7656 C4G variant, and in time give a more accurate prognosis and counseling of patients and their families. Conclusions: Our case consists of a ‘‘potential MFS’’, meaning that a familial FBN1 mutation was identified, but the aortic root Z-score was less than 3. Early diagnosis allowed the attending physicians to recommend continuous follow up in order to monitor for the need for surgical intervention, to our patient’s benefit. Keywords: syndrom Marfan, neonate, variant Presenter: A. Daskalaki

Keywords: SACROCOCCYGEAL TERATOMA neonatal surgery Presenter: F. Chioukh

ID 436

A NEW VARIANT OF MARFAN SYNDROME IN A NEONATE. CASE REPORT AND REVIEW OF THE LITERATURE A. Daskalaki, H. Kapsambeli, B. Sideri, S. Spanou, E. Kotsia, H. Kondaki, C.H. Vliora, & P. Mexi-Bourna NICU, 3rd Pediatric Department, Attikon University Hospital, Athens Greece. Brief Introduction: Marfan syndrome (MFS) is an autosomal dominant connective tissue disorder resulting from widely distributed mutations in the gene encoding fibrillin-1 (FBN1) along the entire FBN1 gene on chromosome 15q21.1. The cardinal features of MFS involve the cardiovascular, ocular, skeletal, respiratory and central nervous system. In infancy the diagnosis of MFS may be difficult and clinical presentation and prognosis are variable. During childhood, MFS is classified into neonatal, severe infantile, early onset and infants with positive familiar history but without major manifestations at the moment. The aim of this study is to present a new variant of Marfan syndrome in a neonate with minimal clinical findings during the first days of life. Materials & Methods: The premature newborn, female, was born at 33 + 4 weeks of gestation by urgent caesarian section, after the mother was transported by air to the hospital because she suffered an acute dissection of descending thoracic aorta. The mother, 33 years old, had previously undergone surgical repair of an ascending aorta aneurism. The mother, her two brothers, and the grandfather presented Marfan phenotype and dilatation of the root of the aorta.

ID 846

OTOCEPHALY: A NEW CASE REPORT J. Methlouthi, S. Nouri1, S. Meddeb2, CH. Hachani1, M. Bellaleh1, H. Ayech1, N. Mahdhaoui1, & H. Seboui1 1

Neonatology Department F Hached Universitary Hospital, Susah, Tunisia, and 2G Obstetrics Department F Hached Universitary Hospital, Susah, Tunisia. Brief Introduction: Otocephaly is a very rare malformation chracterized by microstomia, hypo or aglossia, agnathia and low inserted ears. The affection results from an anomaly of development of the first and second branchial archs. Affected patients have poor prognosis and death occurs generally shortly after birth because of respiratory problems. Materials & Methods: case report Clinical Cases or Summary Results: We report the case of a male premature infant Ahmed, born at 32 weeks GA, presenting with severe respiratory distress at birth. Parents were consanguineous. He was born to a young healthy woman Para II. Fetal ultrasound was normal at 22 weeks GA and revealed hydramnios without associated anomalies at 31 weeks GA. Ahmed was born at 32 Weeks GA. Apgar Score was 3 at 1st minute and 6 at 5th minute. Weight was 1700 g, height 40 cm and head circumference 29 cm. He presented with total mandibular agenesis, hypoplasic lips, important microstomia and low inserted ears. Morphological features were consistent with the diagnosis of otocephaly. Death occurred shortly after birth. Autopsy was performed and didn’t find any associated malformation. Caryotype was normal: 46 XY. Conclusions: Otocephaly is a scarce malformation with a poor outcome. Progress in the field of fetal and perinatal medicine might allow an early recognition of this condition in utero in order to evaluate the prognosis especially by tridimensional face reconstitution. Keywords: Presenter: J. Methlouthi

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ID 171

NEONATAL ACUTE RENAL FAILURE ASSOCIATED WITH MATERNAL EXPOSURE TO ANGIOTENSIN II RECEPTOR ANTAGONIST: A CASE REPORT G.S. Dhooria, H.S. Bains, & D. Bhat

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Department of Pediatrics, Dayanand Medical College and Hospital, Ludhiana, Punjab, India. Brief Introduction: Introduction: Angiotensin II receptor blocker (ARBs) are commonly used antihypertensive drug at present. Toxic effects of angiotensin II receptor blocker have been described on human fetus. Materials & Methods:. Clinical Cases or Summary Results: Case: We report a case of oliguric renal failure in a three day neonate with no features of obstructive uropathy, sepsis or perinatal asphysia. Renal ultrasound and renal Doppler were normal and UTI was ruled out. History of maternal consumption of losartan, an angiotensin II receptor blocker (ARB) during third trimester of pregnancy for control of PIH was found. The neonate was treated conservatively and oliguria and renal failure improved within two weeks and was discharged in a stable condition. Conclusions: Conclusion: Like ACE inhibitors, ARB should not be prescribed during all trimester of pregnancy and breastfeeding. Long term follow-up of these patients is necessary because of high risk of persistent and secondary renal insufficiency.

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Keywords: pregnancy; angiotensin receptor blockers; fetopathy; prenatal exposure Presenter: G.S. Dhooria

ID 352

NEW ONSET OF PULMONARY HYPERTENSION DURING PREGNANCY. A CASE REPORT C. Martı´nez Go´mez, M.D. Monta´nez Quero, P. Barbero Casado, P. Vallejo, O. Villar, & R. Moreno Vidal Obstetrics and gynecology Department, Hospital Universitario 12 de Octubre, Madrid, Spain Brief Introduction: Amount diseases that could complicate pregnancy, cardiovascular disorders are known to be less frequent (0.4–2%) but they have high morbimotality. Materials & Methods: Thirty one years old pregnant women, with no medical history of diseases, is derived to our hospital at 21 weeks diagnosed of new onset primary pulmonary hypertension (PPH). Clinical Cases or Summary Results: At 19 weeks of pregnancy, the patient was made a electrocardiogram in a routinely work exam which showed a complete right bundle branch blockage, and after an hemodynamic studio, a severe PPH was diagnosed without criterion of right ventricle dysfunction. After a thorough anamnesis, the only clinical finding our patient told us was a progressive dyspnoea with moderate efforts. Sildenafil and enoxaparin prophylactic dosage were initiated. Once monthly she had obstetric consultation until the last trimester, when the visits were weekly. Cardiologist controlled her each three weeks. The woman kept in I functional class of NYHA, good capacity in effort tests, low quantity of BNP and no deterioration of right ventricle function except a slightly depressed function. An obstetric, cardiologyst and anesthetist committee met and decided to end at 34 + 4 weeks of pregnancy. Five days before, the gravid was hospitalized to administrate corticoids for fetal lungs madurity and systemic prostanoids in intensive care. Caesarean section and tubal ligature was made without complications and a 2600 grams healthy woman was born. Apgar test 9–10. Postoperative period developed normally and she was discharged from hospital after 12 days. Postcesarean Echocardiac examination showed no changes. Conclusions: Pregnancy physiologic changes could mimic cardiac symptoms such as dyspnoea, so it is very important not to attribute all this to pregnancy, and in case of persistence, an electrocardiogram should be made at least to discard high mortality pathologies like we expose. Keywords: primary pulmonary hypertension, pregnancy Presenter: Monta´nez Quero M.D

ID 311

APLASIA CUTIS CONGENITA CIRCUMSCRIPTA S. Stefanovic´, S. Prcˇic´, A. Radulovic´, V. Stefanovic´, V. Stefanovic´, & T. Panic 1

Medical Faculty University of Novi Sad, Serbia, 2Medical Faculty University of Novi Sad, Serbia, 3Institute for Children’s and Youth Health Care of Vojvodina, Novi Sad, Serbia, 4 Institute for Children’s and Youth health Care of Vojvodina,

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DOI: 10.3109/14767058.2014.924236

Novi Sad, Serbia, 5Health Care Center Novi Sad, Serbia, and 6 Health Care center Ruma Serbia Brief Introduction: Aplasia cutis congenita is a rare skin disorder with the incidence of 3 cases per 10.000 newborns, characterized by the localized or widespread absence of skin. The first case was described by Cordon in 1767. It most commonly (70%) manifests as a solitary defect on the scalp, but sometimes it may occur as multiple lesions affecting also the face, the trunk or the limbs. Skin defects can be superficial (epidermis or dermis) or deep (involving dermis, fat tissue, muscles, periost). The appearance of the lesions varies, depending on when they occur during intrauterine development. There are few theories about its etiology 1. intrauterine conditions (teratogens, trauma, viral infections, placenta abnormalities), 2. family history (genetic factors)

Materials & Methods: We will describe our patient and point out the most important details of his medical history Clinical Cases or Summary Results: It is a term male newborn infant with healthy young parents, but mother dyed her hair frequently during pregnancy with hair dye colors which she bought on the market eg. At birth the child was eutrophic for gestational age, (BW 3350 g, BL 51.5 cm, HC 34 cm) SP index 2.45 represents slight asymetric intrauterine growth retardation. Large defect on right leg (cruris et metatarsus skin region, approximately 3.3% of whole body surface) was seen at first glance so this baby was promptly transported to NIC in our Institute, where local problem was recognized and treated by plastic surgeon (Mepitel dressing-soft silicone wound contact layer, silver sulfadiazine and aminoglycozide ointment) as well as by neonatologist with parenteral antibacterial therapy (Pentrexyl, Garamycin, Vancomycin), parenteral hydratation

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and parenteral nutrition (mouth mucose was covered with numerous bubbles -bullas), nails were grey and rough with subungval haemorrhages. Lab tests: CRP 2.68 mg/l, WBC 10.66 g/L (gra 0.65%, lym 0.34%), RBC 5.01 T/L, Hgb 183 g/L, Hct 51%, Ret 0.014, Plt 175 g/L, Elisa test IgM Antibodies against Varicella and Varcella Zoster, Toxoplasmosis, Rubella, Citomegalovirus, Herpes simplex, Herpes genitalis were absent. Imaging methods did not reveal congenital abnormalities of organs. Kariotype: 46 xy. Dermatologist: Aplasia cutis congenita circumscripta. Erosionis regionis mucosae oris. Onychodystrophia. Clinical treatment was beneficial, new skin covered the defect, bucal mucose spontaneusly recovered so parenetaral nutrition was replaced by normal per os feeding with formula, due to mother’s agalctia, healthy nails replaced dystrophic ones. Conclusions: Aplasia cutis congenita is a rare skin disorder but whwnever it occurs, our role as neonatologist is to prevent water and electrolytes loss and to prevent secondary infections either local or general Keywords: aplasia cutis congenita, rare case, neonate

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There is one reported case of father to daughter transmission of SRS. This could be the second case. The newborn could be a SRS, considering the above mentioned genetic mechanisms. Rare cases of dominant inheritance were described without locus description. Final diagnose of SRS wasn’t confirmed. By studying maternal uniparental dysomy and methylation study of genes IGF2 and H19 up to 40 to 60% of cases could be diagnosed. Methylation study with CGH study could detect up to 60–70% of cases, no papers confirm these findings. We could not find other reports of pregnant women with SRS to establish natural history of pregnancy. In this couple prenatal counselling is complex; there isn’t diagnosis neither in the mother nor child. Keywords: Silver Russel Syndrome, Prengancie, Intrauterine Growth Restriction Presenter: P. Putti

Presenter: Svetlana Stefanovic´

ID 532 ID 100

CASE REPORT SILVER RUSSELL SYNDROME AND PREGNANCY P. Putti1,2, E. Citrı´n2, & R. Guec¸aimburu´3 1

Head of Prenatal Service – Department of Perinatology – Instituto de Previsio´n Social – Montevideo - Uruguay – Uruguay, 2Obstetrician and Gynecologist at SMI (Servicio Me´dico Integral) Montevideo – Uruguay, and 3Geneticist at the Prenatal Service – Departme Brief Introduction: Silver Russell Syndrome (SRS) is a rare disorder with dominant autosomic transmission with a prevalence of 1/100.000. Most cases are sporadic and case reports are rare. Etiology is unknown, probably multifactorial. There are no reports of pregnancies with SRS. The importance of this report is being the first case reported of pregnancy with SRS. Materials & Methods: Patients’s chart review. Online Search SRS is an embryogenesis defect, probably related to a defect of imprinting in region 11p15, mycroduplication 11p15, uniparental maternal disomy of chromosome 11 or 7 or mycroduplication 7p11.2p13. SRS is characterized by intrauterine growth retardation (IGR). SRS have normal head circumference, wide prominent forehead, triangular face, small pointed chin, wide mouth, thin lips, large eyes and bluish sclera. Shortness and/or clinodactyly of the fifth fingers are common. Patients may be slow to learn motor skills. Clinical Cases or Summary Results: 20 yo girl with SRS, diagnosed at birth, no genetic study done. Attends doctor’s office at 7 wGA. At 12 wGA 1st T screening showed low risk of aneuploidies, no further studies. Structural US at 21 wGA is normal with fetal growth at P5. IGR was diagnosed, Doppler US showed increase in resistances of uterine, umbilical arteries, cerebral vasodilation and impairment of fetal hemodynamia. LMWH start with induction of pulmonary maturation. US and Doppler 15 d later informs fetal growth at P5 with oligohydramnios and fetal flow redistribution. Admitted at 29 wGA for C section. He weighted 670 gr Apgar 5/7 admitted in ICU. Stayed 14 d with AVM and surfactant. Extubated and ventilated with CPAP for 39 d. Discharged from ICU at 83 d with 1.649 gr, with SRS presumption. Genetic study of comparative genomic hybridation; no significant findings. Readmitted at 8 months with pneumonia leading to, cardio respiratory arrest. Resuscitated for 30 m with full resuscitation measures, died. Conclusions: This is the first case of a pregnancy in a patient with SRS in Uruguay. No cases were found in international data. Prenatal screening overruled aneuploidies.

MATERNAL MEDICATION PART OF INFANT MORTALITY R. Jashi & N. Gorgadze Perinatal Center at Health Center ‘‘Medina’’ Batumi, Georgia Brief Introduction: In Georgia, the greater part of infant mortality falls to perinatal mortality. Perinatal mortality is a useful integrated indicator of the quality of services provided to pregnant women, delivering mothers and infants. However, to achieve a further improvement in the quality of services, individual components of this indicator should be analyzed. The common causes of perinatal mortality are respiratory disorders specific to the perinatal period, including Respiratory Distress Syndrome (RDS) of newborn – 21.6% and intrauterine hypoxia and birth asphyxia –8.5%. Understanding the etiology of these conditions is a very important step towards developing preventive strategies. Materials & Methods: Objectives: Our aim is to identify medicationrelated risk factors. Methods: Retrospective and pharmacological analysis of diseased newborns and maternal medical records (total number 225). Maternal data: age, diagnosis, medications used during pregnancy and delivery; newborn data: gestational age at delivery, birth weight, diagnosis and medications used. We analyzed the mortality risks associated with pharmacologic treatment for newborns and medications used by mothers during pregnancy and delivery. Clinical Cases or Summary Results: The study revealed that RDS in newborns was often associated with maternal use of certain medications during pregnancy(RDS is mostly associated with gestational age). 1 Magnesium Sulfate: 11% newborns had symptoms of Magnezium Sulfate intoxication, such as CNS disturbances 2 Diazepam: newborn asphyxia was related to maternal Diazepam use during delivery (9%) - apnea, hypothermia and feeding problems identified in these newborns could be caused by this medication. 3 Naphthyzinum: in one case, during pregnancy, the mother routinely used Naphthyzinum, because of the difficulty with breathing. Four hours after the birth signs of neural excitation, periodic breathing, apnea and convulsions developed in the newborn 4 Nadroparin: premature infants are predisposed to coagulopathy, which may increase the incidence of intraventricular haemorrhage (IVH). Coagulation values vary with gestational age. There is only limited clinical data concerning transplacental passage of a blood thinner nadroparin in pregnant women. We observed twins born at 28 weeks of gestational age. Their mother was treated with nadroparin during pregnancy 10 days before delivery. Our Analysis shows that Activated Partial Thromboplastin Time (APTT) values were the highest at 1 day

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of life (DOL) (twin I: APTT 90,8 at 1 DOL and APTT 50,1 at 2 DOL;TWIN II:APTT 54,5 at 1 DOL, and APTT 40,8 at 2 DOL.) Ultrasound images show IVH II in both infants. Conclusions: For appropriate treatment of neonates, it is necessary to take into consideration maternal medication use during pregnancy and delivery. This is important because of both the direct side effects of these medications newborns and their potential for altering kinetics of other medications in the fetus as well as in the newborn. We think that the information on the maternal medication use during pregnancy must be included in the patient care system software (PCS, IBM) for immediate detection of possible drug-interactions in newborns. Using computerizing methods of documentation for improving quality of drug therapy is currently limited due to the absence of patients’ clinical database in hospital information systems. The inclusion of such a database could be useful for the systematic detection of adverse drug reactions and improvement of drug safety in neonatal patients. Using computerized methods should lead to significant time savings and improvements in cost effectiveness.

(68.4 pg/ml and 54.5 pg/ml) and in women with male fetuses (66.4 pg/ml and 68.4 pg/ml). Conclusions: The received results indicate certain differences in the functioning of the system of vascular endothelial growth factors in the organism of a mother subject to fetus gender. Pregnant women with female fetuses have a more expressed functional activity of this system from the earliest stages of gestation and up to delivery. On the one hand, it indicates a more expressed anatomic-functional «request» from the uterine-placental-fetus complex in women with female fetuses and, on the other hand, it confirms different intensity of functional processes in placenta by this type of sexual dimorphism at all stages of pregnancy.

Keywords: medication-related risk factors.maternal medication. treatment of neonates

OSTEOPOROSIS POSTPARTUM, A CASE REPORT; IMPLICATIONS FOR MIDWIVES

Presenter: N. Gorgadze

ID 269

FUNCTIONING OF THE SYSTEM OF VASCULAR ENDOTHELIAL GROWTH FACTORS SUBJECT TO FETAL GENDER IN PHYSIOLOGICAL PREGNANCY T. Botasheva, N. Ermolova, O. Sargsyan, N. Palieva, & V. Avrutskaya Rostov Scientific-Research Institute of Obstetrics and Pediatrics, Rostov-on-Don, Russia Brief Introduction: The system of vascular endothelial growth factors determines the processes of angiogenesis in the uterine-placental complex, on which life support of a fetus depends at all stages of pregnancy. Deviations in the formation of vasculature are a leading pathogenetic component in the pathogenesis of obstetric complications. However the peculiarities of functioning of this system with the account of sexual dimorphism remain practically not researched. Materials & Methods: We examined 107 women with the physiological course of pregnancy: 52 – with male fetuses, 55 – with female fetuses. Vascular endothelial growth factor (VEGF), placental growth factor (PGF), epidermal growth factor (EGF), endothelin 1 (ET-1) and tumor necrosis factor (TNF-a) levels were determined in venous blood of pregnant women using the immune-enzyme assay («TECAN» photometer sunrise - Tecan Austria GmbH) in I, II and III trimester of gestation. Clinical Cases or Summary Results: It was discovered that in I trimester a double increase of VEGF concentration 8.9 ± 0.8 pg/ml was recorded as compared with non-pregnant women. VEGF level increased in II and III trimester in all pregnant women, but in women with female fetuses it was more expressed (by 31.5%–32.8 and 48.0 pg/ml; by 13.4%–51.6 and 59.6 pg/ml). ET-1 content in blood serum of pregnant women only with female fetuses in II trimester increased (3.1 and 4.8 pg/ml). Subject to fetus gender it was established that both in case of male fetuses and in case of female fetuses during the progression of pregnancy an increase of PGF level (by 31.5% and 44.4%) was recorded. TNF-a in case of the physiological course of pregnancy content in blood serum was 2 times lower as compared with nonpregnant women. Depending on the fetus gender of this index during the progression of pregnancy in women with female fetuses

Keywords: Presenter: T. Botasheva

ID 463

J.L. Nu´n˜ez1, M.D. Gonza´lez2, & T. Angulo3 1

Senior Nurse- Midwife, Obstretric Dept, Virgen Macarena Hospital, Seville, Spain, 2Nurse Administrator. ICU Dept. Virgen Macarena Hospital, Sevilla, Spain, and 3Midwife, Obstretric Dept, Virgen Macarena Hospital, Seville, Spain. Brief Introduction: Pregnancy and lactation represent stress states for maternal health and development. Pregnancy and lactation -associated osteoporosis are a uncommon and rare conditions characterized by de ocurrence of fragity fracture, most commomly vertebral, in late pregnancy or during de pospartum period. Due to the rarity of this desease, various isolated clinical cases are reported. The aim of this presentation is to show the alert signs and symptoms of this uncommon condition that can cause severe complications to women such as vertebrae fractures which could contribute to women physical safety. Materials & Methods: Literature research ** is undertaken in the main health data base (CINHAL, MEDLINE, CUIDEN. . .) The scientific evidence available is limited due to the low incidence of this condition. However, there is enough evidence to consider pregnancy as a risk factor to develop transient osteoporosis, especially if it is associated to prolonged breastfeeding. Nevertheless some authors identify prolonged breastfeeding as a protective factor of osteoporosis. Clinical Cases or Summary Results: The patient under study is a 37 year old woman with no past medical history. She had two uncomplicated spontaneous vaginal births. The patient breastfed for 24 months with her first child and is currently breastfeeding her second. She refers to her midwife for lumbar pain, weigh loss, general weakness and lost of height. The midwife refers the lady to the medical team for further assessment. Following a radiological review of the vertebral spine metastasis is suspected; the image shows demineralisation areas and lost heigh in thoracic and lumbar vertebras. Subsequently, breastfeeding is withdrawn and further complementary tests are undertaken including MRI, tumoral markers blood tests, endoscopy and colonoscopy, CT scan and vertebrae biopsy. All tests were negative, except for the MRI of the spine that revealed compression of thoracic and lumbar vertebras with collapsed D11, D12 and lumbar vertebral body. Densitometry shows a general demineralization of the vertebral spine. After excluding neoplasic origin and secondary osteoporosis, a differential diagnosis is established: postpartum osteoporosis or lactation-associated osteoporosis. She is consequently treated with antiresorptive and anabolic medication, a lumbar corset and she is advised to rest and avoid exertion. The midwife developed an

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action plan*. The evolution of the condition is positive, mineralisation levels improved and the pain subsided. Conclusions: CONCLUSION: All women that present lumbar mechanical pain during the puerperium that continues despite rest and analgesics should be assessed for a possible postpartum osteoporosis or lactation-associated osteoporosis especially if reduction of height is detected.

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surgery significant decrease in the M30-M65 level also detected (p50.001). Conclusions: Findings of the study demonstrates that apoptotic activity dysregulation may be a factor in the ovarian tumoral development. On the other hand oxidative stress may be effective in the malign character development.

Keywords: Osteoporosis, lumbar pain, lactation, midwife

Keywords: Epithelial ovarian cancer, Ovarian Neoplasms, Benign ovarian tumor, Cytokeratin-18, M30 M65, oxidative stres

Presenter: J.L. Nu´n˜ez

Presenter: A. Incebiyik

ID 804

ID 219

OXIDATIVE STRESS LEVEL AND ANTIGEN M30-M65 AS CIRCULATING BIOMARKERS OF CELL DEATH IN WITH EPITHELIAL OVARIAN CANCER PATIENTS

CERVICAL NEUROBLASTOMA IN THE NEONATAL PERIOD

A. Incebiyik1, H. Camuzcuoglu1, M. Vural2, N.G. Hilali1, A. Camuzcuoglu1, A. Seker3, A. Taskin4, & N. Aksoy4 1

Harran University, Faculty of Medicine, Depatment of Gynecology and Obstetrics, Sanliurfa/Turkey, 2Marmara University, Faculty of Medicine, Depatment of Gynecology and Obstetrics, Istanbul/Turkey, 3Harran University, Faculty of Medicine, Depatment of General Surgery, Sanliurfa, Turkey, and 4Harran University, Faculty of Medicine, Depatment of Biochemistry, Sanliurfa, Turkey Brief Introduction: Ovarian cancer is the second most seen gynecologic cancer and 80% of cancer cases originate from ovarian surface epithelium. Since early phase cases do not have specific symptom, 65% to 75% of the cases diagnosed in the progressed stage. Five year survival is accepted to be below 30%. Even etiology is unknown, apoptosis dysregulation and oxidative stress is believed to have a key role. In this study we aimed to evaluate whether oxidative stress and apoptotic activity have any role in the pathogenesis of the ovarian cancer. Materials & Methods: Among the patients who admitted to the our university with the diagnosis of ovarian tumor, 26 women with postoperative diagnosis of epithelial ovarian cancer and 25 women with postoperative diagnosis of benign ovarian tumor (totally 51) were included into study. Control group was consisted of 30 healthy women who admitted for routine gynecologic control. Venous blood samples were drawn from ovarian tumor patients preoperatively in order to study oxidative stress markers and serum M30-M65 antigen titers. Additionally to detect whether reducing tumor mass affected M30-M65 level, second blood samples were collected on the postoperative 8th day. Clinical Cases or Summary Results: Among all three groups, oxidative stress markers were highest in the epithelial ovarian cancer group. Besides this there was no significant difference between other two groups. M30-M65 level which is accepted as the demonstrative of the apoptotic and necrotic activity, was higher in the epithelial ovarian cancer group with respect to other two group (p50.001). Not as oxidative stress marker level, M30-M65 level also was higher in the benign ovarian tumor group with respect to the controls (p50.001). M65 and stage of the disease was positively correlated in the serous cystadenoma patients (r = 0.611, p = 0.007). When we accept the cut-off point for M30 as 166 U/L, sensitivity was 73.1%, specificity was 83.6%. When we accept the cut-off point for M65 as 602 U/L, sensitivity was 88.5%, specificity was 83.6%. After

R. Vieira1, ME. Ceccon1, U. Tannuri2, V. Odone Filho3, & W. Carvalho1 1

Neonatology Division, Pediatric Dept., Hospital das Clı´nicas da Faculdade de Medicina da Universidade de Sa˜o Paulo, Sa˜o Paulo, Brazil, 2Pediatric Surgery Division, Pediatric Dept., Hospital das Clı´nicas da Faculdade de Medicina da Universidade de Sa˜o Paulo, Sa˜o Paulo, Brazil, and 3Pediatric Onco-Hematology Division, Pediatric Dept., Hospital das Clı´nicas da Faculdade de Medicina da Universidade de Sa˜o Paulo, Sa˜o Paulo, Brazil Brief Introduction: Cervical neuroblastoma in infants is extremely rare (55% of cases) and may present as tumor, stridor, difficulty breastfeeding, Horner’s Syndrome, making differential diagnosis of most common diseases of this age, such as cervical adenitis, laryngomalacia, branchial cleft cyst and lymphangioma. Thus, with different clinical presentations, delayed diagnosis may occur and the tumor spread to the liver, lungs, bone marrow and bones. Generally, the prognosis is good when diagnosed early, with little local recurrence and metastasis. Materials & Methods: There aren’t materials & methods because this is a case report. Clinical Cases or Summary Results: Female infant was born at term (39 weeks), appropriate for gestational age (3040 g), Apgar scale 9/10, and presented at 10 days of life stridor discrete, bulging of the right cervical region and dyspnea during breastfeeding. At 1 month of age had rapid growth of the lesion, diagnosed as laryngomalacia, but after cervical computed tomography and magnetic resonance imaging scan, mass was observed 6.6  8 cm with tracheal compression and deviation of the spine. The patient was intubated due to respiratory failure and transferred from other hospital to our NICU. She underwent complete surgical excision of the tumor and was extubated in the immediate postoperative period. Evolved after surgery with palbebral right ptosis. Showed negative urinary VMA; negative N-myc oncogene amplification in neuroblastoma cells; myelogram without strangers elements to the bone marrow; pathological examination of the resected mass with undifferentiated neuroblastoma, unfavorable histology, and cervical lymph nodes without evidence of neoplasia; normal abdominal ultrasonography and echocardiogram. She was discharged after 8 days of hospitalization to follow with the Oncology and Ophthalmology. Bone scintigraphy performed after discharged was normal. Conclusions: Despite the rarity of neuroblastoma in the cervical region, we call attention to that when diagnosed early and before 2 years of age there is a tendency to a better prognosis. Keywords: Cervical neuroblastoma, magnetic resonance imaging scan and early diagnosis Presenter: R. Vieira

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ID 312

A RARE CAUSE OF ACUTE ABDOMEN: SPONTANEOUS UTERINE RUPTURE DUE TO GESTATIONAL CHORIOCARCINOMA A. Incebiyik1, N.G. Hilali1, A. Camuzcuoglu1, H. Camuzcuog˘lu1, A. Seker2, & M. Vural1

actively-bleeding lesion was detected in the fundus. A total abdominal hysterectomy was performed, as the patient was 45years-old and did not desire to conceive. Conclusions: Uterine rupture due to choriocarcinoma is a lifethreatening condition and should be considered among the differential diagnosis of patients in the reproductive phase, with a history of recent pregnancy, and having acute abdomen with hemoperitoneum. Keywords: Choriocarcinoma, Uterine rupture, Acute abdomen Presenter: A. Incebiyik

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Harran University School of Medicine, Department of Gynecology and Obstetrics; Sanliurfa; Turkey, 2Harran University School of Medicine, Department of General Surgery; Sanliurfa; Turkey Brief Introduction: Choriocarcinoma is a rare neoplasia characterized withal the invasion of trophoblastic tissue into the myometrium and distant metastasis. The problems which will take place during diagnosis, treatment and follow-up of the disease may lead to lifethreatening complications, such as uterine rupture. Materials & Methods: Here we present a case of a patient who was previously operated on with vacuum aspiration for molar pregnancy, who did not attend the follow-up examinations, and was finally admitted with acute abdomen due to uterine rupture due to choriocarcinoma. Clinical Cases or Summary Results: A 45-year-old patient was admitted to our hospital with vaginal bleeding for 2 days and increasing abdominal pain, nausea and vomiting for the previous 10 hours. The patient had a history of nine normal births and three abortions. Approximately 4.5 months earlier, the patient was operated on with vacuum aspiration for molar pregnancy, but then did not attend the follow-up examinations. The patient had no symptoms until 2 days prior to admission to the hospital. During the physical examination, the patient was pale, afebrile, had a blood pressure of 70/40 mm Hg, was tachycardic (pulse: 110 bpm) and had sensitivity in whole abdomen, especially in the lower part. During the abdominal ultrasonography the uterus was larger than normal, and a 45  35 mm and 25*32 mm, irregular, and heterogeneous mass was localized in the fundus, and high amount of intra-abdominal free fluid was present. The decision was made to perform an emergency laparotomy on the patient with acute abdomen. The uterus was found to be enlarged and an approximately 60  40 – 30*35 mm

ID 459

ACUTE MYELOBLASTIC LEUKEMIA IN SECOND TRIMESTER OF PREGNANCY AND TRANSPOSITION OF GREAT ARTERIES A. Castillo Martı´n, J.E. Asenjo de la Fuente, C.S. Pin˜el Pe´rez, N. Izquierdo Me´ndez, T. Illescas Molina, & M.A. Herra´iz Martı´nez Hospital Clı´nico San Carlos, Madrid, Spain Brief Introduction: We hereby present the clinical case of a thirty seven years old pregnant mother being diagnosed with a myeloblastic leukemia in the 17th week of pregnancy (hereinafter, the Patient), so as to assess the: progression; treatment; and outcome of the disease. Materials & Methods: Case Report Clinical Cases or Summary Results: Patient with no relevant medical history but for a caesarean performed two years ago. First trimester echographic and analytical controls with normal results. Check analysis due to asthenia was carried to the Patient, with the following results: Hb 4.2 g/dL, Hematocrit 11.5%, Platelets 200.000, leucocytes 4.100 (Lymphocytes 35%, Myelocytes 2%, Blasts 24%). Bone marrow test was carried out, confirming the Acute Myeloblastic Leukemia diagnose M-4, FAB, NPM1+, FLT3-, being

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necessary to start with the chemotherapy treatment as soon as possible. Ultrasound exam was carried out, confirming the ongoing pregnancy with fetal development in accordance with amenorrhea. Placenta placed front. Normal amount of amniotic fluid. Complete transposition of great arteries’ heart disease was diagnosed. The Patient decides to keep going with the pregnancy. Two days after her admission in the hospital the induction of remission treatment with Idarubicin and Ara-c was initiated. After two weeks of chemotherapy another ultrasound exam was carried out, with a moderate level of oligohydramnios with flow redistribution and a rising MCA speed blood. Six days later, having finalized the first chemotherapy cycle, and before receiving the medical discharge from the Hematology department, the echography was repeated once again, noting ahydramnios. Fetal deterioration was observed with signs of serious placental insufficiency. Three days later, severe placental insufficiency in hemodynamic imbalance phase was observed. Both: pericardial; and low-key pleural effusion were noted. Finally, having elapsed four days from the last echography, being the pregnancy of the Patient of twenty weeks in that moment, fetal death was verified. Hematological stability of the Patient was checked and the prostaglandine induction was applied. Uterine vacuity was checked by ultrasound. Fetal autopsy: Simple transposition of great arteries. At completion of this abstract, the patient has just received an autologous stem cell transplant Conclusions: - The incidence of acute leukemia (AL) during pregnancy is estimated to be 1/75000. AML accounts for more than 2/3 of leukemia that are seen during pregnancy. - Delays or modifications in therapy to ensure the birth of a healthy infant may affect the maternal prognosis adversely. - Leukemia in pregnant patients increase the risk of abortion, fetal growth restriction, myocardial alterations, preterm delivery and perinatal mortality - During 1st quarter offering the pregnant mothers the therapeutic abortion may be considered, due to the potential teratogenic action of the chemotherapy. In the 3rd quarter is always recommended to continue with the pregnancy, assessing the right time delivery. During de 2nd quarter each case must be individualized - The uniqueness of this case report is located in the concurrence of two unusual processes (leukemia during pregnancy and fetal transposition of the great arteries) and the atypical evolution of gestation in connection with the administration of chemotherapy Keywords: leukemia and pregnancy, transposition of great arteries, chemotharapy and pregnancy Presenter: A. Castillo Martı´n

ID 094

NEONATAL ABSTINENCE SYNDROME – RECOGNITION IN THE MATERNITY WARD T. Lazic´ Mitrovic´, L. Hajnal Avramovic´, Dj. C´ec´ez, T. Macut, T. Sˇljivancˇanin, & A. C´urkovic´ Neonatology Dept., Gynecology and Obstetrics Clinic "Narodni Front", Belgrade, Serbia Brief Introduction: Neonatal Abstinence Syndrome (NAS) refers to newborn neurological, respiratory, gastrointestinal, vegetative disorders if a child was exposed to psychoactive substances in utero. Drug elimination, which starts after birth, is a base of early NAS clinical presentation. In differential diagnosis we can have perinatal asphyxia, infection, metabolic imbalance, polycythemia. Usually, the extended anamnesis of psychoactive substances misuse during the

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DOI: 10.3109/14767058.2014.924236

pregnancy and toxicological analyses in newborns are negative, thus the doctor must act in accordance with clinical presentation only. Aim of this study is to point out the problems in diagnosis and care of the patients with an early NAS. Materials & Methods: Report of four cases with the prominent NAS symptoms. Clinical Cases or Summary Results: Four newborns with the prominent NAS symptoms are reported in this study, paying special attention to the differential diagnosis. Neurological and gastrointestinal symptomatologies were dominated, with minimal respiratory and vegetative disorders. Finnegan Score (FS), as a predictive scale, has been used in our institution for the NAS clinical assessment. The first reported child had negative mother’s anamnesis of drug misuse and toxicological urine findings, FS 11–13, and positive response to the therapy. For the second newborn – negative anamnesis, positive urine analysis, FS 13–17, positive response to the therapy. The third newborn had FS 11–17, positive anamnesis and response to the therapy. The fourth newborn had positive anamnesis, negative urine analysis, FS 9–13 and positive response to the therapy. The therapy for three of them was non-pharmacological and Phenobarbital, while one had dual pharmacotherapy (Phenobarbital and Morphine). Conclusions: Since the possibilities of prenatal and postnatal diagnosis of the children who have been exposed to the intrauterine psychoactive substances inflow are limited, clinical presentation is the gold standard which leads to the diagnosis. The NAS suspicion for the children who have been noted as having the NAS characteristic signs is particularly important. The clinical signs quantification pursuant to the adopted scales leads to the right choice of nonpharmacological and pharmacological therapy. The response to the therapy is monitored by scoring. This approach to the treatment leads to the recuperation of a child with NAS and the establishment of one of the basic rhythms which a child should have upon the leaving the maternity ward – the rhythm of feeding and sleeping. Keywords: newborn, neonatal abstinence syndrome, differential diagnosis, misuse of substances Presenter: Tanja Lazic´ Mitrovic´

ID 453

MYELODYSPLASTIC SINDROME AND PREGNANCY J. Cordero1, E. Arango2, M. Alvaro3, M. Gonzalez4, & J. Plaza5 1 Obstetrics Dept., Hospital universitario Fundacio´n Jimenez Diaz, 2Obstetrics Dept., Hospital universitario Fundacio´n Jimenez Diaz, 3Obstetrics Dept., Hospital universitario Fundacio´n Jimenez Diaz, 4Obstetrics Dept., Hospital Universitario Fundacio´n Jimenez Diaz, and 5Obstetrics Dept., Hospital universitario Fundacio´n Jimenez Diaz

Brief Introduction: Incidency of Myelodysplastic sindrome have increased in the last few years in young population and therefore in pregnant women, in this case report we want to present and discuss the effects of this sindrome during the pregnancy and the perinatal results based in our experience Materials & Methods: Case report Clinical Cases or Summary Results: We present the case of a myelodysplastic syndrome in a 37 aged chinese pregnant in the third trimester (33 weeks) follewed in our high risk section due to her haematologic illness. We talk about the clinical repercusion in pregnancy, the perinatal results, the postpartum evolution and the general manage of this sindrome based in the actual scarced articles in obstetrics literature and our experience

Conclusions: Myelodysplastic sindrome incidence is increasing in young and pregnant population. High risk obstetricians should start to know the effects on the pregnancy and the perinatal results in order to achieve a good manange. Correct treatment of this illness have been related with excellent perinatal results. Keywords: Myelodysplastic Sindrome, Pregnancy, Haematology, Platelets Presenter: Javier Cordero Ruiz

ID 468

CEREBRAL CAVERNOUS HAEMANGIOMAS OR CAVERNOMAS IN PREGNANCY M. Azpeita Rodrı´guez, A. Mun˜oz Ledesma, M. Navarro Monje, C. Montoya Garcı´a, A. A´lvarez Gonza´lez, S. Del Olmo Bautista, & F. Vazquez Camino Department of obstetrics and gynecology, section of obstetrics, university hospital rio hortega, Valladolid, Spain Brief Introduction: Cerebral cavernous malformations are a collection of small blood vessels (capillaries) that are formed –without neural structures involved- in a white substance that of cerebral hemispheres and brainstem. Between 0.1 and 4% of population presents this kind of malformation. Most common symptoms of these injuries are: seizures, more frequent if the malformation is located near the cerebral cortex; strokes due to bleedings; and focal neurological deficits. Less frequent symptoms are; hydrocephalus, intracranial hypertension, hypothalamic disorders and overall neurological compromise. On rare occasions these injuries appear during pregnancy, and when they do, their manifestations may be easily confused with signs or symptoms of preeclampsia or eclampsia. Materials & Methods: CASE REPORT Clinical Cases or Summary Results: A 20-years-old woman, was diagnosed in 2012 with left insular cavernoma. The patient came to the emergency room with dysesthesia in right side of the body and Jacksonian march The treatment started with the administration of Keppra (levetiracetam) showing a poor initial response, so it was followed by the administration of Lamotrigine, achieving the control of the symptoms. In 2013 with the symptomatology stabilized, the patient becomes pregnant. Pregnancy is developing normally, no seizures or right hemiparesis –which had been the patient’s only symptoms until now-, as she was continuously being treated with Lamotrigine and Zonisamide (both category C FDA). The treatment was continued throughout the pregnancy period because it was considered that the potential benefits justify the potential risks to the fetus.

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After 25 weeks of gestation, we consult neurosurgery team in order to decide which was the best way to end pregnancy. They suggested to develop a caesarean delivery pathway, as the safer solution for the mother. Meanwhile, the anesthesiologist stressed the appropriateness of performing the procedure under general anesthesia to avoid the risks of a possible increase in intracranial pressure, that could be caused by spinal anesthesia. Finally on March, 4th, 2014 elective caesarean section was performed without incidents. A female was born 2940gr, Apgar 8/9 and pH: 7.30, without any pathology. No incidents during the period after delivery. The patient continued receiving her usual treatment. The analgesia was paracetamol and metamizol magnesium (Nolotil) because NSAIDs are contraindicated due to their risk of increasing increase blood pressure. Conclusions: There is no consensus on the most appropriate obstetric methods regarding these patients. There are few cases in the literature. In principle there is no clear contraindication to attempted vaginal delivery. The risk of bleeding from these cavernous malformations is of a 0.7 to a 1.5% of patients per annum (although it is higher for individuals with a history of clinical bleeding or that have multiple malformations). Uterine contractions and Valsalva maneuver during vaginal delivery are accompanied by a transient increase in BP and cardiac output, causing fluctuations in cerebral blood flow that may precipitate bleeding in certain tumors or vascular malformations. Although mean intracranial pressure during contractions is 20 mmHg, it can sometimes reach up to 70 mmHg. In addition, hyperventilation during birth could reduce the seizure threshold. Despite these statements seem to be obvious contraindications of vaginal delivery in patients with cerebral vascular malformations, another fact is that cavernomas represent a low-flow vascular malformation so should not implya higher risk of bleeding during childbirth. Thus there are different trends: ‘‘Robinson et al (1)’’ recommend performing a cesarean section at week 38 of gestation. ‘‘Sawin et al (2)’’ suggest that delibery, can be carried out either through vaginal way or by caesarean section. ‘‘Simonazzi G et al (3)’’ conducted a study in which 16 cases of symptomatic cavernomas were collected. Among those there were four preterm births, only one of them caused by neurological symptoms at week 30 of gestation. In nine cases the pregnancy was terminated by cesarean section, eight of which were for elective because of the vascular malformation. In conclusion there is not enough data to determine which is the safest way of delivery. Although there have been cases in the past, in which vaginal delivery have been successful the right thing so far is to individualize each case. Keywords: cavernous hypertensio

malformations,

pregnancy,

intracranial

Presenter: A. Mun˜oz Ledesma

ID 267

PECULIARITIES OF THE FETUS GROWTH RATE IN THE DYNAMICS OF PHYSIOLOGICAL PREGNANCY DEPENDING ON THE ETHNIC AFFILIATION OF PREGNANT WOMEN T. Botasheva, E. Aleksandrova, N. Ermolova, N. Palieva, & Zh. Elzhorukaeva

Rostov Scientific-Research Institute of Obstetrics and Pediatrics, Rostov-on-Don, Russia Brief Introduction: A comparative analysis of a medical and biological situation in the constituent entities of the Russian Federation according to different parameters allowed to determine that in Russia there are ethnic groups of the population, which exist at the same time and differ in morphofunctional characteristics. It is obvious that medical service and preventive treatment of high quality become possible only with the creation of regional systems of the environment and population health monitoring. The study of individual differences, which include the ethnic affiliation, is of considerable interest for reproductive physiology. In publications there are data on the irregularity of the fetus growth rate in women living in different regions of the world. Materials & Methods: With the purpose of studying the growth rate of the fetal we examined a parietal-coccygeal length of an embryo in the 1st trimester of pregnancy, growth rate of a biparietal diameter and fetal head circumference, lengths of humeral, ulnar, femoral and shin bones as well as abdominal circumference of a fetus in the 2nd - 3rd trimesters of physiological pregnancy in 80 women of Russian nationality (group 1), 76 women of Ingush nationality (group 2) and 74 women of Chechen nationality (group 3). The determination of biometric indices was performed by means of two-dimensional ultrasonic scanning on Voluson-730 ultrasonic apparatus with the sensor frequency of 2–7 Hz using fetometric standards of Hadlock and Jeanty. Clinical Cases or Summary Results: We revealed the maximum differences in the growth rate of biometric indices of the fetus depending on the ethnic affiliation in the 3rd trimester of pregnancy. The indices of biparietal diameter and fetal head circumference in the representatives of Caucasian nationalities were higher, and in women of Russian nationality they were less than 50 percentiles of the standard for these indices (p = 0.00426). The length of the femoral and shin bones in the fetuses of the women from the 2nd and 3rd groups were less than 50 percentiles of the standard (p = 0.00279), while in the women from the 1st group these indices were more than 50 percentiles (p = 0.00371). We did not reveal any significant differences in the indices of the length of humeral and ulnar bones as well as abdominal circumference. The variability of individual biometric indices (dispersion of indices) in the women of Russian nationality was considerably higher, than that in the representatives of Caucasian nationalities. Conclusions: The received results indicate the presence of statistically significant differences in the character of changes in the biometric indices of a fetus at different stages of intrauterine period of ontogenesis depending on the ethnic affiliation of pregnant women. It was typical for the representatives of Caucasian nationalities to have more apparent growth rate of the fetal head and less apparent growth rate of the lower extremities in the 2nd and 3rd trimesters of pregnancy as compared with the similar indices in women of the 1st group. These peculiarities must be taken into account in the process of ultrasonic scanning as the growth retardation of a thigh and a shin is one of the signs of skeletal dysplasias and chromosomal anomalies and the increase in the fetal head size is associated with some genetic syndromes. Therefore an ethnic aspect must be taken into account during standard ultrasonic examination of pregnant women. Keywords: Presenter: T. Botasheva

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ID 268

ID 424

THE INFLUENCE OF A FETAL GENDER ON THE INDICES OF THE BLOOD COAGULATION SYSTEM OF A MOTHER IN THE DYNAMICS OF PHYSIOLOGICAL PREGNANCY

CASE OF COMPLETE PERITONEAL HYDATIDIFORM MOLE

T. Botasheva, V. Linde, E. Kapustin, N. Palieva, & V. Guimbut

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Rostov Scientific-Research Institute of Obstetrics and Pediatrics, Rostov-on-Don, Russia Brief Introduction: The fetal gender is a genetically determined factor that influences the formation of differences in functioning of different elements of the system ‘‘mother-placenta-fetus’’. Although the fetal genders start different course of an intrauterine period and influence the pregnancy outcomes, exact mechanisms of this process remain insufficiently studied. It particularly refers to blood coagulation system of pregnant women, which is a physiological and a biochemical ‘‘mirror’’ of the majority of functional processes in a female organism. Materials & Methods: We performed a retrospective analysis of 259 coagulograms of women in the dynamics of physiological pregnancy without any pathologies of the blood-vascular system. Out of this amount 116 women had fetuses of a female gender (group 1) and 143 women had fetuses of a male gender (group 2). We determined the level of hemoglobin, hematocrit and erythrocytes as well as the erythrocyte sedimentation rate by means of the hematology analyzer ‘‘CellacF’’ MEK – 8222 J/K, Japan; we also determined the level of fibrinogen and thrombocytes, activated partial thromboplastin time, prothrombin time, thrombin time, prothrombin ratio (PR), international normalized ratio and soluble fibrin monomer complexes by means of the coagulometer ACL – 9000, USA. Clinical Cases or Summary Results: In the 1st trimester the indices of PR (p50.0114) were significantly different with the numerical values prevailing in the mothers of girls (109% and 102%). In the 2nd trimester the indices of D-dimer were significantly different: was 37% higher in the women with male fetuses (339 ng/ml and 250 ng/ml, p = 0.0013). In the 3rd trimester D-dimer were significantly different with the average values prevailing in the women with male fetuses (400 ng/ml and 300 ng/ml, p50.0005). The clotting duration by Sukharev in the boys’ mothers was almost twice longer (0.7 min. and 0.4 min); the time of the clotting start was also later in the boys’ mothers (start 3.5 min., end 4.1 min.) as compared with the girls’ mothers (start 3.1 min., end 3.5 min.). In the 3rd trimester the amount of thrombocytes in the women with male fetuses was larger (207.5  109 and 231.5  109, p50.0053). The prothrombin time was also longer in the pregnant women with male fetuses (16 sec. and 14 sec. p50.0005). Conclusions: It was revealed that in the women with male fetuses the tension of the hemostasis system was more apparent (within the norm limits) as compared with the mothers of female fetuses. The difference in the indices of the blood coagulation system depending on sexual dimorphism indicates the existence of certain differences in the functional ‘‘request’’ of the male and female fetuses to the hemostasis system of a maternal organism. Apparently, lower adaptability of boys during the intrauterine period of ontogenesis and higher probability of the development of placental dysfunction in their mothers require more tension of the coagulation system that reflects potential ‘‘system readiness’’ in the prevention of gestational hemorrhages. Keywords: Presenter: T. Botasheva

M. Bejan1 & S. Gatcan2 1 Department of Obstetrics and Gynecology, Mother and Child Institute, Chisinau, Moldova, and 2Department of Surgical Gynecology, Mother and Child Institute, Chisinau, Moldova

Brief Introduction: Ectopic hydatidiform mole is rare. N. Casian et al. reported that the incidence of hydatidiform mole is 1: 2000 childbirths in Moldova with an increased incidence of the disease in southern Moldova. Variations are caused by place of residence, especially when it includes a harmful industrial environment 1. Hassadia et al. reported that there were only three cases of complete hydatidiform mole in a series of 6708 patients diagnosed with ectopic gestational trophoblastic disease 2. Atrash et al. estimated that there are 10.9 abdominal pregnancies per 100 000 births and 9.2 abdominal pregnancies per 1000 ectopic pregnancies 3. On the other hand, ectopic hydatidiform mole has a tendency to be overdiagnosed, 4,5 and the true incidence of ectopic complete hydatidiform mole (ECHM) is unknown. Materials & Methods: A 18-year-old woman, who was hospitalized to our Institute. To confirm the diagnosis of hydatidiform mole we used human chorionic gonadotrophin and transvaginal ultrasound. With a preoperative diagnosis of ruptured ectopic pregnancy, emergency laparotomy was performed. After removal of the conceptus, histological examination showed features of complete hydatidiform mole. Clinical Cases or Summary Results: A 18-year-old woman, gravida 1, para 1, was transferred to our hospital with acute lower abdominal pain and a small amount of vaginal bleeding. Her blood pressure was 90/50 mmHg with a pulse rate of 100 b.p.m. Rebound tenderness and guarding of the lower abdomen were observed. Human chorionic gonadotrophin (hCG) level was 8000 mIU/mL, and hemoglobin concentration was 7.0 g/dL. Transvaginal ultrasound revealed an echofree space and mosaic echo pattern in the right adnexal area (Fig. 1). Her amenorrheic period was 8–9 weeks and there was no gestational sac in the uterus. With a preoperative diagnosis of ruptured ectopic pregnancy at 8–9 weeks of gestation, emergency laparotomy was performed. The Pouch of Douglas was filled with many clots containing small amounts of villous tissue. The uterus, bilateral tubes, and ovaries were intact. Following removal of villous tissue, which was infiltrating the peritoneum in the Pouch of Douglas, continuous bleeding from a defect in the peritoneum was noted and controlled. The total blood loss was 700 mL; four units of packed red blood cells were transfused. On histological examination, the conceptus showed features of complete hydatidiform mole (Fig. 2). The patient’s serum hCG titers decreased steadily and reached the normal range at 7 weeks after surgery. Her menstrual cycle resumed at 4 weeks, and her basal body temperature returned to a biphasic pattern at postoperative week 7. No additional treatment was needed and her serum hCG titers remained within the normal range during the 8-month follow-up period. Conclusions: The clinical course of this patient highlights important clinical issue: the peritoneum in the Pouch of Douglas is a possible site of ectopic complete hydatidiform mole. To our knowledge, this is the first report of ectopic complete hydatidiform mole infiltrating into the peritoneum in the Pouch of Douglas in our Institute. There are few confirmed cases of ectopic hydatidiform mole. Only 40 cases of tubal hydatidiform mole 4,6,7 and fewer cases of peritoneal hydatidiform mole have been reported in the literature 8. Tubal hydatidiform mole has a tendency to be overdiagnosed. Therefore, ectopic hydatidiform mole should be diagnosed only when strict histological criteria are applied, and immunohistochemical stain or DNA analysis should be performed as necessary. Burton et al. reported that 20 cases of suspected tubal ectopic hydatidiform mole for the period 1986 to 1996 were reviewed by two pathologists using DNA flow cytometric analysis. On review, only three cases had the

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Figure 1. Transvaginal ultrasound demonstrates mosaic echo with hypoechoic lesion in (a) the right adnexal area to (b) the Pouch of Douglas and no gestational sac in the uterus.

Figure 2. (a, b) Hematoxylin–eosin stains show scalloping villi with trophoblastic inclusion and proliferation of trophoblastic cells. Stroma is edematous with karyorrhexis of stromal cells. (c) Immunohistochemical staining shows negative results in the villous cytotrophoblasts and the stromal cells. In contrast, it shows a positive result in the intermediate trophoblast. histological features of an early complete hydatidiform mole and the other 17 cases showed no evidence of hydatidiform mole (11 of these showed features of early placentation and six showed hydropic abortion) 4. Sebire et al. reviewed 132 cases that were identified with a referral diagnosis of tubal hydatidiform mole for the period 1986– 2004, and reported that the final diagnosis was ectopic partial mole in two cases, ectopic complete mole in five cases, and ectopic hydatidiform mole (not otherwise specified) in one case 5. CortesCharry et al. determined the clinical, pathologic, immunohistochemical, and imaging characteristics of hydatidiform mole in ectopic pregnancy (HMEP) compared with intrauterine hydatidiform mole (IUHM) and reported that abdominal pain and vaginal bleeding were the most common clinical symptoms in the HMEP group, all of which were partial moles, while vaginal bleeding alone was the most common symptom in the IUHM group. They also reported that ultrasound findings of HMEP were similar to those traditionally described in nonmolar ectopic pregnancy. Therefore, histological examination is essential to confirm the diagnosis of HMEP.9 The prognosis of ectopic molar pregnancies is the same as that for other forms of gestational trophoblastic disease. 2,10 We monitored the serum hCG concentration as is done for intrauterine hydatidiform mole. Clinicians must be aware that the peritoneum in the Pouch of Douglas is a possible site of ectopic complete hydatidiform mole. Keywords: complete hydatidiform mole, peritoneal pregnancy, Pouch of Douglas, ultrasound. Presenter: Marcel Bejan

ID 310

ENDOMETRECTOMY FOR TREATMENT OF THE NON COMMUNICATING RUDIMENTARY HORN A. Incebiyik1, A. Camuzcuoglu1, N.G. Hilali1, A. Seker2, H. Camuzcuglu1, M. Vural1 1

Harran University, Faculty of Medicine, Department of Obstetrics and Gynecology, Sanliurfa, Turkey, and 2Harran University, Faculty of Medicine, Department of General Surgery, Sanliurfa, Turkey Brief Introduction: Rudimentary horn is a developmental anomaly of the uterus. The symptoms of this anomaly are dysmenorrhoea, endometriosis, infertility, and for various pregnancy complications like recurrent miscarriages, preterm labor and malpresentations. This case reports describes a new surgical technique in the management of unicornuate uterus with a non-communicating rudimentary horn in women who presented with lower abdominal pain and dysmenorrhoea. Materials & Methods: case report Clinical Cases or Summary Results: 16 years old girl admitted to our clinic with cyclic lower abdominal pain. She had begun menstruating a year ago. The pain had been episodic and colicky and was aggravated around the time of her periods, especially over recent months. On ultrasonographic examination, uterine anomaly was suspected. Lower abdominal magnetic resonance imaging has showed hematometra like cystic lesion in the right side of the uterus and a primarily unicornuate uterus with a non- communicating

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rudimentary horn, 6.5 cm in diameter, was suspected. Accompanying urinary system anomalies were excluded by ultrasound and intravenous urography. CA125 was 26.3 U/ml (normal range: 0–35) and other tumour markers were negative. With the presumptive diagnosis of the non - communicating rudimentary horn laparotomy was planned. During laparotomy, on the right side of the uterus, endometriotic cystic mass was observed and excised as endometrectomy. Since this kind of patients commonly is operated with more extensive surgery (hemi-hysterectomy) or hysterescopic septum resection we offer more definitive treatment of this disease. Both alternatives have disadvantages when compared with endometrectomy. If hemi-hysterectomy is planned, fallopian tube of one side would excised also. Conclusions: If septum resection is planned, recanalization of this thick septal region may be difficult or nonfunctioning endometrium may preserve potential future morbidities. Keywords: Dysmenorrhoea, Endometrectomy, non - communicating rudimentary horn Presenter: A. Incebiyik

ID 392

SURVEILLANCE OF INFANTS OF DIABETIC MOTHERS FROM OUR NEONATAL INTENSIVE CARE UNIT N. Ko¨ksal, _I. Varal, H. O¨zkan, O. Bag˘cı, P. Dog˘an, & M. Topcu Neonatology Department, Uludag University, Faculty of Medicine, Bursa, Turkey Brief Introduction: Prevalance of diabetes in pregnancy changes between%3–10. Eighty eight percent of these are gestational diabetes, remaining cases are pre-gestational. Pregestational diabetes are%65 type II and%35 Type I diabetes. Both gestational and pregestational diabetes are associated with increased perinatal morbitidity for infants and mothers. We aimed to identify the clinical characteristics of infants of diabetic mothers in relation with their mothers’ diabetic status.

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330 Materials & Methods: Medical records of 75 infants of diabetic mothers admitted to Uludag˘ University Medical Faculty between January 2010 – January 2014 are retrospectively inspected Clinical Cases or Summary Results: Mothers of 13 (%17.3), 10 (%13.3) and 52 (%69.3) cases had Type I, Type II and gestational diabetes, respectively. Thirty six of cases were female (%48) and 39 (%52) were male. Twenty two of cases (%30) were delivered vaginally and 53 (%70) of cases were delivered via cesarean section. Considering birth weights, 10 of cases (%13.3) were small for gestational age (SGA), 51 (%69) were AGA and 14 were (%18.7) LGA. Mean gestational age and birth weight of these infants were 34 ± 3.6 weeks and 2558 ± 1199 gr. respectively. Mean APGAR scores were 5 ± 2 and 7 ± 2 in 1. and 5. minutes. Most common morbidities were hyperbilirubinemia (42,%56), congenital heart defects (34,%45), hypoglycemia (21,%28) and hypocalcemia (24,%32). Echocardiography revealed septal hypertrophy, atrial septal defect and patent ductus arteriosus as most common heart defects. Major heart defects such as transposition of great arteries, truncus arteriosus and complete atrioventricular canal defects were detected in infants of mothers with gestational diabetes. Eleven patients (%14) had additional gastrointestinal, musculo-skeletal and genitourinary anomalies. Three of these infants had birth trauma due to difficult labor. Four (%5.4) of cases had died. Mothers of 48 (%64) cases had routine follow-up during pregnancy. Only 23 (%30) of previously diagnosed mothers were evaluated with HbA1c. Mean HbA1c levels of these mothers was 6.9 ± 1.6. Eleven of these mothers had an HbA1c level below 6.5 Conclusions:: Infants of diabetic mothers has increased risk for congenital anomalies and postnatal morbidities. High rate of congenital heart defects in gestational diabetes raises the question whether these gestational diabetes cases are in fact undiagnosed type II diabetes. Detecting and treating hyperglycemia early in pregnancy must be a goal for obstetricians in order to prevent and reduce the severity of neonatal metabolic disorders and congenital anomalies. We conclude that hyperglycemia must be detected in pregnancy as early as possible. Ideally, routine follow-up should be started and metabolic control must be achieved pregestationally. Keywords: Infants of diabetic mother, surveillance Presenter: N. Ko¨ksal

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Clinical Cases or Summary Results: The care that meet the identified needs of the child in the conquest of autonomy process are: time and space for baby, person or object that carries the paradoxical function, limits and confrontation in a balanced way between indifference and retaliation. Clinical vignettes showed how gaps in this period of development may appear in the relationship and in the context of adolescents and adults psychotherapy as a feeling of emptiness, lack of references, difficult to contain his/hers impulses, among other possibilities. It is likely that in these cases, the therapist will need to provide cares related to the period of the conquest of autonomy to help the person to constitute the gaps that remained in his or hers growth process. Conclusions: It could be interesting to investigate in future work how care that meet the needs related to the period of the conquest of autonomy can be offered by psychotherapist to help the person to establish the gaps that remained throughout his or hers growth process. To this end, a case study that reports the clinical management underpinned by these considerations and the evolution of the therapeutic process from this perspective can help reveal how elapses care of a person who reveals significant gaps in the initial stages of his or hers growth process in a Gestalt - therapy point of view. Keywords: Child Development, Personal Autonomy, Gestalt Therapy Presenter: Edna Maria Severino Peters Kahhale

ID 217

KMC AND BREASTFEEDING THE PREMATURE INFANT: EXPERIENCE AND RESULTS AT ONE YEAR OF CORRECTED AGE IN A COHORT OF 11442 INFANTS DISCHARGED HOME IN KANGAROO POSITION (2001–2013) N. Charpak1 & S. Fernandez2

ID 229

THE PROCESS OF GROWTH RELATED TO THE PERIOD OF THE CONQUEST OF AUTONOMY OF THE CHILD C. Poppa1 & E. Kahhale2 1

Pontificia Universidade Catolica de Sa˜o Paulo, Sa˜o Paulo, Brasil, and 2Pontificia Universidade Catolica de Sa˜o Paulo, Sa˜o Paulo, Brasil Brief Introduction: This presantation aims to describe through a dialogue with the theory of maturation of D. W. Winnicott, the cares that underpin the ability of the child to take ownership of his or hers experiences in their cycles of contact, to reach the opening to the dimension of play and inter-human, to constitute a permeable contact boundary and to develop his or hers ability to make creative adjustments in a Gestalt therapy perspective. It will be explained how these achievements happen when the child begins to gain his or hers independence, perceiving themselves as a person separate and independent of the maternal body. It will be illustrated by clinical vignettes as any gaps in that period of the conquest of autonomy may appear in the therapeutic context. Materials & Methods: Dialogue with the theory of maturation of D. W. Winnicott and clinical vignettes

1

Kangaroo Mother Care Program, Hospital Universitario San Ignacio, Bogota´, Colombia. Kangaroo Foundation, Bogota, Colombia, and 2Kangaroo Foundation, Bogota´, Colombia Brief Introduction: Objective: To evaluate the rate of breastfeeding and growth results at one year of corrected age in a cohort of 17004 preterm or low birth weight infants LBWI treated in our ambulatory KMC program between 2001 and 2013. Materials & Methods: Design and Methods: Prospective cohort of 17004 LBWI infants (GA 37 weeks at birth or BW52500g) discharged home in kangaroo position (KP) with periodical followup until 12 months of corrected age. Promotion of breastfeeding is part of the KMC intervention. Clinical Cases or Summary Results: Results: 17004 eligible infants (37 weeks of gestational age or weight 2500 at birth) were admitted to the ambulatory KMC program. 11.9% of them were less than 30 weeks of GA at birth, 13.7% between 31 to 32, 27.4% between 33 to 34, 32.3% between 35 to 36, and 14.7% and more than 37 weeks. 56.9% infants received exclusive breastfeeding at 40 weeks of gestational and 40.5% of infants received mix feeding at 40 weeks. At three months, 34.1% of infants were breastfed exclusively, 48.5% received mixed feeding and 17.5% received exclusive artificial feeding. Anthropometric data at 40 weeks were for weight 2906 g, height 46.9 cm and 34.6 cm for head circumference. At one year the weight was in average 8652 g, height 71.7 cm and head circumference 45.6 cm. The overall mortality was 0.8% from discharge up to one year of corrected age. Conclusions: Conclusions: Considering the beneficial effects of breast milk on digestive tolerance, nutritional quality and protection against

331

DOI: 10.3109/14767058.2014.924236

infection and the anthropometric results of this cohort, the argument to stimulate feeding preterm babies with milk from their own mother is valid. Breastfeeding the premature and/or LBWI is the cornerstone KMC nutrition strategy and one of the 3 components of the KMC method. Keywords: Breastfeeding, premature infant, Kangaroo Mother Care Presenter: S. Fernandez

required to evaluate the clinical significance and potential application of these findings. References: a). W. Walker, J. Parkhill, Fighting obesity with bacteria. Science 341, 1069–1070 (2013). b). V. K. Ridaura et al., Science 341, 1241214 (2013). Keywords: Fatty acids, Microbiota, Pregnancy, Nutrition, Infant, Lipid, Fish oil, Gut, Meconium, fetus. Presenter: Shu-Ling Chuang

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

ID 905

FATTY ACID PROFILES IN PREGNANCY AND CORD BLOOD RELATED TO MECONIUM MICROBIOTA S-L. Chuang1, Y. Wang2, E. Demertzi3, S. Willetts3, I. Talbot2, M. Johnson2, P. Pantelidis3, M. Crawford2, & E. Ogundipe2 1

Department of Neonatology, Chelsea and Westminster Hospital, London, United Kingdom, 2Imperial College London, Chelsea and Westminster Campus (Obstetrics and Gynaecology/Neonatal Unit), London, United Kingdom, and 3 Infection and Immunity Science, Imperial College Healthcare NHS Trust, London, United Kingdom Brief Introduction: Gut microbiota and early dietary exposure are critical in modulating the developing mucosal and systemic immunity. Microbial deviations in early life may have later health implications. The acquisition and development of microbial diversity in infancy is not fully understood. Maternal dietary fatty acids (FAs) have been shown to alter fetal fatty acid composition and neonatal immune responses. We investigated the effect of maternal and fetal lipid profiles on early neonatal gut colonization. Essential FAs such as arachidonic acid (AA) and docosahexaenoic acid (DHA) have been reported to be key requirements for fetal vasculogenesis and immunogenesis as they influence membrane synthesis and pliability, a major feature of the gut lining. Materials & Methods: A RCT of maternal fish oil supplementation study in high risk pregnancies was conductued at Chelsea and Westminster Hospital, a regional perinatal centre. As a secondary outcome, meconium microbiota from day 1 were analysed by culture and semiquantitative genus-specific real time polymerase chain reaction (PCR). Stool bacterial diversity to maternal FA at recruitment, delivery and cord blood FA was statistically evaluated. Clinical Cases or Summary Results: 143 stool samples from infants of enrolled mothers were analysed. Meconium samples were not sterile, with 8% Bifidobacteria spp, 4% Lactobacillus, 26% Bacteroides sp, 33% Enterococci, 40% Enterobacteriaceae and 8% Staphylococci isolated. The correlation of bacterial predominance with maternal and fetal fatty acid levels are shown (Table 1). Maternal FAs at delivery and cord FAs were closely correlated to infant microbiota. High LA and saturated lipid levels significantly correlated to a predominance of ‘bad bacteria’ whilst high AA, DHA levels appeared to confer protection against colonisation by ‘bad bacteria’ i.e. Enterobactericeae, Staph aureus and Enterococcus and these also correlated inversely with high LA/AA or LA/DHA ratio. Higher AA/DHA ratios were associated with ‘good bacteria’, Lactobaccilus and Bacteroides isolation and AA seems important in gut immunogenesis. Conclusions: This study gives preliminary evidence of neonatal gut microbiota being related to maternal fatty acid profile in early pregnancy. Optimisation of maternal nutrition may be key to influencing newborn intestinal colonisation closely correlated to early immune function and even longer term metabolic health. Fetomaternal nutritional interaction may present an early critical window for nutritional and immune programming. Further studies are

ID 946

EARLY OR DELAYED ENTERAL FEEDING FOR INFANTS WITH ABNORMAL ANTENATAL UMBILICAL ARTERY DOPPLER WAVEFORMS – A 10 YEAR RETROSPECTIVE STUDY I. Periquito1, J. Oliveira1, C. Fernandes1, M. Ferreira1, & R. Barroso1 1 Neonatology Department, Hospital Prof. Doutor Fernando Fonseca

Brief Introduction: Fetal growth restriction (FGR) is usually associated with blood flow redistribution to vital organs, in order to preserve brain growth. The reduction of blood flow to visceral organs may lead to a higher risk of gastrointestinal morbidity, including necrotizing enterocolitis. These findings have led to frequent delay in initiating enteral feeding in newborns considered to be at risk. However, some studies have shown no evidence of benefit in delaying the introduction of small volumes of enteral feeding, in FGR infants. The aim of this study was to determine the effect of early, compared to late enteral feeding on the incidence of gastrointestinal morbidity and age which full enteral feeding was established, in neonates with abnormal antenatal umbilical artery Doppler waveforms. Materials & Methods: Retrospective analysis of all neonates admitted to a level III NICU, in Portugal, between January 2004 and December 2013, with abnormal antenatal Doppler ultrasounds. Eligible criteria were: umbilical artery pulsatility index (UAPI) above the 95th percentile for gestational age, absent or reversed end diastolic flow velocity in the umbilical artery or cerebral redistribution pattern for the corresponding gestational age. Only the last measurement before birth was used for the analysis. Two groups were created: early enteral feeding (initiation  to 48h after birth) and late enteral feeding (448h after birth). Data was analyzed using the IBMÕ SPSSÕ software, and outcomes were assessed by performing a binary logistic regression with the forward Wald method for categorical variables and a stepwise linear regression for continuous variables. A p value 50.05 was considered statistically significant. Clinical Cases or Summary Results: Ninety eight infants were included, 46 infants in the early feeding group and 52 in the late feeding group. In the early feeding group the mean gestational age was 33.3 weeks, with a standard deviation (SD) of 2,8; the mean birth weight was 1473g (SD 493); 10.9% needed invasive ventilation support (IVS) and 15.2% had late onset sepsis. Human milk was the first enteral feeding in 15 cases (32.6%). In the late feeding group, the mean gestational age was 32.1 weeks (SD of 2.5), the mean birth weight was 1336g (SD 382); 15.4% needed IVS and 42.3% had late onset sepsis. Human milk was given as the first feed in 22 cases (42.3%). After adjusting for independent variables, in the binary logistic regression, there was no statistical significant difference between

332

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Stool Microbiota

Bifidobacteria

Lactobacillus

Bacteroides

Enterobacteriaceae

Enterococcus

Staphylococcus

e.g. E Coli Fatty Acid (FA)

Pearson Regression coefficient (p Value) N = 143 samples Black = Recruitment FAs; Blue = Delivery FAs; Red = Cord Blood FAs

C18:2n6 LA

0.24 (0.028)

0.43 (0.001)

C20:4n6 AA

-0.28 (0.0008)

0.24 (0.025) -0.37 (0.005)

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C20:5n3 EPA

-0.27 (0.050)

C22:6n3 DHA

-0.28 (0.039)

LA/AA ratio

0.31 (0.003)

LA/DHA ratio

0.23 (0.029)

AA/DHA ratio

0.34 (0.012)

0.60 (0.000)

0.44 (0.001)

0.41 (0.002)

Sat FAs

0.27 (0.048)

Oleic acid

C160 Palmitic

0.71 (0.001)

0.51 (0.025)

MUFAs

C16:1n7

-0.65 (0.003)

0.51 (0.027)

0.30 (0.004)

-0.66 (0.037)

-0.24 (0.030)

-0.25 (0.021)

0.23 (0.035)

0.21 (0.048)

0.39 (0.003)

0.24 (0.030)

0.38 (0.004) C180 Stearic

0.58 (0.049)

0.30 (0.032)

N6: N3 ratio

0.33 (0.014)

N6LC: N3LC

0.39 (0.003)

groups in necrotizing enterocolitis (p 0.86), septic ileus (p 0.92) and gastrointestinal surgery or perforation (p0.88). The early feeding group had a significantly lower risk of feeding intolerance (p 0.026, OR 0.198, 95% CI 0.048–0.198) The early feeding group achieved full enteral nutrition earlier than the late feeding group (mean of 11.2 vs 15.1 days, p 0.59) and the length of hospital stay was also shorter in 7.3 days (p 0.53). Conclusions: There appears to be no increase in gastrointestinal morbidity when introducing early enteral feeding (48 hours), in

-0.40 (0.003)

infants with abnormal antenatal Doppler waveforms. Early introduction of enteral feeds seems to reduce the risk of feeding intolerance. There is a trend towards less time to achieve full enteral feeding and duration of hospital stay in the early feeding group. Keywords: Enteral nutrition abnormal umbilical artery doppler waveforms Presenter: I. Periquito

333

DOI: 10.3109/14767058.2014.924236

ID 821

EVOLUTION IN THE PROFILE OF RECIPIENTS OF DONOR MILK FROM A HOSPITAL MILK BANK SINCE ITS OPENING M.V. Jime´nez Cabanillas, L. Serrano Lo´pez, L. Zamorano Bonilla, E. Martı´n A´lvarez, M. Pen˜a Caballero, & J.A. Hurtado Suazo

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Neonatology Dept. University Hospital "Virgen de las Nieves", Granada, Spain. Brief Introduction: Introduction: Breast milk (BM) is the best choice for all newborn. In preterm or sick babies, if the mother doesn’t have sufficient milk supply, pasteurized donor milk (PM) is the best alternative. The usual recipients of pasteurized milk (PM) are premature babies with birth weight under 1500g or gestational age below 32 weeks. Others recipients who might also benefit from PM are babies with intestinal resection, congestive heart failure or any condition with increased risk of necrotizing enterocolitis. Objective: To analyze if the recipients profile has changed since the implementation of a human milk bank (HMB) in the Neonatal Unit of a tertiary hospital, as well as the clinical indications of PM. Materials & Methods: Material and Methods: A descriptive research has been carried out by revising the HMB database from June 2010 to December 2013. The following variables were taken into account: gestational age (GA), birth weight (BW), time of PM reception, volume of PM received and reasons for the PM administration. Data analysis obtained from the statistical program SPSS20.0. Clinical Cases or Summary Results: Results: During the researched period, 255 newborn babies received PM in our center: 29 (2010), 75 (2011), 84 (2012), 67 (2013). The average gestational age was 310 5. Birth weight was 1575 g. Average duration of intake was 17 days. Annual stratified analysis: In 2010, the average gestational age is 31 weeks and the average birth weight is 1335g. In 2011, 31 weeks and 1657g. In 2012 31 weeks and 1657g In 2013, 31 weeks and 1688g. The indications for PM are summarized in this figure 1 highlighting the prematurity as the main variable in this period (2010–13). Enteral feeding intolerance is becoming an important indication for PM. In 15% of recipients in 2013, this was the reason for prescription. Conclusions: Conclusions: According to the present information the main reasons for giving PM have been both prematurity and low birth weight (63% of all recipients were premature babies born before 32 gestational weeks). The number of children who take advantage of donor milk has increased as the human milk bank has provided higher amounts of PM in our centre. The administering indications for PM have been also

increased, outlining the enteral feeding difficulties in moderate and late preterm babies (32–36 + 6 gestational weeks). Keywords: Presenter: M.V. Jime´nez Cabanillas

ID 783

PARENTERAL NUTRITION IN PRETERM INFANTS OF BIRTH WEIGHT 51250 G: POSSIBLE INFLUENCES ON GROWTH AND BONE STATUS G. Rizzi, P. Gaio, M. Meneghelli, A. Tessari, A. Pasinato, M. Fantinato, E. Valerio, & G. Verlato Department of Women and Children’s Health, University Hospital of Padova, Padova, Italy Brief Introduction: Preterm infants are at risk of developing not only growth retardation but also metabolic bone disease (MBD). MBD occurs in 39% of preterm infants with a birth weight 51500 g and in the long term might adversely affect linear growth and childhood height. Although non-nutritional factors could contribute to the development of growth and bone failure low nutrient intakes also play a major role. Several studies have demonstrated the safety of the early provision of higher protein and energy intakes but there are still few data on the possible influences of early nutrition on bone status. Aim: to determine whether a more aggressive nutritional regimen with earlier and higher aminoacids and energy intakes improves growth and bone status of premature infants born 51250 g. Materials & Methods: From November 2007-April 2009 67 infants with birth weight (BW) 51250 g who received late aminoacids (24–48 hours after birth) and lower non-protein energy intakes (70 Kcal/Kg/ day; first group) were compared with 64 infants (November 2010-May 2012) who received parenteral nutrition with early aminoacids (in the first 24 hours of life) and higher non-protein energy intakes (480 Kcal/ Kg/day; second group); no other differences were reported according to the local clinical practice of the Neonatal Intensive Care Unit, University Hospital of Padova. Patients with 472 hours of life, congenital infections, major congenital anomalies and metabolic disorders were excluded. We evaluated clinical, nutritional and growth parameters. Bone status was prospectively assessed with quantitative ultrasound by measuring metacarpus bone transmission time (mcBTT, us) at birth, 21 days and 36 weeks of gestational age (GA). Data are expressed as mean+/standard deviation. Significance is set at p50.05. Clinical Cases or Summary Results: No significant differences between groups were detected in demographic, clinical characteristics and bone status at birth (BW 939 +/- 256 vs 902 +/- 205, GA 28.2 +/- 2.3 vs 27.9 +/- 2.1 in the second and first group respectively). Among nutritional intakes parenteral aminoacids intake (g/Kg/ day) in the first (2.8 +/- 0.6 vs 2.4 +/- 0.6, p50.01) and in the second week of life (3.7 +/- 0.5 vs 3.2 +/- 0.5, p50.01) was significantly greater in the second group as mean energy intake (Kcal/kg/day) in the first week (70 +/- 11 vs 56 +/- 9, p50.01) and mean total energy intake in the first month of life (95+/- 13 vs 81+/- 11, p50.01). The regain of birth weight was earlier in the second group (13.1 +/- 6 vs 15.8 +/- 6.3 days, p50.05) and the days to reach a body weight of 1800 g were fewer (50.8 +/- 17.8 vs 59.7 +/- 20.9, p50.01). McBTT was significantly higher at 36 weeks GA in the second group (0.46 +/- 0.06 vs 0.40 +/0.07 us, p50.01). Furthermore energy intakes of the first week significantly positively correlated with weight (r = 0.28, p50.01) and mcBTT (r = 0.44, p50.01) at 36 weeks of GA and significantly negatively correlated with days to reach 1800 grams of weight (r = 0.39, p50.01). Total energy intakes of the first month

334 significantly positively correlated with mcBTT at 36 weeks of GA (r = 0.43, p50.01). Conclusions: A more aggressive parenteral nutrition regimen early in life could positively influence growth and bone status in premature infants. Further studies are needed to evaluate influences on long term outcomes and adult life. Keywords: preterm infants, parenteral nutrition, bone growth Presenter: Giovanna Verlato

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

ID 833

IS BREAST MILK COMPOSITION AFFECTED BY NEONATE OR MOTHER CHARACTERISTICS? E. Martin1, M. Pen˜a1, E. Nievas1, L. Zamorano1, L. Serrano-Lo´pez1, & J.A. Hurtado 1

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

ID 238

MATERNAL PRE-PREGNANCY UNDERWEIGHT AND FETAL GROWTH IN RELATION TO INSTITUTE OF MEDICINE RECOMMENDATIONS FOR GESTATIONAL WEIGHT GAIN D. Roje1, M. Jeric2, N. Medic3, M. Vulic4, & Z. Mestrovic5 1

Gynecology and Obstetric Department, Clinical Hospital Center Split, Split, Croatia, 2Department of Anatomy, School of Medicine University of Split, Split, Croatia, 3Gynecology and Obstetric Department, Clinical Hospital Center Sv. Duh, Zagreb, Croatia, 4Gynecology and Obstetric Department, Clinical Hospital Center Split, Split, Croatia, and 5Gynecology and Obstetric Department, Clinical Hospital Center Split, Split, Croatia Brief Introduction: Maternal nutritional status is one of the most important factors of fetal growth and development. Consequently, the currently increasing prevalence of underweight women worldwide has come in the focus of interest of perinatal medicine. The aim of the study was to assess the effect of low pre-pregnancy body mass index (BMI) on fetal growth. Materials & Methods: Data on 4678 pregnant women and their neonates were retrospectively analyzed. Pre-pregnancy BMI of study women was categorized according to the WHO standards. Fetal growth was assessed by birth weight and birth length, birth weight for gestational age, and ponderal index. Clinical Cases or Summary Results: Study group included 351 (7.6%) women with pregestational BMI518.5 kg/m2, while all women with pregestational BMI 18.5–25 kg/m2 (N = 3688; 78.8%) served as a control group. The mean birth weight and birth length of neonates born to underweight mothers were by 167 g and 0.8 cm lower in comparison with the neonates born to mothers of normal nutritional status, respectively (p50.001 both). The prevalence of small for gestational age (SGA) births was twofold that found in the control group of mothers of normal nutritional status (9.7% vs. 4.9%; p50.001). The inappropriately low gestational weight gain additionally increased the rate of SGA infants in the group of mothers with low pre-pregnancy BMI (21.4% vs. 10.4%; p = 0.02). Pre-pregnancy BMI category did not influence neonatal growth symmetry. Conclusions: Low maternal pregestational BMI is associated with fetal growth assessment. Improvement of the maternal nutritional status before pregnancy can increase the likelihood of perinatal outcome. Keywords: Body mass index (BMI), Underweight, Fetal growth, Small for gestational age, Ponderal index, Maternal weight gain Presenter: Damir Roje

Neontal Unit, Paediatric Dept, University Virgen de Las Nieves Hospital, Granada, Spain Brief Introduction: Recent studies on the field of evolutive biology have shown that the individual variability in breast milk composition may reflect mother or neonate characteristics. These results are focused on Trivers and Willard’s evolutive theory (1973) who advocate that natural choice may favour the inversion of the breastfeeding pattern discriminating between males and females under certain conditions (favouring daughters in times of difficulty and sons in times of excess) Objective: To prove that breast milk composition may be altered on the basis of neonate sex, mother age or number of children. Materials & Methods: Descriptive study of breast milk composition donated by mothers in a hospital breast milk bank from April 2013 to January 2014. Different variables were registered: Nutritional variables (fats, proteins, lactose, calories that donor breast milk may contain and obtained by HMA MIris); mother variables such as age; neonate variables such as sex and order of birth. Statistic programs SPSSvs 20. Clinical Cases or Summary Results: 280 breast milk donation sets performed with 79 mothers were analysed in this research. From the overall of women, 37 (46.8%) were mothers who had daughters and 42 (53.2%) had sons. It was their first child in 37 mothers. It could not be observed the correlation between mother age and fats, proteins, lactose and caloric value. In respect to the order of birth in children it has been shown that the amount of fatty acids is much higher in first borns than in each child born subsequently (p 0,027). Regarding the other variables, it could not be demonstrated this correlation. Nevertheless, it has been shown that breast milk obtained from mothers who had daughters has a much higher protein (p ¼ 0.009), lactose (p ¼ 0.055) content and caloric value (p ¼ 0.05) than the one obtained from sons. Conclusions: Breast milk composition is affected by sex and order of birth. The fatty acids that originate from mammary tissue are mobilised during lactation and their concentration diminishes with the birth of each subsequent child. Therefore the results of this research, in agreement with further recent studies, have shown nutritional differences in breast milk composition, favouring daughters Keywords: evolutive biology; breast milk composition; newborn Presenter: E. Martin

ID 258

GROWTH AND BODY COMPOSITION IN PRETERN INFANTS AT THE HOSPITAL DISCHARGE I. Belyaeva, E. Tarzyan, & V. Skvortsova 1

Department of Premature Infants, Scientific Centre of Children’s health under RAMS, Moscow, Russia, 2Department of Premature Infants, Scientific Centre of Children’s health

DOI: 10.3109/14767058.2014.924236

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

under RAMS, Moscow, Russia, and 3Department of Premature Infants, Scientific Centre of Children’s health under RAMS, Moscow, Russia Brief Introduction: Growth and body composition in preterm infants have been gaining special importance for determining their further development prognosis. Aims are to estimate nutritional status of premature infants, received different types of feeding, on basis of estimating fat (Fat mass, kg., Body fat%) and fat free (FFM, kg) mass at the hospital discharge. Materials & Methods: The study of body composition in 60 preterm infants (gestational age = 28–34 weeks, birth weight and growth are corresponded to GA), received different types of feeding: preterm formula – 36 infants (GA = 34.0 [29.0 – 36.0] weeks, weight = 2170.0 [1380.0 – 2730.0]g or human milk, which includes fortified milk – 24 infants (GA = 33.0 [28.0 – 36.0] weeks, weight = 1875.0 [1140.0 – 2500.0]g, before the hospital discharge (36 – 37 weeks of postconceptional age) by air plethysmography (PEA POD, LMi, USA). Besides it, birth weight z-score was studied, and z-score of body weight, body length and body-weight index (BWI) at the hospital discharge (WHO, ANTHRO, 2009). Clinical Cases or Summary Results: At the hospital discharge less z-scores of weight (3.92), length (3.82), and BWI (3.12) were noticed in preterm infants received human milk in comparison with patients fed by formula (2.87; 2.57; 2.30). FFM, kg was less (p50.05) in preterm infants received human milk, while fat% was higher (16.2% against 13.8%, p50.05) in patients received formula. In preterm infants received formula a positive correlation between body weight, BWI z-score, and figures of FFM, kg, Fat mass, kg, Body fat,% was found at the hospital discharge. In preterm infants received human milk group figures of growth: BWI and weight z-scores, and length and head circumference, had a positive correlation only with FFM, kg at the hospital discharge. Conclusions: Growth of preterm infants received human milk, which includes fortified milk, is connected with the growth of FFM in body composition. These infants had more optimal body composition (less Fat mass,%, and Body fat,%) in comparison with patients fed by formula. Keywords: Preterm infants, Nutrition, Body composition Presenter: I. Belyaeva

ID 801

QUALITY AND SAFETY OF HUMAN DONOR MILK IN A HOSPITAL HUMAN MILK BANK L. Zamorano Bonilla, L. Serrano Lo´pez, M. Pen˜a Caballero, V. Jimenez Cabanillas, E. Martin Alvarez, & J.A. Hurtado Suazo Neonatology Dept., Paediatric Dept., Universitary Hospital "Virgen de las Nieves", Granada, Spain.

335 Brief Introduction: Donation of breast milk is an activity as old as humanity itself. However, the current model of Milk Banks has been developed in the last century. Human Milk Banks provide pasteurized human milk from selected donors, which is considered the best choice when fresh milk form the mother is not available, specially for premature or sick babies. In Spain there are currently seven Human Milk Banks. Increasing needs of human donor milk in the Neonatal Units have arised the interest to develop attention points for donors, in hospitals where the Milk Bank is not present OBJECTIVES: To analyze the activity of the external points for donors attention of the Spanish Third Hospital Milk Bank. Assessment of quality of the process of these points. Materials & Methods: A protocol for donors attendance and reception of donor milk was designed to be used at the Hospitals collaborating with our Human Milk Bank Staff members from these centres were trained, visiting the Milk Bank and with a written protocol. A transfer system was stablished with refrigerators and temperature records along the process. The hospital milk bank is responsible for ensuring the traceability of the process. Several variables were analyzed and compared: acidity, microbiological culture and volume of pasteurized milk rejected during 2013. Acidity is a quality criteria of donor milk, which is related to its microbiological content. Applying the Dornic scale, acidity from 1 to 7 is considered adequate. Clinical Cases or Summary Results: Two points of attention for milk donors have been operating regularly since 2012. The farthest (point 2) is 160 Km from the Milk Bank and the closest (point 1) 65 Km. In 2013 the total number of active donors in Hospital Milk Bank was 109. 406 liters of donor milk were collected. The average acidity of donor milk in 2013 was 3.8  D. Analyzing the acidity of donor milk according to the point where it was received: 30 7 in the Milk Bank, 4 in point 2 and 5 in point 1. In 2013, 7% of the total volume of human milk received in the Hospital Human Milk Bank was rejected. Analyzing the percentage of rejected milk according to its origin: 4% of the volume received in the bank was not processed, 12% of the volume received from point 2 and 8% of the volume received from point 1 were discarded. This difference lead us to the revision of the storage system, transportation and adequate information for hygiene during milk collection. Conclusions: Donation of human milk is a solidarity activity with increasing presence in our society. Milk Banks should facilitate the effort of donors stablishing attention points that enable an increase in donors Procedures for donors attention, registration, storage, transportation and milk collection from attention points to the Milk Bank should preserve the security and quality. The comparison of average acidity according to the origin of milk, could be an adequate advisor in order to promote better strategies to minimize the percentage of rejected milk

336 Keywords: Quality, Hospital Human Bank Milk, Donors, Donation Human Milk Presenter: L. Zamorano Bonilla

ID 937

INFLUENCE OF THE ANTIBIOTIC TREATMENT IN THE DEVELOPMENT OF THE NEONATE FECAL MICROBIOTA M.V. Jime´nez Cabanillas

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Neonatology Dept. University Hospital "Virgen de las Nieves" Granada, Spain, Brief Introduction: The process of intestinal colonization has been related to the type of birth, type of feeding received or the use of antibiotic. The mechanisms that result in the heterogeneity of the bacterial flora in adult population are little known, there are not so many neonate studies and above all premature ones. Molecular biology techniques have allowed the advance in the stool sample analysis. Objective: Evaluating the effects that the antibiotic treatment would have in the neonatal period (administered in the first two weeks of life) over the newborn’s composition of the intestinal microbiota and its influence on other ages of the infant. Materials & Methods: Study of the prospective cohorts carried out between January 2013 and February 2014 in the Neonatal Unit of a third level hospital. 3 stool samples were collected: M1 (admission), M2 (discharge), M3 (1st month of life). It is analysed the influence of the antibiotic parenteral treatment in the first 15 days of life on the intestinal colonization of the 4 bacterial groups: Bacteroids, Clostridia, Lactobacillus and Escherichia Coli, using molecular biology techniques (qPCR). Perinatal and neonatal variables are registered. Clinical Cases or Summary Results: 27 neonates have been enrolled in the study: 15 babies have received parenteral antibiotic and 12 babies have not. The content of Lactobacillus when discharge is lower in those who have received antibiotic treatment (9.28  102 CFU/g vs 7.21  10  3 CFU/g; p ¼ 0.005). This difference is the same in a month (1.79  102 CFU/g vs 4.77  105 CFU/g; p ¼ 0.16). The influence of the antibiotic treatment over the colonization of the rest of groups studied has not been demonstrated. Conclusions: The use of antibiotic in the neonatal period has shown to have an influence on the neonate’s intestinal colonization process, provoking a decrease in the content of lactobacillus (bacterial group related to beneficial effects for the guest) after that. This difference could be levelled out in the first stages of life. Antibiotic has not altered the stool content in pathogen groups like Bacteroids, Clostridia and E. Coli. This research is considered to be the basis of future strategies in order to care these neonates. (Specially based on probiotics) Keywords: Presenter: M.V. Jime´nez Cabanillas, E. Martı´n A´lvarez, B. Garcı´a Cuerva, L. Serrano Lo´pez, M. Pen˜a Caballero, J.A. Hurtado Suazo.

ID 548

FOLIC ACID SUPPLEMENT USE IN IRELAND By S. Cawley1, L. Mullaney1, A. McKeating2, A.C. O’Higgins2, D. McCartney1 & M.J. Turner2

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437 1

School of Biological Sciences, Dublin Institute of Technology, Dublin 8, Republic of Ireland, and 2University College Dublin, Centre for Human Reproduction, Coombe Women and Infants University Hospital, Dublin 8, Republic of Ireland Brief Introduction: Neural tube defects (NTDs) are major congenital anomalies that have a profound impact on families and on health services. It is well established that up to 70% of NTD are preventable through adequate intake of folic acid (FA) peri-conceptionally. A study published this year has reviewed NTD rates nationally. This study has shown that the incidence of NTD in the Republic of Ireland appears to be increasing, rising from 0.92/1000 in 2009 to 1.17/1000 in 2011. A limitation of this national review was lack of information on FA supplements and its correlates. If Ireland is to maintain a lower rate of NTD, then up-to-date information on NTD birth rates, and dietary folate and FA supplementation in pregnancy needs to be gathered and analysed for the Irish population Materials & Methods: Women were recruited at their convenience in January 2014 after sonographic confirmation of a singleton pregnancy in the first trimester. Maternal body composition was measured using 8-electrode bioelectrical impedance analysis. A structured questionnaire about FA supplements was completed. Maternal dietary information was assessed by a research dietitian using a 4-day retrospective food diary (FD) (including two weekend days) in combination with a food frequency questionnaire (FFQ), an approach that has been previously validated against biomarker data. During this interview all reported portion sizes were fully quantified and confirmed by the research dietitian using food portion size estimation tools. The food composition database Weighed Intake Software Package (WISP, version 4.0; Tinuviel Software, Llanfechell, Anglesey, United Kingdom) was used to calculate daily energy and folate intakes. When Black’s equation for under-reporting was employed no under-reporters were found. Clinical Cases or Summary Results: Of the 65 women recruited, the mean maternal age was 30.8 (4.5) years and 33.8% (N = 22) were primagravidas. The mean maternal body mass index (BMI) was 26.6 kg/m2 ( ± 6.1), with 21.9% (N = 14) obese. Of the 22 (33.8%) women who took FA preconceptionally, only 9 (13.8%) had taken FA for the recommended 12 weeks. Once the women became pregnant, 61 (93.8%) took FA and daily compliance was excellent (60/61; 98.4%). An absolute difference in BMI was observed between those who took pre-conceptional FA and those who did not (24.6 (4.3) kg/m2 versus 27.6 (6.7) kg/m2, p = 0.06). This was not statistically significant to date, possibly as a result of insufficient statistical power in the low sample size to date. Only 22 (34%) of women were aware of the role of FA in preventing NTDs. Of the 43 women who did not take preconceptional FA, 30 (69.8%) said they did not expect to get pregnant and 10 (23.3%) said they did not think they needed FA. Of the women who completed the supervised FD (N = 63), 54% (N = 34) had a dietary folate intake less than the estimated average requirement (EAR) of 246mg/day. Dietary folate intake was unrelated to BMI. Dietary folate was unrelated to pre-conceptional FA use. None of the obese women took the recommended higher dose of FA. Conclusions: Compliance with existing guidelines to take FA supplements for 12 weeks preconceptionally remains poor. Unplanned pregnancy remains the main reason for not taking FA preconceptionally. Over one fifth of our sample were unaware that they should be taking FA before conception, suggesting that maternal knowledge regarding its importance is sub-optimal optimal. Over half of the women had an intake of dietary folate below the EAR suggesting that maternal dietary intakes of folate are also sub-optimal. If Ireland is to maintain a lower rate of NTD, then co-ordinated measures are needed in order to gather up-to-date information on birth rates of NTDs and FA use through supplements and dietary intake. The incidence if NTD are higher in obese compared to ideal weight women. The Royal College of Physicians in Ireland states that there is evidence to support the supplementation of obese women with a higher dose of FA. However results from our study suggest that

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DOI: 10.3109/14767058.2014.924236

compliance with this recommendation is poor as none of the obese women took a FA supplement of more than 400ug. Preconceptional FA use was poorer in more overweight women versus normal weight women. Obesity rates in Ireland are rising as is the prevalence of NTD. Given that NTD are higher in obese compared with normal weight women, it is important to further investigate FA use in this group. Keywords: Presenter: Shona Cawley

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ID 906

DIETARY PATTERNS ARE REFLECTED IN THE METABOLIC PROFILES OF SECOND TRIMESTER MATERNAL BLOOD AND AMNIOTIC FLUID C. Fotakis1, M. Fotiou2, A.C. Chatziioannou3, P. Zoumpoulakis1, A.M. Michaelidou2, G. Menexes4, N. Athanasiadou5, C. Kyrkou2, F. Tsakoumaki2, H. Gika6, A.P. Athanasiadis5, G. Theodoridis3, C.G. Biliaderis2, & B.C. Tarlatzis5 1 Institute of Biology, Medicinal Chemistry and Biotechnology, National Hellenic Research Foundation, Athens, Greece, 2 Department of Food Science & Technology, School of Agriculture, Aristotle University of Thessaloniki, Thessaloniki, Greece, 3Laboratory of Analytical Chemistry, Department of Chemistry, Aristotle University of Thessaloniki, Thessaloniki, Greece, 4Department of Field Crops and Ecology, School of Agriculture, Aristotle University of Thessaloniki, Thessaloniki, Greece, 51st Department of Obstetrics & Gynecology, Aristotle University of Thessaloniki, Thessaloniki, Greece, and 6 Department of Chemical Engineering, Aristotle University of Thessaloniki, Thessaloniki, Greece

Brief Introduction: The studies of metabolite concentration in maternal blood and fetal fluids have increased our understanding of the interaction between maternal and fetal metabolism. However, no study to date has investigated the role of maternal habitual diet on human amniotic fluid composition. In this direction, metabolomics could offer a valuable analytical tool, as it determines a range of small metabolites in biological fluids that, in combination with multivariate statistical analysis, can expand our knowledge on amniotic fluid biochemistry. Thus, this study aspires to bridge habitual diet and NMR metabolic profiles of maternal serum and amniotic fluid, retrieved in the second trimester of pregnancy. Materials & Methods: Serum and amniotic fluid samples were obtained from 27 women that underwent amniocentesis for prenatal diagnosis – between the 18th and 24th gestational week. Dietary assessment was carried out by registered dietician using a

food frequency questionnaire and 24-h recall. Hierarchical Cluster Analysis was used to identify dietary patterns. A holistic metabolomics approach was employed using a 600MHz Varian NMR spectrometer and CPMG pulse sequence to suppress protein signals of the untreated samples. All NMR spectra were phase and baseline corrected, reduced into spectral buckets of 0.001 ppm and aligned using the MestReNova software. The SIMCA-P 13.0 software was used to implement Principal Component Analysis (PCA) and Orthogonal Partial Least Squares Discriminant Analysis (OPLS-DA). Clinical Cases or Summary Results: Cluster analysis identified 3 dietary patterns on the basis of the energy contribution of 31 different food groups. Cluster 1 had a significantly higher energy contribution from white bread and rice-pasta. Cluster 2 was characterized by a higher energy contribution from red meat and red meat products, full fat milk/yogurt, eggs, potatoes, sugars - preserves, and fruit juices. Cluster 3 had higher contribution from whole-wheat bread, fruits, low fat milk/yogurt, nuts and legumes. In this context, chemometrics were implemented on the CPMG NMR spectral data. At first, PCA was applied to explore the data sets and monitor the clustering of the samples depending on the intake of specific food groups. Then, application of supervised OPLS-DA technique and derived S-line plots accomplished to elicit information that allowed the identification of metabolites associated with different dietary patterns. Specifically, maternal serum and the corresponding amniotic fluid samples from Cluster 2 were, mainly, characterized by the metabolites a-glucose, valine, alanine, acetic, lipids, glutamine/glutamate, leucine, carnitine, creatinine and ethanolamine. Conclusions: The results of the present study verify the scalability of NMR metabolomics to elucidate the role of maternal nutrition on fetal growth and development. Further investing in ‘‘metabolomics’’ shows promise in the quest to unravel the biochemical pathways underlying fetal development and gain insight on the potential impact of maternal nutritional management on fetal growth regulation. Keywords: amniotic fluid, maternal blood, maternal dietary patterns, NMR metabolomics Presenter: A.P. Athanasiadis

ID 677

IMPORTANCE OF VITAMIN A FOR LUNG MATURATION AND FUNCTION HK Biesalski Food Security Center and Dept. Biological Chemistry and Nutrition, University Stuttgart-Hohenheim; Garbenstrass 30n D 70593 Stuttgart Brief Introduction: During pregnancy and the breastfeeding period the need for vitamin A and b-carotene is increased. On average, intake should be one third higher during pregnancy and during the breastfeeding period it should be 0.7 mg/day higher than for nonpregnant or non-breastfeeding women. Based on studies in Germany and the US inadequate vitamin A supply (30% below recommendation) is evident in females in 45–65%. Due to the importance of the

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338 vitamin for lung development and maturation, sufficient intake should be especially ensured during the second and third pregnancy trimesters.In different studies it was shown that the risk of Bronchopulmonary Dysplasia in preterm infants showing insufficient vitamin A supply is significantly increased. Materials & Methods: The study was conducted as a cross sectional pilot study. 23 women with single conception pregnancy within short birthrates defined as second delivery within 24 months were recruited consecutively at the Universita¨tsfrauenklinik Ulm between September 03 and August 04. Additionaly 6 women with gemini birth were enrolled to the study. Participants were healthy with absence of chronic disease during pregnancy (gestational diabetics), aged between 20 and 40, normal delivery, full term gestational period (436 + 0) and smoking less than 5 cigarettes/day. Women were eligible to be enrolled to the study if prenatal no supplementation with42000 IE/day vitamin A nor with b-carotene 42 mg/day occurred. Clinical Cases or Summary Results: The frequency distribution of maternal plasma retinol showed that 27.5% of the study population had levels below 1.4 mmol/L which can be taken as a boarderline deficiency near to the deficiency range (51.05 mmol/L) according to WHO (REF). In one case the retinol level was in a clear vitamin A deficiency range (0.66 mmol/L).It becomes evident, that in cases of multiparous birth mean values of retinol and b-carotene were significantly lower in samples of maternal plasma (p50.05) and colostrum (p50.0001) for retinol. Mean cord blood concentration was 0.51 umol which was significantly lower than the borderline to inadequacy of 0.7umol. There is no clear consensus on the ‘‘cut-off’’ concentration for vitamin A deficiency in cord blood. Levels below 0.35 and 0.7mmol/L are discussed. Taking 0.35 mmol/L as cut off levels, 31% of newborn showed levels below. Conclusions: Despite a good scioeconomic status vitamin A supply in pregenant females was below the recommended intake and with consequences for the supply of the developing child. There is clear evidence from human and animal studies that the lung needs vitamin A during the last 3–4 weeks prior delivery for adequate maturation (e.g. surfactant protein synthesis). The active metabolite of vitamin A, retinoic acid, which controls gene expression of a couple of important proteins in the lung, is delivered from specific vitamin A stores in the lung. If vitamin A stores in the embryonic lungs are not formed at the beginning of the last trimester the formation of retinoic acid in the lung might be inadequate. This raises the question how vitamin A status might be improved in particular in cases of preterm birth. In animal experiments we tested different supply routes (parenteral, inhalation) to elucidate how we can increase the vitamin A concentration in the lung. Whether this might be an approach for humans needs to be discussed. Keywords: Vitamin A, Lung maturation, Supplementation Presenter: HK Biesalski

ID 391

ROLE OF C-REACTIVE PROTEIN, PROCALCITONIN AND SERUM AMILOID A AS EARLY DETECTING MARKERS OF TOTAL PARENTERAL NUTRITION INDUCED CHOLESTASIS IN PREMATURE INFANTS

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

majo¨r complications of TPN and is reported to be encountered as frequent as%18–67 of babies receving TPN for more than two weeks. The aim of this study is to determine the role of serial measurements of C-reactive protein (CRP), procalcitonin (PCT) and serum amyloid A (SAA) to detect TPN induced cholestasis in premature infants. Materials & Methods:: A total of 131 babies born before 34 weeks of gestation were enrolled in this prospective study. All babies received TPN contaning 3 gr/kg/day of %10 amino acid solution (Primene) and 1 gr/kg/day of %20 olive oil based lipid (Clinoliec) solution in first day of life. Protein was increased to 4 gr/kg/day in babies with birth weight 51000 gr. and to 3.5 gr/kg/day in babies 51500 gr. Lipid dose was increased 1gr/kg per day to a maximum of 3 gr/kg/day. CRP, PCT and SAA levels in addition to routine biochemical work-up were measured in days 0,3,7,14 and 21. Infants who received TPN less than two weeks and who had sepsis and necrotizing enterocolitis were excluded from the study. Finally a total of 85 cases were evaluated. Fourteen of these patients developed cholestasis, remaining 71 babies were evaluated as non-cholestatic group. Clinical Cases or Summary Results: Mean birth weight and gestational age of cases were 1226 ± 329 gr. and 29.4 ± 1.8 weeks respectively. There was no significant difference for gestational age between groups, but birth weight of cholestasis group was significantly lower compared to non-cholestasis group. Inıtiation of enteral feeding was found to be achieved in 6.5 ± 1.1 days in cholestasis group, this was 4.1 ± 0.4 days for non-cholestasis group and difference was statistically significant. CRP levels in 7., 14. and 21. days in cholestasis and non-cholestasis group were 1.75 ± 0.5, 1.65 ± 0.6, 1.8 ± 0.5 mg/dl and 1.47 ± 0.29, 1.44 ± 0.29 ve 1.22 ± 0.24 mg/dl respectively. Mean CRP levels were higher in babies with cholestasis but difference was not statistically significant. PCT levels in 0,3,7. days were similar between groups. Mean PCT in 14. day was 5.5 ± 3.2 ng/ml in cholestasis group and 1.1 ± 0.42 ng/ml in non-cholestasis group.This five fold increase of PCT in cholestasis group was statistically significant (p = 0.01). PCT in 21. Day was also higher in cholestasis group (0.95 ± 0.3 mg/dl vs. 0.62 ± 0.15 mg/dl) but difference was not significant. SAA levels were similar between groups in 0,3,7,14. days. SAA in 21. day was found to be higher in cholestasis patients (8.6 ± 3.1 mg/dl vs. 4.1 ± 1.2) go¨re yakla¸sık Difference was not statsitically significant. Correlation analysis revealed no association between congugated bilirubin leves and inflammatory markers in 0,3,7,14,21. days. Conclusions: Increased levels of CRP and cytokine levels is reported to be associated with TPN induced cholestasis in premature babies. PCT is shown to be an effective marker for detecting bacterial infection and to estimate mortality in adults with liver disease. However, there is no study investigating the relationship between PCT, SAA and liver pathologies in neonates. To our knowledge, this is the first study to investigate the role of PCT and SAA in neonates with TPN induced cholestasis. We found that CRP levels tend to be higher in cholestatic patients. PCT levels in 14. day and SAA levels in 21. day were higher in cholestasis group. We conclude that elevation of these markers in neonates receiving TPN can alert clinicians for developing cholestasis and may prevent unnecessary use of antibiotics in otherwise healty neonates. Keywords: Premature, TPN, cholestasis Presenter: N. Ko¨ksal

ID 533

N. Ko¨ksal, O. Bag˘cı, H. O¨zkan, P. Dog˘an, & _I. Varal

DIETARY PATTERNS IN PREGNANCY AND ASSOCIATIONS WITH SOCIO-DEMOGRAPHIC AND LIFESTYLE FACTORS

Neonatology Department, Uludag˘ University, Faculty of Medicine, Bursa, Turkey

N. Darani Zad1, M. Vaezi2, H. Esmaeli3, M.A. Hamedani4, & S. Khalatbari5

Brief Introduction: Total parenteral nutrition (TPN) is widely applied for prolong periods of time in prematu¨re infants. Cholestasis is one of the

1

Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang,

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DOI: 10.3109/14767058.2014.924236

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Malaysia, 2Department of Health, Islamic Azad UniversityTehran Medical Branch, Tehran, Iran, 3Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, 4Islamic Azad University-Tehran, Tehran, Iran, and 5 Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia Brief Introduction: To assess the dietary patterns in the third trimester of pregnancy among women living in Tehran, Iran, and their association with socio-demographic and lifestyle factors. Materials & Methods: In a cross-sectional study, 800 pregnant subjects aged between 20–40 years were selected. Socio-demographic, lifestyle characteristics and dietary intake were assessed using a food frequency questionnaire. To determine the dietary patterns, factor analysis was carried out, and to assess the association between socio-demographic and lifestyle factors to dietary patterns, analysis of covariance was performed. Clinical Cases or Summary Results: Three dietary patterns were found. These patterns were labeled as ‘vegetable and poultry’, ‘western’ and ‘mixed’. In this study, increased parity (b = 0.33, p50.01), and those with primary education (b = 0.30, p50.05) presented lower adherence to the ‘vegetable and poultry’ pattern, compared to decreased parity and those with a university degree. Participant with more physical activity had more likely to follow the ‘vegetable and poultry’ pattern. There was a positive association with increasing age (b = 0.28, p50.05), and non-smokers 9(before pregnancy)(b = 0.59 p50.05), and those with less physical activity (b = 0.81, p50.001) were associated with the ‘western’ pattern. Patients who had a higher income were more likely to have the ‘mixed’ pattern. Conclusions: We found socio-demographic and lifestyle factors of pregnant women were different according to the dietary patterns type. ‘Vegetable and poultry’ pattern includes healthier foods, but further studies are necessary to confirm the benefits of this pattern. Keywords: Dietary pattern, lifestyle, socio-demography Presenter: Nasrin Darani Zad

ID 209

MAC/HC RATIO:A SIMPLE AND INEXPENSIVE TOOL TO EVALUATE NEONATAL NUTRITION D. Bhat1, & R. Soni2 1

Department of Paediatrics, Dayanand Medical College, Ludhiana, Punjab, India, and 2Department of Social and Preventive Medicine, Dayanand Medical College, Ludhiana, Punjab, India Brief Introduction: Each neonate has a unique pattern of growth.Anthropometry is useful and the most practical method to assess growth and physical development.Birth weight has been used traditionally as critical determinant for future growth and development of an infant.Since 80% of deliveries occur in community setting in India and there is paucity of accurate weighing scales in these areas, there is an urgent need to have a suitable, cheap and acceptable method of identifying LBW infants.Mid upper arm to head circumference ratio(MAC/HC) is a simple procedure for evaluating nutritional status of newborns. Materials & Methods: The present study was conducted on all the consecutive newborn babies delivered in a tertiary care hospital in north India. This was a prospective study conducted over one year period. These babies were subjected to various anthropometric measurements like head circumference(HC), mid upper arm circumference(MAC), mid thigh circumference(MTC), birth weight etc between 24–48 hours of life.The data thus obtained was analysed with various statistical methods.

Clinical Cases or Summary Results: In present study total of 700 newborn infants were included and subjected to various anthropometric measurements.Out of these newborn babies,232 were low birth weight(33.1%).Regression analysis of MAC/HC ratio with birth weight showed a statistically significant correlation.On analysis of sensitivity, specificity, positive and negative predictive value for each anthropometric variable, MAC/HC ratio had the highest predictive power on basis of highest sensitivity and specificity product. Conclusions: MAC/HC ratio correlated highly with birth weight and could be used as a simple, practical and inexpensive alternative to birth weight for assessing nutritional status of newborns in a resource restricted country like India. Keywords: newborn, nutrition, head circumference, mid upper arm circumference Presenter: Deepak Bhat

ID 517

NUTRITIONAL STATUS OF PREMATURE INFANTS FED BY BREAST MILK V. Skvortsova1, T. Borovick1, I. Belayeva1, E. Tarzian1, T. Garankina1, & S. Gribakin2 1

Research Center of Children’s Health, Moscow, Russian Federation, and 2Russian Medical Academy of Postgraduate Education, Moscow, Russian Federation Brief Introduction: To evaluate a nutritional status of premature babies fed by breast milk (BM). Materials & Methods: 24 premature babies were observed. 1st group consists of 12 babies with gestational age below 34 weeks, body weight 1790 g (1140–1840 g) who received BM + Breast milk fortifier (with protein content + 1.4 g per 100 ml BM). 2nd group consists of 12 babies born after 34 weeks of gestation with body weight 1920 g (1895–2500 g) fed by non-fortified BM. At the age of 7–10 days and 1 month biochemical parameters were checked in all infants including urea level, creatinin, prealbumin, transferrin by means of automatic biochemical analyser Unicell DxC800 (Beckman Coulter, USA) and ceruloplasmin by means of automatic immunochemical analyser Immage (Beckman Coulter, USA). Investigation of tissues composition (Fat mass, per kg, Body fat,%, and FFM, kg) was done at the end of the study by means of air pletismography. Clinical Cases or Summary Results: Results: Average daily weight gain was 12.4 g/kg/day. In the 1st group the body weight increased up to 2210 g (2114–2248 g), in the 2nd group up to 2307 g (2097–2510 g). In patients of the 1st group all biochemical parameters had a tendency to decrease, i.e. urea level decreased from 1.3 mmol/L (0.8– 0.25) to 1.05 mmol/L (0.75–1.2) and prealbimin level decreased from 102.0 mg/l (93.0–114.0) to 81.0 mg/l (65.5–98.5). Creatinin level was statistically significantly decreased (p50.05). In the 2nd group ceruloplasmin and transferrin levels in serum were stable, urea level had a tendency to increase from 1.2 mmol/L (0.9 – 1.95) up to 1.45 mmol/L (1.05–3.0) as well as prealbimin from 71.0 mg/l (68.5– 88.0) to 87.5 mg/l (74.5–101.0). Body tissues composition of all patients revealed that FFM was 2.08 kg (1.95–2.25). Fat mass – 0.30 kg (0.27–0.37) and body fat 13.8% (11.4–16.6). There was a positive correlation of body mass to FFM, kg r = 0.848, and fat mass, kg r = 0.576. Conclusions: Physical development of premature babies fed by both fortified and non-fortified BM does not reach the intrauterine growth parameters. We detected the lower indexes of protein metabolism especially in infants with gestational age below 34 weeks fed by fortified BM. Optimal content of fat mass in this case is an indication of insufficient quantity of FFM. It shows the necessity of BM fortification for babies below 34 weeks of gestation and probably for more mature infants with the counting of growth velocity.

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Keywords: Nutritional status, premature infants, breast milk

ID 294

Presenter: V.Skvortsova

MICRONUTRIENT SUPPLEMENTATION IN PRECONCEPTIONAL PERIOD AND THE PREGNANCY ASSOCIATED WITH LOW BIRTH WEIGHT

ID 751

FACTORS INFLUENCING BREAST FEEDING LENGTH IN PRETERM INFANTS 1

2

3

I. Belyaeva , M. Rtischeva , L. Namazova-Baranova , & M. Cheremisina

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1

Scientific Centre of Children’s Health under RAMS, Moscow, Russia, 2Scientific Centre of Children’s Health under RAMS, Moscow, Russia, Scientific Centre of Children’s Health under RAMS, Moscow, Russia, and 4Scientific Centre of Children’s Health under RAMS, Moscow, Russia Brief Introduction: The new adopted criteria of live birth highlight the current healthcare problem of developing recommendations on nutrition and feeding of premature infants. Clinical studies demonstrated that breast milk is an easily digestible source of nourishment with well-balanced composition. However, lack of awareness about possibility and necessity of premature infants’ breastfeeding (BF) leads to unreasonably early introduction of supplemental feeding. The aim is to examine the attitude of premature infants’ mothers to the process of breastfeeding to create of necessary conditions for the domination of lactation. Materials & Methods: 84 mothers (25–39 years old) of premature infants (gestational age 26–38 weeks) at the 2nd stage of developmental care in the first months after having a baby. Methods: interviews, conversations, observation, history analysis, technique of Hospital Anxiety and Depression Scale (HADS), adapted BF questionnaire (based on IFPS II). Clinical Cases or Summary Results: The factors that have negative and positive effects on mother’s attitude to breastfeeding were found. Negative: 1) External circumstances of quitting BF – 92%; 2) Poor awareness about the benefits and potentials of BF – 67%; 3) Mother’s emotional and personal traits – 35%; 4) Specifics of the social situation – 20%; 5) Physical discomfort when feeding and pumping milk – 15%. Positive: 1) Positive emotions in the process of breastfeeding – 93%; 2) Need for maternal self-fulfilment – 76%; 3) Support by medical personnel – 68%; 4) Family support and previous experience of BF – 57%. Conclusions: To support and improve the prevalence of BF among mothers of premature babies it’s necessary to realise package of measures aiming at the increase of awareness and improvement of their emotional state in the first months after having a baby. Widescale questioning of mothers at the 2nd stage of developmental care will identify risk factors for early giving up on BF. Analysis of the positive and negative factor ratio, that determines mother’s attitude to BF, creates conditions for increasing motivation to breastfeed a baby and maintain lactation and facilitates the provision of targeted medical and psychological care. Keywords: Preterm infnats; Breastfeeding; Human milk, Nutrition Presenter: I. Belyaeva

E. Borra`s Bentanachs1, N. Martinez Coso2, S. Capdevila Bert3, V. Cortesao Trevesset4, & M.C. Roig Garcia5 1

Midwife. Hospital Universitari Arnau de Vilanova de Lleida, Spain, 2Nurse. Hospital Universitari Arnau de Vilanova de Lleida, Spain, 3Midwife. Hospital Universitari Arnau de Vilanova de Lleida, Spain, and 4Midwife Student. Hospital Nostra Senyora de Brief Introduction: According to the etiology we can classify the fetuses under gestational weight (UGW) into several groups:  Constitutional PEG (80–85%). Without structural alterations, normal amniotic fluid, Doppler of the umbilical artery and normal speed of normal growth.  PEG anomalous (5–10%). With genetic abnormalities, structural or secondary to infection  Uterine growth restricted (CIR) (10–15%). Placental alterations identified by Doppler abnormal umbilical artery or reduction of the growth rate. A CIR is refers to a poor growth of intrauterine fetus, the fetus weighs less than 90% of other babies of the same gestational age. Several studies relate the supplementation with micronutrients, vitamins, minerals in the pregnancy and the weight of the newly born. Materials & Methods: A literature review was done in the Spanish Society of Gynecology and Obstetrics (SEGO), the Spanish Society of Neonatology (SEN), World Health Organization (OMS) and the databases: Pubmed, Medline, Cochrane . . . Clinical Cases or Summary Results: - There is the relationship of a supplement intake of vitamins and minerals in the periconceptional period and preconceptional and the lower risk of low birth weight (PEG). – The multiple micronutrient supplementation during pregnancy in developing countries, it is observed that there is a significant reduction of the PEG in a 9% and is only maintained the PEG in women with a body mass index (BMI) 422 kg/m2. – In studies where it has carried out a systematic review of randomised controlled trials reiterated that supplementation of multiple micronutrient deficiencies in developing countries is more effective than the iron and folic acid supplements to reduce the risk of low birth weight or PEG. – A randomised controlled trial in rural areas of Burkina Faso which is considering prenatal supplementation with micronutrients multiple has shown that newborn infants have a slightly higher weight (31gr) with respect to mothers who have not taken prenatal supplementation. – A study has been made with double-blind randomized, controlled in Xin, managing a micronutrient supplementation in pregnancy and is observed as a result that the administration of iron, folic acid and other prenatal micronutrient supplementation does not affect neonatal outcomes. – In our country in the preconceptional period, three months before and in the first trimester of pregnancy, women take folic acid and iodine. The folic acid to prevent spina bifida and the iodine to prevent mental retardation and deterioration of the motor powers. Conclusions: The risk factors in the mother that can contribute to a PEG include: medical illnesses, infections, substance abuse, drugs and nutritional status. The low weight of the mother before the pregnancy or the little weight gain and malnutrition during pregnancy is related to the low birth weight. It is also recommended that the consumption of foods rich in folic acid. In Catalonia, he specified that they be used preparations

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containing only folat and not multivitamin by the risk of overdosage with fat soluble vitamins. Supplementation with folic acid perinatal, the need for prophylaxis of additional prenatal iron with or without other micronutrients remains uncertain according to studies. In developing countries has been shown that making maternal nutritional interventions has improved perinatal outcomes. On the other hand, in developed countries has not demonstrated a significant change in weight of the newborn at birth. Keywords: Pregnancy, underweight, newborn, micronutrients. Presenter: Maria Elena Borra`s Bentanachs

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ID 724

VARIATIONS IN GLUCOSE AND WEIGHT BY NUTRITIONAL ROUTES DURING 1ST WEEKS OF LIFE IN HIGH-RISK NEWBORNS Y.M. Ahn1, Y.H. Jun2, N.H. Kim3, E.Y. Lee4, M.Y. Kwak5, & M. Sohn6 1

Department of Nursing, Inha University, Incheon, Korea, Department of Pediatrics, Inha University, Incheon, Korea, 3 Department of Nursing, Inha University, Incheon, Korea, 4 Department of Nursing, Inha University, Incheon, Korea, and 5 Department of Nursing, Inha University, Incheon, Korea 2

Brief Introduction: High-risk newborns undergo a critical course of extra-uterine adaptation for cardiopulmonary stabilization, thermoregulation, and sensory incorporation to stimuli, etc. As well, they experiences physiologic weight loss possibly more than 10% percent of the birth weight which could be worsen due to high-risk conditions such as prematurity, requiring tremendous nutritional and metabolic energy during first week of life. To meet nutrition and energy need, oral or gastrointestinal (OGI) route for feeding is encouraged as long as tolerated, while parenteral (P) route has exclusive benefits for those who have little ability for OGI. Either OGI or P route, blood glucose and weight variation needs to be closely monitored during 1st week of life in high-risk newborns. Materials & Methods: A prospective study was conducted with 48 Korean high-risk newborns (female = 20) who were hospitalized at least one week of life immediately after birth. Independent variable was nutritional route; OGI or P, while the blood glucose (mg/dl) and weight variations (g) as dependent variables. The hospital IRB approved the study and variables were collected daily bases (day1, day2, day3, day5, day7) after obtaining informed consent from parents of newborns. The mean gestation was 33.6 weeks at birth with 2106.0 g and 7.7 for weight and 5 minute Apgar score, respectively. The main problems at birth was prematurity (72.9%), TTN (9.1%), meconinum aspiration (5.6%), distress (5.6%), etc. Clinical Cases or Summary Results: There was no difference in birth weight (2205 g versus 2148 g), gestation at birth (34.2 weeks versus 33.6 weeks), 5 minute Apgar score (8.0 versus 7.6), glucose (87.3 mg/ dl versus 88.6 mg/dl), and weight at study day (2159 g versus 2141 g) in newborns between OGI route and P route. Glucose (F = 40.243, p = 0.000) and weight difference (F = 3.753, p = 0.054) between birth and the study day showed significant variations during 1st week of life; however there is no difference in glucose (F = 0.225, p = 0.636) and weight difference (F = 0.010, p = 0.919) between OGI group and P. A significant interaction observed between 1st week of life and types of route (OGI or P) for glucose (F = 6.860, p = 0.009); while no interaction in weight difference (F = 1.172, p = 0.280). Conclusions: The findings suggest that glucose level may fluctuate by nutritional routes regardless of stable weight variations. Keywords: high-risk newborns, nutrition, glucose, weight Presenter: Youngmee Ahn

ID 350

CARNITIN EFFECT ON SERUM CHOLESTEROL AND TRIGLYCEID LEVEL DURING TPN IN PRETERM NEONATES A.S. Farhat, A. Mohamadzade, G.H. Firozi3, & M. Rezaie4 1 Assistant professor of neonatology Neonatal research center, Faculty of medicine, Mashhad University of Medical Sciences, Mashhad, IRAN, 2professor of neonatology Neonatal research center, Faculty of medicine, Mashhad University of Medical Sciences, Mas

Brief Introduction: Parenteraly fed preterm neonates are to be at risk for carnitine deficiency. Carnitine deficiency results in limitation of intralipid utilization that increases plasma lipid levels.thus we designed to study the carnitin effect on serum cholesterol and triglyceid level during TPN in preterm neonates. Materials & Methods: In our study, 58 premature neonates with BW 52500 gr, 29 neonates in carnitine supplemented group (BW = 1233 ± 311 gr, GA = 31.3 ± 2.9 wk) and 29 neonates in control group (BW = 1245 ± 287gr, GA = 30.3 ± 1.7wk) were studied. Both groups received PN consist of 12 gr/kg/d glucose, 2.5 gr/kg/d intralipid and amino-infusion. Oral feeding started as standard protocol. 25 mg/kg/d oral carnitine was given to carnitine supplemented group up to 7th day of age. Plasma levels of triglyceride and cholesterol were measured at 2nd and 7th days of birth. Infants’ weight were measured at birth and 7th day of birth and compared. Clinical Cases or Summary Results:: Plasma levels of triglyceride and cholesterol at the end of study were significantly greater than before initiation of PN in both groups (p50.006, p50.002). Although plasma levels of triglyceride and cholesterol in both groups after initiation of PN were significantly higher, yet were in normal range. Both groups had weight loss and each either didn’t regain to birth weight (p = 0.001, p = 0.001). Conclusions: We concluded that with this amount of IL infusion at short period, carnitine supplementation in this dose does not have effects on plasma levels of triglyceride, cholesterol and on weighting and is not advisable Keywords: newborn, carnitine, parenteral feeding Presenter: Ahmadshah Farhat

ID 537

ASSOCIATION BETWEEN PRE PREGNANCY BODY MASS INDEX AND FIRST TRIMESTER VITAMIN D N. Darani Zad1, M. Vaezi2, H. Esmaeli3, M.A. Hamedani4, & S. Khalatbari5 1

Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia, 2Department of Health, Islamic Azad University-Tehran Medical Branch,Tehran,Iran, 3Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia, 4Department of science, Islamic Azad UniversityTehran,Iran, and 5Department of Nutrition and Dietetics, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia Brief Introduction: Vitamin D deficiency during pregnancy has important health implications for the mother and infant. The aim of

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the present study was assess the effect of prepregnancy BMI on 25–hydroxyvitamin D [25(OH) D] concentrations. Materials & Methods: One hundred and eighty women aged between 19- 39 year, in a first trimester of pregnancy were enrolled serially from a referring university hospital in Tehran. Serum 25(OH) D was measured at the first trimester. The normal range for serum 25(OH) D was 25–125nmol/L (10–50 ng/mL). Spearman rank correlation coefficient was used to test for correlations between prepregnancy BMI and serum 25 (OH) D levels. Clinical Cases or Summary Results: Mean maternal serum 25(OH)D was 21.4 + 1.34nmol/L. The prevalence of hypovitaminosis [25(OH) D  25 nmol/L] was 62.4%. In this study half of the participant had BMI430 kg/m2 and the others had BMI30kg/m2 and 24.4% BMI530 kg/m2had vitamin D deficiency. Hypovitaminosis D was independently associated with conception of dairy, eggs, fish5twice a week. There was no significant association between vitamin D deficiencies, parity, gravity, age was seen. There was a moderate, negative correlation between pre pregnancy BMI and serum 25(OH) D in first trimester (r = 0.38; p50.001). Conclusions: These findings support the need to balance prepregnancy weigh to decrease the risk of mother and infant health complications and Higher-dose supplementation is needed to improve maternal and neonatal vitamin D nutriture.

collected using the Willett Food Frequency Questionnaire in the first trimester. Maternal height and weight were measured in the first trimester. BMI was calculated and women were classified as obese (BMI430kg/m2). GDM was diagnosed using a 75g 2 hour glucose tolerance test between 24 and 28 weeks gestation. Clinical Cases or Summary Results: 78 obese women were included in the final analysis. The mean age was 29.6 ± 5.9 years, mean weight was 93.8 ± 14.1 kg and mean BMI was 35.0 ± 4.8 kg/m2. Total energy intake was 1848.5 kcal. Total percentage energy from protein, fat, carbohydrate and non-milk extrinsic sugars (NMES) was 17.6, 26.9, 47.7, and 6.3% respectively. 31 women (40%) developed GDM. Anthropometric and nutrient intake differences between GDM and non-GDM women are shown in table 1. There was no difference in macronutrient intake between GDM and non-GDM women. Conclusions: Our findings suggest that nutrient intake in early pregnancy is not predictive of GDM risk. Macronutrient intake may influence GDM incidence over the long term and my influence glucose control subsequent to the development of GDM. However, the relatively short duration of a single pregnancy may not allow time for diet to affect the risk for GDM. The focus may need to be on reducing obesity prevalence among young women of childbearing age.

Keywords: pre pregnancy, hypovitaminosis, first trimester, vitamin D

Keywords: gestational diabetes, macronutrients, obesity

Presenter: Nasrin Darani Zad

Presenter: L. Mullaney

ID 545

ID 166

MACRONUTRIENT INTAKE AND GESTATIONAL DIABETES IN OBESE WOMEN

THE EFFECT OF SYMBIOTICS ON SERUM CYTOKINE LEVELS OF VERY LOW BIRTH WEIGHT NEONATES

L. Mullaney, A. O’Higgins, S. Cawley, A. Doolan, D. McCartney, & M.J. Turner

O. Serce1, D. Benzer1, T. Gursoy1, E. Aktas Cetin2, G. Karatekin1, & F. Ovali1

School of Biological Sciences, Dublin Institute of Technology, Dublin 8, Republic of Ireland

1

Brief Introduction: The incidence of gestational diabetes mellitus (GDM) in women who are obese is greater than in women who are not obese. Women with GDM are at increased risk of developing Type 2 diabetes in later life. Increased dietary fat and decreased carbohydrate intake during pregnancy has been linked with increased risk for the development of GDM. However other studies suggest that carbohydrate intake or carbohydrate quality during pregnancy is not associated with the risk of developing GDM. The aim of this study was to investigate any association between maternal macronutrient intake in obese women in early pregnancy and the development of GDM. Materials & Methods: Women were recruited after sonographic confirmation of a singleton pregnancy in the first trimester as part of the Body Composition in Pregnancy Study. Dietary information was Table 1. GDM vs non-GDM women GDM (n = 31) 1

Age (years) Parity2 Weight (kg)1 Height (cm)1 BMI(kg/m2) 1 Energy (Kcal)2 % energy from protein2 % energy from fat2 % energy from carbohydrate2 % energy from NMES 1

27.9 1 93.7 163.7 34.9 1857 17.4 27.0 49.5 6.3

6.1 1 16.3 6.7 5.1 1375 3.5 6.9 10.0 6.8

Non-GDM (n = 47) 30.7 1 93.8 165.3 35.0 1840 18.6 26.9 46.0 6.1

mean, standard deviation 2median, interquartile range

5.6 4 12.6 5.2 4.6 1014 5.0 6.0 9.0 3.7

p 0.05 0.48 0.98 0.98 0.91 0.63 0.06 0.66 0.06 0.72

Neonatology Unit, Zeynep Kamil Maternity and Child Health Education and Training Hospital, Istanbul, Turkey, and 2 Department of Immunology, Istanbul University, Institute of Experimental Medicine (DETAE), Istanbul, Turkey Brief Introduction: Symbiotics have immunmodulatory effects via proand anti-inflammatory cytocines. So, the efficacy of symbiotic combination on the immun mechanisms related with necrotizing enterocolitis (NEC) of very low birth weight neonates was investigated in this study. Materials & Methods: The infants (32 GWs, 1500 g) were randomly assigned either to receive symbiotic preparation (NBL Probiotic ATP, ½ sachet every 12 hours) (study group) or placebo (distiled water) (control group). Blood samples were obtained at postnatal 0 ± 2.days, 14 ± 2 days and 28 ± 2. days. Serum cytokine levels (IFN-g, IL-5, IL-10, IL-17A) were mesured by ELISA method. Clinical Cases or Summary Results: In terms of birth weight [1230 + 262 g ve 1266 + 228 g, p = 0.15], gestational age [29.8 + 2.3 wks vs. 30.1 + 2.03 wks, p = 0.32] and delivery by caesarian section [N = 25 (89.3%) vs. N = 24 (%96), p = 0.61] were not different between control (N = 28) and study group (N = 25). Breast milk ratio was 80% in both groups. While 3 neonates have severe NEC in control group; it was not observed in the study group (p = 0.23). When cytokine levels were compared between groups, the only significant difference was observed at IFN-g levels measured at 28 ± 2. days [7 (6–7.8) vs. 9 (7–12) pg/ml, p = 0.01). When the course of cytokine levels was investigated, the significant decrease was determined at IL-5 (p = 0.005) and IL-10 (p = 0.014) serum levels measured at 14 ± 2. days and 28 ± 2. days in the study group. Conclusions: Pre- and pro-biyotik combination can potentially reduce the incidence of NEC in very low birth weight neonates.

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Keywords: Cytokine; necrotizing enterocolitis; simbiotic; very low birth weight Presenter: T. Gursoy

ID 640

PROBLEM OF OBESITY AMONG PREGNANT WOMEN IN POLAND

NECROTIZING ENTEROCOLITIS ALMOST DISAPEARING AFTER NEW FEEDING PROTOCOL WITHOUT AND WITH PROBIOTIC ADDITION T. Sa´nchez-Tamayo1,2, G. Espinosa Ferna´ndez1, & E. Salguero Garcı´a1

J. Marzec, N. Banas´, & K. Skrzyn´ska Gynaecology and Obstetrics Dept., Medical University of Silesia in Katowice, Poland

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ID 461

1

Brief Introduction: Nowadays, obesity is a permanently increasing health and social problem. It is estimated that the issue concerns almost 10–20% of pregnant women. Obesity in obstetrics is considered as a risk factor for complications of pregnancy, delivery and the postpartum period. Also, the growth of weight of a pregnant woman has the same significance for optimal fetal development as the weight before fertilization. The aim of the study was to investigate an influence of excessive body mass growth during pregnancy on a way of delivery, body mass of a newborn and assessment of a newborn in Apgar scale; investigation of nutritional habits of pregnant women and awareness of an influence of maternal obesity on an occurrence of many complications during pregnancy, labour and puerperium. Materials & Methods: A group of 580 women at age 20–41 took part in a self-prepared survey. Results were analyzed by the STATISTICA. Clinical Cases or Summary Results: Obesity was identified in 180 women (average BMI = 34.5), overweight in 190 (average BMI = 29), while 210 women had correct body weight (average BMI = 22.8). Average age of surveyed was 29.16; average height 166.02cm. Caesarean section was performed more often with obese women (38.75%). In that group an average weight of a newborn baby was 355g higher than in a group with correct weight. Keeping to a diet before pregnancy was declared by 28% of questioned. Obese women consumed sweet beverages and juices a few times a day (84%), and fast-food meals a few times a week (54%). Conclusions: Caesarean section was performed more often with obese women. Average weight of a newborn was higher in this group. What is more, the number of babies that had some health problems was larger among obese mothers. Women with obesity were hardly ever on a diet before pregnancy. They rarely paid attention to the kind and energy value of nutrition. Keywords: obesity; nutrition; pregnancy

UGC Neonatologı´a, Hospital Regional de Ma´laga (Carlos Haya), Ma´laga, Spain, and 2Pediatric department, Ma´laga University, Ma´laga, Spain. Brief Introduction: In 2009 and 2011 in our hospital there was an unexpected increase in necrotizing enterocolitis(NEC). To check whether our nutrition policy was involved, we drew up clinical practice guidelines (CPG) and an standaridized protocol about enteral feeding in VLBW infants. One year after we added to the protocol the sistematic use of probiotics. Materials & Methods: Before-After study. Our unit prospectively gathers several items from newborns under 1500 g that are afterward registered in a multicenter database. For this study we set the percentaje of NEC in the previous years against two later periods: the first year after the introduction of the new feeding protocol, without probiotics (may 2012-april 2013), and a second one with sistematic adittion of probiotics (july 2013-February 2014). The main points of the feeding protocol are: predominant use of mother milk or donated human milk from the beginning, cautious increases in feedings, no feeding if bowel isquemia was suspected, and restricted use of omeprazol to active gastrointestinal bleeding. The probiotic we use is a mixture of lactobacillus acidophilus and Lactobacillus biffidus. As posible confunding factors, since 2011we have been limiting the medical treatment of PDA and delaying its beginning. Clinical Cases or Summary Results: See table1 Conclusions: These CPG aim to help physicians in their decision making. The protocolized application of well-proven measurements reduces the variation in clinical practice and improves results. The new protocol of feeding has been asociated to a remarcable decrease in NEC. After the later addition of probiotics this low rate of NEC has manteined. Focal perforation continues being a problem and does not seem to be reduced with the feeding regimen or the use of probiotics. Keywords: necrotizing enterocolitis; clinical practice guidelines; focal perforation; prevention; very low birth weight neweborn

Presenter: Joanna Marzec

Presenter: Toma´s Sa´nchez Tamayo

Table 1. PDA, focal perforation, NEC and Survival from 2008.

Medical PDA treatment Focal perforation** NEC  2–3 Survival

2008*

2009

2010

2011

GPC-New Feeding protocol

*

After probiotics

56/182 (31%) 1/182 (0.5%) 17/182 (9%) 84%

77/165 (47%) 11/165 (6%) 18/165 (11%) 81.5%

91/176 (52%) 6/176 (3%) 20/176 (11%) 85%

73/158 (46%) 8/158 (5.10%) 18/158 (11.5%) 84.00%

47/138 (40%) 3/118 (2.5%) 1/118 (1%) 91.30%

N.S. P = 0.02 P50.001 N.S.

43/99 (43%) 5/99 (5%) 1/99 (1%) 88%

*In 2008 we used indomethacin prophylaxis in ventilated preterm babies51000 g without weight restriction. From 2009, we left this practice and began to use ibuprofen for PDA treatment. **Most of focal perforations happened after medical treatment of PDA

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ID 324

META-ANALYSIS OF LOW BIRTHWEIGHT (LBW), IN MEXICO.2000–2014 J.A. Gutierrez Padilla, H. Gutierrez Gonzalez, L.C. Zepeda Romero, R. Martinez Veronica, & L. Avalos Huizar

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Hospital Civil De Guadalajara "Faa" Guadalajara, Mexico Pediatric Div., University Of Guadalajara Brief Introduction: Low birth weight (LBW) is considered a major determinant of morbidity and mortality, and disability in infancy and childhood. It also has a long-term impact on the evolution of health during adulthood. In Mexico, l(LBW) is considered a major determinant of morbidity and mortality, and disability in infancy and childhood, and also has a long term impact on the evolution of health during adulthood. We require a better understanding of the causes of low birth weight in Mexico and more accurate estimates of the incidence of LBW, in addition to sharing of international data and effective prevention measures related to this problem that can be applied in every region of the country, as well as improving access to effective obstetric and neonatal care. Materials & Methods: The data included in Mexican scientific reportsshow that, in addition to its impact on infant mortality, LBW has been associated with higher odds of infection, malnutrition and disability in childhood, including cerebral palsy, mental disabilities and problems associated with behavior and learning in infancy. Children who survive a LBW have a higher incidence of disease, delays in cognitive development and malnutrition a meta-analysis refers to methods that focus on contrasting and combining results from different studies of lowbirth weight in Mexico, in the hope of identifying patterns among study results, sources of disagreement among those results, or other interesting relationships that may come to light in the context of multiple studies. Clinical Cases or Summary Results: Most Mexican women of childbearing age have not had schooling beyond elementary education, and 60% belong to groups in adverse socioeconomic conditions; 1 in 6 pregnancies occurs in teenage mothers, of whom half are unemployed or underemployed. Their social condition is Most Mexican women of child-bearing age have not had schooling beyond elementary education, and 60% belong to groups in adverse socioeconomic conditions; 1 in 6 pregnancies occurs in teenage mothers, of whom half are unemployed or underemployed. Their social condition is characterized by high stress due to increased levels of violence and financial insecurity, as well as poor access to health services. Children who survive a LBW have a higher incidence of disease, delays in cognitive development and malnutrition. There is also evidence that LBW or its determinants are associated with increased

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

susceptibility to diabetes, heart disease and other chronic health problems in the future. The heterogeneity among Mexico’s diverse population groups means that the findings related to measures undertaken in one population group may not apply equally across the country; therefore, it is necessary to conduct studies that take into account the specific geographical, racial, cultural, social and economic context of each region and ethnic or social group.(4) characterized by high stress due to increased levels of violence and financial insecurity, as well as poor access to health services. Conclusions: The heterogeneity among Mexico’s diverse population groups means that the findings related to measures undertaken in one population group may not apply equally across the country; therefore, it is necessary to conduct studies that take into account the specific geographical, racial, cultural, social and economic context of each region and ethnic or social group.(4) In the case of Mexico, we believe that these results provide a starting point in the search for better indicators and paradigms to assess the actual situation of Low Birth Weight among the Mexican population and define other causes of LBW, such as social condition, reproductive health, an increase in the number of women addicted to substances like alcohol, tobacco and illegal drugs, among urban, suburban, rural and indigenous population Keywords: mexico lowbirth weight Presenter: Gutierrez Padilla Jose Alfonso

ID 708

THE PROMOTION OF BREESTFEEDING IN CHINESE WOMEN IN A UNIVERSITY HOSPITAL IN MILAN E. Grossi, MD1, P. Pileri, MD1, L. Pogliani, MD2, A. Moscatiello, MD2, P. Antonazzo, MD1, G. Zuccotti, MD2, I. Cetin, MD1 & E. Goggi, MD3 1

Unit of Obstetrics and Gynecology, University of Milan, Hospital L.Sacco, Milan, Italy, 2Unit of Pediatrics, University of Milan, Hospital L.Sacco, Milan, Italy, and 3Health Director of University Hospital L. Sacco, Milan Brief Introduction: The University Hospital Luigi Sacco, together with ASL Milano, has subscribed to the UNICEF and WHO Baby Friendly Hospital Initiative (BFHI), supporting the good practice for encouraging breastfeeding. In 2013, out of 1199 childbirths, 7,6% were from Chinese mothers. This ethnic group has a low rate of breastfeeding due to social and cultural reasons. In addition, supporting and promoting breastfeeding among these patients is particularly difficult due to language difficulties. In 2013 we implemented the BFHI good practices in the Chinese outpatient clinic. Here, we show the positive effects of promoting and supporting breastfeeding according to the good practice of the Baby Friendly Hospital Initiative on Chinese women breastfeeding rates. Materials & Methods: Our study was an observational study comparing breastfeeding rates in Chinese women delivering in our Hospital before and after the implementation of BFHI good practices. Chinese pregnant patients were seen throughout gestation in and outpatient clinic by an obstetrician and a Chinese mediator, both trained in breastfeeding promotion by the BFHI course. They were regularly informed about the benefits of breastfeeding and all were provided informative documents in Chinese language. After delivery brestfeeding was monitored through:  delivery room registries.  Excel files recording clinical and epidemiological data, especially neonatal features, rooming-in and breastfeeding rates and

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different types of milk formulas, although the risk of complications among such groups was not determined. A sub-group was established to compare and analyze NNs born pre-term and at full term; a positive correlation was found in the group of NNs born at full term. Conclusions: The benefits of ready-to-use formulas over powdered formulas used in the nutritional medical course of NNs in the intensive care unit are not yet clear, although significant differences were observed. Therefore, it is recommended that more studies be conducted in order to determine such advantages. Keywords: Presenter: Gutierrez Padilla Jose Alfonso

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ID 544

breastfeeding post discharge rates among Physiological (PHY) and Pathological (PAT) neonates  Monitoring with a check list of pediatric and obstetrical discharge documents. Clinical Cases or Summary Results: Table 1 presents results about breastfeeding rates in Chinese women comparing data obtained in 2012 and in 2013, before and after BFHI good practice implementation. Conclusions: These results demonstrate a significant improvement in breastfeeding among Chinese pregnant women thanks to an active and widespread promotion and support of breastfeeding by clinicians and mediators with aid of informative papers, according to the BFHI good practice. We believe that the first reason of breastfeeding desertion or not starting breastfeeding is mother’s desire. Explaining the importance of this choice throughout pregnancy and supporting mothers after delivery is essential. Keywords: Breastfeeding, Chinese. Presenter: E. Grossi

ID 325

CLINICAL COURSE OF NEONATES FED IN THE NICU WITH READYTO-USE FORMULA Gutierrez Padilla Jose Alfonso Hospital Civil de Guadalajara Fray Atonio Alcalde, Centro Universitario de Ciencias de la Salud, Universidad De Guadalajara Brief Introduction: Neonatal nutritional support is the most important issue related to survival in the intensive care unit. The milk of the infant’s own mother is the cornerstone in this survival process; nevertheless, there are situations when it is not available. In the 1990’s, ready-to-use formulas were introduced in order to be used as an additional resource. Objective: To compare the benefits of ready-to-use formulas and powdered formulas used in neonatal nutritional support. Materials & Methods: Descriptive longitudinal study, including 2893 neonates (NNs) of the intensive care unit, over a 7 year period; the sample was divided into two groups: prior to 2005, NNs fed with powdered milk formula and after 2005, NNs fed with ready-to-use milk formulas and assessing the existence of gastrointestinal complications. The statistical analysis was conducted using the SSPS 18 program. Clinical Cases or Summary Results: 2893 NNs were included, of which 69% were male and 31% female; 67.5% of all NNs had a preterm birth. A significant difference was found with regard to the existence of gastrointestinal complications when comparing the use of the two

EARLY PREGNANCY AND POSTPARTUM DIET QUALITY AND INFANT WEIGHT L. Mullaney, A. Doolan, A. O’Higgins, M. Sheridan-Pereira, D. McCartney, & M.J. Turner School of Biological Sciences, Dublin Institute of Technology, Dublin 8, Republic of Ireland Brief Introduction: Maternal nutritional intake and breastfeeding may programme fetal development. The aim of this study was to investigate the association between maternal diet quality in early pregnancy, maternal diet quality at four months postpartum, and breastfeeding, with infant birth weight and infant weight at four months. Materials & Methods: Women were recruited after sonographic confirmation of a singleton pregnancy in the first trimester. Maternal dietary quality was collected in the first trimester and at 4 months postpartum using an online Dietary Assessment Tool (DAT). Infant birth-weight was measured within 24 hours of delivery, and was measured again at 4 months of age. Women were asked at 4 months postpartum whether they breastfed from this latest pregnancy and whether they were themselves breastfed. Breastfeeding was defined as any breastfeeding from birth. Clinical Cases or Summary Results: There were 301 women recruited with a mean age of 30.6 ± 5.8 years. The mean BMI of the sample was 25.5 ± 5.7 kg/m2, with 15.3% (N = 46) obese. Maternal diet quality at 4 months and breastfeeding was not associated with infant weight at 4 months. 101 women (33.6%) also had diet quality scores in early pregnancy which was not associated with infant birth weight or infant weight at 4 months. Women who breastfed their infants had a better diet quality at 4 months compared to women who didn’t breastfed (p  0.001). Women who were themselves breastfed had a better diet quality at 4 months then women who were not breastfed (p = 0.002). Conclusions: Socio-demographic factors may be associated with breastfeeding rates and maternal diet quality. Keywords: Diet quality, breastfeeding, weight, pregnancy Presenter: Laura Mullaney

ID 862

FOOD PROTEIN INDUCED ENTEROCOLITIS SYNDROME (FPIES): EARLY DIAGNOSIS AND FAVORABLE OUTCOME L. Di Luca1, V. Nardi1, A. Mareri1, M. Maresca1, M. Saccomandi1, C. Di Natale2, G. Nigro1, & S. Di Fabio2

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1

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Pediatric Unit, Maternal-Infant Department, San Salvatore Hospital, University of L’Aquila, L’Aquila, Italy, and 2Neonatal Intensive Care Unit, Maternal-Infant Department, San Salvatore Hospital, L’Aquila, Italy Brief Introduction: Food Protein Induced Enterocolitis Syndrome (FPIES) is a non-IgE-mediated disorder caused by gastrointestinal hypersensitivity to specific proteins like cow’s milk, soy and rice. Symptoms typically begin in the first month of life, and few cases have been reported to occur at birth after prenatal sensitization. Materials & Methods: Following tests has been performed: complete blood count, coagulation function tests, immunological and metabolic investigation, blood and urine colture, screening for congenital infections, food-specific IgE antibody and skin prick test to b-lactoglobulin, a-lactalbumin and casein. Clinical Cases or Summary Results: A full-term (39 W + 3 d) baby boy was referred to our neonatal department on day 6 because of persistent vomiting, dehydration, lethargy and bloody diarrhea. No abnormalities during the gestational period were noted in either the patient and his mother. The baby boy was exclusively breast-fed with no maternal dietary restriction. Physical examination on admission revealed pallor, lethargy, dehydration (410% of the birth weight lost in the last 3 days), tachycardia, hypotension (MAP 38 mmHg) and refusal of milk. An intravenous line was placed and total parenteral nutrition was immediately started. Laboratory data showed peripheral eosinophilia and fecal eosinophils; other blood tests, including CRP and coagulation function tests, showed normal results. No evidence of congenital or acquired infections. Urine, blood and stool cultures proved negative. After 3 days on total parenteral nutrition symptomatology improved, and breast milk was given on day 5. After 6 days the baby developed again vomiting, lethargy, diarrhea and atopic dermatitis (AD). All the tests for food-specific IgE antibody and skin prick test to b-lactoglobulin, a-lactalbumin and casein and metabolic screening were negative. A special milk without lactose was initially followed by improvement but 8 days later he presented again recurrent vomiting and hematochezia. FPIES was suspected and an aminoacid formula feeding was given. The symptoms gradually improved and within 5 days his body weight began to increase. A 3 month follow-up showed good growth without vomiting, diarrhea or AD. Conclusions: FPIES is frequently misdiagnosed at the initial presentation with infections, sepsis, metabolic disorders and surgical abdominal emergencies. Early diagnosis is essential for a favorable outcome. Keywords:

Keywords: Infant formula, growth, probiotic, safety Presenter: M. Mitra

ID 375

Presenter: L. Di Luca

ID 313

SAFETY AND TOLERANCE OF INFANT FORMULAS CONTAINING PROBIOTICS IN INDIA: A MULTICENTER RANDOMIZED CONTROLLED TRIAL 1

establish safety of probiotics in South Asia. This study was conducted to evaluate the safety and tolerance of starter infant formulas containing probiotics Lactobacillus reuteri (L. reuteri DSM17938) or Bifidobacterium lactis (B. lactis) in India. Materials & Methods: In this prospective, non-inferiority, multi-center, randomized, double blinded clinical trial study, healthy full term infants received study formulas containing either probiotics L. reuteri DSM17938 (Group 1, n = 92) or B. lactis (Group 2, n = 92) or a control formula (Group 3, n = 95) from 2 weeks to 6 months of age. A group of exclusively breast-fed infants (n = 100) was included for reference. The primary objective was to assess non-inferiority in weight gain. Secondary objectives included assessment of weight for Z-score, length, BMI, head circumference and their corresponding WHO Z-scores from birth to 12 months. Digestive tolerance and adverse events were evaluated until 12 months of age. Clinical Cases or Summary Results: In the randomized groups, 93% of infants (93% in Group 1, 92% in Group 2, and 94% in Group 3) completed their 6 months visit and 91% (92% in Group 1, 90% in Group 2, and 93% in Group 3) completed the study up to 12 months. In the reference (breast-fed) group, 96% of the infants completed the 6-month visit and 95% completed the 12 months visit. Both the probiotic supplemented formula groups, Group 1 and Group 2 met the non-inferiority margin of -3 g/day compared with Group 3. The mean (SD) weight gain (g/day) was 22.73 (5.47), 20.93 (5.42) and 21.73 (5.42) for Group 1, 2, and 3 respectively. Secondary growth outcomes including WHO Z-scores were found to be similar between the randomized groups at 12 months of age. There were no statistically significant differences with respect to serious and non-serious adverse events among any of the study groups. In addition, in a subset of infants (n = 100, Group 1[n = 24], Group 2 [n = 25], Group 3 [n = 21], Breastfed [n = 30]) at 4.5 months of age, significantly higher Lactobacilli counts were observed in the L. reuteri DSM17938 formula group. Conclusions: Infants fed formula containing probiotics L. reuteri DSM17938 or B. lactis have similar rate in weight gain compared with those fed a control formula, or those who are breast-fed. The formulas containing probiotics were well tolerated and safe. The study did find some benefit in gut colonization in the L. reuteri DSM17938 group but this was not consistent across the other groups.

2

3

4

5

M. Mitra , E. Adarsh , A. Narang , R. Agrawal , U. Vaidya , & S. Ganguly6 1

Institute of Child Health Kolkata, India, 2Rajarajeswari Medical College & Hospital Bangalore, India, 3Chaitanya Hospital Chandigarh, India, 4Dolphin Hospital & Research Foundation Indore, India, 5K.E.M. Hospital Pune, India, and 6 Nestle India Ltd. Gurga Brief Introduction: Several studies have documented safety of probiotics in infant formula; however, there is lack of data to

THE USE OF A MULTIVITAMIN SUPPLEMENT, DHA AND FOLIC ACID AS WELL AS HEALTH PROMOTING AWARENESS OF PREGNANT WOMEN IN POLAND K. Kus´mierska-Urban, K. Rytlewski, D. Ochrem, I. Kaim, & H. Huras University Hospital, Department of Obstetrics and Perinatology, Cracow, Poland Brief Introduction: Although the benefits of the supplementation of Omega-3 acids during pregnancy are known and has been shown in many studies it seems that many of them are still waiting to be discovered. Among beneficial impact of DHA supplementation during pregnancy these must be mentioned: the reduced risk of the preterm delivery and prolonged gestation, the increased birth weight. Some studies show the reduction of the gestational diabetes. From the biochemical point of view the Omega-3 and -6 acids are essential in the proper development of the nervous system at the cellular level, resulting also in proper cognitive function. The available reports are

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DOI: 10.3109/14767058.2014.924236

not consistent, because on the one hand some of them negate the benefits described above, on the other hand has not been established optimal daily dose Materials & Methods: The aim of this study was to estimate the amount of women supplementing the multivitamin medicaments during pregnancy. The data was collected after giving birth with the usage of a questionnaire among women of the Department of Obstetrics and Perinatology in Cracow. The additional part of the questionnaire was related to smoking cigarettes during pregnancy. Other data, including the education and marital status, age and BMI, a place of living and the history of previous pregnancies, were also analyzed. Clinical Cases or Summary Results: In the analyzed database 97% of pregnant women applied multivitamin supplements during pregnancy and 44% of them did not used DHA acid. Among pregnant women who applied DHA acid over 79% planned the pregnancy and 70% used folic acid before pregnancy (range 4 weeks- 4 years), while those who did not supply DHA 61% planned the pregnancy with 53% the preconceptional usage of folic acid. The time of usage of multivitamin was also different between the groups. More than 25% of pregnant women admitted active or passive smoking. No difference was noted between the birth weight or the time of delivery between the groups. Conclusions: Although the knowledge about the beneficial effects DHA acid seems to be insufficient, the need for folic acid is quite well understood. most of the women declared planning the pregnancy, but only a part of them used vitamin supplement before conception. The high rate of the exposure to the cigarette smoking proves the need for expanding public education about the harmful effects of tobacco on fetus and a mother herself. The general situation needs to be improved for a better mother and a family preparing for the pregnancy. Keywords: pregnancy, DHA Presenter: Katarzyna Kus´mierska-Urban

ID 071

INTRODUCTION OF COMPLEMENTARY FOODS AND LATER WEIGHT AND EATING BEHAVIOR: THE ROLE OF A BABYLED WEANING APPROACH A. Brown1 & M. Lee2 1

Department of Public Health and Policy Studies, and Department of Psychology, Swansea University UK

2

Brief Introduction: Nutrition during infancy may have a long-term impact upon weight gain and eating style. Breastfeeding and a later introduction of solid foods have both been shown to be protective against obesity. How infants are introduced to solid foods may also be important. Traditionally, infants are introduced to solid foods via spoon-feeding of purees. However, an alternate approach known as baby-led weaning advocates allowing infants to self-feed foods in their whole form. Proponents of the baby-led weaning method suggest this may promote healthy eating styles, but evidence surrounding the method and its impact is sparse. Materials & Methods: The aim of the current study was to thus to compare child eating behaviour at 18–24 months between infants weaned using a traditional weaning approach and those weaned using a baby-led weaning style.Two hundred ninety-eight mothers with an infant aged 18–24 months completed a longitudinal, selfreport questionnaire. In Phase One, mothers with an infant aged 6–12 months reported breastfeeding duration, timing of solid foods, weaning style (baby-led or standard) and maternal control, measured

using the Child Feeding Questionnaire. At 18–24 months, postpartum mothers completed a follow-up questionnaire examining child eating style (satiety-responsiveness, food-responsiveness, fussiness, enjoyment of food) and reported child weight. Clinical Cases or Summary Results: Infants weaned using a baby-led approach were significantly more satiety-responsive and less likely to be overweight compared with those weaned using a standard approach. This was independent of breastfeeding duration, timing of introduction to complementary foods, infant birth weight, maternal demographic background and maternal control. Baby-led infants were also less likely to be rated as fussy eaters but lower levels of maternal control explained this. Conclusions: A baby-led weaning approach may therefore encourage greater satiety-responsiveness, lower fussy eating and healthy weight-gain trajectories in infants. Potentially, allowing the infant to self-feed enables the infant to be in greater control of their intake and may also lead to longer meal durations, both of which may promote positive appetite control. Additional explanations might include post ingestive learning, a wider variety of flavours and participation in family meal times, which encourage a healthier relationship with food. However, the limitations of a self-report, correlational study with self-selecting participants are noted. Data also needs to explore whether these differences remain into later childhood. Further research using a more rigorous design is needed given the increasing numbers of parents choosing to follow this approach in the UK. Keywords: Complementary foods, eating behaviour, obesity Presenter: Amy Brown

ID 444

PERFORMANCE OF A NEXT GENERATION PLGF 1–2-3 ASSAY T. Hanses & T. Korpima¨ki PerkinElmer, Inc., Turku, Finland Brief Introduction: Placental growth factor (PlGF) is an angiogenic growth factor that plays a role in placental development. PlGF has been shown to be a discriminating biochemical marker for preeclampsia. PlGF has also been shown to be a biochemical marker for Down’s syndrome, and inclusion of PlGF in Down’s syndrome biochemical screening can improve screen performance. We have developed a new DELFIAÕ Xpress PlGF 1–2-3 TM assay (6007–0030) to address the need for sensitive PlGF measurement. The objective of this study was to verify the analytical performance of the PlGF 1–2-3 assayTM on the PerkinElmerÕ DELFIAÕ XpressTM instrument. A comparison to the published performance of another commercially available PlGF kit and system was also done. Materials & Methods: The limit of detection (LoD) was determined in accordance with Clinical and Laboratory Standards Institute (CLSI) guideline EP17-A2. Ten separate runs of six replicates per each of the five LoD-samples were performed over five operating days. Two kit lots and two DELFIAÕ XpressTM instruments were used for the analysis. Assay precision and limit of quantitation were determined based on the recommendations of CLSI guideline EP5-A2. Twelve serum samples and five controls were analyzed during 23 operating days in 45 runs with four replicates per sample using three kit lots and three DELFIAÕ XpressTM instruments. For comparison purposes, published PlGF results were obtained from a poster entitled ‘‘P. Caruhel, N. Guerin, G. Demirdjian, C. Renoult and F. Vandevelde: Development and validation of a new highly sensitive automated PlGF assay, using BRAHMS KRYPTORÕ compact Plus’’ (Fetal Medicine Foundation course in London 1–2 Dec 2012, Thermo ScientificÕ ). These experiments were reported to be performed according to CLSI EP5A2 by using 21 pools of serum samples and three controls that were

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measured during 20 days in 40 runs using three reagent lots and four B.R.A.H.M.S.Õ KRYPTORTM Compact PLUS instruments. Clinical Cases or Summary Results: The LoD of the DELFIAÕ XpressTM PlGF 1–2-3TM kit was 1.9 pg/mL (vs. 3.6 pg/mL with the published KRYPTORTM results), the LoQ was 3.3 pg/mL (vs. 6.9 pg/mL with the published KRYPTORTM results) and the total assay variation (interassay) was 13% at 5 pg/mL, 10% at 10 pg/mL, 6% at 30 pg/ml level and 5% at 100 pg/mL level. The reported inter-assay variation of the published KRYPTORTM results is 420% at 5 pg/mL, 14% at 10 pg/mL, 6% at 30 pg/mL and 4% at 100 pg/mL. Conclusions: In experiments performed according to CLSI guidelines, the next generation PlGF 1–2-3TM (6007–0030) assay optimized for the DELFIAÕ XpressTM instrument was more sensitive (lower LoD and LoQ) than the published B.R.A.H.M.S.Õ KRYPTORTM PlGF results. Furthermore, the DELFIAÕ XpressTM PlGF 1–2-3TM kit showed better precision at PlGF concentrations below 30 pg/mL. The increased sensitivity and precision of the DELFIAÕ XpressTM PlGF 1–2-3TM assay are a benefit when analyzing samples taken during the first trimester, when the clinically relevant PlGF concentration is very low. For example, at gestational week 11, about half of such samples are expected to contain 530 pg/mL. Keywords: DELFIA, DELFIA Xpress, PlGF, pre-eclampsia, preeclampsia Presenter: Tuija Hanses

ID 254

ORTHOSTATIC SHIFTS OF CARDIOVASCULAR MEASUREMENTS DIFFER BETWEEN SUBTYPES OF HYPERTENSIVE DISEASES IN PREGNANCY A. Staelens1,2, S. Vonck1,2, K. Tomsin2, T. Mesens1, & W. Gyselaers1,2 1

Department of Obstetrics and Gynecology, Ziekenhuis Oost-Limburg, Genk, Belgium, and 2Faculty of Medicine and Life sciences, Hasselt University, Hasselt, Belgium Brief Introduction: Impedance cardiography (ICG) is a promising technical device to determine the cardiovascular function in

pregnant women. ICG enables orthostatic testing in which the patient is moved from supine to standing position which might elucidate differences of maternal hemodynamic function and cardiovascular (mal)adaptation in different types of maternal hypertensive disorders. The aim of this study was to evaluate the shift of ICG cardiovascular measurements from supine to standing position, in uncomplicated and hypertensive pregnancies. Materials & Methods: Cardiovascular function was evaluated in pregnant women using ICG (NICCOMO, Medis, Ilmenau, Germany) according to a standardized protocol in supine and standing position. Exclusion criteria were twin-pregnancies, preexisting maternal comorbidity, atypical preeclampsia and non-hypertensive gestational complications. Measurements of blood pressure, aortic flow velocities (VI: velocity index; ACI: acceleration index), left ventricular output (HR: heart rate; CO: cardiac output; SV: stroke volume), pre-ejection period (PEP) and thoracic fluid (TFC) were assessed. Orthostatic index (OI) was calculated as valuesupine/valuestanding for all parameters. Values are presented as median with interquartile range. Patients were divided into 4 groups: uncomplicated pregnancies (UP), gestational hypertension (GH), early-onset preeclampsia (EPE,534weeks) and late-onset preeclampsia (LPE, 34weeks). Measurements were compared using Mann-Whitney U test (significance at the level of a50.05) in SPSS 22.0. Clinical Cases or Summary Results: A total of 215 patients were assessed: 56 UP, 56 GH, 36 EPE and 67 LPE. Results are shown in Table 1. In UP, blood pressure and aortic flow velocities increase from supine to standing position and PEP decreases. This trend is also true for the GH group but not for EPE and LPE. ACI increases significantly less in GH than in UP. In EPE and LPE, blood pressure hardly changes (OI around 1), aortic flow velocities decrease and PEP increases from supine to standing. Except for diastolic blood pressure in LPE, orthostatic shifts in EPE and LPE are significantly different from UP (p50.036). OI of left ventricular output parameters and TFC were not different between groups. Conclusions: When moving from supine to standing position, blood pressure and aortic flow velocities increase in UP and GH, and decrease in preeclampsia. Similarly, pre-ejection period decreases in UP and GH, and increases in preeclampsia. Orthostatic impedance cardiography testing shows all characteristics needed for an instantaneous differential diagnostic test between GH and preeclampsia. Keywords: Preeclampsia, impedance cardiography, cardiovascular profile, orthostatic shift Presenter: A. Staelens

Table 1. Orthostatic Index (OI) presented as Median with interquartile range. UP (n = 56)

GH (n = 56)

OI SBP DBP MAP TFC HR SV CO VI ACI PEP

0.964 0.951 0.952 1.114 0.884 1.012 0.907 0.964 0.868 1.014

(0.892;1.016) (0.895;0.989) (0.901;0.980) (1.088;1.144) (0.847;0.929) (0.889;1.150) (0.798;0.997) (0.814;1.098) (0.788;1.033) (0.939;1.093)

OI 0.959 0.964 0.963 1.113 0.906 0.991 0.909 0.993 0.982 0.980

(0.899;1.011) (0.915;1.018) (0.913;1.000) (1.071;1.138) (0.839;0.938) (0.858;1.180) (0.784;1.020) (0.848;1.142) (0.830;1.184) (0.882;1.057)

EPE (n = 36) p Value 0.958 0.198 0.200 0.231 0.341 0.919 0.802 0.42 0.045 0.071

OI 1.038 1.000 1.016 1.104 0.862 1.086 0.904 1.094 1.085 0.848

(0.981;1.128) (0.972;1.064) (0.982;1.083) (1.082;1.140) (0.788;0.927) (0.950;1.280) (0.860;1.109) (0.885;1.200) (0.904;1.328) (0.773;0.946)

LPE (n = 67) p Value 50.0001 50.0001 50.0001 0.157 0.152 0.055 0.258 0.036 0.001 50.0001

OI 1.000 0.952 0.972 1.100 0.873 1.033 0.895 1.018 1.011 0.934

(0.937;1.052) (0.921;1.022) (0.932;1.015) (1.080;1.145) (0.816;0.915) (0.895;1.201) (0.803;1.000) (0.870;1.226) (0.803;1.215) (0.856;1.007)

p Value 0.019 0.129 0.030 0.233 0.200 0.776 0.739 0.036 0.032 50.0001

OI: Orthostatic index = valuesupine/valuestanding (OI51: increase from supine to standing; OI41: decrease from supine to standing); UP: Uncomplicated Pregnancy; GH: Gestational Hypertension; EPE: Early Onset Preeclampsia; LPE: Late Onset Preeclampsia; SBP: Systolic Blood Pressure; DBP: Diastolic Blood Pressure; MAP: Mean Arterial Pressure; TFC: Thoracic Fluid Content; HR: Heart Rate; SV: Stroke Volume; CO: Cardiac Output; VI: Velocity Index; ACI: Acceleration Index; PEP: Pre-Ejection Period (Bold: OI significantly different relative to UP at the level of a50.05)

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ID 334

BIOIMPEDANCE IS USEFULL TO MEASURE INTRA- AND EXTRACELLULAR WATER IN NORMAL AND HYPERTENSIVE PREGNANCIES

Keywords: bioimpedance, extracellular water, intracellular water, pregnancy, hypertension Presenter: S. Vonck

S. Vonck1,2, A. Staelens1,2, T. Mesens1, & W. Gyselaers1,2

ID 769

1

IMPACT OF GENETIC POLYMORPHISM ON THE DEVELOPMENT OF PREECLAMSIA AND ITS SEVERITY

Department of Obstetrics and Gynecology, Ziekenhuis Oost-Limburg, Genk, Belgium, and 2Faculty of Medicine and Life sciences, Hasselt University, Hasselt, Belgium

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third trimester pregnancies. Bioelectrical impedance is a promising non-invasive tool to measure body fluid composition in pregnant women.

Brief Introduction: Total Body Water (TBW) is the sum of intracellular water (ICW) and extracellular water (ECW). The latter consists of plasma fluid, interstitial fluid and transcellular fluid. The aim of the study was to evaluate ICW and ECW in each trimester of pregnancy and in third trimester hypertension. Materials & Methods: Fluid assessments were done using bioelectrical impedance (Maltron BIOSCAN 920-II; Maltron International LTD, Essex, UK) after positive confirmation of reliability of one simple measurement at any time point during the day, irrespective of physical activity or food/fluid intake. Four groups of pregnancies were assessed: (1) First trimester pregnancies (1T), (2) Second trimester pregnancies (2T), Third trimester pregnancies (3T) and (4) Hypertensive third trimester pregnancies (3HT). ECW(%) and ICW(%) were measured and expressed as mean ± SD. An independent, two sampled t-test in SPSS software (version 22.0) was used to compare values (1) between each trimester of pregnancy and (2) between third trimester normal and hypertensive pregnancies. Clinical Cases or Summary Results: A total of 256 women were assessed: 106 1T, 55 2T, 67 3T and 29 3HT. ICW% is lower with advancing gestation: 57.12 ± 1.54 vs. 56.1 ± 1.65, p50.00015 (1T-2T) and 56.1 ± 1.65 vs. 55.24 ± 2.26, p50.02 (2T-3T) respectively. Similarly, ECW% is higher with advancing gestation: 42.87 ± 1.54 vs. 43.88 ± 1.65, p50.00015 (1T-2T) and 43.88 ± 1.65 vs. 44.75 ± 2.26, p50.02 (2T-3T) respectively. In third trimester pregnancies, ICW% is lower and ECW% is higher in hypertensive than in uncomplicated pregnancies: 53.78 ± 2.58 vs. 55.24 ± 2.26; p50.0064, and 46.12 ± 2.58 vs. 44.75 ± 2.26; p50.0064 respectively. (Figure 1) Conclusions: With advancing gestation, ICW% values are lower and ECW% values are higher, which is compatible with a gradual shift from ICW to ECW. This effect is even most prominent in hypertensive

Ahmed F. Galal & Maged Zin Eldin ob&gyn department, Alexandria University, Alexandria, Egypt, High institute of research, Alexandria University, Alexandria, Egypt Brief Introduction: Pre-eclampsia, a life-threatening disease during pregnancy, Although there is substantial evidence of a genetic background, the complexity of the processes involved and nature of the maternal-fetal phenomenon do not make the search for the causative genes. Objective:studying the possible role of methylene Tetrahydrofolate reductase (MTHFR), Factor five (FV Lieden), Prothrombin genes’ polymorphisms and angiotensin converting enzyme (ACE) polymorphism as associated risk factors for preeclampsia in Egypt. Materials & Methods:: A prospective case control study that included 120 preeclamptic patients and 120 age-matched normotensive pregnant females.Preeclamptic cases were divided into two subgroups mild and severe.all studied females were on the 3rd trimester of pregnancy, Singleton pregnancy 0.2 ml venous blood samples were taken under a septic technique on Vaccutainer EDTA tubes. DNA Extraction and Purification using a DNA salting-out technique. Detection of C677T MTHFR gene polymorphis, G1691A Factor V Lieden, G20210A Prothrombin genes and insertion/deletion(I/D) ofACE polymorphisms were done. Clinical Cases or Summary Results: there is statistically significant increased risk for developing severe preeclampsia in women carrying

Figure 1. ICW and ECW parameters in first, second and third trimester, and in hypertensive third trimester (HT). An asterix indicates significantly different values at normal level a  0.05.

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350 G1691A Factor V Lieden polymorphism (Odd ratio = 5.32, 95% CI 01.5219.5), another statistically significant risk for developing severe preeclampsia in women carrying G20210A Factor II polymorphism (Od = 7.8, 95% CI 01.16–84.8), a significant increased risk for developing preeclampsia in women carrying C677T MTHFR and G1691A Factor V Lieden polymophisms (Od = 3.14, 95% CI 00.55- 23.2) and a significant increased risk for developing preeclampsia in women carrying C677T MTHFR and G20210A Prothrombin polymophisms (Od = 2.76, 95% CI 00.4–71.5), on the other hand non significant risk for developing preeclampsia was found regarding C677T MTHFR polymorphism and G1691A Factor V Lieden polymorphism.Another non significant risk for developing severe preeclampsia with C677T MTHFR polymorphism.regarding I/D of ACE non significant difference was found between preeclamptic and control groups (26.5% versus 15.135 resspectively) also the difference was not significant between mild and severe preeclampsia. Conclusions: C677T MTHFR, G1691A Factor V Lieden, and G20210A Prothrombin genes polymorphisms are risk factors for developing preeclamptic toxaemia in Egypt. A highly significant cumulative effect of C677T MTHFR, G1691A FV Lieden, and G20210A Prothrombin alleles to develop preeclampsia and to determine the severity.On the other hand I/D polymorphism of the ACE gene is not a useful marker to study the relationship between the ACE gene and preeclampsia. Variations of the ACE I/D polymorphism is in linkage disequilibrium with the functional marker ACE G2350A and do not play a major role in the determination of preeclamsia in Egyptian community Keywords: preeclampsia. gene, polymorphism Presenter: Ahmed Fawzy Galal

ID 228

RISK EVALUATION ACCORDING TO CLINICAL FEATURES AND RENIN ANGIOTENSIN SYSTEM (RAS) POLYMORPHISMS IN A GROUP OF PREECLAMPTIC ROMANIAN PATIENTS G. Nemeti1, G. caracostea1, LM. Procopciuc2, & F. Stamatian1 1

Department of Obstetrics and Gynecology I, ‘‘Iuliu Hatieganu’’ University of Medicine and Pharmacy, Cluj-Napoca, Romania, and 2Department of Medical Biochemistry, ‘‘Iuliu Hatieganu’’ University of Medicine and Pharmacy, Cluj-Napoca, Romania Brief Introduction: Preeclampsia is a pregnancy associated complication characterized by endothelial dysfunction and consequent vascular maladaptation. Genetic variants of RAS proteins have been proposed as possible cause of the deficient uteroplacental perfusion. Therefore, increased sensitivity to angiotensin II, perhaps through angiotensin receptor type I (AGTR1) activation could be a possible etiopathogenic pathway. This study aimed at risk stratification according to clinical and genetic features related to RAS polymorphisms in a group of preeclamptic Romanian patients. Materials & Methods: 100 patients were enrolled in the study group, with pregnancy induced hypertension, mild and severe preeclampsia and 111 patients with normotensive pregnancies in the control group. The clinical profile parameters analyzed were maternal age, parity, gestational age, pregestational body mass index (BMI) smoking habit and contraceptive use. Genetic evaluation of RAS polymorphisms including A235T angiotensinogen, T174M angiotensinogen, angiotensin converting enzyme (ACE) I/D, ACE 8 and AGTR1 variants was performed in all cases. Clinical Cases or Summary Results: The study group comprised 35 patients with pregnancy induced hypertension, 45 with mild

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

preeclampsia and 20 cases of severe disease. The clinical profile of the study group patients confirmed the increased frequency of severe disease in nulliparous OR = 5 (95% CI 2.1–28.9) and obese OR = 3.1 (95% CI 0.89–26.5) patients. Fetal vascular adaptive changes were encountered in cases with severe preeclampsia: increased resistivity on the umbilical artery OR = 6.5 (95% CI: 1.7 – 24.6), brain sparing OR = 5.38 (95% CI 0.39–20.78) and venous reverse flow OR = 6.7 (95% CI 1.16–39.13). Furthermore, poor fetal outcome was recorded in these patients, characterized by low birth-weight for gestational age OR 3.2 (95% CI 2.1–18.6), Apgar score 57 at 5 minutes OR = 2.7 (95% CI 1.04–7.17) and fetal complications OR = 3.8 (95% CI 1.44–10.14). The M235T angiotensionogen, ACE I/D and A1166C, and AGTR-1 genetic variants associated an increased frequency of the severe form of the disease (OR = 2.6 (95% CI 1.1–18.1), OR = 1.8 (95% CI 1–15.2), respectively OR = 2.3 (95% CI 1.4–12.4)). Conclusions: The present study shows that nulliparity and increased pre-gestational BMI, as clinical parameters, and M235T angiotensinogen, ACE I/D and A1166C AGTR-1 allele, as genetic parameters, are associated with a severe outcome in preeclampsia. Keywords: preeclampsia, endothelial, angiotensin, polymorphisms Presenter: Georgiana Nemeti

ID 356

PATHOGENESIS AND DIAGNOSIS OF HYPERTENSIVE DISORDERS IN PREGNANCY. THE ROLE OF PLATELETS ASSOCIATED ENDOTHELIAL DYSFUNCTION A.B. Tusupkaliyev, S.S. Zhumagulova, A.N. Gaidai, S.A. Assembay, M. Kadrushev, N.S. Zhubanyshev, & N. Isbussinov Department of Obstetrics and Gynecology of West Kazakhstan State Medical University after Marat Ospanov, Aktobe, Kazakhstan Brief Introduction: Current management guidelines for pregnancy with risks of hypertension do not provide significant decrease in frequency and quality of diagnostic measures in regard of combined type of this complication. Therefore, further improvement of prognostic approaches considering newly revealed risk factors is necessary. Current management guidelines for pregnancy with risks of hypertension do not provide significant decrease in frequency and quality of diagnostic measures in regard of combined type of this complication. Therefore, further improvement of prognostic approaches considering newly revealed risk factors is necessary. Materials & Methods: The study involved 96 full-term pregnant women – healthy, having risk factors and clinical signs of hypertensive syndrome. Patients were grouped according to the following criteria: uncomplicated pregnancy (Group I, n = 26), chronic hypertension (Group II, n = 23), mild preeclampsia (Group III, n = 24), severe preeclampsia (Grop IV, n = 23). Clinical Cases or Summary Results: The detailed examination of endothelium functioning revealed the decrease of nitric oxide (NO) serum component in majority of women with hypertension. There was an evident 2 or 2.5 times decrease of NO in patients with mild and severe preeclampsia respectively (p50.05) comparing to patients in uncomplicated pregnancy. Analysis of NO-synthase blood activity in different groups showed the following changes: the significant decrease of NO-synthase level in pregnant women with mild and severe preeclampsia for 1.2 and 1.4 times respectively comparing to control group. The level of

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DOI: 10.3109/14767058.2014.924236

endothelin 1 was increased in Group II for 1.9 times, in Group III for 3.6 times, and in Group IV for 4.8 times. Analysis also revealed a significant increase of homocysteine level in pregnant women with preeclampsia compared to normal pregnancy level namely for 2.9 times in Group III and for 4.8 times in Group IV. Morphological and functional parameters of platelets in blood of Group I revealed the significant increase in number of cells ((214.2 ± 11.6)  109/L) comparing to general groups. This measurement was greatly lower in women of risk group and in case of preeclampsia severity improvement. The changes in Mean Platelet Volume (MPV) and degree of anisocytosis in Platelet Distribution Width (PDW) were the most representative. The evident increase was detected in MPV (8.6 ± 0.2 and 9.3 ± 0.24fl) and PDW (18.89 ± 0.75 and 19.9 ± 0.84%) levels in women with mild and severe preeclampsia respectively (p50.05). Platelet aggregation was 88.4 ± 2.9% in Group II and 108.2 ± 4.1% in Group III (p50.05). At the same time, the decrease of this parameter revealed in women with severe preeclampsia compared to control group (p50.05). There was decrease of aPTT for 1.4 times revealed in Group IV compared to control group. In Groups II and III the amount of fibrinogen is 1.3 and 1.5 times higher than those in normal pregnancy. The prothrombin ratio, specific for extrinsic pathway of coagulation, was 94.6 ± 3.2% in Group I and significantly decreased in Groups II and III for 1.2 (78.8 ± 1.9) h 1.3 (72.7 ± 2.3) times respectively. The observed variations of platelets (from fine to large forms) associated with gestosis severity confirm the role of thrombocytic component of hemostasis in course of this pathologic condition. Conclusions: It can be concluded that significantly expressed changes in endothelial dysfunction marker homocysteine, fluctuation in morphological parameters of platelets (the amount decreased up to 30.7%), increase of Mean Platelet Volume (MPV) up to 19.4%, fibrinogen concentration up to 44.3% and Soluble Fibrin Monomer Complex (SFMC) up to 22% appear to be prognostic evaluation criteria for gestosis severity. Keywords: preeclampsia, hypertension, endothelial dysfunction Presenter: A.B. Tusupkaliyev

ID 714

PREDICTION OF PRE-ECLAMPSIA BY MATERNAL CHARACTERISTICS: A CASE-CONTROLLED VALIDATION STUDY OF A BAYESIAN NETWORK MODEL FOR RISK IDENTIFICATION OF PREECLAMPSIA A. van Meurs1, M. Velikova2, M.B. van der Hout - van der Jagt1,3, B. Vermeulen1,4, & S.G. Oei1,5 1

Department of Gynaecology and Obstetrics, Ma´xima Medical Care Center, Veldhoven, The Netherlands, 2Institute of Computing and Information Sciences, Radboud University Nijmegen, The Netherlands, 3Department of Biomedical Engineering, Eindhoven University of Technology, The Netherlands, 4Department of Applied Physics, Eindhoven University of Technology, The Netherlands, and 5Department of Electrical Engineering, Eindhoven University of Technology, The Netherlands Brief Introduction: Pre-eclampsia (PE) is worldwide a leading and rising cause of maternal and perinatal morbidity and mortality. As PE remains a serious and poorly understood complication of pregnancy,

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it is necessary to recognize the disease before it threatens the survival of mother and fetus. A validated tool that allows real-time maternal risk stratification is needed to guide care. A recent advanced model for pre-eclampsia presented in Velikova et al. 2014 provides that potential. In contrast to the previous study where the testing with this model was done with data for high-risk pregnancies, in this study we aimed at evaluating the capability of the BN model for pre-eclampsia, by looking at the predictions for normal and pre-eclamptic pregnancies. Materials & Methods: The model is based on a Bayesian network methodology, which has been successfully applied for clinical problems. A Bayesian network (BN) is a statistical model that represents a set of variables (e.g. risk factors, diseases and symptoms) and their dependencies by means of a graph and probability distributions. The advantage of a Bayesian network is that it can be used to make personalized predictions, for example for the development or presence of a disease, by entering patient-specific data. We validated the BN model for PE (PE model) in a retrospective case-control study. 10 women diagnosed with PE admitted to the obstetric high care ward of a tertiary care center were enrolled. Their characteristics were matched with 10 pregnant women without any illness. We collected pregnancy data that was relevant for the model, including: (i) risk factors: age; BMI; smoking; parity; twin pregnancy; family history of PE; previous history of PE; preexisting vascular disease; preexisting renal disease; anti-phospholipid syndrome; diabetes mellitus, (ii) medication and measurements from 10 standard check-ups during the pregnancy: blood pressure, protein-to-creatinine ratio, serum creatinine and hemoglobin and medication and (iii) the outcome variable: whether or not preeclampsia is present. PE risk estimation from the model for each patient was compared to PE development. Model performance was assessed by means of the area under the receiver operating characteristic (ROC) curve (AUC). Clinical Cases or Summary Results: Throughout pregnancy, the PE model predicted a high absolute risk for PE in 9 out of 10 PE patients versus 2 out of 10 non-preeclamptic women. This is shown in Figure 1. Each pregnancy week shows the number of patients that has not delivered yet, the color indicating whether they are ultimately diagnosed with PE (red) or not (green). The predicted risk by the model is indicated with a percentage (y-axis) for each patient at each gestational week (x-axis). ROC curves and PE-risk cut-offs were calculated for different gestational weeks. This resulted in AUC score at 24 weeks of 0.895, at 28 weeks of 1.000, at 32 weeks of 0.986, at 36 weeks 1.000, at 38 weeks of 0.375, at 40 weeks of 1.000. Concluding, we find high AUC scores, except for the prediction at 38 weeks of gestation, due to missing data. Therefore no cut-off value was calculated for week 38. Sensitivity, specificity, the positive predictive value (PPV) and negative predictive value (NPV) of the PE model are as well calculated per week of gestation, except for week 38. The sensitivity of the PE model is 100% at each pregnancy week. We find a specificity of 83%, 100%, 91%, 100% and 100% at 24, 28, 32, 36 and 40 weeks, respectively. Thus, 8–17% of women without PE will be screened as having an increased risk. The PPV is calculated as 33%, 100%, 83%, 100% and 100% at 24, 28, 32, 36 and 40 weeks, respectively. The NPV is calculated as 100% at each pregnancy week.

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352 Conclusions: When data is available in early pregnancy, the PE model is able to distinguish between PE and non-PE pregnant women and able to predict a higher risk for the diagnosed patients. In particular, at gestational week 12 the chance for PE was twice or higher for PE patients than for 8 of the non-PE pregnant women, and for weeks 16–24 this chance for PE patients was up to eight times higher for the PE patients. This is a particularly important result given the aim of a timely identification of women at risk, which is to facilitate much targeted monitoring. Despite the fact not all data was available for all pregnancy checkups, the PE model was still able to compute the individual, absolute risk for pre-eclampsia. Although for some patients PE was only predicted late in pregnancy, this was for all patients before or at latest at the same moment of clinical diagnosis. However, we expect that prediction will improve when all measurements are available from the pregnancy checkups. From the model it follows that a dynamic cut-off is needed that increases with pregnancy duration. Current results are promising. We propose to perform an RCT with a larger number of patients to establish this cut-off curve with more accuracy and to validate the PE model prospectively. Once validated, the model can assist in early PE diagnosis and thus allow early treatment of PE. The PE model can be integrated in e-health applications to allow real-time monitoring of pregnant women anywhere. By this way we can personalize the healthcare during pregnancy. Keywords: Pre-eclampsia, prediction model, bayesian network, risk, e-health Presenter: Andrea van Meurs

ID 419

PREVENTIVE DATA OBTAINED IN THE STUDY: PROGNOSTIC VALUE OF PROTEIN S100 B IN HIGH RISK PREGNANCY N. Boscaneanu Obstetric and Gynecology Department, Mother and Child‘s Institute, Chisinau, Republic of Moldova Brief Introduction: Aim of the study: Early diagnostic and prognostic value of protein S100 B in case of Preeclampsia with IUGRF and Doppler hemodynamic changes. Materials & Methods: Material and methods: In this study was included 17 pregnant women with 28–32w.a. with Preeclampsia. Fetuses were diagnosed with IUGRF and hemodynamic Doppler changes manifested by Circulatory Insufficiency Gr IA-IB. All cases where applied expectative management because corrigible values of Arterial Tension and prematurity of the fetus. Protein S100B was collected from maternal blood at hospital admission, after 3 days and after 6 days. Obtained dates were compared with hemodynamic Doppler data and neonatal results. Clinical Cases or Summary Results: Preventive obtained results: In 5 cases, dynamic assessment of S100B on the period of 7 days demonstrated marked intensive increase above physiologic values in the limit of the following intervals1.92–2.6 mg/l, which corresponded with exasperation of Doppler data and were relevant to reserved neonatal outcome. In 7 cases, dynamic evaluation of S100B protein, indicated augmentation above physiologic values equal with 0.9–1.54 mg/l despite of Doppler data without aggravation and correspond to neonatal complications, manifested by low Apgar score and neurologic diagnostic as Ischemic-Hypoxic Encephalopathy. In 5 cases protein S100B corresponded with 0.13–0.3mg/l, which did not manifested enhancement above physiologic values in each from three probes, corresponded with stabile Doppler results without aggravation and correlated with satisfactory neonatal outcome.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Conclusions: Preventive obtained data suggest that protein S100B evaluation in biologic fluids as maternal peripheral blood may be a useful tool in perinatal medicine for early diagnostic of fetal distress and can be informative when Doppler investigation is still normal. Keywords: Protein S100B, Preeclampsia, Fetal brain lesion Presenter: Natalia Boscaneanu

ID 599

MATERNAL AND FETAL PHENOTYPES IN HYPERTENSIVE DISORDERS OF PREGNANCY ARE GREATER DETERMINANTS OF PERINATAL OUTCOME THAN GESTATIONAL AGE AT ONSET OF HYPERTENSION S. Zullino1, T. Todros2, T. Stampalija3, L. Marozio4, F. Mecacci5, M. Gervasi6, P. Vergani7, P. Cavoretto8, S. Oggioni1, & E. Ferrazzi1 1

Dept. Woman, Mother and Neonate, Buzzi Hospital, University of Milan, 2Dept. Surgical Sciences, University of Turin, 3Unit of Prenatal Diagnosis, IRCCS Burlo Garofolo, Trieste, 4Dept. Gynecology and Obstetrics, Sant’Anna Hospital, University of Turin, 5High Risk Pregnancy Unit, University Hospital of Careggi, Florence, 6Ob/Gyn Unit, Dept. for Health of Mothers and Children, Padua, 7Dept. Obstetrics and Gynecology, University of Milano-Bicocca, Monza, and 8 Obstetrics and Gynecology Unit, San Raffaele Scientific Institute, Vita-Salute University, Milan. For the ‘‘Associazione Italiana Preeclampsia’’ Brief Introduction: Fetal growth and placental Doppler velocimetry could be helpful to discriminate between hypertensive disorders of pregnancy (HDP) associated with endothelial damage caused by placental insufficiency and HDP predominantly caused by a maternal metabolic syndrome. The aim of this study was to assess different phenotypes of HDP based not only on time-domain (early and late HDP), but also on maternal and fetal characteristics. Materials & Methods: This is a multicentric retrospective cohort of 920 singleton pregnancies with HDP. Early (534wks) and late (34wks) HDP were further stratified according to: fetal growth restriction (IUGR, abdominal circumference 40 pc in two consecutive exams); abnormal uterine artery pulsatility index (UtPI). Umbilical PI was measured to assess the severity of placental damage. Cesarean section (CS) was performed for worsening maternal and/or fetal conditions. Appropriate statistics (p50.05) was adopted. Clinical Cases or Summary Results: Complete data were obtained for 780 women. Mean age at delivery was 34 weeks of gestation. IUGR was diagnosed prenatally in 166 fetuses. Table reports key clinical outcomes for early and late onset HDP stratified according to their association with IUGR. Abnormal UtA was observed in 70% (116/166) of IUGR and it was never observed in HDP with AGA fetuses. Maternal BMI was significantly higher in cases of HDP without IUGR, independently from gestational age at onset. The prevalence of CS and NICU admission were significantly higher in HDP cases with IUGR and abnormal UtPI than in cases with HDP without IUGR and abnormal UtPI (p50.001). Conclusions: The present data show that hypertensive disorders associated with IUGR (placental origin) can occur late in pregnancy and, similarly, hypertensive disorders without placental involvement (maternogenic origin) might develop early in pregnancy. Our findings

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DOI: 10.3109/14767058.2014.924236

CASES AGE NULLIPAROUS BMI GA AT DELIVERY (WEEKS) NEWBORN WEIGHT (g)

EARLY IUGR

EARLY AGA

LATE IUGR

LATE AGA

108 (14%) 34 ± 4.8 70% (76) 25.0 ± 5.02 32 ± 3.3 1364 ± 563.5

126 (16%) 34 ± 5.3 44% (55) 26.7 ± 5.26 35 ± 3.9 2544 ± 909.7

58 (7%) 34 ± 6.0 64% (37) 26.5 ± 4.75 37 ± 1.5 2226 ± 409.1

488 (63%) 34 ± 5.4 69% (336) 29.2 ± 6.55 39 ± 1.5 3156 ± 464.9

address the possibility that the present classification based on the time domain criteria of onset of hypertension could not explain thoroughly maternal and fetal conditions in HDP.

Keywords: placenta, mRNA expression, preeclampsia, Ang-1, Ang-2, Tie-2 Presenter: S. Sifakis

Keywords: HDP, IUGR, preeclampsia. Presenter: Zullino Sara

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ID 660

ALTERED PLACENTAL MRNA EXPRESSION OF ANGIOPOIETINS (ANG)-1 AND ANG-2 AND THEIR RECEPTOR TIE-2 IN PREGNANCIES COMPLICATED BY PREECLAMPSIA AND INTRAUTERINE GROWTH RESTRICTION D. Kappou1, V. Androutsopoulos2, A. Konstantinidou3, D. Spandidos2, N. Papantoniou1, & S. Sifakis4 1 1st Department of Obstetrics and Gynaecology, University of Athens, Alexandra Hospital, Athens, Greece, 2Department of Clinical Virology, University of Crete, Heraklion, Greece, 3 1st Department of Pathology, University of Athens, Athens, Greece, and 4Department of Obstetrics & Gynecology, University Hospital of Heraklion, Crete, Greece

Brief Introduction: Angiopoietin (Ang)-1 and Ang-2 are trophoblastderived angiogenic growth factors that bind to the same receptor (Tie-2) and play a crucial role in the later stages of angiogenesis. Our aim was to investigate the placental expression of angiopoietin (Ang)-1, Ang-2 and their receptor, Tie-2, in preeclampsia (PE) with or without intrauterine growth restriction (IUGR). Materials & Methods: Case-control study including placentas from 28 PE pregnancies, 30 PE–IUGR pregnancies and 40 controls. The expression status of the genes was evaluated by quantitative real-time PCR. Clinical Cases or Summary Results: In both PE and PE-IUGR groups, compared to the control group, there was significantly higher expression of Ang-2 (p50.001) and Tie-2 (p = 0.008) and lower expression of Ang-1 (p = 0.001). The magnitude of the difference was similar for Ang-1 for both groups, whereas the magnitude of the differences was higher for Ang-2 and Tie-2 in the PE-IUGR group compared to the control group. Ang-2 and Tie-2 were correlated in both the PE (r = 0.8602, p50.001) and PE-IUGR (r = 0.6342, p50.001) groups. In the PE–IUGR group, Ang-1 was associated to Ang-2 (r = 0.3458, p = 0.0452) and Tie-2 (r = 0.4448, p = 0.0084). log10 Ang-1 but not Ang–2 was gestational age dependent (R2 = 0.40, p50.001). After conversion in Multiples of the Median (MoM) log10 MoM Ang-1 was reduced in the PE group (mean = -0.8181, p50.001) and the PE-IUGR group (mean = -1.2583, p50.001) compared to control group (mean = -0.0924). Conclusions: We have demonstrated an increased placental expression of Ang–2 and Tie–2 along with lower expression levels of Ang-1 in pregnancies with PE and PE-IUGR. Whether the results of this study represent the angiogenic imbalance observed in PE pregnancies or they are part of the pathophysiology of this condition has to be further investigated.

CLINICAL AND MORPHOLOGICAL FEATURES OF EARLY-ONSET AND LATE PREECLAMPSIA D.N. Vodneva, V.V. Romanova, R.G. Shmakov, K.A. Pavlov, & A.I. Shegolev Federal State Budget Institution ‘‘Research Center for Obstetrics, Gynecology and Perinatology’’ Ministry of Healthcare and Social Development of the Russian Federation Brief Introduction: Recently, in connection with possible different pathogenetic mechanisms of development, there is evidence of the division of preeclampsia on the early (before 34th week of pregnancy), and late (after 34th week). However, the exact pathogenesis of preeclampsia is not fully understood. Recently, more and more attention has been paid to the development of preeclampsia in connection with sleep apnea syndrome and the number of studies devoted to this issue is increasing. Materials & Methods: The study included 36 patients aged from 20 to 41 years, who were divided into two groups depending on the time of manifesting of preeclampsia. Inclusion criteria were: mild and severe preeclampsia, singleton pregnancies and woman’s consent for the study. Exclusion criteria were: genetic fetal malformations, hypertension, severe somatic disorders and multiple pregnancy. Polysomnography was performed, as well as morphological study of the placentas. Statistical analysis was performed using Statistica 6.0. Clinical Cases or Summary Results: The average age of patients in the group with the early and late preeclampsia was 33.05 ± 1.36 years and 33.67 ± 1.18 years, and the number of nulliparous women was 10 and 9 people, respectively, and they were not statistically different (p40.05). It should be noted that in this study early preeclampsia significantly differed from the late weight limitation on the time of prolongation of pregnancy. So, in group 1 in 61.1% (n = 11) cases preeclampsia was severe, and in 38.9% (n = 7) preeclampsia was moderate, whereas in group 2 severe preeclampsia was diagnosed in 11.1% (n = 2) cases and in 88.9% (n = 16)moderate preeclampsia (p50.05). A lower value of the expression of VEGF and VEGFR-2 was set in placentas of women who suffered early preeclampsia. The most pronounced decrease of VEGF (by 17.1% in comparison with the control indicators) was observed in mesenchymal cells and VEGFR-2 in the syncytiotrophoblast by 29.7%. While indicators in the expression of VEGF during the late preeclampsia don’t differ from those of the control group (p50.05). Sleep apnea diagnosed significantly more frequently in the late (88.9%) compared with the early preeclampsia (5.5%). The average value of the index apnea/hypopnea in pregnant women with sleep apnea syndrome was 5.7 in the second group and 0.44 in the first group (p50.05). The maximum index apnea-hypopnea in the group with late preeclampsia was 8.

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Conclusions: The decrease of level of expression of VEGF and its receptors in terminal placental villi, expressed in more observations with early preeclampsia demonstrates the role of endothelial growth factor vessels in the development of preeclampsia before 34th week of pregnancy. The revealed changes in immunohistochemical profile in terminal placental villi indicate damage to the placenta and accordingly lie at the basis of violations of prenatal development. However, the observed differences in placental terminal villous at the early and late preeclampsia, apparently, reflect the different pathogenetic mechanisms of their development. Basing on these data we can expect that the main cause of early preeclampsia is a disturbance of trophoblast invasion, late preeclampsia may be associated with pathogenic mechanisms such as intermittent hypoxia at night sleep apnea, which leads to endothelial dysfunction, systemic inflammatory response, oxidative stress.

in all of the other groups (p 0.001). There is no significant difference between the areas under the curve [95% CI] obtained for uPlGF and proteinuria during dipstick testing (p = 0.512) in the differentiation of women with severe preeclampsia from the women in all of the other groups. Conclusions: sPlGF and uPlGF can diagnose women with preeclampsia and should be considered at least as important as proteinuria in the diagnosis of preeclampsia. However, we recommend that a large study that considers the cost-effectiveness of adding these markers to the diagnosis of preeclampsia to be conducted before our recommendation is applied.

Keywords: preeclampsia, vascular endothelial syndrome of obstructive sleep apnea.

ID 272

growth

factor,

Presenter: R.G. Shmakov

ID 198

CAN THE PLACENTAL GROWTH FACTORS, URATE, LACTAT DEHYDROGENASE, AND DIPSTICK PROTEINURIA DIAGNOSE PREECLAMPSIA AND ITS SEVERITY? R. El Rifaei1 & M. Khalil2

Keywords: Presenter: Rabab Mohamed Khalil

IS THERE ANY DIFFERENCE IN THE RATE OF PREECLAMPSIA REGARDING PREGNANCIES ACHIEVED BY ASSISTED REPRODUCTIVE TECHNIQUES IN COMPARISON WITH NATURAL CONCEPTIONS? A. Perez-Mun˜uzuri, J.R. Cervilla, A. Iglesias Deus, R. Saborido Fian˜o, & M.L. Couce Pico

1

Neonatology Unit. Assistance Pediatric Area. Hospital Clinico Universitario (CHUS). Santiago de Compostela (SPAIN)

Brief Introduction: Preeclampsia remains a potentially serious complication of pregnancy that is responsible for a significant amount of maternal and perinatal morbidity and mortality worldwide. The etiology of preeclampsia remains elusive, although the leading theory is that defects in placental implantation and function ultimately manifest as the development of preeclampsia. Researchers have examined various placental markers to determine whether they may be of value in the prediction and diagnosis of preeclampsia, Placental growth factor (PlGF) is an important regulator in the human placenta, and can be isolated from the maternal circulation and the maternal urine. Materials & Methods: Urine and blood samples were taken from pregnant women that have been already diagnosed as late onset severe preeclampsia (30 cases), mild preeclampsia (30 cases), gestational hypertension who did not meet the criteria for preeclampsia (30 cases), gestational proteinuria who did not meet the criteria for preeclampsia (30 cases), and healthy pregnant control women (30 cases). A receiver operating characteristic (ROC) curves analysis was performed, to evaluate the diagnostic accuracy and to select the optimal cutoff points for different markers. The objective was to assess the diagnostic accuracy of Serum and urinary placental growth factor (sPlGF and uPlGF, respectively), urate, lactate dehydrogenase (LDH), and proteinuria on dipstick testing to diagnose and differentiate women already been diagnosed as preeclampsia from women with a normal healthy pregnancy, gestational hypertension, and gestational proteinuria. Clinical Cases or Summary Results: The level of sPlGF is the best test for the differentiation of women with severe preeclampsia from women

Brief Introduction: Preeclampsia (PEC) is the most common complication of pregnancy that occurs especially near term or postpartum, in a global rate of approximately 5% of pregnancies. Among others known risk factor of PEC, one of them is extreme maternal age435 or 515 years. Offspring of mothers with PEC have higher risk of intrauterine growth restriction, disorders related with prematurity and even perinatal death. Our aim was to analyze in the rate of PEC in the period 2008–2012 in two cohorts of consecutive pregnant women. One group was naturally conceived (NCG), and another group by assisted reproductive techniques (ART-G), mainly by IVF. Materials & Methods: In the period 2008–2012 we have reviewed and analyzed data from a group of 306 deliveries (DLV) achieved by artificial aid ART and a group of 396 consecutive DLV after natural conception NCG. We examined data of both groups regarding median maternal age, mode of DLV, vaginal or by cesarean section (CS) and the rate of twin birth with a target to discover if there was any differences in the PEC rate. Clinical Cases or Summary Results: There were overall 306 DLV (165 vaginal and 141 CS) in the ART-G and 396 overall DLV (325 vaginal and 71 CS) in the NCG. Median maternal age 37.2 (range 53–23 years) in the ART-G, was significantly higher p50.01 than the median maternal age 32.3 (range 45–19 years) in the NCG. PEC rate in the ART-G (33 cases from 306) was 55% higher than (15 cases from 396) in the NCG. (p50.01). Rate of PEC overall DLV was significantly higher in the ART-G (10.8% vs. 3.8%) than in the NCG, a decline in the latter of -64.8 percent. Rate of CS overall DLV was also higher in the ART-G than in the NCG (46.0% vs. 17.9%). Twin birth percent rate overall DLV was 12 fold higher in the ART-G (28.4% vs. 2.3%), a decrease of -64.8 percent in the NCG. Conclusions: The elevated median maternal age of 37.2 years in the ART-G is the most probable incriminating risk factor of PEC. ART-G tripled the rate of PEC compared with NCG (10.8% vs. 3.8%), and it is twice as high as the 5% global prevalence. Furthermore the rate of CS is two-fold higher and the twin percentage rate overall DLV is twelve-fold higher in the the ART-G compared with the NCG rate.

Rabab M ELRIFAEI, MBBCH, MRCOG, Senior Registrar, Department of Obstetrics and Gynecology, Security Forces Hospital, Riyadh, Kingdom of Saudi Arabia, and 2Mohamed Ibrahim KHALIL, MD, MRCOG, Consultant, Department of Obstetrics and Gynecology, Security Forces Hospital, Riyadh, Kingdom of Saudi Arabia, and Professor of Obstetrics and Gynecology, Faculty of Medicine, Menoufiya University, Egypt

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DOI: 10.3109/14767058.2014.924236

Therefore, older maternal median age 437 years in the ART-G, possibly, is the main risk factor for the raised PEC rate. Keywords: preeclampsia, assisted reproductive techniques, natural conceive group Presenter: J.R. Cervilla

ID 538

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PREVENTION OF RECURRENT PREECLAMPSIA IN WOMEN WITH THROMBOPHILIA: MATERNAL AND PERINATAL OUTCOMES A.D. Makatsaria, V.O. Bitsadze, & S.V. Akinshina Department of obstetrics and gynecology, I.M. Sechenov First Moscow State Medical University, Russia Brief Introduction: Our aim was to evaluate the preconception treatment efficacy in women with recurrent preeclamsia. Materials & Methods: Group I: 75 patients with recurrent preeclampsia and group II: 76 primagravida with preeclampsia were tested to have genetic thrombophilia, antiphospholipid antibodies and polymorphisms if proinflammatory cytokines. Group I received treatment in preconception period and during pregnancy LMWH guided by D-dimer, omega-3-acides, vitamins of B group, folic acid. In the group II treatment was started after the preeclampsia symptoms development. Clinical Cases or Summary Results: Thrombophilia and polymorphisms if proinflammatory cytokines were detected in 100% women with 2 and more recurrent preeclamsia, in 93.7% with one previous preeclampsia and in 60% women from the group II. In the group I nobody had moderate or severe forms of preeclampsia, mild preeclampsia was observed in 16%. In the group II therapy with LMWH was not effective: 33 patients developed severe and 43 – moderate preeclampsia. All patients from the group I were delivered after 37 weeks (50% via c.s.), all babies were alive. In the group II 30.3% patients were delivered prematurely via s.c., and in 43.4% c.s. was performed after 37 weeks of gestation. One baby died in the early neonatal period due to multiple birth deffects. Conclusions: Thrombophilia might be the essential pathogenetic mechanism of recurrent preeclampsia. Preconception treatment with LMWH, antioxidants and vitamins allows preventing severe and moderate preeclampsia in 100% cases. Patients with preeclampsia require the early pathogenetic therapy in future pregnancies.

Brief Introduction: Hyperuricemia has been described commonly in preeclamptic pregnancies, often preceding the diagnosis of preeclampsia and historically was used as a diagnostic marker of preeclampsia. The aim of this study was to determine the usefulness of gestation corrected hyperuricemia to predict the recurrence of preeclampsia on subsequent pregnancy Materials & Methods: The retrospective study of 64 women who had previous preeclampsia and checked serum uric acid was analyzed. Gestation corrected hyperuricemia (GCH) was defined as being one standard deviation above the gestation-specific mean. And we used uric acid z-scores ([serum uric acid value - gestation specific mean]/ standard deviation of the population) to account for gestationspecific alterations in uric acid and tested this as a continuous variable. The relationship between GCH and recurrence of preeclampsia on subsequent pregnancy was analyzed. Obstetric outcomes were reviewed according to absence or presence of GCH. p50.05 was considered as significant. Clinical Cases or Summary Results: Of 64 women, seventeen had the development of recurrent preeclampsia (26.6%). The absence or presence of GCH was not associated with the recurrence of preeclampsia on subsequent pregnancy (p = 0.267). And gestationspecific uric acid z-score as a continuous variable did not show any association with the prediction of preeclampsia on subsequent

Table 1. Values used to determine maternal serum hyperuricemia based on uric acid corrected for gestational age (mean + 1 standard deviation)[26] Gestational age

Serum uric acid (mg/dl)

532 weeks 32–35 weeks 36–37 weeks 38 weeks

44.0 44.5 44.9 45.6

Table 2. The subgroups of hypertensive complication at first and second delivery First delivery

Second delivery MP SP SuP CH Nr Total

MP

SP

EC

SuP

Total

1 0 0 2 3 6

2 9 0 1 29 41

0 0 0 1 1 2

0 0 5 10 0 15

3 9 5 14 33 64

Keywords: Preeclamsia, thrombophilia, prevention, LMWH Presenter: A.D. Makatsaria

ID 600

THE USEFULNESS OF GESTATION CORRECTED HYPERURICEMIA AS PREDICTORS OF THE RECURRENCE OF PREECLAMPSIA AND OBSTETRIC OUTCOMES ON SUBSEQUENT PREGNANCY J.W. Kim, Y.H. Kim, & T.B. Song Obstetrics and Gynecology, Chonnam National University Medical School, Gwangju, Republic Of Korea

MP, mild preeclampsia; SP, severe preeclampsia; EC, eclampsia, SuP, superimposed preeclampsia on chronic hypertension; CH, chronic hypertension; Nr, no hypertension or proteinuria

Table 3. Clinical characteristic and biochemical data at first and second delivery. First delivery Second delivery Maternal age (y, mean ± SD) Gestational age (w, mean ± SD) Nulliparous (n) Vaginal delivery (n) Birth weight (g, mean ± SD) SGA, 5th percentile (n) SGA, 10th percentile (n) Serum uric acid concentration (mg/dl) Gestation corrected hyperuricemia (n) Z-score SGA, small for gestational age

30.4 ± 4.21 33.8 ± 4.34 47 (73.4%) 20 (31.3%) 1,970 ± 922 16 (25.0%) 23 (35.9%) 6.0 ± 1.25 54 (84.4%) 2.7 ± 1.68

33.1 ± 4.23 35.6 ± 3.67 2,515 ± 874 5 (7.8%) 8 (12.5%)

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Table 4. Clinical characteristic and biochemical data at first delivery according to the occurrence of gestation corrected hyperuricemia

Maternal age (y, mean ± SD) Gestational age at first delivery (w, mean ± SD) Gestational age at second delivery (w, mean ± SD) Birth weight (g, mean ± SD) Z-score Nulliparous (n) SGA, 5th percentile (n) SGA, 10th percentile (n) Recurrent preeclampsia (n)

Yes (n = 54)

No (n = 10)

p Value

30.5 ± 4.17 33.0 ± 4.21 35.4 ± 3.81 1,734 ± 784 3.1 ± 1.45 39 (72.2%) 16 (29.6%) 23 (42.6%) 16 (29.6%)

30.0 ± 4.66 38.2 ± 1.67 36.6 ± 2.65 3,241 ± 454 0.4 ± 0.5 8 (80.0%) 0 0 1 (10.0%)

0.744 50.001 0.336 50.001 50.001 1.000 0.055 0.010 0.267

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Table 5. Clinical characteristic and biochemical data at first delivery according to the recurrence of preeclampsia on subsequent pregnancy

Maternal age (y, mean ± SD) Gestational age (w, mean ± SD) Birth weight (g, mean ± SD) Time interval between two deliveries (y, mean ± SD) Uric acid concentration (mg/dl) Z-score Nulliparous (n) SGA, 5th percentile (n) SGA, 10th percentile (n) Vaginal delivery (n)

pregnancy (p = 0.427). GCH was associated with the small for gestational age (p = 0.010). Conclusions: GCH does not predict the recurrence of preeclampsia on subsequent pregnancy. Keywords: gestation preeclampsia

corrected

hyperuricemia,

predictor,

Presenter: Jongwoon Kim

ID 870

UTERINE ARTERY DOPPLER FINDINGS AND PREGNANCY COMPLICATION M. Trajchevski1 1

Special Hospital for Gynecology and Obstetrics ‘‘Mother Teresa’’ Chair, Skopje, Macedonia Brief Introduction: High diastolic velocity and decrease in uterine artery (UtA) impedance to flow occure in the normal pregnancy. Preeclampsia (PE) and fetal growth restriction (FGR) are accompanied with increased impedance to flow, presence of notch and high pulsatility and resistence index (PI, RI) at UtA Doppler. The objective of this study was to find how permanently is associated the inadequate placentation with abnormal UtA Doppler waveform. Materials & Methods: A total of 84 single pregnancies complicated by PE and/or FGR were included in a clinical observation and Doppler examination. The presence of a diastolic notch, RI and PI at both uterine arteries were recorded along with the mean maternal arterial pressure (MAP). The RI and PI at uterine arteries were assigned pathologic if they have been over the 95-th centile gestational age cutoffs. After deliveries, infants suitable to their birth weight (BW) and gestational age (GA) were classified as being appropriate for the GA (AGA) or as being fetal growth restricted (FGR).

Yes (n = 17)

No (n = 47)

p Value

32.2 ± 4.14 32.8 ± 4.52 1,813 ± 808 2.8 ± 1.33 6.1 ± 1.38 3.0 ± 1.64 8 (47.1%) 3 (17.6%) 5 (29.4%) 6 (35.3%)

29.8 ± 4.11 34.2 ± 4.25 2,026 ± 961 2.5 ± 1.15 5.9 ± 1.21 2.6 ± 1.70 39 (83.0%) 13 (27.7%) 18 (38.3%) 14 (29.8%)

0.051 0.247 0.418 0.382 0.555 0.427 0.004 0.414 0.513 0.675

Clinical Cases or Summary Results: Fifty-seven percent of the pregnant women in this study were nuliparous. The mean age of all women was 29 years. The mean fetal GA, at delivery, was 38 weeks. The mean BW was 2330 g. for FGR infants and 2940 g. for AGA. Twenty-three pregnancies were with normal mean MAP and FGR, while 61 pregnacies were preeclamptic of these 19 were FGR. Abnormal UtA Doppler waveforms were seen in 28 pregnancies with FGR, but also in 25 pregnant women with AGA fetuses. Pathologic UtA Doppler indices were recorded in 48 out of 61 pregnancies complicated with preeclampsia. The presence of a diastolic notch was a better predictor for preeclampsia, recorded in 51 preeclamptic women. Diastolic notch was present in 9 out of 23 pregnancies not complicated with PE as well as with 33 out of 42 AGA fetuses. Conclusions: Increased impedance to flow in uterine arteries is not obvious in any preeclamptic woman and abnormal UtA Doppler can be seen in FGR pregnancies not complicated with PE. There is not an unique sign that is strictly associated with PE and FGR. Doppler findings at uterine arteries during pregnancy should be a complement of whole clinical picture. Keywords: doppler, uterine artery, preeclampsia, fetal growth restriction Presenter: Metodi Trajchevski

ID 232

THIRD TRIMESTER PREDICTION OF LATE PREECLAMPSIA E. Meler, N. Li, E. Scazzocchio, I. Rodriguez, & B. Serra Dexeus, Salut de la Dona. Institut Universitari Quiro´n-Dexeus Brief Introduction: It is well known that a multiparametric model including maternal factors, uterine Doppler and biochemical parameters could be useful at 1st and 2nd Trimester for the prediction of early PE (534 weeks of gestation) but less accurate for late PE

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a

(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 prediction of late PE. Our objective was to define the prediction capacity of maternal characteristics and uterine Doppler at third trimester for late PE. Materials & Methods: 710 pregnancies followed up and delivered in our centre were included in a cross sectional study. Out of these, 17 cases developed late preeclampsia (2.4%). Controls were gestations with no diagnosis of PE nor gestational hypertension. All patients made a 3rd trimester visit at 31.0–33.6 weeks, where diastolic (dBP), systolic (sBP) and Mean (MAP) arterial blood pressure and the weight were measured. An ultrasound for fetal biometry and uterine Doppler was performed concomitantly. 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. Clinical Cases or Summary Results: Third trimester dBP, sBP and MAP were significantly higher in those patients who developed late PE (74.7 vs 64.4 mmHg, 120 vs 110.6 mmHg and 89.8 vs 79.8 mmHg, respectively) (p50.05). No differences were found in maternal age and body mass index. Mean Pulsatility Doppler of uterine arteries was significantly higher in those patients with Late PE. 50% of third trimester impaired uterine Doppler were de novo. Mean GA at delivery of cases was 37.2 (range 35–40 weeks) and of controls 38.8 (range 34–42 weeks). In a multivariate logistic regression analysis, third trimester MAP and uterine Doppler were independent and significant predictors of late PE at 3rd Trimester. The model including had an AUC of 0.769 (0.642–0.895). Conclusions: A third trimester screening could be useful in the prediction of late-onset PE.

The general state gets worst, with BP 105/70 & T : 35 C and the fetal frequency goes to 80 lpm. An urgent caesarean is required, with a several haemoperitoneum about 2.5–3 litres. The fetal extraction is done: woman, 1240 g. Apgar test 5/9. Normal placentae manually extracted. Normal uturus & ovarics. A right rupture liver of 10 per 4 cm with a profuse bleeding is seen. A hemostatic substance is added & packing with 5 compress Blood analitics: Hemoglobine 5 g/dl. Platelets 90000. 7 PRVCS, 2 plasma & 2 platelets packets are trasfused The vascular radiologist makes a selective embolization of the right hepatic artery, stanching the bleeding. 48 hours later, the packing is retired. After surgery: Hemoglobine 10 g/dl & liver failure with LDH: 30.000, GPT 4.800 UI/L, Platelets: 88.000. CAT (4th day): right liver necrosis & moderate ascites She stays in Intensive Care Unity for 7 days, having a favourable evolution & goes home 14 days later. Conclusions: Hellp syndrome & liver rupture is a rare but a grave clinical situation, with a high mortality in preeclampsia pregnant women. Keywords: Hellp sindrome, liver rupture Presenter: L. Pilar, J. Cordero

ID 845

Keywords: Late Preeclampsia, prediction

NEURODEVELOPMENTAL OUTCOMES OF PREMATURE NEONATES BORN TO PREECLAMPTIC MOTHERS AT 36TH MONTHS OF AGE

Presenter: E. Meler

I. Tas, T. Gursoy, S. Dırman, N. Erbil, & F. Ovali

ID 923

HELLP SYNDROME & HEPATIC RUPTURE L. Pilar, J. Cordero, P. Sa´nchez-Go´mez, E. Arango, & F.J. Plaza Obstetrics Dept., Hospital universitario Fundacio´n Jime´nez Dı´az. Madrid, Spain Brief Introduction: Spontaneous hepatic rupture is a well recognised but rare condition. Because of the difficulty in diagnosis, it is often associated with a high mortality rate. Pregnant women with Hellp Syndrome are more prone to hepatic rupture. Different modalities of treatment, like liver resection, packing, hepatic artery embolization- ligation and even transplantation are descibed. Materials & Methods: Clinic case Clinical Cases or Summary Results: 38 years old. 31 weeks pregnant. Anxiety & epigastric pain 2 hours long. No Headache, no photopsies. Blood pressure: 170/100. Intrauterine fetal growth restricted Ultrasound: alive fetus. Normal placentae & amniotic liquid. EWF 1300 g. AUIP 1.07 Fetal registration: normal. No contractions. ANALITICS: Hemoglobine 15 g/dl. Platelets 357000. GPT: 67. LDH 69. Proteines/Creatinine rate: 8116. In the first 30 minuts, the epigastric pain gets stronger. She vomits twice & gets agitated.. Doesn’t get better with intravenous theraphy. Blood pressure similar. Betametasone im, Labetalol 10mg, & Magnesium sulphate are prescribed



Neonatal Intensive Care Unit, Zeynep Kamil Maternity and Children’s Research and Training Hospital, Istanbul, Turkey Brief Introduction: Preeclampsia, one of the main reasons of preterm birth, is a major cause of maternal, fetal and neonatal morbidity and mortality, and can also cause neurodevelopmental problems. The aim of this study was to evaluate the impact of preeclampsia on the neurodevelopment of very low birth weight infants. Materials & Methods: Babies born to preeclamptic mothers and who were younger than 32 weeks of gestation were enrolled in the study group. The control group consisted of babies whose birth weight and gestational age are matched with the study group, however, their mothers did not have any preeclampsia. All the babies were born in Zeynep Kamil Maternity and Children’s Training and Research Hospital between January 2008 and December 2009. Antenatal and prenatal history, laboratory results, clinical course, morbidity were recorded retrospectively. Neurological examination and Bayley neurodevelopmental test was performed to all babies when they reach 3 years of age. Clinical Cases or Summary Results: Sixty four babies were included in the study. Thirty six babies were in the study, and 28 babies were in the control group. Early morbidity and neurodevelopmental outcome did not differ between the groups. However, white blood cell count, absolute neutrophil count and discharge weight percentile was statistically significantly lower in the study group. Language development scores of girls were than boys. Fifth minute Apgar score positively correlated with the language cognitive development and motor development index scores. All the babies with major neurological deficits detected in neurological examination had abnormal Bayley language development and motor scores. Conclusions: Preeclampsia does not seem to be an additional risk factor over prematurity for neurodevelopment in preterm infants. Babies born to preeclamptic mothers should be followed up taking into account all the potential risks like all other premature babies. It is

358 important to provide the highest physical and developmental potential for these bebies by preventing and/or treating of acute problems in the early phase of life, and using long-term follow-up programs for the long-term sequelae. Keywords: Preeclampsia, prematurity, neurodevelopment, Bayley test. Presenter: F. Ovali

ID 961

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

OBSTETRIC AND PERINATAL OUTCOMES IN PREGNANT WOMEN WITH PREECLAMPSIA

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

The rate of surgical delivery in the comparison group was 52%, while the main group - 87.1% (p50.01), with indications for C-section as follows: severe pre-eclampsia - 75.26% women, severe hypoxia of fetus - 33.3% cases, placental abruption - 2.2%. A direct correlation probability of eclampsia was forecasted in the comparison group: its frequency was 1 case in 1738 deliveries, and the in the core group -1 case per 15044 deliveries (p50. 01). Perinatal mortality in the core group was twice less than in the comparison group (22.0% vs. 56.57%, p50.01), mainly due to the reduction of antenatal mortality (8.8% compared to 37.7%, p50.01). Conclusions: Active management of patients with preeclampsia had significantly improved obstetric and perinatal outcomes in comparison with previous period, prior to the introduction of the new classification and management protocols. Keywords: pre-eclampsia, proteinuria, management of pregnancy, Republic of Moldova, perinatal mortality Presenter: L. Stavinskaya

L. Stavinskaya, U. Tabuica, I. Sagaidac, & G. Paladi Department of Obstetrics and Gynecology State University of Medicine and Pharmacy ‘‘N. Testemiteanu’’ Chisinau, Republic of Moldova Brief Introduction: The classification of hypertension according to WHO was introduced in the Republic of Moldova in the period 2000– 2001, to be considered and followed in Obstetric practice and also the management of pregnancy and childbirth in patients with preeclampsia was reviewed.Active management included early/immediate delivery, the use short-term antihypertensive treatment. In 2010, In Moldova there have been recorded 18.1 cases of preeclampsia/ eclampsia reported to 1000 deliveries, resulting in 13% deaths. Objective:To perform a comparative analysis of major obstetric and perinatal indicators, considering pregnancy outcomes in women with preeclampsia, in the period 1998–2000, before the new classification was introduced and the subsequent years 2001–2009 after the adoption of the WHO classification. Materials & Methods: A retrospective study was conducted, that included 226 cases of pre-eclampsia, registered in the period from 2001–2009 years in the Republican level III Perinatal Center. The comparison group was composed by 106 cases in the period of years 1998–2000. The files were analyzed, taking into consideration the anamnesis, clinical data, laboratory results and ultrasound examinations (proteinuria, liver function tests, coagulation indicators, fundus oculi examination). The management of patients with preeclampsia was conducted based on the following criteria: length of antihypertensive treatment, indications, pregnancy term and mode of delivery. Clinical Cases or Summary Results: The incidence of preeclampsia was 0.5% in the main group and 1.01 in the comparison group. Proteinuria, as the main criterion of preeclampsia, was not detected in 24.7% cases. However, the loss of protein, detected in urine up to 1g was detected in 23.65% women, in 31.8% proteinuria ranged from 1.1 to 3.0g and in 19.85%, it was above 3g in 24 hours. The diagnosis of preeclampsia was given in 41.9% at admission to the hospital considering the level of blood pressure 160/110 mm Hg and above). Also active management has been applied in cases of failure of antihypertensive treatment while maintaining high levels of blood pressure and/or appearance of clinical symptoms of preeclampsia: headache - 88.1% women, epigastric pain - 21.5%, nausea and vomiting -20.4%, visual impairment - 21.5%, and oliguria was detected in 25% cases. High levels of transaminases were detected in 23.6% of women, progressive thrombocytopenia has been observed in patients in 12.9% and in 11.8% other violations of homeostasis were detected. After establishing the diagnosis of preeclampsia in less than 12 hours 39.8% of patients delivered. The pregnancy was prolonged for the period of 12–24 hours in 5.4% of women, for the period of 24–48 hours in one thirds of cases, for 8–10 days in 15.05%. In only 3.2% of analyzed cases expectant management was undertaken, for a period of 2 to 4 weeks, in order to increase the survival rate of infants in the very early stages of preeclampsia, with strict and constant monitoring of the state of the pregnant woman.

ID 162

PREECLAMPSIA AND HELLP SYNDROME – OBSTETRIC PROGNOSIS V. Kuzmin Department Obstetrics and Gynecology, Moscow State University of Medicine and dentistry, Moscow, Russia Brief Introduction: Many investigators consider the HELLP syndrome to be a variant of preeclampsia. The obstetric complication that is frequently misdiagnosed at initial presentation. Materials & Methods: We are selected 185 pregnant women with HELLP syndrome and severe preeclampsia. The physical examination of patients the blood, function of liver, ultrasound. The peripheral smear may reveal spherocytes, schistocytes, triangular cells and burr cells. increase in Bilirubin and lactic dehydrogenase levels. The elevated liver enzyme levels in the syndrome are thought to be secondary to obstruction of hepatic blood flow by fibrin deposits in the sinusoids. The laboratory abnormalities in HELLP syndrome typically worsen after delivery and then begin to resolve by three to four days postpartum. Clinical Cases or Summary Results: This obstruction leads to periportal necrosis and, in severe cases, intrahepatic hemorrhage, subcapsular hematoma formation or hepatic rupture. The thrombocytopenia has been attributed to increased consumption and/or destruction of platelets.Our results of clinical presentation: 90%of patients present with generalized malaise, 65% with epigastric pain, 30% with nausea and vomiting, 31% with headache. Because of the variable nature of the clinical presentation, the diagnosis of HELLP syndrome is generally delayed for an average of eight days. Only two of 14 patients entered the hospital with the correct diagnosis. Because early diagnosis of this syndrome is critical, any pregnant woman who presents with malaise or a viral-type illness in the third trimester should be evaluated with a complete blood cell count and liver function tests. Conclusions: The diagnosis requires the concurrence of hemolysis, elevated liver enzymes, and low platelet count. However, there is obviously still a lack of consensus on the laboratory parameters and their cutoff values used to diagnose. We are examination laboratory diagnostic criteria for HELLP syndrome. Clinical utility of strict diagnostic criteria for the HELLP the use of strict diagnostic criteria in the definition of the HELLP syndrome allows for greater prediction of complication rates. and define the cases that are Eligible to conservative management. Patients with HELLP syndrome who complain of severe right upper quadrant pain, neck pain or shoulder pain should be considered for hepatic imaging regardless of the severity of the

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DOI: 10.3109/14767058.2014.924236

laboratory abnormalities, to assess for subcapsular haematoma or rupture. Patients with HELLP syndrome should be routinely treated with corticosteroids. Keywords: Preeclapcia, HELLP syndrome, pregnancy, complication Presenter: Vladimir Kuzmin

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ID 308

THE CASE OF LIVER TRANSPLANTATION DUE TO MATERNAL HELLP SYNDROME OF NORMAL BLOOD PRESSURE, 2 DAYS PRIOR TO CHECK WITH NORMAL BLOOD TESTS AND URINE ANALYSIS EXCEPT PROTEINURIA AT ADMISSION W. Park1, J. Hwang2, H. Lee2, D. Lee2, S. Hong3*, & S. Na2* 1 Department of Physiology, School of Medicine, Kangwon National University, Chuncheon 200-701, South Korea, 2 Department of Obstetrics and Gynecology, Kangwon National University Hospital, School of Medicine, Kangwon National University, Chuncheon 200-701, South Korea, and 3 Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon 200-701, South Korea * Corresponding author

High Risk Pregnancy Unit, Department of Neurosciences, Reproductive and Dentistry Sciences, Naples Italy Brief Introduction: The relation between maternal blood group and preclampsia have yielded conflicting results in previous studies. The main objective of our case-control study was to find an association and correlation between maternal blood groups and preclampsia. Materials & Methods: In our study we included and analyzed data on 205 preclamptic patients and 205 controls. All the patients were followed in our High-Risk Pregnancy Unit between 2010 and 2013. For each pregnant were collected data about age, anthropometric measurements for calculation of the BMI, information about obstetric anamnesis, complications and any medications taken during pregnancy. In addition to this, we collected also data on maternal diseases in particular diabetes, hypertension, autoimmune disorder, thrombophylia. For the neonatal outcome were collected data on: sex, weight, Apgar scores at 1 and 5 minutes and admission at NICU. So, we analyzed the maternal blood groups and the Resus-factor of both cases and controls. Statistical analysis was carried out by the Statistical Package for Social Sciences (SPSS) Statistics v. 19 (IBM Inc., Armonk, New York, USA). Clinical Cases or Summary Results: In our population 32 cases had zero blood groups against 122 controls. Actually, we had 173 non-zero cases and 84 non-zero controls. So we observed statistical difference between these two groups: p50.0001; cOR (Cl, 95%) 7.8 (4.9–12.5). In addition to this, a statistical difference was observed about Rhesusfactor. Indeed we had 133 RhD-positive in case group against 169 RhD-positive in control group, and 72 cases RhD-negative against 37 controls RhD-negative: p50.0001 cOR (Cl,95%) 2.5 (1.6–3.9). Conclusions: In conclusion, the results of this study suggest a possible association between maternal blood group and preclampsia. The women of zero group and RhD positive has minor probability to develop preclampsia. These findings need to be confirmed in larger studies. Keywords: preclampsia; blood groups; risk factor; Rhesus-factor

Brief Introduction: Liver disease is a rare complication of pregnancy. When it occurs, the results may be tragic for mother and infant. Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome occurs in 0.5%–1.0% of all pregnancies and in 10%–20% of women with pre-eclampsia, but the underlying pathophysiology of disease is poorly understood and the optimal management of complicated HELLP syndrome are unclear. Liver hemorrhage and rupture are unusual, but serious complications of HELLP with an average incidence of 1/45,000. Liver transplantation is regarded as the last choice, in cases in which other techniques fail. Materials & Methods: We report case of liver transplantation of HELLP syndrome. Clinical Cases or Summary Results: It is very rare case because HELLP syndrome was developed of normal blood pressure and 2 days prior to check with normal blood tests and urine analysis except proteinuria at admission. Conclusions: We report a liver transplantation case for complicated HELLP syndrome with a brief review of the literatures. Keywords: HELLP syndrome, liver transplantation, proteinurina, normal blood pressure Presenter: S. Na

ID 771

MATERNAL BLOOD GROUPS AND PRECLAMPSIA: WHICH CORRELATIONS? G. Saccone, M. Di Cresce, L. Sarno, L.L. Mazzarelli, GM. Maruotti, A. Capone, A. Sirico, V. Donadono, R. Saviano, C. Di Donna, A. Giudicepietro, & P. Martinelli

Presenter: G. Saccone

ID 432

APOPTOSIS AS POTENTIAL ASPIRIN TARGETS TO PREVENT PREECLAMPSIA A. Yogi Pramatirta1, P. Nanda Fauziah2, B. Laksono3, S. Rifayani Krisnadi4, A. Deborah Anwar5, J. Mose6, & D. Soefie Retnoningrum7 1

Department of Obstetrics and Gynecology, Faculty of Medicine, Padjadjaran University, Indonesia, 2Department of Biology, School of Life Sciences and Technology, Bandung Institute of Technology, Indonesia, 3Department of Biochemistry and Molecular Biology, Faculty of Dentistry, Padjadjaran University, Indonesia, 4Department of Obstetrics and Gynecology, Faculty of Medicine, Padjadjaran University, Indonesia, 5Department of Obstetrics and Gynecology, Faculty of Medicine, Padjadjaran University, Indonesia, 6Department of Obstetrics and Gynecology, Faculty of Medicine, Padjadjaran University, Indonesia, and 7School of Pharmacy, Bandung Institute of Technology, Indonesia Brief Introduction: Background: Oxidative stress has been reported as a major factor to contribute in endothelial dysfunction in preeclampsia. Embryonic and placental cells are highly sensitive to oxidative stress due to their proliferation. Endothelial cell dysfunction is assumed as a part of wider maternal inflammatory reaction which is associated with the clinical syndrome of preeclampsia. Oxidative stress triggers

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360 placental apoptosis, causing the release of microvillous particles containing oxidized lipids. Lipid peroxides and other oxidatively modified are known to be increased in blood and tissues of women with preeclampsia for many years. Lipid peroxidation can trigger the process of apoptosis. It was thought that aspirin is a potential therapeutic agent to reduce apoptosis in preeclamptic patients. Materials & Methods: Objectives: The aim of this review is to discuss the role of aspirin to prevent apoptosis in preeclampsia. Methods: A systematic review of studies that examines the role of aspirin in preeclampsia. Clinical Cases or Summary Results: The study revealed that low-dose aspirin therapy started before 16 weeks of gestation reduces the incidence and severity of preeclampsia in women identified to be at a moderate or high risk for preeclampsia. The effectiveness of aspirin to prevent preeclampsia might relate to the ability of aspirin in inhibiting lipid peroxide formation. It has been shown that preeclampsia is associated with increased lipid peroxidation in the maternal circulation and in the placenta. Lipid peroxidation is a process where polyunsaturated fatty acids and other lipids are oxidized by intermediate free radicals to form conjugated dienes, lipid hydroperoxides, malondialdehyde (MDA) and many other products. Conclusions: Conclusions: Aspirin is a potential therapeutic agent to reduce apoptosis in preeclamptic patients and it might relate to inhibition of lipid peroxide formation.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Conclusions: This case study indicates timely diagnosed complication of hypertensive syndrome in pregnancy and timely conducted therapy, multidisciplinary approach to pregnancy monitoring completed by Cesarean section close to the term and with the delivery of a healthy newborn. Keywords: pregnancy, preeclampsia, Cesarean section Presenter: Z. Tatic-Stupar

ID 522

TOP RESEARCH PRIORITIES FOR PRETERM BIRTH IN THE UK: PRIORITY SETTING WITH SERVICE USERS AND HEALTH CARE PROFESSIONALS

Keywords: apoptosis, aspirin, oxidative stress, preeclampsia

S. Uhm1,2, F. Alderdice3, I. Brady4, B. Chambers1, Z. Chivers5, S. Crowe6, A.L. David7, S. Deshpande8, C. Gale9, G. Gyte10, C.P. James7, L. Duley11, J. McNeill3, A. Shennan12, M.A. Turner13, & S. Oliver1

Presenter: A. Yogi Pramatirta

1

ID 179

PREECLAMPSIA: ONE OF THE INDICATIONS FOR CESAREAN SECTION Z. Tatic-Stupar1, M. Bogavac1, D. Stajic1, & S. Milosevic1 1

University of Novi Sad, Medical Faculty, Clinical Centre of Vojvodina, Department of Obstetrics and Gynecology, Novi Sad, Serbia Brief Introduction: Preeclampisa is a serious complication of pregnancy, characterized by increase of blood pressure with manifestations on both mother and fetus. Delivery in pregnancy complicated with preeclampsia demands special treatment due to risk of maternal and fetal morbidity and mortality, and Cesarean section (SC) is performed according to obstetric indications. The Aim of this study was to present a case of successfully completed pregnancy complicated with preeclampsia, with repeated Cesarean section in 36 week of gestation (WG), due to symptoms of preeclampsia and previous Cesarean section. Materials & Methods: Medical documentation of a patient with her prior consent was used in this case study. Clinical Cases or Summary Results: Pregnant women aged 33 years, was admitted to our clinic with 36 weeks of gestation for observation and determination of the end time of pregnancy, due to preeclampsia complicated pregnancy and previous SC due to preeclampsia. The current pregnancy was from the very beginning followed by high blood pressure for which she was taking antihypertensive therapy. At admission to our hospital, she had a sensation of rapid heartbeat, fatigue, headache and nausea. Due to the subjective problems, headache, nausea, pain in the epigastrium and a jump in blood pressure and given obstetric history (previous SC) it was decided on the surgical completion of pregnancy. Cesarean section was performed at the spot of the previous SC. We performed uterine incision technique by Cohen and extracted a vital newborn with Apgar score of 8/8. The uterus was sutured with continuous suture in two layers.The postoperative course was uneventful.The patient was discharged four days after the operation.

Institute of Education, University of London, London, United Kingdom, 2Kookmin University, Seoul, South Korea, 3TinyLife – the premature baby charity for Northern Ireland, Carryduff, United Kingdom, 4Irish Premature Baby, 5Bliss – the premature and special care baby charity, London, United Kingdom, 6James Lind Alliance, 7UCL Institute for Women’s Health, London, United Kingdom, 8British Association of Perinatal Medicine, London, United Kingdom, 9Imperial College, London, United Kingdom, 10National Childbirth Trust, 11 Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom, 12Kings College London, London, United Kingdom, and 13Liverpool Women’s NHS Foundation Trust, Liverpool, United Kingdom Brief Introduction: Preterm birth is the most important determinant of adverse infant outcomes including survival, quality of life, psychosocial impact on the family, and healthcare costs. Research agendas in this area have been determined primarily by researchers. The aim was to identify and prioritise future research areas in preterm birth that are most important to service users and practitioners. Materials & Methods: A priority setting partnership was established with: families with experience of preterm birth and organisations representing them, obstetricians, neonatologists, midwives, neonatal nurses, and other relevant health care professionals. Research uncertainties were gathered from surveys of service users and healthcare practitioners, and analyses of systematic reviews and clinical guidance. Priorities were set through on-line voting and paper surveys, and further distilled in a facilitated workshop, as advocated by the James Lind Alliance. Clinical Cases or Summary Results: Eliciting research suggestions from all types of stakeholders required extensive networking. 593 uncertainties were submitted by 386 respondents (58% service users, 30% healthcare professionals and 12% from those in both roles); 52 were identified from literature reviews. After merging similar questions, 104 were distributed for voting. From the 30 most popular uncertainties, the top 15 questions were prioritised in a facilitated workshop of service users and clinicians. These include prevention and prediction of preterm birth, neonatal infection, lung damage, necrotising enterocolitis, pre-eclampsia, preterm premature rupture of the membranes, optimal neonatal feeding strategy, pain perception and management, a care package at neonatal discharge, emotional and practical support, attachment and bonding, and the best time for cord clamping.

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DOI: 10.3109/14767058.2014.924236

Conclusions: These 15 top priorities provide guidance for researchers and funding bodies to ensure that future research addresses questions that are important to service users and to clinicians. Challenges for the priority setting partnership included maximising participation amongst people most affected by preterm birth; the breadth of the topic; and securing input from an appropriate range of clinicians. Keywords: priority setting, preterm birth Presenter: Bev Chambers

ID 619

CORTICOSTEROIDS AND FETAL HEART RATE VARIABILITY

Keywords: corticosteroids, fetal heart rate variability

K. Verdurmen , J. van Laar , & S. Oei

Presenter: Kim Verdurmen

1 The Department of Obstetrics & Gynaecology, Ma´xima Medical Centre, Veldhoven, the Netherlands

ID 057

1

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were no significant differences between the subgroups (growthretarded fetuses, preterm onset of labour, preeclampsia and placenta previa). In Figure 1, an overview of the effects of corticosteroids on fetal heart rate and fetal heart rate variability is shown, combined with the proposed mechanisms of action. Conclusions: Following maternal corticosteroid administration, fetal heart rate and fetal heart rate variability show a biphasic course. The ‘‘pharmacological’’ decrease in fetal heart rate variability, combined with a decrease in fetal body and breathing movements, can be misinterpreted as fetal distress, causing unnecessary iatrogenic preterm delivery. With fetal heart rate variability being an upcoming field in perinatal monitoring, clinicians should be aware of these sideeffects.

1

1

Brief Introduction: Corticosteroids are used daily in the management of threatened preterm delivery worldwide. It is known that they have a direct, transient effect on fetal heart rate parameters. Since fetal heart rate variability is a promising new field in fetal monitoring, it is important to interpret the changes in fetal heart rate parameters during corticosteroid treatment correctly, in order to avoid unnecessary iatrogenic preterm delivery. Materials & Methods: We performed a systematic review of the literature in CENTRAL, PubMed and EMBASE. We included studies that describe the influence of corticosteroids (betamethasone and dexamethasone) on fetal heart rate variability, assessed by computerised analysis. Our initial search revealed 37 reports, of which 15 were included in this review. A total of 538 fetuses were described. Data abstraction and quality assessment were performed independently by two authors. In all studies, day 0 is defined as the ‘‘control day’’, before administration of corticosteroids. All values measured on subsequent days are compared with the baseline value, measured on day 0. Clinical Cases or Summary Results: Nearly all studies show a biphasic change in fetal heart rate parameters after administration of corticosteroids (Table 1). Mean fetal heart rate decreases during day 1, whereas there is an increase during days 2–3. On the contrary, fetal heart rate variability shows an increase during day 1, and a decrease during days 2–3. Although dexamethasone is less well studied compared to betamethasone, most studies found comparable results. Furthermore, body and breathing movements of the fetus were significantly reduced during day 1 and 2 after betamethasone administration. All values returned to baseline during day 4. There

IMPACT OF FETAL CARRIAGE OF TLR4 (896A4G, 1196C4T) GENE POLYMORPHISMS ON THE RISK OF PREMATURITY IN THE POLISH POPULATION – PRELIMINARY REPORT J. Kalinka & A. Bitner Department of Perinatology, First Chair of Gynecology and Obstetrics, Medical University of Lodz, Lodz, Poland Brief Introduction: Preterm birth (PTB) is a worldwide health problem responsible for the majority of newborns morbidity and mortality. It is believed that intrauterine infection is one of the most significant causes of PTB. Gram-negative bacteria which enter amniotic cavity activate Toll Like Receptors 4 (TLR4) expressed in decidua, chorion, and amnion. Activation of TLR4 leads to prostaglandin production and to onset and maintenance of preterm labor. Different genetic variants of TLR4 can interact with gram-negative bacteria in different manner and thus influence the risk of prematurity. The aim of the study was to evaluate for the first time the impact of fetal carriage of TLR4 gene polymorphisms (896A4G, 1196C4T) on the risk of PTB in the Polish Population. Materials & Methods: Genetic variants of TLR4 gene were determined in 49 term newborns and 35 newborns who were born before 37 week of gestation. Polymorphisms were determined with the use of PCR-RFLP. Genotype frequencies in the study and control groups were compared using an exact logistic regression model. Analysis was used to estimate the OR and its 95% confidence intervals. Clinical Cases or Summary Results: We have noticed differences in frequency of TLR4 polymorphic alleles between term and preterm newborns. Polymorphic 896G allele was two times more frequent among term newborns than among preterm newborns (20.5% vs 10%), OR = 0.43(95% CI:0.09–1.61). Polymorphic 1196T allele was three times more frequent among term newborns than in preterm newborns (18% vs 6%), OR = 0.27 (95% CI:0.04–1.14). However, our results did not obtain statistical significance probably because of a relatively small sample size. Conclusions: Base on the results of these preliminary study it seems that further studies performed on larger and genetically disparate populations are necessary to estimate the impact of fetal carriage of TLR4 variants on the risk of prematurity. Results of such studies allow better understanding of mechanisms leading to PTD and in future can be utilize in diagnosis and management of PTD. Keywords: TLR4, gene polymorphisms, 896A4G, 1196C4T, preterm birth Presenter: J. Kalinka

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ID 514

PROPRANOLOL EYE DROPS FOR TREATMENT OF RETINOPATHY OF PREMATURITY: PHARMACOKINETICS AND LOCAL SAFETY PROFILE IN RABBITS

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

L. Filippi1, L. Padrini1, M. Daniotti1, C. Amador1, E Laudani1, B. Isacchi2, A.R. Bilia2, A. Pini3, E. Masini4, M.L. Della Bona5, & G.P. Donzelli1 1 Medical Surgical Fetal-Neonatal Department, ‘‘A. Meyer’’ University Children’s Hospital, Florence, Italy, 2Department of Chemistry, University of Florence, Florence, Italy, 3Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy, 4Department of Neurosciences, Psychology, Pharmacology and Child Health (NEUROFARBA), University of Florence, Florence, Italy, and 5Department of Pediatric Neurosciences, ‘‘A. Meyer’’ University Children’s Hospital, Florence, Italy

Brief Introduction: Recent animal studies have demonstrated that propranolol is able to reduce the progression of oxygen-induced

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

retinopathy (OIR), a worldwide used model for Retinopathy of Prematurity (ROP). Following these observations, two independent prospective pilot trials demonstrated that oral propranolol administered in preterm newborns with ROP is effective in counteracting the progression of the disease, but it appeared unsafe. Topical propranolol was demonstrated to cross the cornea and reach the periocular tissues in rabbits or the retina of mice with OIR, drastically reducing their retinal neovascularization. This study aimed to find, in rabbits, a propranolol eye drops concentration able to induce lower plasma but higher retinal concentrations than those obtained after oral administration. Materials & Methods: In order to analyze trans-corneal kinetics of propranolol eye drops at different concentrations, and to obtain information useful to choose the concentration for chronic administration, a preliminary experiment performed on male New Zealand white rabbits compared propranolol concentrations in plasma and aqueous humor after the application of a single eye drop at the 1, 0.5 and 0.1% concentrations. Rabbits were then treated with oral propranolol (0.25 mg/kg/6 hours) for 5 days, and propranolol concentrations were measured after 1, 2, 3 and 6 hours in plasma, aqueous humor, vitreous humor and retina. These concentrations were compared with those obtained after the administration of one drop of 25 mL of propranolol 0.1% prepared in saline, topically applied every 6 hours to both eyes for 5 days. A Draize eye test and histological analyses were performed to assess propranolol eye drops 0.1% tolerability. Clinical Cases or Summary Results: Only the administration of a single eye drop at 0.1% concentration produced plasma concentrations significantly lower than those observed after 1 and 0.5% administration, and this concentration was chosen for chronic application. The administration of propranolol eye drops 0.1% produced retinal concentrations similar, but plasma concentrations significantly lower (p50.01) than those measured after oral administration (Figure 1). Draize test showed no appreciable alterations between control and treated (with propranolol or saline) eyes. Regarding histological analysis, no differences were detected between the corneas or the retinas of control and treated rabbits (Figure 2). Conclusions: Propranolol eye drops 0.1% are able to ensure high retinal and low plasma concentration of propranolol, with excellent local tolerability profile. This finding opens the perspective of possible topical treatment with propranolol in newborns with retinopathy of prematurity. Keywords: preterm newborn, retinopathy of prematurity Presenter: Luca Filippi

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ID 493

NEONATAL PHYSIOLOGICAL CORRELATES OF NEURODEVELOPMENT AT 18–22 MONTHS IN VERY-LOW-BIRTHWEIGHT PRETERM CHILDREN Jessica Rose, PhD1,2, Katelyn Cahill-Rowley, PhD1,2,3, Rachel Vassar, PhD1, John Tamaresis, PhD4, Susan R. Hintz, MD4, & David K.. Stevenson, MD4

ID 011

A COMPARISON BETWEEN NIFEDIPIN AND INDEMETHACIN FOR THE TREATMENT OF PRETERM LABOR AND THEIR SIDE EFFECTS B. Zolali Iran

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1

Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford CA, 2Motion Analysis Lab, Lucile Packard Children’s Hospital, Stanford CA, 3Department of Bioengineering, Stanford University, Stanford CA, and 4 Division of Neonatal & Developmental Medicine Stanford University School of Medicine, Stanford CA Brief Introduction: This study examined neonatal physiological risk factors in relation to neurodevelopment at 18–22 months in verylow-birth-weight (VLBW) preterm children. We hypothesized that preterm infants exposed to neonatal inflammatory risk factors would demonstrate lower neurodevelopment based on BSID-III and gait scores at 18–22 months. Materials & Methods: 102 VLBW preterm neonates (BW  1500g, gestational age (GA)  32wks) admitted to the NICU were recruited to participate from 2010–2011. Neonatal physiological risk factors examined included GA at birth, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), retinopathy of prematurity (ROP), and sepsis, as well as serum levels of C-reactive protein (CRP), albumin, and total bilirubin during the first two weeks of life. Neurodevelopment was assessed at 18–22 months adjusted age with the Bayley Scales of Infant-Toddler Development, 3rd edition (BSIDIII). Gait velocity and% single limb support (SLS) were assessed using a GAITRite mat. Collinearity was estimated by calculating variance inflation factors (VIF). Two-tailed significance was defined as p50.05. Clinical Cases or Summary Results: Among the 102 neonates, BW was 1087 ± 279g, GA-at-birth was 28.7 ± 2.4 wks. The mean GA of children was lower in those with580 BSID-III cognitive (p = 0.029) and motor (p = 0.034) composite scores. Mean BSID-III cognitive composite scores were lower in children with neonatal BPD (91.7 ± 11.6 versus 97.6 ± 12.6, p = 0.013). Lower BSID-III cognitive composite scores correlated with higher neonatal mean and peak serum CRP (Rho = 0.298, p = 0.008; Rho = 0.325, p = 0.002), respectively. Lower BSID-III motor composite and fine-motor scores correlated with higher mean CRP (Rho = 0.264, p = 0.013; Rho = 0.292, p = 0.008) and peak CRP (Rho = 0.275, p = 0.009; Rho = 0.262, p = 0.013), respectively. Slower gait velocity correlated with higher mean and peak CRP (Rho = 0.298, p = 0.008; Rho = 0.279, p = 0.013). Higher mean and peak CRP correlated with lower serum albumin (Rho = 0.338, p = 0.001; Rho = 0.398, p = 0.000). Lower BSID-III motor composite score correlated with lower neonatal mean serum albumin (Rho = 0.262, p = 0.013) and to higher serum bilirubin (Rho = 0.230, p = 0.029). Risk factors analyzed were found to be noncollinear (VIF510). Conclusions: Low to moderate associations found between neonatal inflammatory risk factors in relation to neurodevelopment and gait at 18–22 months of age suggest associations between early neurodevelopmental outcomes and biomarkers including neonatal BPD, CRP, albumin, and bilirubin warrant further investigation. Preliminary analysis of this ongoing research may offer neonatal clues that may ultimately inform neuroprotective treatment to improve neurodevelopment and quality of life for preterm children. Keywords: preterm infant, risk factors, bronchopulmonary dysplasia, neurodevelopment Presenter: Jessica Rose and Rachel Vassar

Brief Introduction: Preterm labor is one of the most serious obstetrics problems and is the most common cause of neonatal mortality. Finding an effective treatment with least adverse effects is always under serious concern. The purpose of the present study is to compare the efficacy of 2 tocolytic agents of nifedipin and indomethacin for the treatment of preterm labor and their complications. Materials & Methods: Study was conducted as a randomized clinical trial on 79 pregnant women who were admitted with labor pains at 26–33 weeks of gestation. The women were randomly assigned into 2 groups. In the nifedipine group (40 cases), oral nifedipine, and in the indomethacin group (39 cases), indomethacin was administered rectally. The women were then evaluated for the response to treatment over the next 2 hours, and how delivery was delayed for 48 hours and 7 days and drug’s adverse effects. All women were monitored up to delivery as well as the interval between drug administration and delivery. Clinical Cases or Summary Results: 2 groups did not show any significant difference according to maternal age, gestational age, cervical dilatation, effacement and consistency. 23 cases (59%) in the indomethacin group, and 10 cases (25%) in the nifedipine group did not respond to treatment (p = 0.002). Neither the 16 remaining women in the indomethacin group nor the 30 women of the nifedipine group delivered during the next 48 hours. 1 woman (6.25%) in the indomethacin group and 4 women (13.3%) in the nifedipine group delivered between 48 hours- 7 days with no significant difference. Mean gestational age at the time of delivery (for the women who responded to treatment during the first 2 hours) was 238.5 ± 19.4 days and 246. 4 ± 15.4 days in the nifedipine and indomethacin groups respectively, which did not show any significant difference (p = 0.182). 17 cases (42.5) of nifedipine group and 11 cases (28.2%) of indomethacin group showed some adverse effects (p = 0.184). Conclusions: Indomethacin was less effective than nifedipine for the fast treatment of preterm labor, but in women who responded to treatment during 2 hours, delaying of delivery was similar to nifedipine. Keywords: Presenter: B. Zolali

ID 005

THE ASSOCIATION BETWEEN AMNIOTIC FLUID IL-6 CONCENTRATION AND PREGNANCY OUTCOME IN

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WOMEN WITH CERVICAL INSUFFICIENCY A. Martı´nez-Varea, A. Perales-Puchalt, A. Diago-Almela, & A. Perales-Marı´n

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Department of Obstetrics and Gynaecology. Hospital Universitario y Polite´cnico La Fe (Valencia, Spain) Brief Introduction: The aim of this study is to determine the amniotic predictor of good prognosis with the highest predictive value in patients with cervical insufficiency and bulging membranes. Materials & Methods: Cohort study with all pregnant women with bulging membranes who were admitted into our hospital between June 2009 and January 2013. Patients underwent an amniocentesis to quantify amniotic glucose, leukocytes, IL-6 and leukocyte esterase levels and for microbiological culture. All patients without intraamniotic inflammation or subclinical chorioamnionitis were proposed to receive a physical examination-indicated cervical cerclage. Those who did not accept the procedure underwent bed rest. Clinical Cases or Summary Results: 23 women enrolled.Median gestational ages at diagnosis and delivery:22 + 6(20 + 5–25 + 6) and 25(21 + 4–34)weeks.Median interval until delivery:11(2–61)days.IL6:the highest diagnostic accuracy for having a good prognosis.2.90ng/mL:best cut-off point(sensitivity88.9%, specificity100%). Patients with IL62.90ng/mL. Conclusions: Amniotic fluid IL-6 is an excellent predictor of the outcome of pregnancies with cervical insufficiency and bulging membranes. Keywords: Presenter: A. Diago-Almela

2009 to June 2010. Patients presenting or transferred to the birth suite with symptoms of preterm labour between 24 + 0/40 and 33 + 6//40 with live pregnancy were eligible for inclusion in the study. Exclusion criteria included ruptured membranes, placenta praevia, dilatation greater than 3cm or cervical cerclage insitu. Use of QuickChek fFN was dependent on availability. Primary outcomes were use of antenatal corticosteroids, tocolysis, hospital admission and ultrasound of cervix length. Secondary outcomes were gestation at delivery, birth weight and admission of baby to NICU/SCN as a reflection of neonatal outcome. Additional data recorded for each woman included maternal age, gestation at presentation, gravidity and parity, origin of patient (local or transfer), gestation at delivery, birth weight, apgars at 1 and 5 minutes, cord pH and mode of delivery. Clinical Cases or Summary Results: Use of the fFN test changed the management of patients presenting with symptoms of preterm labour. All patients who presented and did not have the test performed were admitted to hospital for observation (n = 47/47) compared to only 50% (n = 24/48) who had the test performed. Differences also occurred in use of steroids (93% vs. 41%), tocolysis (89% vs. 37%) and ultrasound (87% vs. 54%). Each of these was statistically significant. Use of the test did not increase admission rates to NICU/SCN. Conclusions: Use of fetal fibronectin in assessment of women presenting with symptoms of preterm labour showed a statistically significant decrease in rates of antenatal corticosteroids, use of tocolysis, hospital admission and ultrasound scan assessment of cervix length, irrespective of test result. There was no statistically significant differences in rates of babies being admitted to NICU/SCN, birth weight or gestation at delivery. This study has shown that using fetal fibronectin in the assessment of women with symptoms of preterm labour does result in a decrease in interventions without increasing perinatal morbidity. Keywords: fetal fibronectin, preterm labour Presenter: Natasha Frost

ID 227

INTRODUCTION OF FETAL FIBRONECTIN IN A TERTIARY OBSTETRIC UNIT

ID 864

N. Frost Obstetrics and Gynaecology, Townsville Hospital, Townsville, Australia. Brief Introduction: Preterm delivery is a significant cause of perinatal morbidity and mortality. The Townsville Hospital has approximately 2500 deliveries per year and is the tertiary referral centre for an area that extends from Mackay north including Thursday Island and west to Northern Territory border. Townsville Hospital has the only tertiary level Neonatal Intensive Care Unit outside of Brisbane meaning a large number of preterm deliveries occur here and a larger number of patients are assessed with symptoms of threatened preterm labour to justify a review of the implementation of fetal fibronectin (fFN). Materials & Methods: Study was a prospective cohort study at Townsville Hospital, Queensland over a 12 month period from June

fFN Used

RISK FACTORS FOR CEREBRAL PALSY IN PRETERM INFANTS – A POPULATION BASED STUDY T. Thorkelsson1,2, H. Kristinsdottir1, M. Halldorsdottir1, O. Thorarensen1,2, & S. Sigurdardottir2,3 1

Neonatology Dept. Childrens’ Hospital Iceland, Reyjavik, Iceland, 2University of Iceland, Faculty of Medicine, Reykjavik, Iceland, and 3The State Diagnostic and Counseling Center, Kopavogur, Iceland. Brief Introduction: The prevalence of cerebral palsy (CP) is higher in preterm than term infants. In order to decrease the prevalence of CP in preterm infants and thus improve their long term outcome, it is important to identify perinatal and neonatal risk factors for CP. The objective of the study was to determine the prevalence and risk factors for CP in preterm infants in Iceland.

fFN Not Used

Number of % of Number of % of Relative 95% Confidence Patients Patients Patients Patients Risk Interval p Value Corticosteroids Tocolysis Hospital admission Ultrasound for cervix length

20/48 18/48 24/48 26/48

41.7% 37.5% 50.0% 54.2%

44/47 42/47 47/47 41/47

93.6% 89.4% 100.0% 87.2%

0.445 0.42 0.5 0.621

0.316–0.627 0.287–0.613 0.377–0.663 0.468–0.823

50.001 50.001 50.001 0.001

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DOI: 10.3109/14767058.2014.924236

Materials & Methods: This was a case-control study. All children in Iceland diagnosed with CP, born at 536 weeks gestation from 1990– 2010 (n = 94) were included in the study. For each CP infant, two controls were identified, matched on gestational age and year of birth (n = 188). Information on possible risk factors was obtained from medical records, whereas the diagnosis of CP was based on physical examination. Clinical Cases or Summary Results: The prevalence of CP among preterm infants in Iceland during the study period was 19.9 per 1000 live born. Multivariate analysis revealed significant association with intracranial hemorrhage (OR 13.3; 95% CI 5.8–30.2), 1 minute Apgar 56 (OR 3.1; 95% CI 1.8–5.2), multiple births (OR 1.91; 95% CI 1.1–3.3) and prenatal steroid administration (OR 0.57; 95% CI 0.33–0.97). Postnatal steroid administration was not associated with CP (16% in both groups; p = 0.98). Conclusions: Multiple births, depression at birth and intracranial hemmorhage are independent risk factors for CP in preterm infants, whereas prenatal steroid administration is protective. Postnatal steriod use, in order to decrease the severity of lung diseases in preterm infants, does not appear to increase their risk of developing CP. Keywords: preterm infants, newborn, cerebral palsy, risk factors Presenter: Thordur Thorkelsson

ID 508

BACTERIAL CERVICAL INFECTION AND THE LEVEL OF SERUM OF IL1 B IN PATIENTS WITH SYMPTOMS OF IMMINENT PRETERM DELIVERY M. Bogavac1, S. Brkic2, D. Celic3, & D. Stajic1 1

Faculty of Medicine, University of Novi Sad, Clinical Centre of Vojvodina, Department of Obstetrics and Gynecology, Novi Sad, Serbia, 2Faculty of Medicine, University of Novi Sad, Clinical centre of Vojvodina, Clinic for infectious diseases, Novi Sad, Serbia, and 3Faculty of Medicine,University of Novi Sad, Clinical Centre of Vojvodina, Department of Nephrology and Clinical Immunology, Novi Sad, Serbia Brief Introduction: Preterm delivery is a major problem in obstetrics and is associated with high mortality and morbidity worldwide. The etiology of preterm deliveries is very complex. Several biochemical markers associated with ascending inflammation, specifically vaginitis, cervicitis, and chorioamnionitis in preterm labor have been reported for predicting preterm delivery. Bacterial infection-associated with inflammation is thought to be the major cause of preterm premature rupture of membranes. Proinflammatory cytokines, such as interleukin 1B (IL1B), can weaken fetal membranes (FM) by upregulating matrix metalloproteinases and inducing apoptosis Materials & Methods: The aim of the study was to determine level of IL1 b pro-inflammatory cytokine in pregnant women with signs of preterm labor, according to the presence of local cervical infections. 60 pregnant women (from 24 to 32 weeks of gestation) were divided into two groups: the study group-patients with clinical symptoms of imminent preterm delivery (No-30) and the control group – healthy pregnant women (No-30). The level of proinflammatory cytokine IL1 b in the serum was measured by ELISA test. Clinical Cases or Summary Results: The following microbes from the study group were identified: Candida sp. in 2 (6.67%), Escherichia coli in 3 (10.00%), Enterococcus in 2 (6.67%), Staphylococcus sp. in 1 (3.33%), and Streptococcus agalactiae in 2 (6.67%) pregnant women. 20 (66.67%) of pregnant womens from the study groups were without infection. IFN- g was detected in the study group in 30% of cases and in 15% of patients from the control group.

Conclusions: Bacterial cervical infection is an important risk factor for preterm delivery. Results of this study suggest that in pregnant women with bacterial cervical infection and symptoms of imminent preterm delivery the serum level of IL1 b is significantly increased. Therefore, screening of cervical bacterial infection and the level of IL1 b in patients with symptoms of imminent preterm delivery can be very important in prevention of preterm delivery. Keywords: preterm delivery, bacterial infection, proinflammatory cytokines Presenter: M. Bogavac1

ID 667

THE IMPACT OF INTRAUTERINE INFECTION ON FETAL BRAIN DAMAGE AND THE PREVENTIVE EFFECTS OF NEUTROPHIL ELASTASE INHIBITOR ASSESSING BY S100B CONCENTRATIONS IN UMBILICAL ARTERIES N. Masaoka, Y. Nakajima, M. Morooka, M. Watanabe, H. Tashiro, M. Wada, & K. Maruta Department of Obstetrics and Gynecology, Tokyo Women’s Medical University Yachiyo Medical Center, Chiba, Japan. Brief Introduction: Objective: to assess the impact of intrauterine infection on fetal brain damage by measuring S100B protein concentrations in umbilical cord arteries as marker of brain damage and study the transplacental effect of Neutrophil elastase inhibitor (NEI) to prevent fetal brain damage in a sheep model of intra-amniotic infection(IAI) induced by Lipopolysaccharide (LPS) injected into the intra-amniotic compartment. Materials & Methods: (1) In the intra uterine infection cases determined pathologically of 30 deliveries (Group I) and non infection cases of 35 deliveries as the control (Group C), we compared the Fetal heart rate monitoring during labor, Apgar score, umbilical artery pH and S100B protein concentrations in umbilical arteries. (2) In the IAI models we measured maternal and fetal blood concentration of cytokines (IL-6, IL-8 and TNFa) chronologically before and after NEI administration through the maternal circulation. Clinical Cases or Summary Results: (1) There was no significant difference between two groups in Apgar score, umbilical artery pH. (2) S100B protein concentrations in umbilical cord arteries in Group I was significantly higher than those of Group C (3.97 ± 0.66 vs. 1.89 ± 0.56 mg/l p50.05). (3) IL-6, IL-8 and TNFa concentration in maternal blood were suppressed significantly by NEI administration via the maternal circulation. Conclusions: Higher concentration of S100B protein in Group I suggest that intrauterine infection itself has an important role on fetal brain damage and the NEI administration might suppress the production of cytokines resulting from intrauterine infection that cause fetal brain damage. Keywords: fetal brain damage, intrauterine infection, neutrophil elastase inhibitor, S100B, Presenter: N. Masaoka

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ID 641

ID 110

"FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING’’ (FEES) AS A METHOD OF DIAGNOSING ASPIRATION IN PREMATURE BABIES

RETROSPECTIVE AUDIT COMPARING MORBIDITY AND MORTALITY OUTCOMES OF PRETERM INFANTS ASSIGNED TO TWO-HAEMOGLOBIN THRESHOLD POLICES FOR BLOOD TRANSFUSIONS

S. Vetter-Laracy1, A. Roca Jaume1, B. Osona Rodrı´guez de Torres2, F. Mohr1, PR. Balliu Badia1, & J. Figuerola Mulet2 1

Paediatric Department, Section of Neonatology, University Hospital Son Espases, Palma de Mallorca, Spain, and 2 Paediatric Department, Section of Paediatric Respiratory Medicine, Hospital Son Espases, Palma de Mallorca, Spain J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Brief Introduction: Swallowing disorders which lead to aspiration are considered a reason for desaturation during feeding in premature infants with a corrected gestational age (CGA) of 435 weeks. There are various methods to investigate such dysphagia and the videofluoroscopic method is considered the Gold Standard. In adults, FEES (Fiberoptic Endoscopic Evaluation of Swallowing) is used for swallowing disorders. Several studies have proved it to be of equivalent diagnostic value as the videofluoroscopic method. As there is insufficient data on the use of FEES on prematures, the objective of this review was to try to assess the viability of its use for diagnosing aspiration in premature infants and to evaluate the efficacy of suggested treatments. Materials & Methods: A retrospective review was carried out from March 2006 to October 2012. 68 prematures with a median gestational age (GA) of 28 + 3 weeks [Q1-Q3 26–31 + 4] underwent FEES as aspiration was suspected during feeding. Demographic and clinical data were recorded from the patient’s clinical reports. Endoscopy findings related to aspiration were recorded. The FEES result was related to suspected swallowing disorders, desaturations during feeding and to demographic data. The efficacy of the recommended treatment was evaluated by the subjective clinical observations of the nursing staff and by recording desaturations 7 days before and 7 days after FEES. Clinical Cases or Summary Results: 38 (55.9%) of 68 prematures with a median CGA of 40 + 1 weeks, were diagnosed with aspiration. 25 (36.8%) were submitted to FEES because of a suspected swallowing disorder, 39 (57.4%) because of desaturations during feeding and 4 (5.8%) due to other causes. 68% of the cases with ‘‘swallowing disorders’’ indication presented aspirations during the test and 51.3% with the indication ‘‘desaturations’’. There was no relation between demographic data and the time without a nasogastric tube or orotracheal tube with the test results. The accumulation of saliva and penetration were related to aspiration (p = 0.003 y p50.001). Of the 70.5% of patients which received therapeutic advice, 42.6% had a thickener added to the feeding, 11.8% received anti-reflux treatment and 10.2% a combined treatment. 5.9% avoided swallowing because of gastrostomy. In 63%, treatment was evaluated by the staff as being positive. Treatment with thickener was evaluated subjectively as being effective in 83% of cases. In addition, adding thickener significantly reduced desaturations (p = 0.043). Conclusions: FEES is a useful method for routine diagnosis of swallowing disorders in premature infants. The recommended treatments are based in the results of the FEES and are generally effective in reducing the risk of aspiration. Keywords: Fiberoptic endoscopic evaluation of swallowing, videofluoroscopy, swallowing disorder, premature infant Presenter: Susanne Vetter-Laracy

T. Whitby, D. Hawkness, G. Whitton, P. Martin, & H. Ibrahim Department of Neonatology, Liverpool Women’s NHS Foundation Trust, Liverpool, UK Brief Introduction: There is considerable variation in neonatal transfusion practice in the UK. There is considerable controversy about the ‘‘trigger’’ points for transfusion in preterm babies. Red blood cell (RBC) transfusions are associated with significant complications and hence it is essential to rationalise transfusion in infants. New transfusion guidelines largely based on the PINT trial were instituted at the Liverpool Women’s Hospital (LWH) in 2011 (Table 1). The aim of the study was to determine if the new RBC transfusion policy lead to a significant differences in the number of blood transfusions, morbidity or mortality in preterm infants. Materials & Methods: A retrospective data analysis was undertaken on infants cared for at LWH before (2010-n = 104) and after (2012-n = 104) institution of the new guidelines. Information was collected on the number of transfusions, weight gain, duration of respiratory support and survival to discharge. The morbidities recorded were chronic lung disease, retinopathy of prematurity, necrotising enterocolitis, intraventricular haemorrhage (incidence and grade) and periventricular leukomalacia. Clinical Cases or Summary Results: Groups were comparable in birthweight (median1145g v/s1085g), gestational age (median 28.5 weeks v/s 28 weeks). With the introduction of the new policy there was a trend towards more infants being transfused but the difference did not reach statistical significance. There was no statistically significant difference in the median number of transfusions per infant, weekly weight gain, incidence of CLD, ROP, IVH, PVL or survival to discharge. Conclusions: The 2012 transfusion policy has been shown to be safe to use in clinical practice, as it has lead to no statistical significant increase in the number of RBC transfusions or in the increase in short term infant morbidity or mortality. Keywords: Preterm, blood transfusion Presenter: Dr T M Whitby

367

DOI: 10.3109/14767058.2014.924236

ID 742

ID 087

INTESTINAL MICROBIOTA EVOLUTION IN PRETERM INFANTS

OUTCOME AT 4-YEAR-OLD CHILDREN BORN BEFORE 29 WEEKS OF GESTATION

E. Martin1, L. Zamorano1, M.V. Jime´nez1, M. Olivares2, J. Fonolla´2, & J.A. Hurtado1 1

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Neonatal Unit, Peadiatric Service, University Hospital Virgen de las Nieves, Granada, Spain, and 2Biosearch Life S.A., Granada, Spain Brief Introduction: In preterm infants, gastrointestinal (GI) tract is still developing. Because of this, they have more susceptibility to disease than term newborn (higher risk of necrotizing enterocolitis NEC and systemic inflammatories processes). The establishment and evolution of the intestinal microbiota in neonates have not been studied in depth, specially in premature newborns. The incorporation of new biological techniques has allowed us to identify new species which were difficult to be isolated according to classical cultivation techniques. Aim: To describe intestinal microbiota in preterm infants admitted to the Neonatal Unit using molecular techniques, and assess the impact of different conditions. Materials & Methods: A two year period Descriptive study (2011–2012) of gut microbiota in stools from newborns under 35 week gestational age at birth, admitted in a Neonatal Care Unit. Stool samples were collected: M1 (meconium), M2 (first week, 7 days old), M3 (first month, 30 days old). 5 groups of bacteria were analysed using qPCR technique: Bacteroides, Bifidobacterium, Escherichia coli, Clostridiums and Lactobacillus. Maternal, perinatal and neonate variables were registered. Statistic programs SPSSvs 20. Clinical Cases or Summary Results: E coli

Clostridium Bacteroides Bifidobacterium

M1 1.51  103 (n = 82) M2 4.77  103 (n = 74) M3 1.14  104 (n = 35)

Lactobacillus

47.3

22.53

4.16  104 3.30  103

31.63

12.39

2.04  105 7.04  103

43.04

32.26

4.98  106 8.39  103

Value: p50 cfu/g In the first month a marked increase (120) in Bifidobacterium is observed. The increase of Lactobacillus (2) and E. coli (7) is lower. Bacteroides and Clostridium remain stable. Regarding gestational age in 30 weeks gestation vs 430 we observed: - Bifidobacterial colonization is delayed at birth (2.35  104 vs 6.02  104 cfu/g; p = 0.09) and at one week birth age (3.98  104vs1.49  106 cfu/g; p = 0.007). - Higher numbers of E. coli from the first sample (4371 vs 906.9 cfu/g; 1.55  104 vs 2.93  103 cfu/g; 2.94  104 vs 9.69  103 cfu/g), although no significant statistically differences were detected. Regarding other conditions such as feeding (breast fed vs formula feeding): a lower content in Clostridium and Bacteroides was detected in Neonates who were breast fed at least 48 hours birth (36.7 vs 76.9 cfu/g; p = 0.06) (9.6 vs 40.8 cfu/g; p = 0.02). Significant differences were not distinguished at week or first month birth age Conclusions: The number of Bifidobacterium and Lactobacillus (groups associated with beneficial effects, such as resistance to pathogen colonization) in fecal samples is higher than the content in Bacteroides, Clostridium and E.coli (pathogenic bacteria). The colonization process of studied bacteria is delayed in prematures born at lower gestational age, except for E. coli. This research is considered to be the basis for future strategies in order to attend to these neonates and therefore prevent them from developing pathologies such as NEC.

C. Boulet1, T. Debillon1, S. Cottereau2, E. Sellier3, C. Jannel4, & F. Cneude1 1

Service de Re´animation Ne´onatale, CHU Grenoble, Avenue Maquis du Gre´sivaudan, 38700 La Tronche, France, 2Re´seau Naıˆtre et Devenir, CHU Grenoble, Avenue Maquis du Gre´sivaudan, 38700 La Tronche, France, and 3Unite´ de Qualitique et d’Evaluation Me´dicale Brief Introduction: Objective. The aim of this study was to report the neurodevelopmental outcome at the age of 4 years of extremely preterm infants. Materials & Methods: Methods. This prospective study included all 128 livebirths between 22 and 28 completed weeks of gestation (WG) in the ‘‘Re´seau de Pe´rinatalite´ Alpes-Ise`re’’ (RPAI) between 2006 and 2009 and followed in the ‘‘Re´seau Naıˆtre et Devenir’’ (RND). The hospital course, the neurologic outcome with cerebral palsy, hearing or visual deficiency and the developmental quotient (QD) were noted. The QD was evaluated with the Brunet Lezine test, the Ages and Stages Questionnaire (ASQ), and a consultation with a psychologist. At the age of 4 years, we defined 5 groups: severe, moderate or minor disability, no disability but need support in special health-care resources, and children out of any trouble. Clinical Cases or Summary Results: Results. In total, 128 children born alive before 29 WG. The mortality rate in delivery room was 9.6%, mainly children of 22WG, and the mortality rate during hospitalization was 14.8%, conversely proportional at the gestational age. None of the 22 and 23WG survived. Eighty seven children were discharged alive from hospital, and 67 were evaluated at 4 years: the follow up rate was 77%. Fourteen children (21%) had disability among which 3 severe, 2 moderate and 9 minor. Sixteen children (24%) needed special care which among none was severe, one moderate and 15 minor. All the severe and moderate deficiency were born under 1000g. Half of children defined as minor special care were born at 27WG. Children out of any trouble represented 55.2% of the followed children, most of them were 26 and 28WG. Conclusions: Conclusions. More than half children born extremely preterm were out of any disability or special health care. Severe disability children had a birth weight under 1000g, half of the children with special care were born at 27WG. It seems essential to follow the extremely preterm infants to detect disabilities or need of special care to optimize the school entry. Keywords: preterm, deficiency, special health care Presenter: C. Boulet

Keywords: intestinal microbiota; preterm infants; Bifidobacterium; Clostridium; Bacteroides; E. coli; Lactobacillus Presenter: E. Martin

Figure 1. Disability or special care according to the gestational age.

368

ID 153

AMBULATORY VERSUS HOSPITALIZED MANAGEMENT OF PATIENTS WITH THREATENED PRETERM LABOR AND A CERVICAL LENGTH 4 25 MM: A RANDOMIZED CLINICAL TRIAL. R. Latorre1,2, R. Gomez2,3, F. Pais1,2, F. Avila1,2, A. Valenzuela1,2, J. Carrillo1,2, & A. Insunza1,2

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

1

Unidad de Gestio´n Clı´nica de la Mujer y el Recie´n Nacido, Hospital Padre Hurtado, 2Facultad de Medicina, Clı´nica Alemana de Santiago-Universidad del Desarrollo, and 3Centro de Diagno´stico e Investigaciones Perinatales (CEDIP), Santiago, Chile.

Brief Introduction: Preterm labor (PTL) is a challenging condition in Obstetrics. Threatened PTL, defined as 3 contractions in 30 minutes and cervical dilatation 25 mm should be managed in the hospital or ambulatory, as outlined in the June 2012 Bulletin of the ACOG. We conducted a prospective trial to test the hypothesis that patients with threatened PTL and a CL425 mm will have similar perinatal outcomes when managed inpatient or in an ambulatory setting. Materials & Methods: Between January and August 2013, patients with the diagnosis of threatened preterm labor and a cervical length 425 mm were randomized to ambulatory management (AM) versus inpatient management (IM). Randomization was established by selecting between even or odd last digits in the National Identity Card. AM group was sent home with indications of bed rest and a control visit to the prenatal clinic. IM group was managed according to hospital clinical guidelines. Statistical analysis was performed with the SPSS package and included contingency tables as well as comparisons between groups with non parametric tests Clinical Cases or Summary Results: 114 patients were randomized to AM and 117 to IM. Gestational age at admission, general demographics and uterine cervix clinical assessment were similar between groups. Patients not delivering spontaneously before 37 weeks were censored. Gestational age at delivery was similar between both groups (mean 38.5 sem [range 35.3 – 41.1] and 38.8 weeks [range 33.0 – 41.5] for AM and IM, respectively (p40.05). There was one preterm delivery535 weeks in the IM group and none in the AM group. Conclusions: To our knowledge, this is the first randomized trial demonstrating that, in patients with threatened preterm labor and cervical length greater than 25 mm, either ambulatory or inpatient clinical management result in similar perinatal outcomes. Clinical decisions derived from these results may substantially modify current management of threatened preterm labor and reduce health costs Keywords: preterm birth, cervical length Presenter: Rodrigo Latorre

ID 974

EQUIPP: EVALUATION OF FETAL FIBRONECTIN WITH A NOVEL BEDSIDE QUANTITATIVE INSTRUMENT FOR THE PREDICTION OF PRETERM BIRTH

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

D. Abbott1, N. Hezelgrave1, P. Seed1, P. Bennett2, M. Chandiramani2, A. David3, J. Girling4, J. Norman5, S. Stock5, R. Tribe1, & A. Shennan1 1

Division of Women’s Health, Women’s Health Academic Centre, Kings College London, London, United Kingdom, 2 Department of Surgery & Cancer, Parturition Research Group, Imperial College, London, United Kingdom, and 3 Institute for Women’s Health, University Brief Introduction: Fetal fibronectin (fFN) is a leading predictor of spontaneous preterm birth (sPTB) in high-risk asymptomatic women. The fFN test currently used in clinical practice provides a positive/ negative result based on a threshold of 50 ng/ml. It offers a high negative predictive value (NPV) for sPTB, but the positive predictive power is modest (550%). Studies using a quantitative enzyme-linked immunosorbent assay (ELISA) have shown that the cervicovaginal fluid (CVF) quantitative fFN (qfFN) concentration correlates with the risk of sPTB. The primary aim of the EQUIPP study was to determine if quantitative analysis of fFN (qfFN) concentration in CVF improved prediction of sPTB. Materials & Methods: A prospective masked observational study (n = 1387) of high-risk asymptomatic women who underwent qfFN testing between 22 + 0 – 27 + 6 weeks’ gestation at 5 UK centres. The primary outcome was sPTB 534 weeks’ gestation. Pre-defined qfFN thresholds were used (510, 10–49, 50–199, 200 ng/mL). Women were eligible if they had a singleton pregnancy, and were considered high risk for sPTB (1 or more of: previous sPTB or premature preterm rupture of membranes, previous late miscarriage (16–23 + 6), previous cervical surgery, or cervical lenth (CL) 525mm in the current pregnancy). Women with a history of sexual intercourse within the last 24 hours, vaginal bleeding or rupture of membranes were excluded from the study due to known interference with fFN measurement, as were women symptomatic of preterm birth. The fFN swab was taken from the posterior fornix using a speculum as per manufacturer’s instructions and divided into 2 aliquots; one analysed using the conventional TLi instrument, the other using the novel bedside 10Q quantitative analyser. 10Q fFN results remained masked until the study was completed. Clinical Cases or Summary Results: A total of 1387 participants provided outcome data for the study. The mean gestational age of testing was 23 + 2 weeks’ (SD+/- 8 days). The overall sPTB rate 534 weeks’ was 7.1%. Only 2.8% (26/941) of women with qfFN concentration 510 ng/mL delivered 534 weeks’ compared with 36.8% (28/76) in the highest category (200 ng/mL). The relative risk of a sPTB before 34 weeks’ was significantly increased in each of the higher fFN concentration categories group when compared with the fFN510 ng/mL group: fFN 10–49 ng/mL: 3.8 (2.3 to 6.6; p50.001), 50–199 ng/L: 5.7 (3.2 to 10.0; p50.001), fFN 200–499 ng/mL: 12.3 (7.3 to 20.8, p50.001), fFn  500 ng/mL: 16.3 (8.8 to 30.1; p50.001). The PPV for sPTB 534 weeks’ increased from 16.6%, 24.1%, 36.8%. 45.0% with increasing thresholds (10, 50, 200, and 500 ng/mL) respectively. The area under the ROC curve for sPTB 534 weeks’ was 0.79 (0.74–0.84). Women with ultrasound short cervix (525mm), had a ten-fold increase in sPTB with qfFN concentration 200 ng/mL (18/45, 40%) vs. qfFN 510 ng/mL (3/68, 4.4%). Conclusions: The results demonstrate that the risk of sPTB 534 weeks’ is significantly related to the concentration of fFN in CVF and that there is particular value in using alternative risk thresholds at 510 ng/ mL and 200 ng/mL to define risk of sPTB. 11% of women who would have been conventionally classified as negative and ‘low-risk’ using the qualitative test (but who had qfFN concentration 10–49 ng/mL) delivered prematurely. However, women with qfFN concentration of 510 ng/mL (68% of cohort) had a risk of sPTB similar to background risk (2.8% vs 3.3% background risk in our population). This would provide reassurance and enable discharge from surveillance. Similarly, the positive prediction of the conventional test has been improved; the PPV of qfFN 200 ng/mL was almost double that seen with the traditional threshold of 50 ng/mL. qfFN is also a valuable tool for risk assessment in women with a short cervix. A formal evaluation of further clinical outcomes and management according to different thresholds based on the quantitative analyser is warranted.

369

DOI: 10.3109/14767058.2014.924236

Keywords: fetal fibronectin, spontaneous preterm birth, prediction, cervical length Presenter: Natasha Hezelgrave

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ID 124

RETROSPECTIVE AUDIT COMPARING MORBIDITY AND MORTALITY OUTCOMES OF PRETERM INFANTS ASSIGNED TO TWO-HAEMOGLOBIN THRESHOLD POLICES FOR BLOOD TRANSFUSIONS T. Whitby, D. Hawkness, G. Whitton, P. Martin, & H. Ibrahim

ID 385

Department of Neonatology, Liverpool Women’s NHS Foundation Trust, Liverpool, UK

EFFECTS OF PLACENTAL TRANSFUSION IN PRETERM BIRTH

Brief Introduction: There is considerable variation in neonatal transfusion practice in the UK. There is considerable controversy about the ‘‘trigger’’ points for transfusion in preterm babies. Red blood cell (RBC) transfusions are associated with significant complications and hence it is essential to rationalise transfusion in infants. New transfusion guidelines largely based on the PINT trial were instituted at the Liverpool Women’s Hospital (LWH) in 2011- Table 1. The aim of the audit was to determine if the new RBC transfusion policy lead to a significant differences in the number of blood transfusions, morbidity or mortality in preterm infants. Materials & Methods: A retrospective data analysis was undertaken on infants cared for at LWH before (2010-n = 104) and after (2012-n = 104) institution of the new guidelines. Information was collected on the number of transfusions, weight gain, duration of respiratory support and survival to discharge. The morbidities recorded were chronic lung disease, retinopathy of prematurity, necrotising enterocolitis, intraventricular haemorrhage (incidence and grade) and periventricular leukomalacia. Clinical Cases or Summary Results: Groups were comparable in birthweight (median1145g v/s1085g), gestational age (median 28.5 weeks v/s 28 weeks). With the introduction of the new policy there was a trend towards more infants being transfused but the difference did not reach statistical significance (Table 3). There was no statistically significant difference in the median number of transfusions per infant, weekly weight gain, incidence of CLD, ROP, IVH, PVL or survival to discharge. Conclusions: The 2012 transfusion policy has been shown to be safe to use in clinical practice, as it has lead to no statistical significant increase in the number of RBC transfusions or in the increase in short term infant morbidity or mortality. Keywords: Preterm; transfusion; mortality; morbidity Presenter: Mr T M Whitby

L.K. Dhaliwal, S. Anjumunnisa, Praveen Kumar, P.K. Saha, & S. Venkataseshan 1

Department of obstetrics and Gynaecology, PGIMER, Chandigarh, 2Department of obstetrics and Gynaecology, PGIMER, Chandigarh, 3Neonatology Dept., PGIMER, Chandigarh, 4Department of obstetrics and Gynaecology., PGIMER, Chandigarh, and 5Neonatology Dept., PGIMER, Chandigarh Brief Introduction: The aim of this study was to evaluate the efficacy and safety of placental transfusion by delayed cord clamping in reducing the risk of neonatal mortality & abnormal neurological examination at 40 weeks POG in comparision to early cord clamping in mothers at 34 -37 weeks POG. Secondary objectives in neonatal group were other morbidities like late onset sepsis, Necrotizing enterocolitis, hyperbilirubinemia, need of phototherapy, hematocrit & need of blood transfusion. In maternal factors, incidence of postpartum haemorrhage, need for therapeutic uterotonics and blood transfusion, need for manual removal of placenta, maternal haemoglobin and ferritin levels at 48 hrs of delivery. Materials & Methods: This Randomised control trail was conducted in Deptt. of Obstetrics & Gynaecology and Deptt. of Neonatology PGIMER Chandigarh. This study was conducted in 300 women with preterm labour between 34 to 366/7 weeks of POG. Patient was randomized into early cord clamping group (ECC510 seconds from birth of the baby) and placental transfusion group (DCC at about 60 seconds form birth of the baby). Clinical Cases or Summary Results: Out of the 300 women found eligible for the study 144 were in ECC group and 156 in DCC group. There were no differences in the incidence of primary neonatal outcomes (death and abnormal neurological exam till 40 weeks of gestation). Significant differences were found in parameters like neonatal anemia requiring transfusion (p value50.05) and clinically suspect sepsis (p value = 0.05). However there was no significant differences found in other parameters like hyperbilirubinemia, need of phototherapy, respiratory distress and intraventricular haemorrhage. There was no siginificant differences observed in third stage of labour like incidence of PPH, need of therapeutic uterotonics, need of blood transfusion and manual removal of placenta between the groups. However, maternal serum ferritin done at 48 hours postpartum was higher in delayed cord clamping which was statistically significant (p value 50.05) Conclusions: Delayed cord clamping is a simple and a cost-free intervention which has reduced neonatal anemia and sepsis a major health burden, especially in preterm babies with no adverse effects on mother in terms of postpartum haemorrhage.

370 Keywords: Placental transfusion, preterm birth, Early cord clamping, Delayed cord clamping. Presenter: L.K. Dhaliwal

ID 877

PROBIOTICS FOR PRETERM PREMATURE RUPTURE OF MEMBRANES

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

G. Daskalakis 1, A. Karampelas 1, V. Gavrili2, N. Papantoniou1, P. Angelopoulos3, A. Ntomali1, & S. Mesogitis1 1 First Department of Obstetrics and Gynecology, University of Athens, Alexandra Hospital, Athens, Greece, 2Department of Neonatal Medicine, Alexandra General Hospital Athens, Greece, and 3Department of Mathematics, National Technical University of Athens,

Brief Introduction: Preterm premature rupture of membranes (PPROM) is responsible for about 1/3 of preterm deliveries. Probiotics and their certain Strain of commensal lactobacilli can safely colonize vagina after vaginal administration, displace and kill pathogens and modulate the immune response that cascade inflammatory reaction leading to preterm delivery. The aim of this study was to evaluate the perinatal outcome in singleton pregnancies with PPROM following vaginal administration of probiotic suppositories. Materials & Methods: This is an ongoing double blind study in pregnant patients with confirmed PPROM between 24th and 34th week of gestation. All singleton pregnancies were treated with prophylactic antibiotics and antenatal corticosteroids from their admission. The probiotics group received simultaneous treatment with vaginal probiotics for ten days. All patients gave a signed informed consent form prior to the study. The primary outcome was time to delivery interval (latency period). Infant outcomes included mortality, infection, respiratory disease, and neonatal recovery. Clinical Cases or Summary Results: So far, a total of 119 cases of singleton pregnant women were analyzed (control group n = 61, probiotics group n = 58).The mean gestational age of PPROM was 35 weeks for the study and 33 weeks for the control group, respectively. The mean latency period in the study group was significantly longer than in the control group (5.16 vs. 3.01 weeks p = 0.011). The mean infant weight was higher for the study group (2198 vs 2022 gr. p = 0.51). The Neonatal Intensive Care Unit (NICU) admission rate was higher in the control (63%), than in the study group (35.1%) (p = 0.01). The average duration of recovery was 18 days for the probiotics group and 17 for the study group (p = NS), while the mean mechanical ventilation time (SIMV and NCPAP) was 8.1 days for the study and 6.9 days for the control group (p = 0.7). Six infants of the study and 4 of the control group developed BPD syndrome, while 2 infants of each group died in the early neonatal period, mainly due to septicemia and severe respiratory insufficiency. Conclusions: Vaginal administration of probiotics in singleton pregnancies complicated with PPROM seems promising. It was associated with a longer latency period and a reduction in the mean NICU admission rate. These are the preliminary results of an ongoing study with the final results awaited in about two years. Keywords: probiotics, preterm birth, pprom Presenter: g. daskalakis

ID 017

OUTCOME PREDICTORS OF RESCUE AND URGENT CERVICAL CERCLAGES

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

M. Alnemer, & M. Shababim King Faisal Specialist Hopsital And Research Center -Riyadh Brief Introduction: Prematurity is the leading cause of perinatal death and disability. Preterm birth before 37 weeks of gestation accounted for 10% of all live births. the majority of prematurity-related adverse outcomes relate to birth before 32 weeks of gestation. Two-thirds of preterm births are the consequence of spontaneous preterm labor and/or preterm prelabor rupture of membranes (PPROM). Cervical insufficiency is a contributing factor for poor pregnancy performance either as recurrent pregnancy loss or preterm delivery, treated with cervical cerclage. In this study we reviewed our experience of Rescue and Urgent cervical cerclage to identify factors that are associated with outcome of rescue and urgent cerclage. Materials & Methods: A retrospective study in which the charts for all pregnant women who underwent rescue or urgent cervical cerclage, between 16 to 28 weeks of gestation over a period of 12 years at single center were reviewed. Patients were identified using database coding system in medical records. Data were collected from clinical charts. Demographic data including maternal age, weight, BMI, parity, previous miscarriages, as well as pregnancy and delivery related data like induced or spontaneous pregnancy, multiple pregnancy, cervical length at time of surgery, membranes status, presence of any infections, gestational age (GA) at cerclage insertion, GA at delivery, mode of delivery, neonatal intensive care (NICU) admission, maternal infections were recorded and compared among the two groups. Clinical Cases or Summary Results: 233 patients had cervical cerclage were identified, 184 patients were excluded as elective cervical cerclage was done. 49 patients remained and they were included in the analysis.18women underwent rescue cerclage and 31 women underwent urgent cerclage. There was no significant difference in demographic characteristics between the two groups.Comparing first follow up measurement of cervical length-post cerclage insertion- in both groups, the urgent group had longer cervices with mean 29.2 ± 8.1mm (95% CI, 25.7–23.7) compared to the rescue cerclage group which had a mean of 18.1 ± 8.9 mm (95% CI, 12.4–23.7) (p = 0.008). The mean funneling depth in rescue group was 29.7 ± 6.7 mm (95% CI, 13.1 – 46.2), which was statistically significantly difference (p = 0.005) from urgent cerclage group 13.5 ± 5.3mm (95% CI, 7.9 – 19.1). There was no difference between the two groups in other maternal or neonatal outcomes Conclusions: Urgent or rescue Cerclage is surgical procedures can be offered to patients at higher risk for extreme preterm delivery secondary to cervical insufficiency, with lower complication rates It can prolong gestation to viability and can be considered as a useful measure for patients with evidence of cervical changes in the second trimester. There significant difference in cervical length between two group post cerclage insertion as well as funneling was more significant in rescue cerclage group, however there is no difference in the maternal or neonatal outcomes between both types of cerclages. Keywords: Presenter: maha alnemer

ID 396

SURVIVAL AND MORBIDITY OF PRETERM INFANT AT THE LIMIT OF VIABILITY: THE GRAY ZONE M.G. Espinosa, C. Go´mez, JE Sa´nchez, M. Gonza´lez, M.A. Rodriguez, T. Sa´nchez, & E. Salguero Neonatology Dept., University Hospital of Ma´laga, Ma´laga, Spain. Brief Introduction: Survival of preterm infants has steadily improved over the past decades

371

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

DOI: 10.3109/14767058.2014.924236

The gestational age (GA) and birth weigth cut off for intact survival in extremely preterm infants is unclear. ILCOR suggests that because of almost certain early death and unacceptable morbidity among survivors, resuscitation is not indicated in preterm infants 523 weeks of GA, while resuscitation is nearly always indicated in preterm neonates 25 weeks of gestation. Infants born between 23 + 0 and 24 + 6 weeks of gestation, in the so called grey zone, the survival outcomes are uncertain and the line between patient autonomy and medical futility is blurred. Our purpose: to report survival and morbidity of a cohort of preterm neonates born in the gray zone of infant viability. Materials & Methods: Retrospective chart review including infants admitted to Level III Neonatal Intensive Care Unit in Malaga, Spain from January 2008 to December 2013. Data from the history of the disease were collected and analysed. Clinical Cases or Summary Results: Forty-seven eligible infants were born over the study period. Eight preterm infants with a GA ranged from 23 + 0 to 23 + 6 were admitted of whom 6 died during their admission meaning a mortality rate of 75%. Mean GA 23 + 3. Mean birthweight 470 grames. 62.5% received a full course of antenatal steroids. Regarding morbidity: all developed respiratory distress syndrome (RDS). Seven needed aggressive ventilatory support. About survivors, both were born at 2011and both presented patent ductus arteriosus (PDA) being necessary surgical closure. One presented necrotizing enterocholitis. Both also required laser treatment for prematurity retinopathy. Serial cranial ultrasounds were normal and neurodevelopmental outcome is apparently normal at present. Concerning premature infants inborn at the range from 24 + 0 to 24 + 6 weeks of gestation,39 were included. Mean GA 24 + 3 and mean birthweight 680g, 74% received antenatal steroids: 22 full course, 7 a single dose. All patients were intubated at birth and endotracheal surfactant was administered. All developed RDS, requiring high frequency ventilation and inhaled nitric oxide in 66% and18% respectively.20% developed bronchopulmonary dysplasia. 64% presented PDA:18 received pharmacological treatment with ibuprofen and 6 with indometacin, in 6 patients surgical closure was required. 23% developed necrotizing enterocholitis. Cranial ultrasound was performed within first 24–48 hours of life in all patients. 51% showed normal, 13% revealed intraventricular haemorrhage grade 1, 5% grade 2, 13% grade 3 and 10% grade 4. Three patients developed periventricular leucomalacia. One patient showed cerebellum affectation.Related prematurity retinopathy was present at the 43% of the patients.13% required laser treatment.The mortality rate was 59%. Conclusions: Novel and aggressive neonatal therapies continue to affect neonatal outcome, mainly in infants born at the limit of viability, thus there still is a high risk of death or impairment in this cohort of infants. Parental desires should be supported at this borderline zone. Therefore, it is important that parents receive timely, understandable, up-to-date and consistent information to make informed decisions. Each center should offer prospective parents assessment of the limits of viability based on their statistics. Keywords: grey zone; preterm infant; viability;extremely low birth weight. Presenter: MG. Espinosa

ID 554

CHANGE IN PLASMA CONCENTRATION OF NT-PROBNP IN THE FIRST 36 HOURS OF LIFE IN EXTREMELY PRETERM NEWBORNS, BORN WITH BODY

MASS 1200G, AND ITS RELATIONSHIP WITH PATENT ARTERIAL DUCT. T. Talar, E.M. Gulczyn´ska, & B. Cyranowicz Neonatology Dept., Polish Mother’s Memorial Hospital Research Institute in Lodz, Poland Brief Introduction: Nt-proBNP is a peptide produced mainly by cardiomyocytes as a by-product, during production of BNP. It has no confirmed biological activity. The main cause for oversecretion of this ‘‘hormone’’ is heart congestion (especially left ventricle congestion). Some authors propose N-terminal pro Brain Natriuretic Peptide[NT-proBNP] as an indicator of significance of PDA. The aim of our study was to check if the change in Nt-proBNP serum concentration (between delivery and second day of life) has influence on PDA status of extremely preterm newborns. Materials & Methods: The main inclusion criteria were: birth body mass 1200g and birth age 28 week of gestation. Newborns with prenatally diagnosed congenital heart and other main organs defects were not included in the study. When the heart anomaly were discovered in the first echocardiography, baby was excluded. Babies born with Apgar score 3, and ones requiring heart massage after delivery, were excluded from the study too. Parents of all babies sign informed consent. The study was approved by local ethics committee. Blood sample for NT-proBNP measurement was collected just after delivery and between 24 and 36 hour of life, gap between this two results was calculated (delta). Echocardiography was performed simultaneously with second Nt-proBNP measurement. Patient were divided in three groups depending on PDA status (I group-without PDA in the second day of life, II-PDA present but not significant, III-significant PDA). The relationship between PDA status and delta of NT-proBNP concentration were analyzed. The results from 39 newborns were analyzed. Presented study constitute a part of a larger research. Clinical Cases or Summary Results: In our study there were 8 patients in group I (20.5%), 12 in group II (30.8%), and 19 in group III (48.7%) of PDA status. The mean delta of NT-proBNP was highest in group III. There were only one patient with decrease of NT-proBNP concentration in this group (5%), whereas in group I, four patients (50%) and in group II three patients (25%) had negative status of delta NT-proBNP. Conclusions: In our study negative delta status of NT-proBNP concentration (between delivery and second day of life) was strongly related with no need of early PDA treatment. High increase in NtproBNP concentration could be a predictor of hemodynamically significant PDA. Keywords: preterm, Nt-proBNP, PDA, arterial duct, newborn Presenter: Tomasz Talar

372

ID 271

PRETERM BIRTHS: PREVALENCE AND NEED OF ADMISSION TO NEONATAL UNIT IN TWO COHORTS OF CONCEPTIONS: ASSISTED AND NATURAL A. Pe´rez-Mun˜uzuri, J.R. Cervilla, M.L. Couce Pico, A. Urisarri Ruiz de Cortazar, & J.M. Fraga

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Neonatal Unit. Pediatric Assistance Area. Hospital Clinico Universitario (CHUS). Santiago de Compostela (SPAIN) Brief Introduction: Preterm births (PTB) occurs at about 7–10 percent of all births and constitute the first cause of death in infant mortality. PTB have higher risk of complications and disabilities at short and long-term time periods. They may suffer handicaps in physical and mental development. Significant progress in neonatal care and in survival rates have occurred in the last twenty years. These advances have not being translated in their prevalence rate. Our aim in this revision was to compare prevalence of PTB and hospitalization rates in two groups of PTB (37 wks GA). A group of pregnancies achieved by assisted reproductive techniques (ART-G) and other by natural conception (NCG) that were taken place consecutively in the last 5 years in the maternity hospital. Materials & Methods: In the period 2008–2012 were born 384 live births (LB) whose mothers got pregnant by ART-G and 405 consecutively LB who were conceived naturally (NCG). Rates of PTB and need of hospitalization due to troubles related with PTB 37wk GA, were examined to assess if there was significant differences between the two groups. VLBW, ELBW, IUGR and presence of major birth defects were excluded as a cause of hospitalization in both groups. Clinical Cases or Summary Results: Overall PTB rate in the ART-G was 45.0% (173 from 384 LB) vs. 10.6% of PTB in the NCG (43 from 405 LB) p50.001. In the ART-G from the total 173 PTB 141 (81.5%) needed admission to NU vs. 66 LB (16.2%) of the NCG p50.001. PTB who need admission to NICU in the NCG were 17 from 66 overall hospitalized (25.7%). The Odds ratio for PTB was 4.3 in the ART-G and the Odds ratio for need of hospitalization was 11.2 in comparison both with the NCG. In both groups of LB, the main cause of NU admission was PTB condition followed by problems related to diabetic mother (5.8%) in the ART-G and high risk of sepsis (13.6%) in the NCG. Conclusions: All the rates, both those LB who need hospitalization and PTB  37wk were significantly higher, taking into account their Odds ratio, in the ART-G comparing with the NCG. These findings may be related with infertility or subfertility conditions of the pregnant mother and the most important risk factor may be the higher median maternal age (37.2 years in the ART-G vs. 32.3 years in the NCG). Keywords: Presenter: JR Cervilla

ID 721

ARABIN-PESSARY IN TREATMENT OF CERVICAL INSUFFICIENCY TO PREVENT PRETERM BIRTH – A PROSPECTIVE, MONOCENTRIC, NON-RANDOMIZED STUDY I.M. Ruehl, A. Andrulat, S. Brugger, M. Fleming, K.B. Moser, K.M. Noll, & N. von Obernitz

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Department of Obstetrics, Red Cross Hospital Munich, Germany Brief Introduction: Premature birth is a central topic in obstetric care and persists to be the main cause for neonatal mortality and morbidity. Mechanical prevention by cervical cerclage is an invasive procedure and failed to show superiority in comparison to other interventions. Arabin-pessaries have been used more frequently again due to recent studies. Aim of this study was to re-introduce Arabin-pessaries in our clinical routine and observe prolongation of pregnancy. Materials & Methods: More than 100 patients have been treated with an Arabin-pessary due to cervical insufficiency (525mm) between 09/2012 and 03/2014 in our department. Relevant parameters (e.g. prolongation, hospital stay, gestational age at delivery) were observed. The study is ongoing. Clinical Cases or Summary Results: Results: Preliminary data showed a median hospital stay of 8 days (1–18 days), median gestational week of application was 30 + 1 (ranging from 22 + 5 to 32 + 6), with a median cervical length of 19mm. Median prolongation of pregnancy was 45 days, ranging from 13 to 101 days, median gestational age of removal was 37 + 0 (33 + 6–38 + 4), median gestational age of delivery was 38 + 2 (30 + 1–41 + 1). One patient was delivered due to placental abruption in 30 + 1. Conclusions: Application of the Arabin-pessary is an effective method to treat cervical insufficiency. Keywords: premature birth, pessary Presenter: IM Ruehl

ID 840

HIGH-DOSE IBUPROFEN FOR PATENT DUCTUS CLOSURE IN VLBW INFANTS: A POSITIVE EXPERIENCE OF A SINGLE CENTRE A. Concheiro-Guisa´n1, M.L. Gonza´lez Dura´n1, I. Ferna´ndez-Santamarina2, M. Pumarada Prieto1, M. Sua´rez Albo1, & J. R. Ferna´ndez Lorenzo1 1

Neonatology Dept. Hospital Xeral-Cı´es (EOXI), Vigo, Spain, and 2Pediatric Cardiology Dept. Hospital Xeral-Cı´es (EOXI), Vigo, Spain. Brief Introduction: A patent ductus arteriosus (PDA) is present in about 40% of VLWB. A conservative attitude indicating treatment with COXinhibitors only for patients with hemodynamic compromise is established. Ibuprofen has a success rate of PDA closure of 60–80%. Treatment failures could be partly explained by increased drug clearance via cytochrome P450 that augments postnatally. This fact might justify the use of higher doses, especially when treatment is started after first week of life. Surgical ligation, the alternative when ibuprofen fails, is associated with short and long term (BPD, ROP) complications and not available to all centres. Materials & Methods: Obsevational study of all preterm infants 24–29 weeks gestational age with PDA and indication for pharmacological ductal closure born at our institution during the study period (2010–13). Since 2012 a new treatment regimen was introduced in our unit. After prior parental written consent, a 3 dose-cycle of intravenous ibuprofen (20, 10, 10 mg/kg bodyweight every 24 h) was administered and repeated in case of ductal closure failure. Renal function, bleeding status and bowel complications during treatment were recorded. New dosage regimen patients (group 1) were compared in terms of morbidities and ductal closure rate to a historical control group (group 2) receiving standard dose (10.5,5 mg/kg/24 hours iv). Inclusion criteria for both groups were GA 1.4 and ductal size41.5 mm.

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DOI: 10.3109/14767058.2014.924236

Clinical Cases or Summary Results: During the study period, 25 patients (35% of 3mm. No patient with ductus43mm responded to treatment with standard dose and only one patient responded to higher doses. A large-sized PDA was related to connatal infection. Ductal closure after one single cycle was achieved in group 1 between the 5th and the 15th of life and with a second cycle between the 9th and 25th day of life. Meanwhile in group 2 closure occurred up to three cycles between the 11th and the 16th day of life. No significant adverse effects were observed in either group. Renal function parameters (urine output and creatinine level) were equivalent in both groups. We did not record any episode of acute renal failure, bleeding disorder (included IVH) or necrotizing enterocolitis during treatment. Conclusions: A higher-dose ibuprofen regimen could be more effective than the standard-dose regimen for closing PDA in preterm infants 15 days of life) as ibuprofen clearance increases with age, this might also justify the eventuality of a 3rd cycle. The rate of surgical intervention was higher in those VLWB preterm with PDA size43 mm. A larger ductal size of some patients in group 2 could have influenced the results. Multicenter studies with larger samples are needed to confirm these hypothesis. Keywords: PDA, ibuprofen Presenter: A. Concheiro-Guisa´n

ID 908

INTERLEUKIN 6 AND FETAL FIBRONECTIN IN PREDICTION OF PRETERM DELIVERY IN SYMPTOMATIC PATIENTS M. Hadzi Lega1, A. Daneva Markova1, & M, Tanturovski1 1

University Clinic of Gynecology and Obstetrics Skopje

Brief Introduction: Preterm delivery of an infant is defined as delivery before completing 37 weeks of gestation is a worldwide obstetrical problem. Preterm delivery is the leading cause of neonatal mortality and morbidity worldwide. The rate of preterm births has been estimated at around 14.9 million, which accounts for 11.1% of all live births worldwide1. Individual countries incidence rates are highly dependent on the degree of development and range from 5% in most developed European countries to 18% in several African countries1. Materials & Methods: Fifty-eight pregnant women were eligible to join the study if they attended the University Clinic for Gynecology and Obstetrics, Skopje and were admitted to Department of High Risk pregnancy Unit with symptoms of preterm labor (symptoms of uterine activity judged by the assessing physician to be indicative of preterm labor) at 24.0 to 36.6 weeks gestation. They were recruited in period of 6 months from September 2013 till March 2014. Clinical Cases or Summary Results: The fetal fibronectin test is a significant predictor of preterm delivery. Patients with a positive fetal fibronectin test have an OR of 6.429 (95%CI 1.991–20.758) to deliver prematurely. The diagnostic performance of the fetal fibronectin test in our study was as follows: Sensitivity = 75%; Specificity = 68.2%; PPV = 79%; NPV = 62.5%; LR+ = 2.46; LR- = 0.37; Area under the curve (AUC) = 0.716; 95%CI = 0.575–0.856. Figure 2 shows the ROC curve for the diagnostic performance of the fetal fibronectin test. The uni-variate logistic regression analysis for the concentration of IL-6 as a predictor of preterm delivery showed that patients with concentrations of IL-6 measured in the CVF higher than 1305pg/mL have and odds ratio (OR) of 3.87 (95%CI 1.23–11.282) to deliver preterm. Conclusions: Our study, despite the small sample size, confirmed the usefulness of determining fFN and IL-6 in the CVF as biochemical markers for identifying patients with high risk of preterm delivery. The combination of both test performed better than each individual test

in our population and decreased the false positive rate, which in turn reduced the chances for inappropriate patient treatment, bringing down the costs. Keywords: preterm, fetal fibronectin IL 6, sensitivity, predictive value Presenter: Marija Hadzi Lega

ID 394

INTESTINAL FAILURE IN NEONATES: REVIEW OF MEDICAL AND NUTRITIONAL INTERVENTIONS. C. Go´mez, M.G. Espinosa, J.E. Sa´nchez, J. Blasco, T. Sa´nchez, M. Gonza´lez, & E. Salguero 1

Neonatology Dept., University Hospital of Ma´laga, Spain, and 2Pediatric Gastroenterology Dept., University Hospital of Ma´laga, Ma´laga, Spain Brief Introduction: Surgical short bowel syndrome (SBS) is the most common cause of intestinal failure in Neonatal Intensive Care Unit (NICU). SBS is associated with increased rates of morbidity and mortality. These infants are at a higher risk of developing cholestasis, liver disease, bloodstream infections, prolonged hospitalization, growth delay and even motor developmental delay. Strategies of management and treatment are therefore a challenge for clinicians. Materials & Methods: We performed a retrospective chart review including infants admitted to NICU of our hospital from January 2010 to December 2013. Intestinal failure was defined as a primary intestinal disease that induces the need of total parenteral nutrition (PN) for more than 4 weeks or the need of partial PN for more than 3 months. Our purpose: to describe the natural course of intestinal failure with onset in the neonatal period to provide data regarding the spectrum of underlying diseases, strategies of management including cycled parenteral nutrition, fish oil lipid emulsion and n acetyl cysteina (NAC) in cases of severe cholestasis (defined as those with direct bilirrubin level over 8 mg/dl) and the subsequent evolution and follow up of the patients. Clinical Cases or Summary Results: A total of 9 patients fulfilled criteria to be included.55% girls. 89% preterm. Mean gestational age 32 weeks of gestation (range 28–37) Mean birthweight 1550 g(820– 2820). Etiology of SBS: 7 secondary to resection following necrotizing enterocolitis, 1 gastroschisis,1 congenital intestinal volvulus. Day of life of primary resection 11.22. Length of bowel resected was 425 cm in 4 patients, in three patients there were not data available. Five required multiple interventions. All patients developed cholestasis, being severe at 56% who presented bilirrubin levels above 8 mg/dl (range 2.8–24mg/dl). Eighty-nine percent received treatment with Phenobarbital and ursodeoxycholic acid, 67% fish oil lipid formulations, 87% cycled parenteral nutrition and 45% NAC. Seventy-seven percent of patients achieve normal serum bilirrubin levels. Enteral feeds after surgery started at 21.2 days reaching full enteral feeding at 30 days. PN was administered for a median of 88.44 days. 77% cases achieved the weaning of PN. Five patients survived to discharge and maintain an acceptable nutritional status, three patients were discharged on PN, and two of them are waiting for bowel transplant. Conclusions: Despite neonates with SBS are at the highest risk of developing intestinal failure associated liver disease, the great capacity of their residual intestine for growth and re-adaptation could allow in certain cases the weaning of the parenteral nutrition and the transition to full enteral feeds. NAC administered by intravenous perfusion, may be beneficial to achieve an abrupt decrease in bilirrubin levels of patients with severe cholestasis Several controversies over clinical management of infants with SBS remain. Most practices are more experienced based rather evidence

374 based, resulting in a wide variation of clinical practices among NICUs. Prospective trials should be encouraged. Keywords: intestinal failure, neonate, surgical short bowel, parenteral nutrition, necrotizing enterocolitis. Presenter: C.Go´mez

ID 828

EMERGENCY CERVICAL CERCLAGE: DOES IT WORK?

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C. Larran˜aga-Azca´rate, B. Pe´rez-Munarriz, M. DonazarEzcurra, J. Zabaleta-Jurı´o, & I. Huarte-Sala Obstetric and gynecologic Service, Complejo Hospitalario Navarra "B". Pamplona, Navarra (Spain) Brief Introduction: Emergency cervical cerclage (ECC) is essentially an invasive procedure to prolong pregnancy in women with advanced cervical changes and prolapsed membranes in the second trimester. However, its effectiveness remains controversial. Materials & Methods: Objective: To analyse obstetric outcomes and to assess the effectiveness of ECC to improve the perinatal outcome in patients with painless cervical dilatation and exposed amniotic membranes. Study design: A retrospective analysis of all cervical cerclages placed at the Virgen del Camino Hospital from 1998 to 2013 was performed. Women with singleton pregnancy managed for prolapsed fetal membranes who did not have premature rupture of membranes, clinically discernible chorioamnionitis, treatment-resistant uterine contractions, haemorrhage or placental abruption from 17 to 28 weeks of gestation were included. All patients received prophylactic antibiotics and progesterone and were under observation for 8–24 hours before the procedure. All women were examined by an anaesthesiologist and underwent a Shirodkar modified technique performed by an experienced obstetric surgeon. Prolongation of pregnancy, gestational age at delivery, birth weight, NICU admission, and neonatal survival rate were included as outcome variables. Clinical Cases or Summary Results: 52 patients underwent Shirodkar modified technique. 29 of these women also had cervical occlusion. 30/48 women received atosiban as tocolytic treatment during gestation. Mean gestational age at the time of cerclage was 23 weeks (W) 1 days (D), (range 17W3D- 28W0D) and mean cervical length (27/52 patients) was 16.67 mm (range 0–48 mm). Mean time from cerclage placement to delivery was 56.54 days, (range 1–135 D). Perinatal results: mean birthweight 1882.04 g (95% CI 1543.68g2220.40 g), perinatal death 11/52, neonatal admission to NICU (Neonatal Intensive Care Unit) 15/52 and to NCU (Neonatal Care Unit) 10/52. Half of the gestations (26/52) exceeded 32 weeks at delivery; and 21/52 went beyond 34 weeks. Median gestational age at delivery was 31W3D when occlusion was not performed, and 32W 2D when occlusion was done (not statistically significant). Conclusions: Emergency cerclage seems to improve perinatal outcome in women with advanced painless cervical dilatation with exposed amniotic membranes Keywords: emergency cerclage, perinatal outcome, single pregnancy, Shirodkar modified technique Presenter: C. Larran˜aga-Azca´rate

ID 330

EXCESSIVE LEFT VENTICULAR MYOCARDIAL GROWTH DIRECTLY AFTER PRETERM BIRTH

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

U. Schubert Department of Neonatology, Karolinska Hospital and Institute Stockholm, Sweden Brief Introduction: Early cardiac re-modelling in preterm animals and increased left ventricular mass (LVM) in young adults born preterm have been reported. We investigated LVM in infants for early adaptational myocardial changes during 6 months after preterm birth. Materials & Methods: Longitudinal echocardiographic study measuring LVM in 25 preterm infants (GA 26–30) directly after birth, at term and 3 months post-term, and comparison to 30 age-matched term children after correction for body surface area (m2). Clinical Cases or Summary Results: LVM/m2 increased with 78% during the first three months after preterm birth (37.43 to 66.73 g/m2) compared to 13% in controls (49.39 to 55.70 g/m2). At term, LVM/m2 was significantly higher in the preterm group (66.73 vs 49.39 g/m2, p50.001). Preterm infants developed even more absolute LVM (12.79 vs 10.79 g, p = 0.02) although they were slightly lighter (3.18 vs 3.45 kg). At three months of corrected age, relative LVM decreased, and no significant differences could be shown between the groups. Conclusions: Preterm infants develop an immediate but transient increase in LVM. Premature myocardial maturation, increased afterload and a narrower vascular tree might be responsible for left ventricular hypertrophy. The impact on short and long term left ventricular function is still unclear and has to be explored. Keywords: echocardiography, preterm, left ventricular mass Presenter: U.Schubert

ID 633

A CASE OF FOOD PROTEININDUCED ENTEROCOLITIS SYNDROME IN A PRETERM NEONATE PRESENTING AS RECURRENT NECROTIZING ENTEROCOLITIS S.A. Liguori1, M.C. Russo1, M. Cuozzo1, R. Boccaccini1, G. Greta1, F. Quattrocchi2, G. Monti2, & P. Savant Levet1 1

Neonatal Intensive Care Unit, Maria Vittoria Hospital, Turin, Italy, and 2Pediatric Dept, University of Turin, Regina Margherita Children’s Hospital, Turin, Italy Brief Introduction: Food protein-induced enterocolitis syndrome (FPIES) is a non- IgE-mediated gastrointestinal food hypersensitivity, typically diagnosed in young infants and elicited most commonly by cow’s milk and soy proteins (1). Severe cases, characterized by profuse vomiting, bloody diarrhea with dehydration, lethargy, and metabolic acidosis, may present within the first days of life, miming sepsis, necrotizing enterocolitis (NEC) and some surgical or metabolic condition (2). We report a case of a preterm newborn with FPIES by cow’s milk proteins (CMP), presenting as recurrent NEC. Materials & Methods: Case report Clinical Cases or Summary Results: A preterm female (GE 28w, twin pregnancy), fed with breast milk since birth, presented on day of life (DOL) 17 with vomiting, inconsolable crying, abdominal distension and bloody stools, after assuming two meals of preterm milk formula. In the suspect of NEC, enteral feeding was stopped, antibiotic therapy and parenteral nutrition were performed. Mechanical ventilation was needed for worsening of general condition and respiratory distress. Hematological examinations showed mild alteration of inflammatory indices, with neutrophilia and a normal value of platelets. Abdominal

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DOI: 10.3109/14767058.2014.924236

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X-ray showed jejunum-ileal tract distension, without pneumatosis intestinalis or ascites. Abdominal ultrasound excluded intussusception. Abdominal distension and bloody stools reappeared after the reintroduction of preterm milk formula on DOL 35, accompanied by eosinophilia (17% eosinophils). A new episode of NEC was suspected, enteral nutrition was newly stopped and antibiotic therapy was performed. The resolution of symptoms after the assumption of an amino-acid formula sustained the hypothesis of FPIES caused by CMP, confirmed by the positivity of cow’s milk (CM) oral food challenge. Conclusions: Neonatal FPIES is a rare condition, presenting both in term and preterm newborns. FPIES has to be considered in a newborn presenting with symptoms and signs of gastrointestinal dysfunction typical of early stages of necrotizing enterocolitis (IA, IB and IIA of modified Bell’s staging) (3), in particular if recurrent episodes occur. Laboratory and radiological examinations may help to differentiate these two conditions, as neutropaenia and thrombocytopenia are typical of classic NEC, while FPIES is mainly accompanied by neutrophilia and thrombocytosis with systemic or faecal eosinophilia (2). Keywords: food protein-induced enterocolitis, preterm Presenter: S.A. Liguori

delivery before 28, 34 and 37 weeks. We further assess the accuracy of a CL5 5th percentile in our population. Clinical Cases or Summary Results: A total of 222 pregnancies were identified. Twenty-three women (10.4%) delivered before 34 weeks’ gestation, of these 8 delivered before 32 weeks and only one before 28 weeks. The median CL was 38 mm; the 5th centile was 24.0 mm. Cervical length was significantly associated with PTB before 34 weeks (area under the ROC curve = 0.657, p50.05), but not before 32 weeks. ROC analysis identified a CL of 17 mm as the optimal cut-off, with a positive likelihood ratio (LR) of 14.42 (95% CI 3.7 – 56.5), and a negative LR of 0.79 (95% CI 0.6–1.0). The sensitivity and specificity of a CL  17 mm for PTB before 34 weeks were 22% and 99% respectively, whereas the positive predictive value (PPV) and negative predictive value (NPV) were 83% and 79%. Using the 5th centile, the positive and negative LR were 6.2 and 0.81, respectively, and the PPV and NPV were 67% and 79%. Conclusions: Our results show that PTB534 weeks of gestation in asymptomatic women was best predicted at 20–24 + 6 weeks of gestation by a CL  17 mm. The 5th centile of CL measurements (24 mm) could be also used in clinical practice for assessing the risk of PTB in twin pregnancies, but the accuracy is lower. Keywords: cervical length; preterm birth; ROC analysis; twin pregnancy; transvaginal ultrasound

ID 621

ABILITY OF CERVICAL LENGTH TO PREDICT SPONTANEOUS PRETERM DELIVERY IN TWIN PREGNANCIES USING THE RECEIVER OPERATING CURVE ANALYSIS AND AN A PRIORI CUT OFF L. Pasquini1, G. Sisti2, F. Sorbi2, V. Seravalli3, M. Fambrini2, & M. Di Tommaso3 1

Department of Maternal and Child Health, Careggi University Hospital, Florence, Italy, 2Department of Biomedical, Experimental and Clinical Sciences – Division of Obstetric and Gynecology, University of Florence, Florence, Italy, and 3 Department of Health Sciences - Division of Obstetric and Gynecology, University of Florence, Florence, Italy Brief Introduction: Over the last years several studies have shown that screening of pregnant women for preterm birth (PTB), based mainly on obstetric history and measurement of the length of the uterine cervix, can identify more than 50% of those who will deliver before 34 weeks’ gestation. Most of the data are collected on singleton pregnancies, while less data are available on twin pregnancies. Previous studies have used receiver operating characteristic (ROC) analysis or the 5th percentile of the population to determine the best cervical length (CL) cut-off, without a direct comparison between the two methods. The aim of this study was to determine the ability of cervical length (CL) to predict spontaneous PTB in twin pregnancies using ROC analysis and an a priori (5th percentile) cut-off. Materials & Methods: A restrospective observational study was performed on asymptomatic twin pregnancies that received routine antenatal ultrasound examination between 20 and 24 + 6 weeks between 2007 and 2012. Transvaginal sonographic assessment of the CL was performed following the routine second trimester ultrasound test. Women with monoamniotic pregnancy, fetal anomalies or intrauterine fetal demise, cervical cerclage, and all women with preterm elective/emergency cesarean section or preterm labor induction for fetal or maternal indication were excluded. ROC analysis was performed to identify the optimal cutoff for the prediction of

Presenter: Viola Seravalli

ID 136

PRETERM PLACENTAL ABRUPTION: TOCOLYTIC THERAPY REGARDED AS A POOR NEONATAL PROGNOSTIC FACTOR S. Suzuki, M. Ogawa, Y. Matsuda, J. Konno, M. Mitani, & H. Matsui Department of Obstetrics and Gynecology, Tokyo Women’s Medical University, Tokyo, Japan Brief Introduction: Objectives: To elucidate factors associated with a poor neonatal prognosis in preterm placental abruption. Materials & Methods: Methods: A multicenter retrospective study was conducted. A total of 247 cases with preterm placental abruption during 2009, derived from an electronic database constructed by the Japan Society of Obstetrics and Gynecology, were investigated as the subjects of this study, and were divided into three groups: very preterm (VPT, n = 66) was delivered at 28 to 31 gestational weeks, preterm (n = 56) was at 32 and 33 weeks, and late preterm (LPT, n = 125) was at 34 to 36 weeks. Risk factors, clinical course, and neonatal/infantile outcomes were compared. Poor neonatal outcome was defined as stillbirth, or neonatal and infantile death, or cases with neurological disability at 2 years of age. Clinical Cases or Summary Results: Results: The number of subjects who received tocolytic therapy was significantly higher in the VPT group as compared with the LPT group. It was higher in the VPT group even after excluding the 57 stillbirths. Multiple logistic regression analysis revealed that poor prognostic factors were umbilical arterial pH (D = 0.1) (0.17 [0.069–0.417], p50.0001) and tocolytic therapy (28.5 [2.014–403.9], p50.0132). Conclusions: Conclusions: Administration of tocolytic agents is a possible factor in a poor neonatal prognosis in preterm placental abruption. This finding may suggest that close observation during the first 10 hours after onset could improve the prognosis. Keywords: preterm placental abruption Presenter: Shiho Suzuki

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ID 214

KANGAROO MOTHER CARE (KMC) FOR DEVELOPPING COUNTRIES N. Charpak , & E. Rodriguez

M. Mendoza1, A. Gascon2, L. Pratcorona3, C. Merced4, C. Rodo, M. Goya5, & E. Carreras6

1

1

1

2

Kangaroo Mother Care Program, Hospital Universitario San Ignacio, Universidad Javeriana, Bogota, Colombia, Kangaroo Foundation, Bogota, Colombia, and 2Kangaroo Foundation, Bogota, Colombia

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CORRELATION WITH WEEKS OF GESTATION

Brief Introduction: Low Birth Weight (LBW) is either the direct or an associated cause in nearly 60% of the 4’000.000 children’s deaths occurring annually worldwide. KMC is an evidence-based technology useful for ameliorating LBW effects on infant mortality and morbidity. Since more than 10 years the objective of the Kangaroo Foundation was 1)To evaluate efficacy and safety of KMC 2)To explore means for transference, adaptation and acceptance of KMC to other settings mainly in the developing world 3)To evaluate the degree of succesfull dissemination, permanence and performance of local and regional KMC programs in different countries Materials & Methods: In a first phase, safety and efficacy of KMC was demonstrated by a set of clinical studies (Cohort, RCT). Second phase consists of an ongoing: 1)Dissemination of KMC to other institutions of developing countries by training health-care teams not only in KMC but in recording and monitoring of key-quality indicators 2)Coaching of new KMC teams while implementing and adapting their programs, 3)Design and implementation of a quality assurance program to support a continuous performance evaluation (KMC network) 4)Identification and analysis of difficulties encountered in other settings for the implementation of KMC. Candidates for KMC training are multidisciplinary health-care teams mainly from crowded cities’ hospitals in developing countries, willing to try interventions to improve LBW survival and quality of life, to rationalize resources use and to humanize neonatal care. Institutions willing to teach others are favored. Clinical Cases or Summary Results: We trained 60 teams from 30 countries since 1994. In 80% of teams trained in Bogota, KMC implementation has been successful, despite specific needs and difficulties encountered by each program in each setting. Various KMC programs already began a national KMC training diffusion program in their countries. The 3 components of KMC: kangaroo position, early discharge with KMC follow up and breastfeeding had been adapted to local circumstances, patients needs and care scenario: NICU, intermediate care, ambulatory care with home discharge in kangaroo position. Early discharge and KMC ambulatory follow-up clinic is the most difficult aspect of KMC to implement, despite its significant impact on hospital costs and risks. Major difficulties to many newly established programs are insufficient access to the network, to scientific literature on KMC and insufficient local research capability. Conclusions: Our experience shows the feasibility of developing a complex effective and efficient heathcare intervention in a developing country, and direct transfer to developping countries through training, coaching, support and development of non-governmental networks. Keywords: Kangaroo Mother Care, developing countries, premature infant Presenter: Eleonora Rodriguez

ID 266

MODIFICATION OF CERVICAL LENGTH AFTER CERVICAL PESSARY INSERTION AND ITS

Maternal Fetal Medicine Unit, Vall d’Hebron Universitary Hospital, Barcelona, Spain, 2Maternal Fetal Medicine Unit, Vall d’Hebron Universitary Hospital, Barcelona, Spain, 3 Maternal Fetal Medicine Unit, Vall d’Hebron Universitary Hospital, Barcelona, Spain, 4Maternal Fetal Medicine Unit, Vall d’Hebron Universitary Hospital, Barcelona, Spain, 5 Maternal Fetal Medicine Unit, Vall d’Hebron Universitary Hospital, Barcelona, Spain, and 6Maternal Fetal Medicine Unit, Vall d’Hebron Universitary Hospital, Barcelona, Spain Brief Introduction: The aim of this study was to observe the modifications of the cervical length (CL) after insertion of a cervical pessary (ArabinÕ ASQ 65/25/32) in patients obtained from the PECEP Trial and also measure the correlation of this modification with the weeks of gestation (WG) at birth, compared with the expectant management group. Materials & Methods: Randomised prospective study of 380 asymptomatic risk-free singleton pregnancies between weeks 20 + 0 and 23 + 6. CL in all patients was short (525 mm) and they were randomised into two groups: expectant management and cervical pessary. Cervical length was measured in all patients after pessary insertion and before 24 + 0 WG. Clinical Cases or Summary Results: The study included 380 pregnant women: 190 underwent periodic controls of CL (expectant management) and 190 were fitted with a pessary. Mean CL in both groups at the time of randomisation showed no statistically-significant differences (pessary group: 19.02 mm and management group: 19.00 mm; p = 0.966). Mean CL measured after randomisation and before 24 + 0 WG was 15.44 mm in patients of the expectant management group and 21.56 mm in the pessary group. These differences were statistically significant (p = 0.000). When means at randomisation and at the second measurement were compared, LC had decreased by 3.58 mm in the expected management group and increased by 2.56 mm in the pessary group; this difference was statistically significant (p = 0.000). Coefficients of correlation showed that in patients with the same CL at 20 WG in both groups, those with a pessary gave birth later. In the expectant management group, a correlation was found between the size of the decrease in CL between 20 WG and later measurement and WG at delivery. However, an increase in CL after pessary insertion did not correlate with an increase in WG at birth. Conclusions: Insertion of an Arabin cervical pessary increased CL in asymptomatic patients with a short cervix Asymptomatic patients with a short cervix at week 20 who received expectant management presented a decrease in CL as WG increased, which correlated with shorter WG at birth The cervical pessary stabilises the progressive decrease in CL, which correlated with longer WG at birth The increase in CL after cervical pessary insertion did not correlate with an increase in WG at birth Keywords: cervical lebgth, cervical pessary, preterm birth Presenter: Manel Mendoza

ID 178

PREDICTIVE VALUES OF SERUM MARKERS OF OXIDATIVE STRESS AND PAPP-A IN PRETERM DELIVERIES M. Bogavac1, A. Jakovljevic2, Z. Grujic1, Z. Tatic-Stupar1, D. Stajic1, & S. Milosevic1

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DOI: 10.3109/14767058.2014.924236 1

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University of Novi Sad, Medical Faculty, Clinical Centre of Vojvodina, Department of Obstetrics and Gynecology Novi Sad, Serbia, and 2University of Novi Sad Medical Faculty, Clinical centre Vojvodina, Centre for Laboratory Medicine, Novi Sad, Serbia Brief Introduction: Preterm delivery in contemporary world presents the most common complication in pregnancy which is also the main cause of perinatal mortality. Multiple studies showed that oxidative stress, balance disorder between defense antioxidative systems and production of free oxygen radicals respectively, may jeopardize any stage of intrauterine development and eventually lead to the preterm delivery with complications in premature babies like bronchopulmonal dysplasia, intraventricular hemorrhage, necrotizing enterocolitis and other. The aim of this study was to confirm if early determination of markers of oxidative stress and PAPP-A in first trimester of pregnancy could identify pregnant women with increased risk for occurrence of preterm delivery. Materials & Methods: The study was conducted at the Department of Obstetrics and Gynecology in Novi Sad.Women were divided into two groups.Control group (n = 94):pregnant women who delivered after 37 + 1 week of gestation (WG) with good outcome.Study group (n = 56):pregnant women who delivered before 34.WG, singleton pregnancies without genetic anomalies of fetus.From all women in the period between 11. and 14. WG, anamnestic, anthropometric, demographic and socioeconomic data that could have an effect on the occurrence of preterm delivery were taken. All women underwent clinical, obstetrical and ultrasound examination as well as laboratory blood tests for determination of serum markers of oxidative stress superoxide dismutase (SOD), total antioxidative status (TAS), glutathione peroxidase (GSH-Px) and protein PAPP-A. Clinical Cases or Summary Results: Women of the study group (31.81 ± 3.44) were on average older that women of the control group (29.31 ± 4.92). In the study group there were more smokers (14.2%) than in the control group (8.5%). BMI was approximately equal in both groups, while frequency of infections (bacterial vaginosis, cervical bacterial infections, urinary tract infections) was higher in the study group (21.3%) than in the control group (14.2%). There is no significant difference between women regarding the application of therapy in pregnancy (utrogestan and progesterone), while the number of previous pregnancies (more than two pregnancies) was higher in the study group (19.5%) than in the control group (10.4%). Markers of oxidative stress SOD and GSH-Px were statistically significant higher in the study group (p50.05), while the values of TAS were equal in both groups (p = 0.26). Values of PAPP-A were higher in the study (1.54 ± 0.33) than in the control group (1.59 ± 0.95). Conclusions: Combining maternal risk factors with markers of oxidative stress SOD and GSH-Px and protein PAPP-A it is possible to create stratification of risk for selection of women to whom more attention to the increased possibility of preterm delivery will be given. Keywords: preterm deliveries, oxidative stress, PAPP-A Presenter: M. Bogavac

ID 061

EARLY DETECTION OF CARDIAC DYSFUNCTION AFTER PRETERM BIRTH BY 2D-SPECKLE-TRACKING ECHOCARDIOGRAPHY U. Schubert Dept. of Neonatology, Karolinska Hospital, Sweden Brief Introduction: Preterm birth is associated with adverse cardiovascular events later in life. The underlying mechanisms are unknown.

We undertook a sequential analysis of cardiac function after preterm birth by speckle-tracking echocardiography (STE) and compared the results to a healthy control group. Materials & Methods: Evaluation of cardiac function of 25 very preterm infants (GA 26–30 weeks) at birth, at term-equivalent age and at 3 months of corrected age and comparison to the findings in 30 healthy term children (1st investigation intrauterine). We measured longitudinal strain (%), strain rate (1/sec) and tissue velocities (cm/s) in both ventricles in systole and diastole to characterize myocardial performance and compared the results to conventional echocardiography. Clinical Cases or Summary Results: At 3 months of corrected age, very preterm infants exhibit significantly lower left ventricular (LV) strain values (19.9 vs 22.0%, p50.001), systolic (5.8 vs 6.4 cm/s, p = 0.01) and diastolic (7.8 vs 10.6 cm/s, p50.001) tissue velocities and early diastolic strain-rate values (3.9/s vs 4.7/s, p50.001) compared to healthy control infants born at term. There was a trend to lower values even in the right ventricle- though not statistically significant. Conclusions: Left ventricular systolic and diastolic dysfunction emerges already 6 months after very preterm birth and can be identified by STE while conventional echocardiography is not able to detect abnormal myocardial performance at this age. LV dysfunction might occur because of premature adaption towards higher systemic afterload and incomplete re-modelling of the LV early in life. Keywords: preterm, echocardiography, speckle-tracking Presenter: U. Schubert

ID 259

EVALUATION OF THE CLINICAL USE OF MAGNESIUM SULFATE FOR CEREBRAL PALSY PREVENTION. P. Jeanneteau, M.D.1, P-E Bouet, M.D.1, A-L. Baisson, R.M.1, V. Courtay, M.D.1, G. Gascoin-Lachambre, M.D.2, P. Gillard, M.D.1, S. Lasocki, M.D., Ph.D.3, P. Descamps, M.D.1, & L. Sentilhes, M.D., Ph.D1 1

Department of Obstetrics and Gynecology, Angers University Hospital – Angers – France, 2Department of Neonatology, Angers University Hospital – Angers – France, and 3 Department of Anesthesia, Angers University Hospital – Angers – France. Brief Introduction: The aim of this study is to evaluate the implementation of a clinical protocol for the use of magnesium for cerebral palsy prevention, focusing on uptake, indications and safety. Materials & Methods: This retrospective and unicentred study included all women with fetuses of gestational age533 weeks whose birth was planned or expected within 24 hours from September 2011 (starting of implementation of magnesium sulfate in our department) to December 2012. We assigned women to receive magnesium sulfate, administered intravenously as a 4g bolus followed by a constant infusion of 1g per hour. If delivery had not occurred after 12 hours and was no longer considered imminent, the infusion was discontinued. The primary study outcome was to assess the rate of predelivery administration of magnesium sulfate over this time period. Clinical Cases or Summary Results: Among the 5610 patients who delivered during the study period, 119 were eligible for the protocol. 68.1% of eligible gravidas received magnesium sulfate before delivery. In 2011, at the beginning of magnesium sulfate implementation, 76% of eligible gravidas received magnesium before delivery. The mean gestational age of the protocol’s implementation was 30 weeks +/- 2 days. The mean duration of magnesium sulfate treatment was 289 +/- 398 minutes. Bolus and constant infusion were

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Table 1. Baseline characteristics of women who received magnesium sulfate

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Characteristic Gestational age (weeks)* Maternal age (years)* Nulliparous, n (%) Multiple gestations, n (%) Receipt of antenatal corticotherapy, n (%) Principal reasons for preterm birth**  Preterm labour, n (%)  Premature rupture of membranes, n (%)  Antepartum hemorrhage, n (%)  Preeclampsia, n (%)  Intrauterine growth restriction, n (%)  Abruptio placentae, n (%)  HELLP syndrom, n (%)  Placenta previa, n (%) Adverse event  Major side effects***, n (%)  Flushing, sweating, n (%)  Palpitation, n (%)  Nausea or vomiting, n (%)  Headache, n (%)  Hypotension, n (%)  Respiratory depression (decrease of 44/min from baseline), n (%)  Hyporeflexia, n (%)  Reduction of respiratory frequency, n (%)

Magnesium sulphate (n = 80) 29.6 ± 2.1 29.8 ± 6.3 48 (60) 15 (18.8) 77 (96.3) 35 25 20 23 12 5 9 7

(43.8) (31.3) (25) (28.8) (15) (6.3) (11.9) (8.8)

0 4 1 2 1 9 1

(5) (2.5) (2.5) (1.25) (11.25) (1.25)

1 (1.25) 1 (1.25)

*Values are given as mean ± standard deviation. **Some patients had more than one reason for preterm birth. ***Respiratory rate of 510/min, diastolic blood pressure decrease of 430 mmHg, areflexia, coma, lung and heart failure.

respectively administered during 33 +/- 12 minutes and 335 +/- 425 minutes. Four patients (4.9%) received magnesium sulfate during more than 12 hours. The mean dose administered was 7.99 +/- 6.73 g. No major maternal side effects were observed. The use of magnesium sulfate improved neonatal adaptation with a decrease of the rate of Apgar score less than 7 at 5 minute (p = 0.03), pH less than 7.10 (p = 0.03), need for closed cardiac massage (p = 0.003) and use of Adrenaline (p = 0.01). There was no difference either on birth weight or on neonatal morbi-mortality. Conclusions: It is feasible to implement a magnesium sulfate cerebral palsy prevention protocol into clinical practice. Keywords: magnesium sulfate, cerebral palsy prevention, preterm birth Presenter: P. Jeanneteau

ID 916

IS THERE AN EPIDEMIC OF LATE PRETERMS? O. Kaabia1, S. Meddeb1, M. Bibi1, R. Fatnassi2, & H. Khairi1 1

The Gynecology and Obstetrics department of Farhat Hached University Hospital in Sousse Tunisia, and 2The Maternity center of Ibn El Jazzar Hospital in Kairouan Tunisia Brief Introduction: Late preterm (LP) defines infants born at 340/7 through 366/7 weeks of gestation, which comprise a majority of preterm births. These infants were treated clinically as ‘‘near-term’’ in the past, but recent studies have implied increased morbidities that differentiate late preterm and term infants. Some authors speak of an epidemic of LP and there is concern that obstetric interventions

(prelabor cesarean section and induced delivery) are drivers of LP birth. The aim of this study was to evaluate the evolution of the incidence and morbidity of late preterm birth in our daily practice, on the one hand and to evaluate the risk factors for LP birth. Materials & Methods: This is a retrospective cohort study performed in both of the Gynecology and Obstetrics department of Farhat Hached University Hospital in Sousse and the Maternity center of Ibn El Jazzar Hospital in Kairouan Tunisia. We reviewed and compared infants born during two different periods: 2001–2002 (group 1) and 2008– 2009 (group 2). Maternal obstetrical factors, neonatal demographic distributions, and neonatal complications were compared in the late preterm births in both groups. The associations were assessed using generalized estimating equation regression. Clinical Cases or Summary Results: During the 2001–2002 study period, there was a total of 25,247 live births, of whom 1,413 late preterm births (5.59%) with a mean gestational age of 35WG and 4 days; the mean birth weight was 2516g with neonatal hospitalization in 1.34% of cases and an average stay in the maternity ward of 6.4 days. During the 2008–2009 study period, there was a total of 25,438 live births, of whom 2,072 late preterm births (8.14%) with a mean gestational age of 35WG and 2 days; the mean birth weight was 2584g with neonatal hospitalization in 1.25% of cases and an average stay in the maternity ward of 6.6 days. There has been an increase in late preterm births (p = 0.045), maternal age 29.6 vs 28.5 years (p = 0.014) and use of tocolytic which doubled (10.3% vs 5.1%). There was no significant difference in the neonatal mortality rate 9.2 (9.2% vs 9.1%).The main cause for LP was twin pregnancy after ART in both groups (24.6% vs 29.2%). There was no significant difference between the two groups in terms of gestational diabetes mellitus, preeclampsia or HELLP syndrome). In the adjusted analysis, ‘‘any obstetric intervention’’ (risk ratio [RR], 0.72; 95% confidence interval [CI], 0.57–0.84) and prelabor cesarean section (RR, 0.56; 95% CI, 0.49–0.77) were all associated with a lower likelihood of LP vs term birth. Only previous cesarean section was identified as an independent potentially modifiable risk factor for LP (RR, 1.88; 95% CI, 1.66–1.98. Conclusions: Even if we cannot speak of an epidemic, there is indeed an increase in the prevalence of late prematurity with a population of newborns. Late-preterm infants have increased risk of neonatal morbidities associated with organ immaturity. The prevention of multiple pregnancies in ART could limit this prematurity. The results of this study also emphasize the importance of judicious obstetrical decision-making when considering late preterm delivery, and the need to set up anticipatory clinical guidelines for the care of late preterm infants that require sustained short, medium and long term follow-up to detect late morbidity. Keywords: late preterm, incidence, morbidity, twin pregnancy Presenter: S. Meddeb

ID 759

MATERNAL OBESITY, PERIODONTITIS AND PRETERM DELIVERY V. Clivio1, M. Mazzocco1, A. Lissoni2, P. Castellarin2, E. Grossi1, S. Calabrese1, C. Mando`1, M. Cardellicchio1, C. Novielli1, G. Anelli1, I. Cetin1, & S. Abate2 1

Unit of Obs and Gyn, L.Sacco Hospital, Center for Fetal Research Giorgio Pardi, University of Milano, Italy, and 2Unit of Oral Diagnosis, San Paolo University Hospital, Dept of Health Sciences, University of Milano, Italy Brief Introduction: Obesity (OB) is associated with changes in proinflammatory and immunomodulatory cytokines in pregnancy, increasing the risk of preterm delivery. OB has also been suggested to be associated with periodontitis. Peripathogenic bacteria may flow

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DOI: 10.3109/14767058.2014.924236

towards placental and fetal tissues increasing local and systemic inflammation and the risk of adverse events. The co-morbidities of OB and periodontitis could be associated to significant up-regulation of several miRNA species involved in the regulation of lipid and carbohydrate metabolism, in inflammatory pathways and in the inhibition of the expression of target genes. The aim of our study is to evaluate the inflammatory pattern of obese pregnant women including periodontal diseases and its correlation to preterm delivery. Materials & Methods: 35 obese (BMI  30 kg/m2) and 15 normal weight (NW: BMI  18 and 525 kg/m2) pregnant women with a singleton spontaneous pregnancy were prospectively enrolled. Nutritional advice was provided to all patients with specific indications related to advisable weight gain. Maternal characteristics, fetal US growth parameters as well as maternal venous blood samples to measure CRP and PTX3 were collected at every trimester. In the 3atrimester, together with a complete oral clinical examination to assess the periodontal conditions and gingival disease indexes, we collected salivary samples for miRNA content analysis and gengival fluid for IL-1b and PGE2 dosage. Placentas are measured at delivery and samples stored for immunohystochemistry and to evaluate the expression of miRNA27 and pPARg. Clinical Cases or Summary Results: OB women were significantly older than NW women (33 ± 5.0 vs 27 ± 4.5 yrs; p50.001) and they had significantly lower weight gain at delivery than NW (6.3 ± 7.5 vs 15.4 ± 4.9; p50.05). No preterm delivery occurred in either groups. Neonatal outcomes were homogeneous between the two groups, with no significant differences in mean gestational age at delivery, Apgar scores, as well as in neonatal and placental weights. However, the cesarean section rates were higher in OB than in NW pregnancies (54% vs 14%; p50.05), all of them being elective C-section. All the biochemical and immunohystochemical analysis are ongoing. Conclusions: The interaction between inflammatory status of obese pregnancies, periodontitis and the pathophysiology of preterm delivery is addressed in this ongoing study. These preliminary results suggest that significantly lower gestational weight gain is associated with better outcomes. However, the increased need for cesarean delivery may represent a proxy for increased risks. miRNAs may play a crucial role in linking the underlying molecular pathways between obesity and periodontal inflammation. Furthermore, these miRNA species may represent novel targets for the diagnosis and therapeutical management of local and systemic inflammation in pregnant patients with periodontal diseases and obesity (supported by PRIN 2010). Keywords: obesity; preterm birth; periodontitis Presenter: E. Grossi

ID 830

EMERGENCY CERVICAL CERCLAGE IN TWIN PREGNANCY: DOES IT WORK? C. Larran˜aga-Azca´rate1, M. Donazar-Ezcurra2, B. Pe´rez-Munarriz3, J. Zabaleta-Jurı´o4, & I. Huarte-Sala5 1,2,3,4,5 Obstetrics and Gynecology Service, Complejo Hospitalario Navarra ‘‘B’’, Pamplona, Navarra (Spain)

Brief Introduction: Few data have been published regarding emergency cervical cerclage (ECC) in high-risk populations such as twin pregnancy. This therapeutic intervention, although controversial, may be beneficial when fetal amniotic membranes are exposed and preterm birth, together with perinatal morbidity and mortality, increases. Materials & Methods: Objective: To analyse obstetric outcomes and to assess the effectiveness of ECC to improve the perinatal outcome in

patients with painless cervical dilatation and exposed amniotic membranes in twin pregnancies Study design: We performed a retrospective analysis of cervical cerclages at the Virgen del Camino Hospital from 1998 to 2013. Women with twin pregnancy managed for prolapsed fetal membranes who did not have premature rupture of membranes, clinically discernible chorioamnionitis, treatment-resistant uterine contractions, haemorrhage or placental abruption from 18 to 28 weeks of gestation were included. All patients received prophylactic antibiotics and progesterone and were under observation for 8–24 hours before the procedure. All women were examined by an anaesthesiologist and underwent a Shirodkar modified technique performed by an experienced obstetric surgeon. Prolongation of pregnancy, gestational age at delivery, birth weight, NICU admission, and neonatal survival rate were included as outcome variables. Clinical Cases or Summary Results: 13 patients underwent Shirodkar modified technique. 2 of these women also had cervical occlusion. 8/ 12 women received atosiban as tocolytic treatment during gestation. Mean gestacional age at the time of cerclage was 23 weeks (W) 3 days (D), (range 18W0D- 27W4D) and mean cervical length (9/13 patients) was 12.22 mm (range 0–24 mm). Mean time from cerclage to delivery was 46 days, (range 0–87 D). Perinatal results: mean birthweight of the first twin 1426 g (95%IC 862.09–1991.45 g), perinatal mortality 1/ 13, miscarriage 3/13, neonatal admission to NICU (Neonatal Intensive Care Unit) 2/13 and to NCU (Neonatal Care Unit) 5/13. Mean birthweight of the second twin was 1386.38 g (95%IC 963.98– 1808.79 g), perinatal mortality was 2/13, miscarriage 1/13, neonatal admission to NICU 4/13 and to NCU 5/13. Almost half of the pregnancies (6/13) exceeded 32 weeks at delivery; and more than a fifth 3/13 went beyond 34 weeks. Median gestational age at delivery was 32W2D when occlusion was not performed, and 31W 0D when occlusion was done (not statistically significant). Conclusions: Emergency cerclage seems to improve obstetric and perinatal outcome in women with advanced painless cervical dilatation with exposed amniotic membranes in twin pregnancies Keywords: emergency cerclage, perinatal outcome, twin pregnancy, Shirodkar modified technique Presenter: C. Larran˜aga-Azca´rate

ID 652

ROLE OF ELECTROMYOGRAPHY OF UTERUS IN PREDICTION OF PRETERM LABOR A. Puertas Prieto, S. Ruiz Dura´n, M. Naveiro Fuentes, & J. Go´ngora Rodrı´guez Virgen de las Nieves University Hospital, Granada, Spain Brief Introduction: Preterm labour continues to be a major contributor to neonatal and infant morbidity, hence the importance of predicting the true preterm birth. The aims of this study were to try to establish a threshold above which cases of preterm labor do not respond to tocolysis. Materials & Methods: In 94 pregnant women with threatened preterm labor we used a noninvasive method (MONICAÕ AN24) to measure uterine dynamics as electrical activity in the uterus (AU) in mV. Measurements were started 30 min before tocolytic treatment was begun with AtosibanÕ and were recorded hourly for up to 19 h posttreatment. The women were divided into two groups: effective treatment (ET) when labor was delayed for more than 48h or greater than 259 days, and ineffective treatment (IET) when delivery occurred within 48h of the start of treatment or before 259 days. Clinical Cases or Summary Results: 94 women received tocolytic treatment. Tocolysis was effective in 84 (89.4%) and ineffective in 10 (10.6%). The average value of AU prior to treatment was 123.10 ± 22.3

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in the ET group, while the values started from 164.44 ± 27.7 (p50.001) in the IET group. At a sensitivity of 66.7% and using the ROC curve, abdominal electromyography of an amplitude of 130 mV prior to treatment had a specificity of 100%, and a diagnostic accuracy of 89.5% in predicting preterm labor. The correlation between uterine activity and the number of hours the delivery is delayed is significant (p50.001) with R = -0.499. The average decrease of electrical AU was as follows for IET and ET groups respectively (the values show the measures from 30 min before treatment and hourly during 12h after starting the treatment): 4.8 v. 11.0, 5.0 vs. 12.5, 5.8 vs. 16.5, 11.3 vs. 17.6, 13.7 vs. 18.5, 17.3 vs. 20.7, 20.8 vs. 21.9, 22.6 vs. 22.3, 26.4 vs. 24.1, 29.0 vs. 24.9, 31.9 vs. 28.0, 32.2 vs. 26.0, 36.9 vs. 26.3 (p50.05 from 30 min before treatment to 4 h posttreatment). Conclusions: The treatement tocolysis with atosiban does not show response if AU is higher than 130 mV before the treatment. In these cases, it might be interesting to associate other treatments aimed at slowing delivery to enhance the tocolytic action during the first four hours. Keywords: Preterm labour Presenter: A. Puertas Prieto

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

delivery room, surfactant administration, number of days of mechanical ventilation, number of RBC transfusions, bronchopulmonary dysplasia, necrotizing enterocolitis, pneumothorax, retinopathy and death. The outborn group showed a greater incidence of severe IVH during the first 48 hours of life compared to the inborn group (27% vs 4%; p50.05). After accounting for intubation, inter-hospital transport and RBC transfusions in a multivariable model, the association between outborn status and IVH lacked statistical significance while the incidence of severe IVH was significantly associated to RBC transfusions during the first week of life (OR: 8.46; 95% CI 1.07 to 36.0). Conclusions: Although premature newborns transported during the first 2 days of life have higher rates of IVH than those born at a tertiary care facility, this relationship may be explained by associations with other clinical variables rather than transport itself. As previously reported, our study confirm that RBC transfusions may have a causative role in severe IVH of preterm newborns. More studies are needed on this association. Moreover, it should be stressed that newborns transfused during the first week of life shown more severe clinical conditions. However, these results may lead to better transfusion practices, to encourage new clinical trials and, perhaps, to prevent this devastating complication. Keywords: Presenter: G. Genoni

ID 499

INTRAVENTRICULAR HEMORRHAGE IN PREMATURE INFANTS AND ITS ASSOCIATION WITH TRANSPORT AND RED BLOOD CELL TRANSFUSIONS G. Genoni1, M. Binotti2, A. Monzani1, A. Bizzocchi1, R. Osello2, R. Cassone2, R. Gilodi2, S. Scarlino2, & F. Ferrero2 1

Division of Pediatrics, Department of Health Sciences, Universita` del Piemonte Orientale ‘‘Amedeo Avogadro’’, Novara, Italy, and 2Division of Neonatal Intensive Care Unit, Azienda Ospedaliero-Universitaria "Maggiore della Carita`", Novara, Italy Brief Introduction: Intraventricular haemorrhages (IVH) greatly impact the outcome of preterm newborns. Severe IVH (grades 3–4) are associated with high mortality and morbidity. Moreover, the incidence of severe IVH has only slightly reduced over recent decades, despite the considerable improvements in neonatal care and the increased survival of preterm infants. As previously reported, IVH is associated with low gestational age, hemodynamic instability, severe perinatal infections, mechanical ventilation, hypercapnia or acidosis, hypoperfusion-reperfusion insults, and patent ductus arteriosus while data about inter-hospital transport and red blood cells (RBC) transfusions during the first week of life are conflicting. Materials & Methods: We retrospectively evaluated factors associated with severe IVH in a cohort of premature newborns (gestational age 534 weeks) born between the 1st January 2013 and the 31st December 2013, in a tertiary-care Italian hospital. Clinical Cases or Summary Results: Out of 61 subjects retrospectively recruited, 50 (82%) were inborn and 11 (18%) were outborn and received an inter-hospital transport during the first 48 hours of their life. The median gestational age was 31 weeks within both groups and the median birth weight was 1395 g within the inborn infants and 1500 within the outborn infants with no significant difference between the two groups. There was no difference between inborn and outborn newborns with regards to sex, race, IUGR, maternal chorioamnionitis, antenatal corticosteroids, Apgar score at 1 and 5 minutes, and mode of delivery. Moreover, no differences were found in terms of intubation in the

ID 466

EFFICIENCY OF THE SILICON CERVICAL PESSARY VS CERVICAL CERCLAGE IN THE SECOND TRIMESTER OF PREGNANT WOMEN WITH CERVICAL INCOMPETENCE R. Stanculescu1, E. Bratila1, V. Bausic1, A. Teodorescu Obstetrics and Gynecology Dept., University of Medicine " Carol Davila", St. Pantelimon Hospital, Bucharest, Romania Brief Introduction: The premature birth affects the premature newborn, mother, family and society. The shortening of cervix in the second trimester could lead to the premature end of pregnancy. In St Pantelimon Hospital the incidence of the premature birth reaches 11.2%. The accessibility to cervical silicon pessary challenges clinicians to use this local device to avoid a surgical intervention such as McDonald cerclage procedure. Targeting to investigate if one of these methods is more appropriate to prolong the gestational age, a comparison was performed as concerns effectiveness of cervical pessary vs cervical cerclage at pregnant women with clinically and ultrasonographically confirmed shortening of the cervix. Materials & Methods: Our retrospective study was carried out at St. Pantelimon Hospital, Bucharest, between the 1st of January 2012 and the 31st of December 2013 and enrolled 90 pregnant women with cervical incompetence at gestational age of 20–24 weeks of gestation. The criteria for selection were represented by the ultrasonographic short cervical length (less than 25 mm at 20 gestation weeks) and the normal vaginal smear. We analyzed the evolution of pregnancy upon 3 study groups: 26 pregnant with cervical surgery cerclage, 24 pregnant with cervical pessary and 40 pregnant with expectative management under antispastical and hormonal therapy. All cases were treated with intravaginal progesterone, 200mg/daily and intercourse was forbidden. The analysis of cases took into account the gestational age at the time of delivery, vaginal or cesarean section, Apgar score. The statistical data were processed by using SPSS 15 version software. For each test the corresponding statistical method is specified (Chi-square, Fischer). The results are presented as

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DOI: 10.3109/14767058.2014.924236

mean ± standard deviation (SD) and frequencies; sometimes the median value is indicated too, in situations when Student T was replaced by Mann-Whitney test (because a non-normal distribution is in place). The test is significant if p-value50.05. Clinical Cases or Summary Results: Pregnant women with cervical pessary have shown a lower significant statistic rate of pre-term birth under 37 weeks of gestation vs the expectative management group (24% vs 56%; risk ratio (RR) 0.34, 92% confidence interval (CI) 0.29 vs 0.47). Mean gestational age at delivery was 37.4 + 2 weeks in the pessary group, 35.2 + 1 weeks in the cerclage group and 34.8 + 4 weeks in the expectative management group. There were no significant differences regarding the delivery mood, rate of prematurity, mean birth weight and Apgar score for the same age of gestation at delivery. An increase in cervical secretion and subsequent vaginal discharge was observed both in cases with cervical cerclage and pessary group. No infectious complications occurred. In 92% of the treated pregnant women the cervical pessary could be removed after the 37-th week of gestation. There was no pregnant woman who abandoned this treatment. Conclusions: Both cervical pessary and cervical cerclage are effective methods for prolongation of pregnancy at pregnant women with cervical incompetence and threatened pre-term labor but cervical pessary proved to be a better attitude. Because silicon pessary offers more advantages (such as avoiding of a surgical intervention under anesthesia, lack of uterine contraction induction and possibility to prolong with two more weeks the gestational age) this method could be successfully used to prevent pre-term birth.

initiated in 85.84% of all study population (21 ibuprofen, 63 indomethacin, and 13 both COX inhibitors). The rate of ductal closure after one course of COX inhibitors 38.14% (37/97) differed from those after two 41.67% (25/60) or more 22.83% (8/35) courses, being highest after two courses. The rate of short-term pharmacological treatment complications such as necrotizing enterocolitis and oliguria was 41.24%. Patients from ibuprofen group were observed with higher rates of oliguria than treated with indomethacin, however this difference was not significant (p = 0.06). The rate of surgical ligation was 22.12%. Neonates after ligation of a PDA, in comparison with treated only by COX inhibitors, were smaller for average gestational age (p = 1.68  106), lower birth weight (p = 1.19  103), had a bigger average narrowest ductal diameter (p = 8.17  104), spent a greater average time on mechanical ventilation (p = 7.64  108) and in hospital (p = 7.05  1012), got more courses of treatment with COX inhibitors (p = 0.01), were significantly more frequently diagnosed with retinopathy of prematurity (ROP) (p = 0.037) and bronchopulmonary dysplasia (BPD) (p = 3.81  106). Conclusions: 7.05% of preterm neonates were yearly diagnosed with a PDA in the tertiary centre of Lithuania during the study period. A PDA ligation has been shown to be associated with more pharmacological treatment, time on mechanical ventilation and additional morbidities such as BPD or ROP. Similar results were observed in scientific literature from other countries. More prospective studies should be performed in a PAD treatment field in Lithuania.

Keywords: cervical pessary; cervical cerclage; premature birth

Keywords: Preterm infant, premature neonate, patent ductus arteriosus, cyclooxygenase inhibitors, ligation, bronchopulmonary dysplasia, retinopathy of prematurity.

Presenter: R. Stanculescu

Presenter: S. Sendzikaite

ID 380

ID 216

THE RETROSPECTIVE STUDY OF PRETERM INFANTS WITH A PATENT DUCTUS ARTERIOSUS IN THE TERTIARY CENTRE OF LITHUANIA

CLINICAL COURSE AND PROGNOSIS AT ONE YEAR OF CORRECTED AGE OF A 5379 COLOMBIAN LOW BIRTH WEIGHT (LBW) INFANTS COHORT DISCHARGED HOME IN KANGAROO POSITION WITH AMBULATORY OXYGEN.

S. Sendzikaite1,2, R. Vankeviciene1,2, A. Liubsys2, K. Petrauskiene1,2, & N. Drazdiene1,2 1 Vilnius University Medical faculty Clinic of Children diseases, and 2Children‘s Hospital, Affiliate of Vilnius University Hospital Santariskiu Klinikos

Brief Introduction: The main goal of this retrospective study of medical records was to evaluate the treatment of preterm infants with a patent ductus arteriosus (PDA) in the only specialized neonatology centre in Lithuania. PDA is still a great challenge to the clinicians in all countries as well as in Lithuania. Materials & Methods: A retrospective chart review of all 23 weeks + 0 days to 36 weeks + 6 days gestational age infants with a PDA born between 2009 and 2013 was performed. The main criterion for initiation of cyclooxygenase (COX) inhibitors was a haemodynamically relevant PDA according to echocardiography, while the surgical ligation was performed only after therapy failure. The evaluation of ductal closure success rate after pharmacological treatment was accomplished. A successful outcome was defined as resolution of clinical symptoms. The duration of mechanical ventilation, courses of COX inhibitors, short-term complications and underlying comorbidities were compared among subgroups of different treatment way. Clinical Cases or Summary Results: The yearly average number of preterm infants hospitalized in our neonatology centre between 2009 and 2013 was 320, 7.05% of these neonates were diagnosed with a PDA. The final study population consisted of 113 (63 females, 50 males) preterm infants with a PDA. The COX inhibitor treatment was

N. Charpak, & E. Rodriguez 1

Kangaroo Mother Care Program, Hospital Universitario San Ignacio, Universidad Javeriana, Bogota, Colombia. Kangaroo Foundation, Bogota, Colombia, and 2Kangaroo Foundation, Bogota, Colombia. Brief Introduction: Objective: To evaluate clinical course and prognosis at one year of corrected age of a cohort of 5379 oxygen dependent preterm infants cared in our ambulatory KMC program between 2002 and 2013. Materials & Methods: Patients and design: Prospective cohort of 5379 oxygen dependent (OD) preterm infants discharged home in kangaroo position (KP) with periodical follow-up until 12 months of corrected age to determine survival, growth, development and morbidity. Intervention: 1) Continuous KP (skin-to-skin contact 24 hours), 2) Exclusive breastfeeding whenever possible and 3) Early discharge in KP with close monitoring and follow-up (dynamic oxymetry each week up the weaning) Clinical Cases or Summary Results: 17004 eligible infants (37 weeks of gestational age or weight 2500 at birth) were admitted in the ambulatory KMC program during this period. 5379 infants (31.7%) were discharged home with supplementary use of oxygen. Weight at

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382 birth for 58.8% of infants was under 1500g and for 10.6% was under 1000g, 27.4% weighted more than 2000g. 28.9% of patients were less than 30 weeks of GA, 50.8% were less than 32 and even 4.3% were more than 37 weeks of GA. Post-natal age at entry was between 1–15 days for 28.1%, 15–30 days for 30.5% and more than 1 month for 41.4% of them. 68.2% were NICU graduates, 42.8% of them have been ventilated. 40.6% were diagnosed with BPD at entry and 11.6% had intraventricular hemorrhage. 17.9% had history of nosocomial infection at entry. Lost of follow up was 21.3% from entry into KMC to one year of corrected age. Overall mortality in the cohort was 1.5% up to one year, with 11.7% of deaths occurring between discharge and 3 months. 15.4% of infants were readmitted at least once. Main cause of readmission before 3 months was acute respiratory infection (51%). In average, oxygen was discontinued at 94 days of chronological age and with an average of 4066 g of weight. 44% received exclusive breastfeeding up to term, 26% up to three months and 51.2% received mix feeding at 3 months of corrected age. Average weight, length and head circumference were 2905 g, 47.6 cm, 34.6cm at term and 8630g, 71.7 and 45.7 cm at one year of corrected age; Retinopathy was detected in 8.7%, laser surgery 2.3% and blindness in 0.2%. Abnormal audiometry results were found in 3.3% of children. Risk of cerebral palsy at one year was 5.1%. Mean developmental coefficient at 6 months was 93.1 and at 12 months 94.2 (Griffiths + Bailey II behavioral subscale). Conclusions: Our experience shows that weight, over age, is a major indicator of oxygen discontinuation. Weaning in our cohort reached its peak at 3431g. There is an unacceptable rate of OD in infants 432 weeks GA that may be explained by inappropriate ventilation practices in NICUs, suboptimal oxygen delivery and factors that need to be further explored in prospective studies. Keywords: Oxygen, preterm infant, Kangaroo Mother Care Presenter: E. Rodriguez

ID 601

VALIDATION OF A QUANTITATIVE ULTRASOUND TEXTURE ANALYSIS OF FETAL LUNGS TO

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

PREDICT NEONATAL RESPIRATORY MORBIDITY E. Bonet-Carne1, M. Palacio2,3, T. Cobo2,3, A. Perez-Moreno1, M. Lopez2, J. Piraquive2, J. Ramirez2, F. Marques4, & E. Gratacos2,3 1 Transmural Biotech SL., Barcelona, Spain, 2Department of Maternal-Fetal Medicine – ICGON, Hospital Clinic of Barcelona - University of Barcelona, Barcelona, Spain, 3Fetal and Perinatal Medicine Research Group - IDIBAPS and CIBERER, Barcelona, Spain, and 4Universitat Politecnica de Catalunya BarcelonaTECH, Barcelona, Spain

Brief Introduction: Neonatal respiratory morbidity, defined as respiratory distress syndrome or transient tachypnea of the newborn, is the leading cause of mortality and morbidity associated with prematurity. It is not only restricted to very preterm babies but occurs also among late-preterm infants and even in early-term babies before 39 weeks. At present, the assessment of fetal lung maturity, if done, is mostly performed by means of laboratory tests in amniotic fluid that requires an amniocentesis. Quantitative texture analysis of fetal lung obtained by ultrasound can provide an accurate result of fetal lung maturity. The objective of this study was to preliminary evaluate the performance of quantitative texture analysis of fetal lung ultrasound images to predict the risk of neonatal respiratory morbidity. Materials & Methods: Lung ultrasound images from 51 fetuses from 28.0 to 39.0 weeks were obtained within 48 hours of delivery. The occurrence of neonatal respiratory morbidity, defined as either respiratory distress syndrome or transient tachypnea of the newborn, was recorded. Lung ultrasound images were processed by means of computerized quantitative analysis with a purpose-designed texture analysis software (quantusFLMä, Transmural Biotech SL., Barcelona, Spain) for the prediction of neonatal respiratory morbidity. The accuracy of the software was evaluated blindly. Image 1 shows a screenshot of the software. Clinical Cases or Summary Results: Mean gestational age at delivery was 34.6 (SD 2.1) weeks. There were 12/51 (23.5%) events of neonatal respiratory morbidity. 75% (9/12) of this events corresponded to deliveries that occurred before 34 weeks of gestation. Quantitative texture analysis presented 83.3% sensitivity, 89.7% specificity and 88.2% accuracy to predict neonatal respiratory morbidity.

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DOI: 10.3109/14767058.2014.924236

Conclusions: Quantitative texture ultrasound analysis seems to predict neonatal respiratory morbidity with an accuracy comparable to current tests using amniotic fluid. These results need to be validated in larger studies. Keywords: Fetal Lung Maturity, Neonatal Respiratory Morbidity, image quantitative analysis, texture analysis Presenter: E. Bonet-Carne

independent predictors of the time interval to delivery (p50.01, r2 = 0.360) (Table 2). Conclusions: A more advanced cervical dilatation and gestational age at admission in women with preterm labor are associated with a shorter interval to delivery. A dilatation over 3 cm doubles the risk of delivery in the first two days. The use of cervical lenght for the prediction of preterm delivery may be of limited value in women with already dilated cervix. Keywords: preterm birth; cervical dilatation

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ID 635

Presenter: Viola Seravalli

RELATIONSHIP BETWEEN CERVICAL DILATATION AND TIME FROM ADMISSION TO DELIVERY IN WOMEN WITH PRETERM LABOR

ID 363

PERINATAL OUTCOME OF SMALL FOR GESTATIONAL AGE VERY LOW BIRTH WEIGHT INFANTS BORN AT A TERTIARY LEVEL OBSTETRICS AND GYNECOLOGY HOSPITAL

V. Seravalli, F. Vellucci, M. Cozzolino, M. Spitaleri, T. Susini, & M. Di Tommaso Department of Health Sciences, University of Florence, Florence, Italy. Brief Introduction: To determine the relationship between cervical dilatation and time interval from admission to delivery in women presenting with preterm labor who subsequently delivered preterm. Materials & Methods: Retrospective cohort study on singleton gestations admitted for preterm labor between 24 and 34 weeks, who subsequently delivered before term. Women with premature rupture of membranes were excluded. Linear regression analysis was performed to assess the relationship between prolongation of gestation and cervical dilatation. Other variables examined were gestational age at admission and cervical length. Women were categorized into three cervical dilatation groups to determine the risk of preterm delivery at different stages of dilatation. Clinical Cases or Summary Results: 83 women were identified. Median gestational age at admission was 29 weeks. The median interval between admission and delivery was two days. Time interval from admission to delivery was inversely correlated with cervical dilatation and gestational age at admission (p50.05). Fourty-eight percent of women with cervical dilatation 0–2 cm delivered in the first 48 hours, compared to 85% of women with a dilatation 3 to 6 cm (Table 1). No significant correlation was found between cervical length and time from admission to delivery. At multiple regression analysis, cervical dilatation and gestational age at admission remained

Table 1 Dilatation at admission and time from admission to delivery CERVICAL DILATATION

n

Delivery 524 h

Delivery 24–48 h

Delivery 3–7 days

Delivery 47 days

0–2 cm 3–6 cm 10 cm

65 14 4

15 (23%) 9 (64%) 4 (100%)

16 (25%) 3 (21%)

18 (28%) 1 (7%)

16 (25%) 1 (7%)

Table 2 Multiple linear regression analysis for prolongation of pregnancy

GA at admission Cervical dilatation Cervical Lengtha

B

Beta

95%CI for B

p

0.88 1.39 0.22

0.31 0.31 0.22

 1.59, 0.17  2.54, 2.35 0.49, 0.05

0.02 0.02 0.11

GA: Gestational age Data on cervical length were available in 56 women.

a

L. Vakrilova1, V. Dimitrova1, St. Hitrova1, B. Slancheva1, A. Popivanova1, P. Radulova1, B. Frandeva1, & A. Dimitrov1 1

Medical University of Sofia, Faculty of Medicine, Chair of Obstetrics and Gynecology, University Obstetrics and Gynecology Hospital ‘‘Maichin Dom’’, Sofia. Bulgaria. Brief Introduction: Small for gestational age (SGA) and intrauterine growth retarded (IUGR) very low birth weight (VLBW) infants have different problems and perinatal outcome compared to appropriate for gestational age (AGA) VLBW neonates. Aims: To analyze the perinatal risks, morbidities and outcome of SGA-VLBW and AGA-VLBW newborns. Materials & Methods: A cohort study was performed on all 683 inborn infants with birth weight (BW)51500g, admitted at the NICU during a 3 year period (2008–2010). SGA was defined as BW510th percentile, severe IUGR - as BW5/= 3rd percentile according intrauterine growth curves [Fenton TR. BMC Pediatr 2003]. Two groups were compared: a mean group of 243/683 SGA-VLBW infants (35.6%) and a control group of 440/683 AGA-VLBW infants (64.4%). A subgroup of 130/683 severely IUGR-infants (19.0%) was additionally analyzed. The following perinatal data were assessed: antenatal steroids, mode of delivery, CRIB and 1/5min Apgar scores, umbilical artery (ua) pH and BE, surfactant therapy for RDS, severe malformations. Outcomes of interest were death, bronchopulmonary dysplasia (BPD) defined as supplemental O2 428d and at 36 gestational week (gw), severe brain injury (IVH III/IV, PVL). Statistical analyses were performed using SPSS Statistics 19.0.0. P-values 50.05 were considered statistically significant. Clinical Cases or Summary Results: The mean BW was 1103g for the SGA-group, 1116g for the AGA-group (p40.05, NS), and 1198g for the severely IUGR-subgroup. The mean GA was 31.4gw, 28.8gw (p50.001) and 32.5gw respectively. Antenatal steroids were applicated in 51.0% of the SGA vs. 50.4% of the AGA-infants (NS). Cesarean section (CS)was performed more frequently in the SGA-group - 70% vs. 59.5% (p50.01). Mean CRIB for the SGA and AGA-infants did not differ significantly: 6.34 vs. 6.48; the same referred to 1/5min Apgar scores - 4.56/6.12 vs. 4.54/5.94. However, mean ua pH and BE were significantly lower among SGA-infants: pH 7.25 vs. 7.30 (p50.001), BE -9.96 vs. -8.74 (p50.01). Congenital malformations were present in 9.0% of the SGA vs. 4.5% in the AGA-group (p50.05), and in 12.3% of the severely IUGRsubgroup. Surfactant for RDS was applied in 34.5% of the SGA vs. 59.3% of the AGA-infants (p50.001). Mortality rate was insignificantly

384

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

higher in the SGA-group 15.6% vs.14.1% (p40.1). Only 16% of the SGA-infants needed supplemental O2428d compared to 28.4% of the AGA (p50.001). Brain injury was diagnosed in 20.6% of the SGA vs. 28.6% of the AGA-infants (p50.02). Conclusions: We established a higher proportion of SGA-VLBW infants in our population compared to data from other studies. No differences in CRIB and 1/5min Apgar scores were found, but SGAinfants were more likely to have metabolic acidosis at birth as a sign of fetal distress which necessitated CS. SGA-neonates had more frequently congenital malformations; their mortality rate was slightly higher, but the frequency of RDS, BPD and severe brain injury was lower, most probably due to the more advanced GA. Keywords: VLBW infants, SGA and AGA neonates, intrauterine growth retardation

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Presenter: A. Popivanova

ID 780

S100A12 PROTEIN: BIOMARKER OF MATERNAL AND FETAL INFLAMMATION? Iliana Bersani, MD1, Maria Pia De Carolis1, Dirk Foell2, Toni Weinhage2, Esther Diana Rossi3, Sara De Carolis4, Serena Antonia Rubortone1, Costantino Romagnoli1, & Christian Paul Speer 1 Catholic University of the Sacred Heart, A. Gemelli Hospital, Division of Neonatology, Rome, Italy, 2Department of Pediatric Rheumatology and Immunology, University Children’s Hospital Muenster, Muenster, Germany, 3Catholic University of the Sacred Heart, A. Gemelli Hospital, Division of Anatomic Pathology and Histology, Rome, Italy, 4Catholic University of the Sacred Heart, A. Gemelli Hospital, Division of Obstetrics, Rome, Italy, and 5University Children’s Hospital, University of Wu¨rzburg, Germany

Brief Introduction: Histologic chorioamnionitis (HCA) is an intrauterine inflammation, which may lead to the fetal inflammatory response syndrome (FIRS). Since inflammation is a pathogenetic mechanism of preeclampsia, FIRS might occur also as consequence of preeclampsia. The aim of this prospective pilot study was to evaluate S100A12, a marker of innate immune activation, in mothers and high risk preterm infants. Materials & Methods: S100A12 concentrations were evaluated in maternal, cord, and neonatal blood of very preterm infants Table 3. Cytokine expression and CRP levels in maternal, cord, and neonatal blood HCA Group n = 15 S100A12, ng/ml Mother 210 (170–380) Cord 130 (78–150) Neonate 250 (55–680) IL-6, pg/ml Mother 15.7 (0–54.0) Cord 0 (0–122) Neonate 0 (0–0) CRP, mg/dl Mother 2.32 (0.82–4.82) Cord 0.15 (0.01–0.21) Neonate 0.96 (0.15–2.38)

Preeclampsia Group Control Group n = 17 n = 33 170 (90–402) 73 (19–182) 145 (80–250) 0 (0–0) 0 (0–0.6) 0 (0–1.2) 0.35 (0.17–0.51) 0.02 (0.02–0.14) 0.33 (0.11–0.57)

p

320 (94–690) 0.75 83 (31–170) 0.4 130 (56–195) 0.41 0 (0–5.4) 0 (0–0) 0 (0–6.8)

0.04 0.06 0.17

0.52 (0.21–1.08) 0.04 0.02 (0.01–0.02) 0.23 0.12 (0.03–0.32) 0.67

Values expressed as median (25th–75th centile) IL-6 (Mother): HCA Group vs Preeclampsia Group p50.05; HCA Group vs Control Group p50.05

(BW51500 g). Histologic examinations of placentae and umbilical cords were performed. Clinical Cases or Summary Results: The 65 mother-neonate pairs enrolled were subdivided into three groups: 1. HCA group (n = 15); 2. preeclampsia group (n = 17); 3. control group, in the absence of HCA/ preeclampsia (n = 33). Significantly higher concentrations of IL-6 (p = 0.04) and CRP (p = 0.04) were found in maternal blood of the HCA group. Maternal, cord and neonatal S100A12 levels were similar between the groups. However, the highest S100A12 concentrations were detected in cord and neonatal blood of two out of three neonates who had been exposed to HCA associated with funisitis. Conclusions: S100A12 might have the potential to identify preterm infants with fetal exposure to inflammation. Keywords: neonate, s100A12, chorioamnionitis, FIRS, preeclampsia, prematurity Presenter: Iliana Bersani

ID 944

DELAYED UMBILICAL CORD CLAMPING IN PRETERM INFANTS IN A THREE LEVEL CARE NICU J. Oliveira, I. Periquito, C. Fernandes, C. Trindade, O. Voutsen, & R. Barroso

385

DOI: 10.3109/14767058.2014.924236

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Neonatology Department, Hospital Prof. Dr. Fernando Fonseca, Lisbon, Portugal Brief Introduction: Suggested benefits associated with delayed umbilical cord clamping includes higher hemoglobin and hematocrit levels, better cardiopulmonary adaptation to extrauterine life, less need for red blood cell (RBC) transfusion and less respiratory distress. The aim of this study was to evaluate the effects of delayed umbilical cord clamping in hematologic parameters and the need for RBC transfusion in newborns between 27 and 32 + 6 gestational weeks. Materials & Methods: Retrospective and comparative study of two groups of neonates, one group with delayed umbilical cord clamping for at least 60 seconds (DCC) and the other group that did not use this approach (control). Variables analysed were: maternal age, gestational age, mode of delivery, birth weight, hemoglobin and hematocrit value in the first 24 hours and at the first week of life (between 3rd and 7th day), need for RBC transfusions, days of invasive ventilation, number of RBC transfusions, hemoglobin and hematocrit value at discharge. Clinical Cases or Summary Results: A total of 185 newborns were included, 73 newborn in the DCC group and 112 newborn in the control group. Both groups were similar in relation to maternal age, mode of delivery and mean gestational age (30.3 in DCC group and 30.2 weeks in control group). Hemoglobin and hematocrit values in the first 24 hours and in the first week of life were significantly higher in the DCC group specially in the very-low-birth-weight infants. 23 of the 73 infants (31.5%) in the DCC group and 45 of the 113 (40.2%) of the control group received RBC transfusions. The number of RBC transfusions was similar in both groups. After multiple logistic regression analysis, lower birth weight, number of sepsis episodes and days of invasive ventilation were found as statistically significant risk factors for the need for RBC transfusions (p50.001 and p = 0.009 for the former). Delayed clamping of the umbilical cord also appeared to have protective effect in the need for RBC transfusions (OR = 0.522) and was a statistically significant independent protective factor for higher hemoglobin and hematocrit values at discharge (p = 0.017; p = 0.045 respectively). Conclusions: Delayed cord clamping in delivery room in preterm infants results in higher hemoglobin and hematocrit values in the first week of life. It also has protective effect in the need for RBC transfusions and for higher hemoglobin and hematocrit values at discharge. Keywords: Late umbilical cord clamping, preterm, RBC transfusion, hemoglobin Presenter: Isabel Periquito

ID 657

MAINTENANCE TOCOLYSIS IN RISK OF PRETERM LABOR J. Parra, S. Ferrero, J. Sabria`, L. Guirado, N. Lorente, & M.D. Gomez-Roig BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clinic and Hospital Sant Joan de Deu), IDIBAS, University of Barcelona. Barcelona, Spain Brief Introduction: The rate of preterm labor is more than 12%, responsible for the 75% of the infant mortality and 50% of long term neurologic deficits. In threatened preterm labor before 34.6 weeks, the delay of the delivery for 48h allows antenatal corticosteroids treatment to improve fetal lungs maturity and decrease the morbimortality. Acute preterm labor could be successfully treated in 70–90% using tocolytics, but recurrent episodes needing hospitalization and retreatment are frequent. The effectiveness of maintenance tocolysis is debated, and related literature is controversial. At present, no beneficial effect on perinatal

outcome has been established, and there are doubts about the side effects. Materials & Methods: We performed a retrospective study of clinical data of 185 pregnant women that have been admitted in our Hospital because of the risk of a preterm labor (uterine contractions +/changes in cervical length) during the period 2009 to 2012. Information related to pregnancy history, as well as pregnancy and neonatal outcome data were obtained from the clinical chart of each patient. Clinical Cases or Summary Results: There were reviewed 185 patients diagnosed of risk of preterm birth, between 22 to 35 weeks of gestation. 73% of the patients evaluated, finished their pregnancy on term, and 27% had a preterm delivery. The cervical length at the time of the hospitalization was inversely associated with the higher risk of preterm delivery (1–10mm finished as a preterm delivery on 43%; 11– 15mm preterm delivery on 40%; 16–25mm preterm delivery on 20% and 425mm preterm delivery on 21%) The first line tocolytic used (according to the protocols at that time) was ritodrine (beta agonist) in 70% of the patients. It was followed by atosiban (oxytocin receptors antagonist) on 25% of the patients. The use of nifedipine (1.1%) and indometacine (3.2%) was lower. The rate of preterm delivery did not vary among the one, two or three series of tocolysis for 48 hours. Maintenance tocolysis was performed on 9.7% of the patients, from 26 to 34 weeks of gestation; 60% of them had have a previous batch of tocolysis and 40% of them, 2 or 3 series, without changes on the rate of term delivery between them. The tocolytics used were: Nifedipine on the 61% of the patients and atosiban in one third of them (33%). 17% of them finished as preterm labor (comparing to 27% of the patients without maintenance tocolysis) and 83% finished on a term delivery (comparing to 73% of the patients without maintenance medication). Neonatal complications were observed on 15.7% of the patients (16% on the patients without maintenance and 11% on the patients with maintenance tocolysis). Conclusions: Preterm birth is an important cause of neonatal morbidity and mortality. Outcome of preterm infants can be improved and health care consumption and costs reduced by postponing delivery for 48 hours with tocolytic agents to allow maximal effect of maternal steroid administration. Prediction of preterm labor is still difficult: only 27% of the patients had real preterm labor. This study confirms that the cervical length at the time of the hospitalization is inversely associated with higher risk of preterm delivery. Tocolysis is indicated during 48 hours for achieving fetal lung maturation which really improves neonatal outcomes. This study shows that the use of maintenance tocolysis in recurrent cases in our hospital, could lead to an increase in the rate of term deliveries on selected patients at risk of preterm birth. It is necessary to conduct studies with larger samples, to check the effectiveness as well as the safety profile of the use of these medications in infants and mothers. Keywords: PRETERM LABOR, MAINTENANCE TOCOLYSIS Presenter: J. Parra

ID 092

LONG-TERM HEMODIALYSIS SAVES VERY LOW BIRTH WEIGHT INFANT WITH POTTER SEQUENCE J. Miyahara, K. Motoshige, & S. Ohki Neonatology Dept., Seierei Hamamatsu General Hospital, Hamamatsu, Japan Brief Introduction: Recent advances in neonatal cardiorespiratory management and neonatal renal replacement therapy have led to

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386 occasional reports of favorable short-term and long-term outcomes for Potter sequence, once thought to be fatal. There is, however, no reported case of surviving Potter sequence among very low birth weight (VLBW) infants requiring renal replacement therapy from the neonatal stage. A case of a VLBW infant presenting with left renal agenesis and right dysplastic kidney and diagnosed with Potter sequence, whose life was saved with concomitant hemodialysis and peritoneal dialysis from the neonatal stage, is reported. Materials & Methods: The present case was a girl born at a gestational age of 34 weeks 4 days with a birth weight of 1398 g. Clinical Cases or Summary Results: She was diagnosed with Potter sequence complicated by pulmonary hypoplasia due to left renal agenesis and right dysplastic kidney. Hemodialysis was started because anuria persisted even after her persistent pulmonary hypertension receded and her cardiorespiratory status improved. Peritoneal dialysis during progression failed to achieve stability because of pericatheter leakage and frequent obstruction of the peritoneal dialysis catheter; in the meantime, hemodialysis was also used. Once her body weight passed 3.5 kg, peritoneal dialysis became more feasible with stability; she was discharged at 9 months and is now on peritoneal dialysis at home, and renal transplantation is planned. Conclusions: The present case has two clinical implications. The first is that combined modality therapy including renal replacement therapy enables survival even in VLBW infants with Potter sequence, which has not been previously reported. The second is that hemodialysis offers favorable maintenance and management even for cases of chronic renal failure among VLBW infants for whom it is difficult to perform peritoneal dialysis, such as with cases of complicating abdominal surgical disease. Keywords: Very low birth weight infant, Potter sequence, Dialysis Presenter: Jun Miyahara

ID 920

INCIDENCE AND DETERMINANTS OF RESPIRATORY SYNCITIAL VIRUS BRONCHIOLITIS IN LATE PRETERM INFANTS L. Serrano Lo´pez, V. Jimenez Cabanillas, L. Zamorano Bonilla, E. Martı´n Alvarez, M. Pen˜a Caballero, & J.A. Hurtado Suazo Neonatology Dept., Paediatric Dept., University Hospital "Virgen de las Nieves", Granada, Spain Brief Introduction: Respiratory Syncitial Virus (RSV) has consistently been noted to be the single most important cause of lower respiratory tract illness in infants less than two years of age. These infections may be severe, especially the premature infant. Palivizumab is a monoclonal anti RSV humanized antibody. In this age group prophylaxis with palivizumab may be important to prevent severe RSV lower respiratory tract infection.In Spain a risk scoring tool has been developed based on the most important risk factors in order to maximize the cost- effectiveness of this preventive approach. This study aimed to evaluate in a Spanish cohort of late preterm infants the incidence and risk factors of hospitalization in their first two years of life. Update the indication of RSV prophylaxis in this population. Materials & Methods: Descriptive study. A cohort of late preterm infants (34 + 0 to 36 + 6 weeks GA), born in a Spanish third level hospital from January 2010 to January 2014 was enrolled. Medical records were reviewed. Risk factors for RSV infections were reviewed: hospital discharge during RSV season, birth season, exposure to passive cigarette smoke, child care attendance, school age siblings and chronic lung disease.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Recommendations for inmunoprophylaxis issued by the Spanish Society of Neonatology in 2010 were followed. This is: palivizumab was administered in premature babies less than 35 weeks GA when two major risk factors were present: chronological age less than 10 weeks at the beginning of the RVS season, born in the first 10 weeks of the season, at least one school age sibling or daycare attendance. Palivizumab prophylaxis is also considered advisable when a major factor and 2 minor factors (history of maternal smoking during gestation or male gender) concur. Clinical Cases or Summary Results: From January 2010 to January 2014, 887 late preterm infants were enrolled. 37 of them (4.1%) were hospitalized for RSV bronchiolitis. The median age to RSV hospitalization was 5 months old. According to the gestational age: six 34 weekers were hospitalized (16%) one of them receiving palivizumab prophylaxis. Seventeen 35 weekers (45%), three receiving prophylaxis, and fourteen 36 weekers (38%), one patient with RSV prophylaxis. The risk factors for RSV hospitalization were determined: 56% (21) neonates were born in RSV season (October to February) 48% had school age siblings 54% (20) were male gender. Anyone was exposed to passive cigarette smoke. 16% were admitted to ICU (6 infants). Of these, three infants required non invasive ventilation. All the hospitalized infants required oxygen at any time, via nasal cannula for apneas and desaturation. No deaths were reported. Conclusions: Hospitalization rate (6%) for RSV bronchiolitis in late preterm infants of our cohort in their first two years of life was higher than the estimated one in overall population, between 1 and 3%. RSV prophylaxis was not routinely scheduled to late preterm infants according to the Guidelines issued by the Spanish Society of Neonatology. Its risk scoring tool for prophylaxis can be used to identify infants at higher risk. Keywords: Late preterm infant, Bronchiolitis Respiratory syncitial Virus, Prophylaxis Palivizumab Presenter: L. Serrano Lo´pez

ID 353

AN INFLUENCE OF APELIN ON THE RISK OF PRETERM LABOUR IN PATIENTS WITH EXCESSIVE BMI H. Huras1, P. Ossowski2, K. Rytlewski3, M. Radon´ – Pokracka4, K. Kus´mierska – Urban5, A. Wo´jtowicz6, M. Sajewicz7, & A. Reron´8 1,2,3,4,5,6,7,8

Department of Obstetrics and Perinatology, Jagiellonian University Collegium Medicum, Cracow, Poland. Brief Introduction: Aim of the study. The aim of this study was: to assess the relationship between levels of apelin and the prevalence of symptoms of preterm labor in patients with excessive BMI. Materials & Methods: Material and methods. The study group were applied to the data obtained from 60 patients hospitalized in the Department of Obstetrics and Perinatology, University Hospital in Cracow during the period from 1 January 2013. to 31 May 2013. The study was a prospective cohort of pregnant and covered in a singleton pregnancy who have had a BMI greater than or equal to 25. They were created three groups of patients (60): 1. Patients with BMI greater than or equal to 25 who have experienced symptoms of preterm labor (n = 20). 2. Patients with BMI less than 25 who showed signs of preterm labor (n = 20). 3. Patients with BMI less than 25 who gave birth to a time (n = 20). Statistically significant results were p40.05.

387

DOI: 10.3109/14767058.2014.924236

Clinical Cases or Summary Results: Results. Age of a patients: 18 – 42, average: 28.8. In 1 group concentrations of apelin: 0.029ng/ml – 0.59ng/ml; mediana:0.34ng/ml. In 2 group: 0.026ng/ml – 0.54ng/ml; mediana: 0.2ng/ml. In 3 group: 0.206ng/ml – 0.51ng/ml; mediana: 0.32ng/ml. Conclusions: Conclusions. Found higher levels of apelin concentrations in the group of patients with symptoms of preterm labor in comparison with the control groups, which may contribute to severity of inflammation that causes the symptoms of preterm labor. Keywords: preterm delivery, BMI, apelin Presenter: P. Ossowski

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ID 784

RISK FACTORS FOR NEC IN PRETERM INFANTS UNDER 32 WEEKS OF GESTATION G. Olariu1, L. Olariu2, M. Tunescu1, & S. Olariu1 1

Municipal Emergency Hospital-Neonatology DepartmentTimisoara, Romania, and 2‘‘Louis Turcanu’’ Emergency Childrens Hospital-Timisoara, Romania Brief Introduction: Necrotizing enterocolitis (NEC) is a major cause of mortality (up to 25%) and morbidity including recurrent sepsis, dependence on parenteral nutrition, need for surgery and survival with short bowel syndrome, in preterm very low birth weight infants. Aim of the study: Identifying risk factors for NECin preterm infants under 32 weeks of gestation in a third level maternity in Romania, using data registered in the National Registry of Respiratory Distress. Materials & Methods: 442 preterm infants under 32 weeks of gestation were included in the study, born in a third level maternity in Romania between 2010–2013.The risk factors were selected in five categories: prenatal, intranatal, ventilatory related, hemodinamic and those related with alimentation.Statistical analysis of data was performed using Independent Samples T-test and Pearson Chi-Square correlation. p was calculated for confidence interval of 95% (statistical significance p50.05). To establish NEC predictors we used binominal logistic regression, the Wald model of regressive elimination.There were anlysed the characteristics that differentiates preterm babies who developed NEC of those who did not developed this condition Clinical Cases or Summary Results: Incidence of EUN was 2.7% (12 preterm infants with gestational age under 32 weeks, stage II and III of disease).Gestationalagewasbetween23–32 weeks (with a medium of 29.60 ± 2.26)birth weight was between480–2350g (1309.86 ± 369.44), gender:female108 (24.4%); male 334 (75.6%) The final model of regression indicates the fact that the higher risk in developing NEC are those who presented materno-fetal infections or nosocomial infections.Other factors implicated in the development of NEC are in order of frecvency: maternal hipertension, persistent ductus arteriosus, mechanical ventilation, beghining of alimentation on day 4 or 5, oxigenoteraphy.There was also a very strong positive relationship between the number of nosocomial infections and NEC, indicating thatthe prevalence in developing NEC increased. Birthweight was not significantassociated with NECin the logistic regression but was associated with NEC probably becauseof its correlation with mecanical ventilation and the number of infections. Conclusions: The number of infections and length of mechanical ventilation were the primary predictory factors of NEC in premature babies. In additions the lack of antenatalcorticotheraphy, severe IUGR increase the risk of developing NEC. The knowledge of risk factors for NEC can allow healthcare providers to evaluate and adjust care practice for preterm infants who present with a higherrisk of NEC based on empirical data. Keywords: Premature infant, necrotizing enterocolitis, risk factors Presenter: Olariu Gabriela

ID 354

AN INFLUENCE OF LEPTIN ON THE RISK OF PRETERM LABOUR IN PATIENTS WITH EXCESSIVE BMI. H. Huras1, P. Ossowski2, K. Rytlewski3, M. Radon´ – Pokracka4, K. Kus´mierska – Urban5, A. Wo´jtowicz6, M. Sajewicz7, & A. Reron´8 1,2,3,4,5,6,7,8 Department of Obstetrics and Perinatology, Jagiellonian University Collegium Medicum, Cracow, Poland.

Brief Introduction: Aim of the study. The aim of this study was: to assess the relationship between levels of leptin and the prevalence of symptoms of preterm labor in patients with excessive BMI. Materials & Methods: Material and Methods: The study group were applied to the data obtained from 60 patients hospitalized in the Department of Obstetrics and Perinatology, University Hospital in Cracow during the period from 1 January 2013. to 31 May 2013. The study was a prospective cohort of pregnant and covered in a singleton pregnancy who have had a BMI greater than or equal to 25. They were created three groups of patients (60): 1. Patients with BMI greater than or equal to 25 who have experienced symptoms of preterm labor (n = 20). 2. Patients with BMI less than 25 who showed signs of preterm labor (n = 20). 3. Patients with BMI less than 25 who gave birth to a time (n = 20). Statistically significant results were p40.05. Clinical Cases or Summary Results: Results. Age of a patients: 18 – 42, average: 28.8. In 1 group concentrations of leptin: 7096.0ng/ml – 99092.0ng/ml; mediana:36040.0ng/ml. In 2 group: 1971.0ng/ml – 52443.0ng/ml; mediana: 19681.0ng/ml. In 3 group: 3427.0ng/ml – 35999.0ng/ml; mediana: 15748.0ng/ml. Conclusions: Conclusions. Found higher levels of leptin concentrations in the group of patients with symptoms of preterm labor in comparison with the control groups, which may contribute to severity of inflammation that causes the symptoms of preterm labor. Keywords: preterm delivery, BMI, leptin. Presenter: P. Ossowski

ID 891

EFFECT ON NEONATAL MORBIDITY OF VERY LOW BIRTHWEIGHT NEONATES BORN FROM MOTHERS WITH PREMATURE PRETERM RUPTURE OF MEMBRANES AND CLINICAL CHORIOAMNIONITIS G. Koroveshi1, A. Nurce1, Gj. Kuli-Lito3, E. Koroveshi2, N. Kodra2, & E. Gora2 1

Neonatology Dept., University Hospital"Queen Geraldine" Tirane, Albania, and 2Obstetric Dept., University Hospital"Queen Geraldine"Tirane Albania Brief Introduction: Premature preterm rupture of membranes and clinical chorioamnionitis of the mothers have their effect on neonatal morbidity in general and much much more on very low birthweight newborns.The aim of this study was to asses the relationship between neonatal morbidity of very low birthweight(VLBW) and clinical chorioamnionitis of mothers with premature preterm rupture of membranes

388 Materials & Methods: Methods:Retrospective cohort study.We included in study 203 VLBW newborns, born in our maternity during a period from January 2008- December 2013. Newborns were devided in two groups.Study group of VLBW newborns(100 babies) of mother with PPROM and clinical chorioamnionitis and control group of VLBW newborns of mother with PPROM(103). Clinical Cases or Summary Results: Results:The study group presented a higher rate of early onset sepsis(10.7%)compared with control group(1.5%). A significantly percentage of study group required intubation(53%) compared with study one (35.8%) and had a lower Apgar score at 5 min, and normal intrauterine growth(90.9%vs.85.4%) Conclusions: VLBW newborns of mothers with PPROM and clinical chorioamnionitis had a higher morbididy and early sepsis compared with VLBW newborns of mother with PPROM. Keywords: PPROM, clinical chorioamnionitis, neonatal morbidity, sepsis

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Presenter: Gentiana Koroveshi

ID 131

PRETERM BIRTH RISK FACTORS RETROSPECTIVE COHORT STUDY IN LATVIA I. Z¯ıle1,2, I. Sˇmate2, E. Podvizˇenko3, I. Str ele1, & A. Villerusˇa1 1

Riga Stradin’s University, Public Health and Epidemiology Department, Riga, Latvia, 2The Centre for Disease Prevention and Control, Riga, Latvia, and 3The Ministry of Health of the Republic of Latvia, Strategic Planning Department, Riga, Latvia Brief Introduction: Prematurity is an important adverse outcome measure of pregnancy. The rate of preterm birth ranges from 5 to 10% in Europe. In Latvia the preterm birth increased from 4.8% in 2008 to 5.9% in 2012. Preterm birth is an indicator of adverse pregnancy outcomes and associated with severe morbidity and increased mortality of newborns. Timely and accurate antenatal care and screening is believed to be an important factor in preventing preterm birth. Objective - to investigate the association with antenatal care and preterm birth. Materials & Methods: Data source – The Medical Birth Register of Latvia. All singleton live birth in spontaneous vaginal deliveries (2000– 2011) (n = 226317) were included in the data analysis. Evaluation of antenatal care is based on the time of first antenatal visit and completeness. Adjusted Odds ratios for preterm birth were calculated (reference category – term deliveries 37th – 42th gestational week (GW)). Multiple regression model adjusted for mother age, education, abortions (spontaneous and legal) and preterm birth history, mother lifestyle factors (smoking, use of alcohol) and urogenital system infections. Clinical Cases or Summary Results: There were 3.3% (n = 7387) preterm birth, who was stratified into mild preterm (birth at 34–36 GW) 68.4%, moderate preterm (32–33 GW) 12.9%, very preterm (28–31 GW)12.1% and extremely preterm (528 GW) 6.6%. The higher odds of having a preterm birth was in women with delayed antenatal care (first antenatal visit after 12th GW) – OR 2.8 (p50.001). Substantially higher odds associated with delayed antenatal care was observed for extremely preterm birth OR = 4.6 (p50.001) and very preterm birth OR = 4.2 (95%CI 3.6–4.9, p50.001) than for moderate preterm birth OR = 3.4 (p50.001) and mild preterm OR = 2.4 (p50.001). The three times higher odds of having a preterm birth was in women without antenatal care (OR = 3.5; p50.001) and incomplete antenatal care – OR = 2.3 (p50.001) than with complete antenatal care. The similar as before the substantially higher odds associated with incomplete antenatal care was observed for extremely preterm birth OR = 4.2 (p50.001) and very preterm birth OR = 3.4 (p50.001).

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Conclusions: Timing and completeness of antenatal care reduced the risk of preterm birth. Within the framework of the public health promotion and education programs on sexual and reproductive health, attention should be paid to issues on timely antenatal care as important predictor of health and health related behavior of pregnant women. Keywords: preterm birth; risk factors; antenatal care Presenter: Irisa Z¯ı le

ID 820

THE ANTENATAL ROLE ADMINISTRATION OF MAGNESIUM SULFATE (MGSO4), AS A NEUROPROTECTIVE DRUG IN PRETERM BIRTH Aliona Lupascu Valeriu Padure, Victor Petrov, Maria Manceva, The Institute of Mother and Child Care, Chishinau, Moldova. Brief Introduction: Objective: To determine antenatal neuroprotective influence of MgSO4 on neonatal results Materials & Methods: In this study were included 140 pregnant women, with monofetal pregnancy in gestational age from 26 till 33 + 6 weeks of gestations, who delivered till term of 34 weeks of gestation, which were divided into 2 groups.

389

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DOI: 10.3109/14767058.2014.924236

In first group in 80 cases had been administrated neuroprotective theraphy with MgSO4 (sol. MgSO4 25%–20.0 ml + sol. NaCl 0.9%–20.0 ml in bolus time of 15 min (slowly, i/v), with continuing perfusion sol. MgSO4 25%–20.0 ml + sol. NaCl 0.9% -200.0 ml (1g/h). In the second group in 60 cases, after the same scheme we perfused NaCl as placebo. Clinical Cases or Summary Results: The neurological complications in the first group occured in 4.4% cases, but in placebo group the neurological complications were presented in 13.4% cases. In the structure of neurological problems we would like to mention seisures, IVH (I, II grade), ischemia.(image n.2). In the first group the range of neurological complications was three times smaller than in group with placebo 1.9% vs 3.5%; relative risk, 0.55; 95% confidence interval [CI], 0.32 to 0.95. Conclusions: Acording to our dates the antenatal administration of MgSO4, as a neuroprotective drug reduce the risk for neurologic adverse outcomes in premature babies.

syndrome 89(10.3%) of LP vs 44 (0.34%) of term infants.The OR = 33 and CI 95% 23- 48(p50.0001). Transient tachypnea of newborn 128 (14%) versus 84 (0.67%) of terms OR = 26 CI 95% 19–35(p50.0001). Apgar score57 the 5-th minute are 37 (4.3%) infants born late preterm and 86 (0.67%) term babies OR = 6.6, CI 95% 4.49.8(p50.0001). Total respiratory mobidity reduces with the increasing GA 21%, 20% and 12% for34, 35 and 36 weeks gestational age. Conclusions: Compared with infants born at term, late preterms have significantly higher NICU admission and respiratory morbidity. Each week increase in estimated gestational age is associated with a decreasing morbidity risk.Further studies in determining the maternal and fetal profile of late preterms must be done in order to reduce the incidence of LP deliveries and their morbidity incidence as well.

Keywords: antenatal neuroprophylaxis, magnesium sulphate,

Presenter: Evelina Kreko

Keywords: late preterm, respiratory morbidity, neonatal intensive care admission

Presenter: Aliona Lupascu

ID 460 ID 422

NICU ADMISSION AND RESPIRATORY MORBIDITY OF LATE PRETERM INFANTS;A PROSPECTIVE STUDY WITH TERM CONTROLS E. Kreko1, M. Kola2, L. Mitro2, G. Nasto2, B. Dardha3, F. Sadikaj3, & E. Tushe1 1,3

Service of Neonatology, University Hospital of Obstetrics and Gynecology’’Koc¸o Gliozheni’’, Tirane, Albania, and 2 Department of Pediatrics, University Hospital Center ‘‘Nene Tereza’’, Tirane, Albania Brief Introduction: Late preterms, estimated as infants born between 34 0/7 to 36 6/7 weeks of gestation is a fast growing group within the premature babies population all over the world.Compared with term infants, late preterms are physiologically and metabolically immature and have higher risks for medical complications. As many studies have focused in low birth weight babies, little is known about LP morbidity and the burden they have in NICU.This study is focused in the respiratory morbidity of LP infants as this risk, beyond 34 weeks of gestation is underestimated by caregivers.To better understand the needs of these infants, we evaluated the respiratory outcome of late preterm infants and their admission in our neonatal intensive care unit. Materials & Methods: This work is a 3 year prospective cohort study recording the data from the NICU register, patients medical records and electronic register of Universty Hospital of Obstetrics and Gynecology ‘‘Koc¸o Gliozheni ‘‘ in Tirana.NICU admission and early respiratory morbidity of late preterms and term infants, as the control group treated in NICU is recorded and analyzed calculating Odds Ratio, Confidence Interval 95% and p value. Clinical Cases or Summary Results: Total number of births from January 2011 to December 2013 in UHOG’’Koc¸o Gliozheni’’ is 14 572.Infants born in term 37 0/7–41 6/7 are 12 722 babies.The number of total preterm babies is 1428 and late preterms are 856 or 60% of the total preterm population.Admitted in NICU are 795 term babies or 6.2% (795/12722) of total terms versus 441 late preterms or 51% of LP(OR = 16, CI 95% 13.6–18.5, p50.0001).The NICU admission rates for infants born at 34,35 and 36 weeks of gestation, were 39%,33% and 28%. Of late preterm infants admitted in NICU 240 or 54% were delivered with cesarean section and 201 or 46% had vaginal delivery.The admission respiratory diagnosis were respiratory distress

VITAMIN D DEFICIENCY IN PREMATURE AND IUGR NEONATES BORN BEFORE 32 G.W. St. Hitrova-Nikolova1, L. Vakrilova1, B. Slancheva1, A. Nikolov1, N. Yarakova1, A. Popivanova1, T. Pramatarova1, P. Radulova1, N. Jekova1, & Z. Emilova1 Medical University of Sofia, Bulgaria, Council of medical science Grand 2013-Project No 36, Faculty of Medicine, Chair of Obstetrics and Gynecology, University Hospital of Obstetrics and Gynecology‘‘Maichin dom‘‘ Brief Introduction: The preterm birth is a reason for reduced mineral reserves of calcium, phosphorus and vitamin D. They are accumulated mainly during the last trimester of pregnancy. Maternal-fetal transport of vitamin D, depends on maternal plasma level. The low maternal levels give rise to decreased supply in preterm newborn. The maternal deficiency of vitamin D may be a reason for preterm birth, preeclamsia, low birth weight of newborn and IUGR. Materials & Methods: Objectives: To analize plazma levels 25-OHD in mother and their VLBW and IUGR newborns at birth. To analyze frequency of deficiency of vitamin D of mother-newborn pairs. To look for differences in vitamin D levels between appropriates for age preterm newborns and IUGR. To examine the correlation between infants 25-OHD plasma levels and serum concentrations- Ca, P, alkaline phosphatase (AP) activity, parathyroid hormone (PTH) at 8 weeks. Materials and methods: This prospective study is carred out in the University hospital, Maichin dom’’ Sofia for the period March 2013January 2014 and included 79 women and 90 their VLBW infants. The newborns were with average gestation age 29.4 g.w./25–32g.w./and average birth weight 1100/450–1490 gr/. Maternal and cord blood newborn samples were taken at delivery and measured 25 OH D using ECLIA method. According to the blood levels vitamin D status was defined as: normal 430 ng/ml; insufficiency 20–30 ng/ml; deficiency 520 ng/ml. The supplementation of newborn with vitamin D started at 20 postnatal day/D3- 1336 IU/day/. Analyzed data from the infants as: Ca, P, AP, PTH at 2 and 8 weeks and 25-OHD levels at 8 postnatal weeks. Clinical Cases or Summary Results: Results: We found that in the studied period 77% of mothers are with vitamin D deficiency/ 10.87 ± 4.8/, 18% with insufficiency/23.93 ± 2.59/, and only 5%/ 37.82 ± 8.48/with normal vit. D. 58%/15.55 ± 8.85/of the infants are with vit. D deficiency at birth, 31% with insufficiency/25.84 ± 5.21/, and only 11%/34.55 ± 10/are with normal vit.D. IUGR newborns were 40% of the studied group with average vit D levels 19.71 ng/ml.

390 Conclusions: Conclusions: Vitamin D deficiency is found at 58% of VLBW newborns. Significant positive correlation between the maternal and the infants vitD levels at birth was found. We found seasonal dependency of 25-OHD values. The initial vit D values in the VLBW infants correlated with these at 8 weeks. There were not significant difference between vit D levels of premature newborns with appropriate weight and those ones IUGR newborns. We recommend monitoring of vitamin D levels for all premature infants at the age of two months.

S. Anic Jurica1, S. Gveric Ahmetasevic2, A. Colic3, & V. Elvedji Gasparovic4

Brief Introduction: Necrotizing enterocolitis is a serious condition that affects mostly preterm infants, with high mortality rate. Objective: to estimate the influence of potentially contributing factors of this multifactorial disease. Materials & Methods: The study group included 51 preterm infants 537 gestational weeks with diagnosis of necrotizing enterocolitis, hospitalized in NICU during 5 years period. The control group consisted of 71 patients with approximately the same gestational age and birth weight. Average gestational age in the study group was 30, 2 weeks (SD 3, 7), average birth weight 1502, 75g (SD 781, 5). Average postnatal age in the time of the presenting NEC was 18, 2 days (SD 12, 8). Clinical Cases or Summary Results: The model of logistic regression is done to estimate the influence of risk factors related to the treatment of sick preterm infants on the likelihood of NEC development. Model consisted of 7 independent variables (nosocomial infections, MV, NCPAP, morphine, inotrops, blood transfusions, and H2 blockers). Whole model was statistically significant, X2 (7, n = 1222) = 49.522, p50. 0001; two independent variables (nosocomial infection and H2 blockers use) made statistically significant contribution to the model. Preterm infants with nosocomial infection have 3 times greater chance of developing NEC, and infants receiving H2 blockers have the chance to develop NEC 1.5 higher than other. Conclusions: Underlying pathology contributes to NEC development and identifying risk factors can be crucial for the early diagnosis and outcome of disease.

1,2,3

Keywords: necrotizing enterocolitis, preterm infant

Keywords: Vitamin D deficiency, preterm births, VLBW, IUGR Presenter: St.Hitrova-Nikolova

ID 753

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

BRONCHOPULMONARY DYSPLASIA IN PREMATURE INFANTS 28 + 6 WEEKS GESTATIONAL AGE NICU, Dept Gyn & Obst, University hospital center Zagreb, Croatia, and 4Dept Gyn& Obst, University hospital center Zagreb, Croatia Brief Introduction: Bronchopulmonary dysplasia (BPD) is one of the leading chronic complications of extremly premature newborns 28 weeks. The aim of our study was the evaluation of incidence of BPD and influence on it by some factors. Materials & Methods: We analyzed incidence of BPD in survivors; as a group, and in different GA within the group. Influence of antenatal corticosteroid therapy and surfactant treatment on incidence were evaluated as well. Clinical Cases or Summary Results: In our 3rd level NICU 93 prematures from 22 to 28 + 6 weeks were born during the 3 years period. About 56% of infants survived. Incidence of BPD was 59.0% (n = 23) in whole group of prematures. There were no significant effect of antenatal corticosteroids nor gestational age on incidence of BPD. Between two groups (with or without BPD) singular significant difference were found in non invasive/invasive ventilation. Prematures on non invasive ventilation had significantly fewer BPD than premature on invasive ventilation, regardless of oxygen concentration. Conclusions: The very premature infants still have high morbidity and mortality. They are unified as a group in immaturity and high risk for development of BPD regardless antenatal corticosteroids. Perhaps, the non invasive ventilatition accompanied by other prenatal and postnatal care gives us a hope. Keywords: BPD, extremely premature infants, prenatal corticosteroids, ventilation Presenter: S. Anic Jurica

ID 146

CONTRIBUTING FACTORS FOR NECROTIZING ENTEROCOLITIS IN PRETEM INFANTS IN NICU Z. Zvizdic1, & S. Heljic2 Pediatric Surgery Dept., Clinical University Center Sarajevo, Bosnia and HerzegovinaNeonatology Dept., Clinical University Center Sarajevo, Bosnia and Herzegovina

Presenter: S. Heljic

ID 441

RISK FACTORS FOR PARENTERAL NUTRITION-ASSOCIATED CHOLESTASIS (PNAC) IN PRETERM INFANTS M. Gheonea, E. Coleta, M. Sirbu, & C. Gheonea Mother and Child Department, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, Craiova, Romania Brief Introduction: OBJECTIVE: To assess risk factors for parenteral nutrition-associated cholestasis (PNAC) in preterm infants. Materials & Methods: METHODS: Retrospective case-control study on preterm infants with cholestasis (n = 21) and control subjects (n = 58) who received parenteral nutrition for more than 14 days. Clinical features and medical management were examined, including PNAC time to debute, duration, the degree of PNAC and hepatic injury. Clinical Cases or Summary Results: RESULTS: Regression analysis showed that preterm infants with PNAC had longer duration of parenteral nutrition, longer duration of ventilation, longer duration of fasting, lower birth weights, higher cumulated amino acid and lipid emulsion intake, and later breast feeding beginning than controls. Best independent predictors of PNAC identified were duration of fasting (OR = 0.78; 95%CI: 0.59–0.83; p = 0.028), oxygen therapy (OR 1.01; 95%CI: 0.92–1.09; p = 0.001), and duration of parenteral nutrition (OR = 0.11; 95%CI: 1.02–1.21; p = 0.007). The prognosis of PNAC was good. Conclusions: CONCLUSIONS: Multiple factors are associated with PNAC. Early enteral nutrition and short duration of parenteral nutrition remain the main factors for the prevention of PNAC. Keywords: preterm infants, parenteral nutrition-associated cholestasis (PNAC), risk factors Presenter: C. Gheonea

391

DOI: 10.3109/14767058.2014.924236

ID 761

REVIEW OF THE INDICATIONS OF CERCLAGE PERFORMED BETWEEN 2008–2012 IN H12O, MADRID. E. Calvo1, I. Hernandez1, O. Villar1, D. Montan˜ez1, P. Barbero1, & P. Vallejo1 Gynecology and Obstetrics Dept., and 12de Octubre Hospital, Madrid, Spain.

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

1

Brief Introduction: The leading cause of perinatal morbidity and mortality is prematurity. Preterm birth (PB) is the biggest challenge of current clinical Perinatal Medicine. The incidence of preterm birth, all arround the world, is increasing. In our terciary hospital is 10%(4–4.5% before 34 weeks). Previous history of PB is one of the most important risk factors for preterm labor (PTL). A short cervix by ultrasound before 24 weeks is the best predictor of spontaneous PB. Identify risk patients would allow us to perform preventive actions to prolong pregnancy. The cerclage is one of them. Currently cerclage is recommended based on the indication. Materials & Methods: With a descriptive study we evaluate the cerclage indications and our results. Collection and analysis of 129 cerclages performed in the Hospital 12 de Octubre, Madrid, between 2008 and 2012: -71 (55%) indications based on obstetric history: 59 patients with a history of 1–2 PB/second trimestrer losses and 12 patients with a history of 3 PB/second trimestrer losses. -28 (21.7%) indications of cerclage by US examination -16 (12.4%) indications of cerclage by physical examination -14 (10.9%) due to other risk factors (Mullerianes abnormalities, history of cervical surgery or multiple cervical dilation and curettage). Clinical Cases or Summary Results: See related table. Conclusions: Most cerclage in our hospital were performed based on obstetric history. However a large part of them were indicated in patients with a history of 1 or 2 fetal losses or PB in preceding pregnancy. According to current recommendations cerclage would only be recommended with a history of 3 or more fetal losses or preterm deliveries. The other patients can be handled with progesterone and/or ultrasound monitoring of cervical length. The role of cerclage in the group of patients with risk factors for CI is not well defined. We have experienced a low rate of complications. In cases performed by physical examination, pregnancy lasted a median of 4 weeks (Min: 1 week, Max: 13 weeks). Keywords: cerclage, preterm birth (pb), Presenter: E. Calvo

ID 940

CERVICAL OCCLUSION DURING CERVICAL CERCLAGE: DOES IT IMPROVE PERINATAL OUTCOMES? C. Larran˜aga-Azca´rate1, J. Zabaleta-Jurı´o2, A. F. Pe´rezRodrı´guez3, A. Atare´s-Pueyo4, M. Roche-Roche5, & M.A. Garcı´a-Mutiloa 1,2,3,4,5

Servicio de Obstetricia y Ginecologı´a, Complejo Hospitalario Navarra ‘‘B’’, Pamplona, Navarra (Spain) Brief Introduction: Cervical Occlusion (CO) is thought to be used for treatment of cervical insufficiency and to protect the cervix from

infection. Usually it is performed together with cervical cerclage (CC). However, its effectiveness remains controversial. Materials & Methods: Objective: To analyse obstetric outcomes and to assess the effectiveness of CO to improve the perinatal outcome in patients with CC Study design: A retrospective analysis of all cervical cerclages placed at the Virgen del Camino Hospital from 1998 to 2013 was performed. Women with singleton pregnancy. A CC could be inserted for prophylactic reasons (based on clinical data), for therapeutic reasons when cervical shortening was detected by ultrasound or clinical examination. All women underwent a Shirodkar modified technique and some of them had CO added. Clinical Cases or Summary Results: 284 patients underwent Shirodkar modified technique. Indication: prophylactic 151, therapeutic 81 ultrasound based and 52 based on clinical examination. Women who also had cervical occlusion: prophylactic 52/151, therapeutic 42/81 ultrasound based and, 29/52 based on clinical examination. Mean gestational age at delivery: prophylactic cerclage without CO 37 weeks (W) 1 days (D); 37 W 5 D with CO; therapeutic ultrasound based without CO 37 W 4 D; 35 W 6 D with CO, therapeutic based on clinical examination without CO 31 W 4 D; 30 W 6 D with CO. There was no statistical difference in gestational age at delivery when CO was performed or not. Between women with second trimester miscarriages (2) or preterm birth: Mean gestational age at delivery 32 W 2 D when Co was not performed and 33 W 3 D when CO was done. There was no statistical difference in gestational age at delivery when CO was performed or not. Conclusions: CO does not seem to deteriorate gestational age at delivery when a CC is performed in a group of patients with a theoretical higher risk of preterm birth. Keywords: cervical occlusion, median gestationa age at delivery, single pregnancy, Presenter: C.Larran˜aga-Azca´rate

ID 691

INFLUENCE OF BLOOD TRANSFUSIONS ON ERYTHROPOIESIS WITH ANEMIA OF PRAEMATURITY T. Pramatarova, N. Yarakova, B. Sluncheva, N. Gekova Neonatology Clinic, Medical University Sofia, University Hospital of Obstetrics and Gynaecology - Maichin dom, Sofia, Bulgaria Brief Introduction: Major gene regulating erythropoietin (EPO) synthesis is hypoxia inducible factor (HIF). Having in mind that blood transfusions (BT) eliminate hypoxia due to anemia and inactivate HIF, the aim of the study was to show decreased activity of erythropoiesis after BT. Materials & Methods: Patients: 40 premature infants534 g.w. and birth weight 51400 g with anaemia of prematurity. We analyzed: Hb/g/l/, Ht%, Thr  109/l, Ret% at 24- 48 hours and 7–10 days after HT. The dynamics of changes of blood lactate levels (mmol/l) after BT was used as an indirect indicator of relative hypoxia (activated HIF). The changes of Hb (g/l) and Ht% determined the need of blood transfusions. Clinical Cases or Summary Results: After BT, along with the increase of Hb from 89.7 ± 10.0 to 119 ± 13.3, there was significant decrease in Ret% from 2.4 ± 1.1 to 1.4 ± 0.5 7–10 day after HT. There was also a reduction of Thr from 391.5 ± 131.5 to 250.7 ± 57.2 and blood lactate in mmol/l from 2.5 ± 1.1 to 1.5 ± 0. 7. The study showed that 7–10 days after HT, the values of Hb and Ht decreased to baseline levels, that required new transfusion.

392 Conclusions: Transfusion of packed red blood cells in patients with anemia of prematurity suppresses erythropoiesis, which is demonstrated by the significant reduction in reticulocyte count. The decreased level of blood lactate after HT shows elimination of the relative hypoxia that is required for hypoxia - induced expression of HIF and erythropoietin synthesis. Keywords: anaemia, erythropoetin Presenter: N. Yarakova

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ID 685

FOXP3+ REGULATORY T CELLS ACCEPT THYMIC SIGNALS CRITICAL FOR THEIR DEVELOPMENT AND PREVENTION OF SEVERE COMPLICATIONS: A NEONATAL PERSPECTIVE L. Pankratyeva1, V. Muchin1, S. Roumiantsev1, & N. Volodin1 1

Federal Research and Clinical Center for Pediatric Hematology, Oncology and Immunology named after D. Rogachev Brief Introduction: A fundamental role of the neonatal immune system is to eradicate pathogens while minimizing immunopathology. Regulatory T (Treg) cells are critical for continued immune tolerance through active control of innate and adaptive immune responses. The thymus is of extreme importance during the first months of life as it provides the environment for Treg lymphocyte differentiation and maturation. Our aim was to identify relations between thymic size, phenotypic characteristics of peripheral blood T-lymphocytes and severity of complications during the first month of life. Materials & Methods: We observed 76 preterm neonates (25–34 weeks’ gestation) admitted to neonatal intensive care unit. The thymic size was assessed by sonography as a volume estimate, thymic index (Ti), at 36 weeks of postconceptional age. T cells were analyzed on day 1 (cord blood), 7–8, 14–16, 30 by multicolor flow cytometry (MACSQuant, Miltenyi Biotec, Germany). Clinical Cases or Summary Results: Compared with term cord blood samples, the median Treg level was increased in preterm cord blood samples and could be of maternal microchimeric origin, responsible for tolerance induction (3.7 [3.1%; 4.5%] vs 1.5 [1.1%; 2.7%], p = 0.025). Taking into account significant Ti variability parameter all premature neonates were divided into 3 groups: group 1 (n = 38) included neonates with median Ti values Q1-Q3 (Me 9.8 [7.4 cm3; 12.8 cm3]); group 2 (n = 19)- high Ti values Q3-Max (12.9 cm3 -25.2 cm3); group 3 (n = 19)- low Ti values Min-Q1 (1.3 cm3–7.3 cm3). Initially neonates of all these groups were comparable with regard to gestational age, weight, Apgar score. Infants in groups 2 and 3 experienced a significantly higher incidence of necrotizing enterocolitis (NEC, p1–2 = 0.009; p1– 3 = 0.017). The progression to stage II NEC was diagnosed in 56% of neonates in group 2 and 80%- in group 3 (p40.05). Infants in group 3 had a progression to severe NEC with intestinal perforation in 87% of cases in comparison with 20% of perforation in group 2 (p50.05). In neonates undergoing mechanical ventilation there was a significantly higher incidence of (p1–3 = 0.037; p2–3 = 0.018) severe bronchopulmonary dysplasia in group 3 than in groups 1 and 2. Ti was positively correlated with CD4 + CD25highFoxp3+ T-regulatory cell percentage and absolute counts on days 7–8 of postnatal life (Rs = 0.56, p = 0.001 and Rs = 0.49, p = 0.005 respectively) and negatively correlated with peripheral CD4/CD8 double-positive T-cell counts (Rs = 0.71, p = 0.006 and Rs = 0.65, p = 0.005). Conclusions: Thymus is essential for mature Treg development and survival. A careful analysis of Treg function in neonates is needed to meaningfully apply Treg based therapies in the clinic.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Keywords: prematurity, tolerance, thymus, Treg cells Presenter: L. Pankratyeva

ID 558

OPTIMISING THE PROVISION OF HUMAN MILK FOR NEWBORN INFANTS IN NICU B. Krolak-Olejnik, & A. Paja˛k Department of Neonatology, University Hospital, Wrocł aw, Poland Brief Introduction: Breastfeeding is the optimal method of infants feeding. The AAP extended its recommendation of breastfeeding to include premature and other high-risk infants either by direct breastfeeding or using expressed mother’s milk.. Most of sick infants can not be directly breastfed at birth. Potential institutional barriers include inadequate information regarding the benefits of mother’s milk feeding for the infant, lack of consistence advice and support from health professionals and also difficulty securing appropriate equipment and supplies to express milk. Materials & Methods: Aim of the study was to evaluate nutritional treatment of neonates born before 32 weeks of gestation and hospitalized from birth to discharge in the Department of Neonatology, Medical University of Wroclaw, the center of the third degree of perinatal referentiality. Clinical Cases or Summary Results: We analyzed 67 premature neonates (32 gestational age) born in 2013 at the delivery room of Department of Obstetric and Gynecology. 35 neonates born prematurely were hospitalized in NICU and neonatal ward from birth to discharge from the hospital to home. Median birth weight was 1527g, 34.26% required mechanical ventilation after birth, 65.21% non-invasive ventilation. 31.43% received surfactant at the delivery room. All infants received parenteral nutrition which continued an average of 15 days, minimal enteral feeding was introduced from 1–7 days after birth and continued for an average of 16 day life. 77.14% of premature infants were fed mother’s milk, from which 65.71% received exclusively mother’s milk and 28.58% were exclusively breastfed at discharge. Conclusions: Mothers received information describing the benefits of human milk for their infants along with the practical help to express breast milk until the baby was able to direct breastfeed. Pumping was initiated as soon as the mothers’ condition permit and proposal to be part of the supportive care was offered by the postpartum staff. Providing knowledgeable, accurate and consistent support is the rule in perinatal center for mothers of high-risk infants who choose to breastfeed. The obstetrician and neonatologist provide an appropriate rules of initiation and maintaining of lactation among these mothers. Keywords: Breastfeeding, mothers’ milk, NICU, premature infants Presenter: Barbara Krolak-Olejnik

ID 307

INDIVIDUAL MANAGEMENT OF PRETERM LABOUR BY USING RAPID FETAL FIBRONECTINTESTAˆ M. Ku¨hnert Department of Obstetrics and Perinatology, University of Marburg, Germany, Baldingerstraße, D-35033 Marburg

393

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DOI: 10.3109/14767058.2014.924236

Brief Introduction: The quantitative Rapid Fetal FibronectintestÕ (fFN; Hologic, Marlborough, MA) was used in patients with symptoms of preterm labour as contractions, shortening of cervical length, funneling. Key benefits were:  To seperate cases with threatened preterm labour from cases with non-threatened labour  To decide that tocolytic therapy and steroid prophylaxis should be withheld (fFN-Test = negative + cervical length by ultrasound42.5 cm)  To decide to treat a patient in or out of the hospital Materials & Methods: 100 patients between 23 + 0 to 33 + 6 weeks of gestation presented with preterm labour symptoms and were managed by a special triage protocol concerning diagnostics (e.g. cardiotocogramm, ultrasound etc.). Rapid fFN-TestÕ was used in case of clinical findings as: short cervix 525 mm with or without funneling, dilatation of cervix and contractions. In case of a negativ fFN-Test we performed outpatient treatment, in case of a positive fFN-Test we used a special SOP, which combines different thresholds of fFN in ng/ml with moderate (15–24 mm) and high risk (515 mm) of cervical length. Clinical Cases or Summary Results:  Up to now we can describe special tendencies using the quantitative rapid fFNÕ -Test, not yet ‘‘fait accomplis’’ (critical threshold of 200 ng/ml as an ‘‘action line’’; admit/treat patients or not etc.)  More datas are needed to reach the goal of an individual treatment of patients with preterm labour (idea: to avoid side-effects of medication and ‘‘fetal programming ’’by means of drugs as e.g. corticoids and anbiotics)  Economical calculations should be done parallel to the ‘‘profiling’’ of SOP’s (idea: using the rapid fFNÕ -Test helps to spare money for hospital treatment and drugs as steroids, tocolysis and antibiotics etc.) Conclusions: The rapid fFNÕ -Test for quantitative determination of fibronectin in combination with cervical length measurement and cardiotocogramm seems to be a hopeful tool for an individual treatment of patients with preterm labour symptoms avoiding unnecessary hospital admission and drug treatment. Keywords: preterm labour, Rapid fFNÕ -Test, individual treatment Presenter: Prof. Dr. med. Maritta Ku¨hnert

ID 526

PERINATAL INDICES AMONG EXTREMELY LOW BIRTH WEIGHT (ELBW) INFANTS (500–1000G) IN REPUBLIC OF MOLDOVA (RM) A. Bogdan-Moraru State University of Medicine and Pharmacy "NicolaeTestemi¸tanu", Chishina˘u, Republic of Moldova Brief Introduction: Background. Currently in RM, on the background of lower birth and increased reproductive loss indices, prematurity and care of premature children, especially ELBW infants represent one of the most important medical and social problem in contemporary obstetrics and perinatology. According to WHO and Ministry of Health recommendations, since 2008, all ELBW infants born between 22–28 weeks of gestation, in RM, were registered in official statistics state. The aim of the study was to determine the incidence and perinatal indices in ELBW infants in RM. Materials & Methods: Patients and Methods. A retrospectivev study, which included 863 cases, over a period of 5 years (2008–2012), was performed. The incidence of ELBW infants was 0.4% by total number of births and 9.1% by number of premature births. About 85% of

children were born before 26 weeks of gestation, which led to high rate of perinatal deaths. The most common complications of pregnancy were: annexes and infectious pathologies, preeclampsia, premature rupture of membranes. A number of 85 pregnant women (10.2%) were recorded after 12 weeks of gestation. By caesarean section were extrated 104 children (12.5%). The surgery was performed only in mother’s major indications. Clinical Cases or Summary Results: Results. A number of 529 ELBW infants were born alive, of which 305 (57.6%) died during the early neonatal period and 95 (17.9%) – in late neonatal period. Survival rate was 24.4%, 75 newborns were discharged home. Neonatal morbidity was represented by respiratory distress syndrome, intraventricular hemorrhage, sepsis, enterocolitis, etc. Conclusions: Conclusions. Results founded an increased incidence of extremely premature births (0.4% by total number of births and 9.1% by number of premature births) compared with developed countries. Viability and morbidity correlated with gestational age (children born at term less than 25 weeks did not survive). Results of the study dictate the need to review national intensive care protocol for ELBW infants born before 25 weeks, which can be accepted only on the insistence of the family. Performing caesarean section after the onset of uterine contractions can improve perinatal indicators. The management algorithm of pregnant women at high risk for preterm birth is necessary to improve. Keywords: Key words: premature births, children with extremely low birth weight, perinatal mortality, reproductive losses. Presenter: Aliona Bogdan-Moraru

ID 576

MAGNESSIUM SULFPHATE FOR PRETERM FETAL NEUROPROTECTION: AN OBSERVATIONAL PROSPECTIVE STUDY. J.M. Xiberta1, L. Castells2, S. Sa´nchez3, E. Guirado4, J. Acosta5, & F. Mun˜iz6 1

Obstetrics Dept., IDC Salud Hospital General de Catalunya, Sant Cugat del Valle`s, Barcelona, Spain, 2Paediatric Dept., IDC Salud Hospital General de Catalunya, Sant Cugat del Valle`s, Barcelona, Spain, 3Obstetrics Dept., IDC Salud Hospital General de Catalunya, Sant Cugat del Valle`s, Barcelona, Spain, 4Paediatric Dept., IDC Salud Hospital General de Catalunya, Sant Cugat del Valle`s, Barcelona, Spain, 5 Obstetrics Dept., IDC Salud Hospital General de Catalunya, Sant Cugat del Valle`s, Barcelona, Spain, and 6Paediatric Dept., IDC Salud Hospital General de Catalunya, Sant Cugat del Valle`s, Barcelona, Spain Brief Introduction: Perinatal brain injury can cause lifelong, motor, sensory and cognitive dysfunction. Injury may occur as a result of hypoxia, thrombosis, hemorrhage, infection and trauma. Prematurity is the most siginficant risk factor for neurologic injury. The long term impact depends on gestational age and duration and severity of the event. In a recently published Cochrane Review, Doyle and colleagues concluded that although there was no significant effect of magnesium sulfate on pediatric mortality, there were significant reductions in neurologic injury. It substantially reduces the risk of cerebral palsy and the rate of gross motor dysfunction. Materials & Methods: Results of a retrospective study to assess the effects of magnesium sulphate as a neuroprotective agent when given to women considered at risk of preterm birth less than 32 weeks of gestation. Period: January 2011- December 2013.

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394 We have administered a dose of 4.5 g of magnesium sulphate and 1g. per hour in the next 12 hours. Babies were controlled at born and one and three months after delivery clinical and ultrasonographic control was carried out at born and one month after delivery. Clinical Cases or Summary Results: We have evaluated 25 babies. 5 twin pregnancies. Gestational age average was 28 weeks of gestation on admission and 32 weeks at delivery. Etiologies: preterm labor 6 (30%); PROM 7 (35%); Intauterine Growht Restriction 5 (25%); Severe Preeclampsia 1 (5%), cervical incompetence 1 (5%). Delivery by cessarean section 13 (65%). Four cases of intracraneal hemorrhage grade II were detected There were not any case of substantial gross motor dysfunction or cerebral palsy. There were not any case of substantial gross motor dysfinction or cerebral palsy in babies controlled one year after delivery. Conclusions: In our study there were not cases of gross motor dysfunction or cerebral palsy. The number of cases is low but the evidence in the literature suggests using magnesium sulphate in cases of high risk for preterm delivery. Keywords: Presenter: JM XIBERTA

ID 614

PROGNOSTIC FACTORS IN PRETERM PREMATURE RUPTURE OF MEMBRANES J. Acosta1, P. Argacha1, M. Xiberta1, R. Peiro´1, X. Arimany2, & M.A. Jime´nez1 1

Obstetrics Dept.; Hospital General de Catalunya. Sant Cugat, Spain, and 2Pediatrics Dept.; Hospital General de Catalunya. Sant Cugat, Spain. Brief Introduction: Preterm rupture of membranes (pPROM) is one of the leading causes of prematurity. Neonatal prognosis is mainly influenced by sepsis and prematurity. We conducted a retrospective analysis of all cases of pPROM  32 weeks between 2007 and 2013 in a tertiary center in Barcelona (Spain). The aim of the study was to define if some variables are prognostic factors of adverse perinatal events. Materials & Methods: First, we described characteristics of our population. Then we analysed the influence of gestational age, latency period, amniotic liquid retained, leucocytosis415000, Creactive proteine and result of vaginal cultures. Perinatal events of interest were: low birth weight, need of intubation, ventricular hemorrhage, hialine membranes, corioamnionitis, neonatal sepsis and days at NICU. Contingency analysis was applied for categorical variables and t-student test for numerical variables. Clinical Cases or Summary Results: Thirty-three cases of PPROM between 22–32 weeks were recorded in the period of study. Only one case of neonatal death was observed. Incidence of adverse perinatal events was: chorioamnionitis 12.5%, Neonatal sepsis 15.6%; intraventricular hemorrhage 9.4%, enterocolitis 3.1%; Low birth weight 6.3%; respiratory distress 81.3%; Hialine membrane 56% and need of intubation 40.6% of cases. When analysing correlation with variables at admission, the following results were obstained (Table 1): Gestational age less than 28 weeks was correlated with more days at NICU (18.6 vs 33.5, p = 0.017) and more need of intubation (32% vs 100%, p 0.02). Leucocytosis at admission was associated with chorioamnionitis (9% vs 66%. p = 0.011) and a latency period of more than 24 hours was associated with more days at NICU (5.7 vs 23.7, p = 0.010). Conclusions: Even though it is a small sample, we can conclude that fetal prognosis significantly improves when gestational age is beyond 28 weeks in terms of stay at hospital and need for intubation. Other

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

important factors at admission are leucoytosis and latency period of more than 24 h. No correlation was observed in other parameters as CRP, amniotic liquid retained or GBS cultures result. Keywords: pPROM, prematurity, chorioamnionitis, sepsis, intubation Presenter: Juan Acosta

ID 316

PERFORATED NEONATAL APPENDICITIS IN A PRETERM NEWBORN L. Vakrilova1, Tz. Georgiev2, St. Hitrova1, & B. Slancheva1 1

Medical University of Sofia, Faculty of Medicine, Chair of Obstetrics and Gynecology, Neonatology Dept. University Obstetrics and Gynecology Hospital ‘‘Maichin Dom’’, Sofia, Bulgaria, and 2Dept. of Pediatric surgery, University Emergency Hospital ‘‘Pirogov’’, Sofia, Bulgaria Brief Introduction: Appendicitis is common in paediatric surgical praxis, but extremely rare in newborn infants. Because of non-specific symptoms diagnosis is as a rule intra-operative. Perforation with rapid progression to peritonitis and sepsis is common, mortality rate remains high. Appendix perforation in neonates may be a complication of Hirschsprung’s disease (HD), of cystic fibrosis (CF) or of a local form of necrotizing enterocolitis (NEC). In many cases it occurs in association with other pathologic states, including prematurity, inguinal hernia and perinatal infection. Materials & Methods: We report a premature male newborn from a twin pregnancy with gestational age of 31(+4) weeks, birth-weight 1580g, who underwent a laparotomy because of suspected NEC and perforation. Clinical Cases or Summary Results: The baby was admitted to NICU after birth with transitory respiratory failure, requiring brief O2supplementation. There were data for early onset neonatal sepsis: MSStaphylococcus epidermidis was isolated from blood culture, gastric contents and all peripheral specimens, C-reactive protein values were slightly elevated after birth and significantly increased before surgery; thrombocytopenia and mild anemia were found; WBC and differential count remained in the reference range. Antibiotic therapy was started after birth. The control blood culture showed Candida albicans, so antimycotica were added. The relatively good condition of the baby was accompanied by periods of abdominal distension and feeding intolerance that hampered the enteral feeding. At day 25 after birth life threatening deterioration occurred: feculent vomiting, progressing distension and palpable rigidity of the abdomen, absence of peristalsis, respiratory distress. Abdominal radiograph showed significantly distension of the intestines, air liquid levels, and discrete signs of pneumoperitoneum. The baby was immediately transferred to the surgery with the diagnosis NEC with perforation. Laparotomia transversalis supraumbilicalis was performed. Appendicitis acuta gangrenosa perforativa and peritonitis fibrinopurulenta totalis were found intra-operatively but without any signs of NEC. Appendectomy and sanitation of the abdominal cavity were carried out. The histological result confirmed gangrenous perforative appendicitis and purulent necrotic inflammation of the peritoneum with hemorrhages. The postoperative course of the patient was unremarkable. After recovery of the intestinal passage a successfully enteral feeding with breast milk was implemented. The boy was transferred to the neonatology on day 33 of life and discharged home 12 days later without further complications. Conclusions: Despite of the low incidence of neonatal appendicitis, it should be taken into consideration in the spectrum of differential diagnosis if unclear abdominal symptoms occur in the neonatal period. Nonspecific clinical signs are found in newborns and especially in premature infants that most frequently mimic NEC. Early surgical intervention contribute to a reduction of the potential complications.

395

DOI: 10.3109/14767058.2014.924236

Keywords: premature newborn, NEC, appendix perforation Presenter: B. Slancheva

ID 289

DIFFERENTIATING TRANSIENT IDIOPATHIC HYPERGLYCEMIA AND NEONATAL DIABETES MELLITUS IN PRETERM

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K. Busiah*1, J. Auger*2, A.L. Fauret-Amsellem3, S. Dahan4, N. Pouvreau3, H. Cave´5, M. Polak6, & D. Mitanchez4 1 Pediatric Endocrinology, gynecology, and diabetology, Necker Enfants-Malades Teaching Hospital; University Paris Descartes, Paris, IMAGINE affiliate, Paris, France, 2Pediatric Endocrinology, gynecology and diabetology, Necker EnfantsMalades Teaching Hospital, Paris, France, 3Department of Genetics, Robert-Debre´ Hospital, Paris, France, 4Department of neonatology, University Pierre et Marie Curie, Paris VI,Trousseau Hospital, Paris, France, 5University Paris Diderot, Sorbonne Paris Cite´, Paris and Department of Genetics, Robert-Debre´ Hospital,Paris, France, and 6Pediatric Endocrinology, gynecology, and diabetology, Necker EnfantsMalades Teaching Hospital, University Paris Descartes, IMAGINE affiliate ; INSERM U1016, Paris, France

*contributed equally to this work Brief Introduction: Transient idiopathic hyperglycemia (TIH) is often reported in very preterm infants and is usually related to defective processing of proinsulin and to insulin resistance.Transient Neonatal Diabetes Mellitus (TNDM) is a rare genetic form of pancreatic beta-cell dysfunction leading to hyperglycemia early in life and resolving in early childhood. Distinction between these two conditions is important for a personalized management and genetic investigation. The aim was to investigate whether metabolic features or treatment help to detect TNDM among TIH in preterm newborns. Materials & Methods: We prospectively recruited TIH preterm newborns (N = 13) between 2008 and 2011 and identified TNDM patients (N = 2) in the French neonatal diabetes cohort, all born before 32 WG. They all had glycaemia more than 10 mmol/L, at least twice during the two first weeks of life. We compared their clinical features, glycemic profile, insulin doses, and nutritional intakes. Clinical Cases or Summary Results: As compared with TIH newborn, TNDM patients had higher day-1 glycemia levels (median 23.5 vs 13.6 mmol/L, p = 0.025), and required a higher daily insulin dose (median 1.2 vs 0.8 unit/day, p = 0.04). Insulin therapy was longer in the TNDM patients (median 85 vs 11 days, p = 0.03) and was stopped at a median age of 39.3 WG vs 29.4 WG in TIH newborns. Conclusions: Metabolic features help to detect TNDM preterm newborns as soon as day-1 of hyperglycemia. TNDM and TIH are clinically and genetically two different entities with specific pathophysiological mechanisms. The identification of TNDM indicates an extended follow up during childhood and puberty due to the possibility of recurrence of glucose intolerance. Keywords: preterm, hyperglycemia, diabetes Presenter: D Mitanchez

ID 859

TO TOUCH MY CHILD: THE EXPERIENCE OF MOTHERS IN A NICU P. Lopes1, A. Franc¸a2, & L. Andrade3

1

NICU, Ju´lio Dinis Maternity, Porto, Portugal, 2Escola Superior de Enfermagem do Porto (Porto Nursing School), Porto, Portugal, and 3Escola Superior de Enfermagem do Porto (Porto Nursing School), Porto, Portugal: Brief Introduction: An early physical contact through touch between mother and son promotes adequate child development and constitutes the origin of bonding between the dyad. However, when the health condition of the new-born requires the admission in the Neonatal Intensive Care Unit (NICU), mother and child are separated and forced to interact in an adverse atmosphere, surrounded by a whole range of technology, essential to guarantee the new-born survival. The present research aims to understand the experiences of mothers when they touch their child in a NICU and thus to define guidelines that promote touching and the involvement of parents in caring for the child, with the purpose of encouraging mother-child interaction and stimulate autonomy in caring for one’s child. Materials & Methods: Using a qualitative research methodology, of phenomenological inspiration, with a descriptive and exploratory design, semi-structured interviews were carried out to ten mothers of new-borns who were in a NICU, in Oporto. Data analysis was done with Bardin’s content analysis technique. Clinical Cases or Summary Results: Three themes emerged from contente analysis: "defining to touch", with the following identified categories: to touch is good, to touch is strange, to touch is to feel herself mother, to touch is to give and to touch is to receive; within the theme "understanding the complexity of touching", the following categories emerged: fears and benefits involving to touch and nurses as motivators for touching; finally, the theme "the contexts involving to touch", which includes two categories: obstacles and strengths. Conclusions: The results of this research constitutes an important contribution for the knowledge and understanding of the experience of mothers that touch their sons in a NICU, in identifying strategies to promote touch and the involvement of parents in the care of their child, with the purpose to allow the implementation of nursing interventions that promote the effective integration of the mother in the environment of the NICU. Keywords: NICU; Experience of mothers, to touch Presenter: A. Franc¸a (Ana Paula dos Santos Jesus Marques Franc¸a)

ID 284

PLACENTAL ABRUPTION AS A CAUSE OF PRETERM DELIVERY OUR EXPERIENCE D. Sokolovic´ C´urkovic´1, A. C´urkovic´2, S. Jankovic´Razˇnatovic´2, S. Rakic´2, S. Babic´2, Ð. C´ecˇez2, N. Karadzov Orlic´2, I. Pesic Stevanovic2, L. Nejkovic2, V. Soldo2, S. Brankovic´2, L. Tasic´2, T. Mitrovic´ Lazic´2, & S. Stanimirovic2 EUROMEDIK, Belgrade, Serbia, and 2G/O Clinic Narodni front, Belgrade, Serbia 1

Brief Introduction: Placental abruption (PA)is one of the most severe complications during pregnancy. In practice it affects 0.65% of all deliveries, our duty is to be very vigilant about it occurrence, primarily for it high fatality for mother and infant.Our task is to keep open eyes through delivery of patients with diagnosed partial and total PA, occurring before 37 gestational weeks (GW). Also we have to study the conditions of the neonates after delivery, comparing the data with the control group, formed of preterm deliveries without PA, with delivery before 37GW. Materials & Methods: Test group was formed of 63 patients with PA. 58 of them had Cesarean Section (CS).Control group-88 patients with preterm labor, without PA. Only 14 of them had a CS. All the results were statistically tested and compared with the experience of other authors.Also it was compared with our experience in the survey performed in 2010.

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396 Clinical Cases or Summary Results: PA had a much higher rate of CS (93.1:13.3%). Ratio of the duration of hospitalization was 4.24:1, for test group, and following that the cost was 7.17 times higher.Deliveries were much shorter in test group, and consumption of blood and its derivatives was 4.8 times higher.Control group neonates had higher Apgar score average (8.71:7.12).Control group lost one neonate intrapartum - in the test group we had 6 neonates lost. None postpartum hysterectomies were performed in the test group. In the control group there was one, after CS. Average gestation in delivery was: test group 34 weeks 5 days, control 34 weeks 3 days. Conclusions: Test group had a much higher rate of previous miscarriages, renal failure, hypertension, gestational diabetes and anemia. Age had no influence. Placental insertion was mainly on the front wall in the test group, in control group, also. Previous uterine operations had 17(25.3%) in the test group, while in control only 5 (6.43%). The results were compared with the ones done in 2010. There was an increase in number of PA and its complications, but the severity was significantly lower. Mainly because of the new protocols that were introduced. There was a much higher rate of multifetal pregnancies mainly due to the IVF/ET technologies that were applied in infertility treatment. Average age was significantly higher in this portion, in both groups, and this is also related with the assisted reproduction methods engaged in solving long term infertility problems. Even though it makes 0.65% of all deliveries PA is still the highest rate killer during delivery, preterm or in term. Because of that IT has to be always on our minds. Keywords: preterm labor, placental abruption, complications Presenter: Aleksandar Curkovic

ID 406

PLEURAL EFFUSION COMPLICATING PERIPHERICALLY INSERTED CENTRAL VENOUS CATHETER S. Amoretti1, R. Diez2, V. Sanmartin3, J. Barberan4, & E. Lobera5 Hospital Mataro´, Mataro´, Spain, 2Hospital Mataro´, Mataro´, Spain, 3Hospital Mataro´, Mataro´, Spain, 4Hospital Mataro´, Mataro´, Spain, and 5Hospital Mataro´, Mataro´, Spain 1

Brief Introduction: The placement of a central venous catheter (CVC) has become an integral component of neonatal intensive care. Percutaneously inserted central catheters (PICC) are useful in the administration of parenteral nutrition and medications. However, the use of PICCs is occasionally associated with complications like sepsis, thrombosis or pleural effusions. We report a case of PICC misplacement leading to the development of pleural effusion. Materials & Methods: Case report Clinical Cases or Summary Results: A 1580 grs girl was delivered by csection at 31 weeks gestation and ventilated with CPAP for respiratory distress syndrome. A single-lumen silicone PICC for parenteral nutrition was placed through the axillary vein. The position of the tip of the PICC was confirmed by chest X-ray. The catheter insertion length wasn’t verified. Seven hours later she became hypoxic and experiencied apnea episodes. Radiographic examination disclosed a right pleural effusion and showed the tip of the catheter had reached the pleural space. Reviewing the first X-ray the catheter tip was found to be in the same location. With the diagnostic suspicion of iatrogenic pleural effusion, it was decided to perform a pleural drainage; but the drainage was successfully made through the PICC before it was removed. A milky-white liquid was obtained, chemically identical to parenteral nutrition. The PICC was then removed, the baby remained asymptomatic, and there was a significant improvement of the pleural effusion.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Conclusions: Parenteral nutrition in preterm newborns unable to start enteral nutrition is a well-establish clinical technique. Reports of ipsilateral pleural effusion following misplaced central venous catheters are not unusual. In some cases, thoracocentesis is needed to ameliorate the symptoms, but drainage through the PICC could be useful as well. The ideal position of the catheter tip is the superior vena cava. Verification of catheter tip location is required following PICC insertion and is typically obtained using an X-ray film; however, there remain no evidence-based guidelines for defining an optimal interval for obtaining X-ray films during the time the PICC is indwelling. It isn’t routine to inject contrast to visualize the catheter tip, even though some studies showed it could be useful. Thus, the present case report reinforces the need for a high level suspicion of a catheter related problem in a newborn with respiratory symptoms or cardio-pulmonary insufficiency. Keywords: Presenter: Sonia Amoretti

ID 658

PARENTS’ EXPERIENCE DURING THE HOSPITALIZATION OF THEIR PREMATURE NEWBORN D. Silva1, E. Silva2, & N. Vieira3 1

Higher School of Health CIDETS, Polytechnic Institute of Viseu, Portugal, 2Higher School of Health CIDETS, Polytechnic Institute of Viseu, Portugal, and 3Hospital Ne´lio Mendonc¸a, Autonomous Region of Madeira, Portugal Brief Introduction: We are witnessing an increase in the birth of premature babies and parents are faced with several difficulties and embarrassments, especially if the premature requires hospitalization. Objectives: To know the experiences of parents who are faced with the hospitalization of their premature son; Ponder on how the hospitalization can influence the adaptation to parenthood. Materials & Methods: A qualitative, exploratory and descriptive study, with a sample of 12 parents whose children had been admitted to UCINP in the Hospital Dr. Ne´lio Mendonc¸a, SESARAM. We used semi structured interviews and analysed its content. Clinical Cases or Summary Results: Seven categories emerged: the impact of a premature birth on the family’s life, ambivalent feelings/ emotions of parents; Parenting throughout the hospitalization; significant events related to the homecoming and communication of bad news; Support received; opinion related to favourable hospitalization, areas for improvement, especially the physical conditions of the intensive care unit.

DOI: 10.3109/14767058.2014.924236

Conclusions: What stands out are some clues related to the understanding of the difficulties and meanings attributed to the parents’ experience as well as strengthening measures to humanize the processes of adaptation to the illness and promotion of parenting, optimizing nursing care. Keywords: Premature, Parents, Nursing Care, Hospitalization Presenter: D. Silva1

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ID 291

ANEMIA OF PREMATURITY – ERYTHROPOIETIN PROPHYLAXIS AND FACTORS THAT INFLUENCE IT V. Atanasova1, M. Krusteva2, & Chr. Mumdzhiev3 1

Neonatology Dept., University Hospital of Pleven, Bulgaria, Neonatal Dept., University Hospital of Plovdiv, Bulgaria, and 3 Neonatal Clinic, University Hospital of Stara Zagora, Bulgaria 2

Brief Introduction: Premature infants are prone to develop a specific pathology, one of which is anaemia of prematurity (AP). Specific etiological treatment is recombinant human erythropoietin. Many factors compromise the clinical management and the general outcome of AP. Purpose of our study is to examine the prophylactic use of recombinant erythropoietin beta (rHuEPO-b) in the AP and the influence of some factors: early blood transfusions (BTs), infections and multiple births. Materials & Methods: 135 newborns, born before 29th gestational week (GW), are studied. They are divided in two groups: case group 1 – with EPO-prophylaxis (n 100), and control group 0 – without EPOprophylaxis (n 35). The effect of EPO-prophylaxis is evaluated by the frequency of late BT (after 28th postnatal day). There are determined additionally following subgroups in the group 1: with early BT (before 28th postnatal day) and without early BT; with intraamniotic infections, with nosocomial infections and without neonatal infections; newborns from single pregnancies and twins. All patients are treated with iron-vitamin substitution and restrictive blood transfusion politics (according to own transfusion protocol) is applied. Clinical Cases or Summary Results: The late BT-frequency (per one patient) in group 1 is 1.0 ± 1.1 and in group 0 – 1.5 ± 1.3 (p 0.02). The late BT-frequency in the group with EPO-prophylaxis is as follows: in the subgroup with early BT 1.1 ± 1.1 and in the subgroup without early BT – 0.5 ± 0.7 (p 0.054); in the subgroup with intraamniotic infections 0.9 ± 0.9, with nosocomial infections – 1.6 ± 1.3, and without infections – 0.6 ± 0.7 (p 0.0000); in the subgroup from single pregnancies – 1.0 ± 1.1, and in the twin subgroup – 1.0 ± 1.0 (p40.05). Conclusions: EPO-prophylaxis reduces significantly the frequency of late BT in the infants, born before 29th GW. Early BT and nosocomial infections compromise effect of this prophylaxis, and the multiple births don’t influence it. Keywords: anemia of prematurity, erythropoietin, blood transfusion, neonatal infection Presenter: Victoria Atanasova

ID 964

THE MODERN ASPECTS OF PREMATURE BIRTH L. Stavinskaya, U. Tabuika, & G. Paladi

397 Department of Obstetrics and GynecologyState University of Medicine and Pharmacy "N. Testemiteanu"Chisinau, Moldova Brief Introduction: In the Republic of Moldova the frequency of premature birth has remained stable during the last years, reaching in 2010 level of 4.8%. In the recent years, new concepts have been radically different from the traditional obstetrics. It refers to the changing of observing of the patients with premature flow of amniotic fluid, providing for extension of pregnancy, possibility of Cesarean section by the long waterless period. This contributes to the birth of children with greater body mass, increases their chances for survival, reduces perinatal mortality and reduces the frequency of severe respiratory diseases. The purpose of the study was to determine the optimum tactics of conducting and analysis of perinatal indicators of premature birth in period 24–34 weeks of pregnancy. Materials & Methods: A retrospective analysis of 328 stories of premature birth in the period 22–34 weeks was performed according to the special questionnaire. The patients enrolled to the perinatal municipal centre of the 3rd level, on the basis of the 1st Municipal Clinical Hospital (all the premature births are registered there) in 2009–2010. The patients were divided in 3 groups, depending on the duration of pregnancy, when premature birth started: the 1st group consisted of 94 patients (28.8%) with 22–28 weeks, the 2nd - 98 patients (30.1%) with 29–31 weeks of pregnancy, the 3rd group - 136 women (41.1%) at 32–34 weeks. Each group was divided into two subgroups depending on the type of delivery: vaginally or by cesarean section. The results included: tactics of delivery leading, mode of delivery, indications for surgery, mass and condition of newborn, course of the early neonatal period, rates of neonatal mortality and morbidity. Statistical analysis was performed by determining the arithmetic mean and the Student’s criterion (t). Clinical Cases or Summary Results: There was not determined relationship between the ages of women, their work and the frequency of premature births. The age of patients ranged from 17 up to 45 years, averaging 28.7 ± 9.52. More than half of the patients were nulliparous-190 (58.0 ± 2.14). This factor points to the need for an early examination, as well as the rehabilitation of reproductive function of female patients with spontaneous abortion in the late stages. It should be noted that approximately 28.2% patients have had a history of no less than 1 miscarriage or spontaneous abortion in the late stages, and about 15.89% were not under the supervision of family doctor. At the same time more than 1/3 women from the everregistered sought after 12 weeks of gestation, indicating significant gaps in the antenatal management of this category of patients, that was one of the causes of premature birth. It is mentioned that 27 (8.2%) of surveyed women suffered the infertility, of whom 22 had a pregnancy through IVF. The pregnancy was complicated by the threat of interruption at 28 patients (8.5%), preeclampsia at 40 (12.2%), intrauterine infection by 27 (8.2%). It should be noted that almost half of the patients with premature birth-134 (40.8%) were hospitalized urgently from home. Wrong position of the fetus was determined at every fifth patient, which is typical for premature birth, with pelvic presentation was observed in 59 (18%) cases and cross in 15 (4.6%). The subject of cesarean section is quite controversial till now and also its impact on the main perinatal rates by this category of women, when each case is solved individually. However, in terms up to 30 weeks of pregnancy, Cesarean operation is strictly in mother interest. As for the fetus, in this term they are justified and are suitable only for women with a history of obstetric complications (long infertility, habitual miscarriage, IVF), as well as pelvic or pathological conditions of the fetus, because the chances of his survival are almost independent of the mode of delivery. Cesarean section in the study group was at 107 (32.6%) women with premature birth, of which 88 (28.3%) operations were performed on an urgent basis (premature detachment of the placenta, preeclampsia, fetal position, chorioamnionitis). These points explain the high rate of perinatal mortality in this subgroup of patients. The largest percentage of the CS was observed in the 3rd group -52.3% cases and the minimum in the 1st group -20.5% Weight of newborn infants were as follows: 500–1000 g-85 (26%), 1001–1500 g-80 (24.4%), 1501–2000–123 (37.6%) and more than 2000 g - 39 (12%) children. Of them alive born were 287

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398 (87.5%) children with the assessment on Apgar scale: 1–3 points at the 27 (8.2%), 4–6 points-260 (79.3%). Rate of stillbirths amounted to 41 (125 %) cases, of which 39 cases of fetal death and 2 cases of intrapartum. Thus, with an extremely low weight (500–1000 g) were born 85 (26%), and low birth weight (1000–2000)-204 (61.8%). Conclusions: The results of our study indicate a high rate of perinatal mortality in the cohort of patients - 112 (341.5 %) cases, of which a significant part is in the 1st group of 56 (608.7 %). Structural analysis of this indicator revealed the prevalence of cases with antenatal fetal death - 41 (125 %), while early neonatal mortality accounts 64 cases, and late neonatal - only 7 instances amounting in total 216 %. About 1/3 cases are preterm delivery between 22–28 weeks of gestation, that is a significant part in the overall structure of premature birth (before 34 weeks), taking into consideration the fact that they define the high level of perinatal mortality among preterm infants (323.2 %). At the same time, the study found the lack of a unified strategy in the management of preterm delivery (early hospitalization of women with the risk of pregnancy loss, lack or insufficient glucocorticoid prevention) that demands the necessity to develop specific protocols of premature birth. Keywords: Pretermen birth, perinatal mortality, management, cesarean section, labor Presenter: L. Stavinskaya

ID 707

SALIVA AS ALTERNATIVE TO PLASMA IN THERAPEUTIC DRUG MONITORING OF CAFFEINE IN PRETERM INFANTS F.Z. Chioukh1,2, A. Chaabane3, H. Ben Hamida1,2, K. Ben Ameur1,2, K. Aouam3, & K. Monastiri1,2 1

Department of Neonatal Intensive Care, Teaching Hospital of Monastir, and 2Research unit 01/UR/08.14- 3- Department of Pharmacology-Teaching Hospital of Monastir-Faculty of Medicine of Monastir-Tunisia. Brief Introduction: Recurrent apnea is common in preterm infants, particularly at very early gestational ages. caffeine and have been used to stimulate breathing in order to prevent apnea and its consequences. The aim of this study is to evaluate whether saliva could be useful alternative to plasma for routine therapeutic drug monitoring of caffeine in preterm infants using an enzyme immunoassay method (EMIT, Siemens). Materials & Methods: We underwent a prospective study including premature infants less than 34 weeks gestation admitted successively from September 2011 to the Department of Intensive Care and Neonatal Medicine of Monastir. The caffeine citrate was administered intravenously once daily at an increasing dose of 5,10,15,20 and 25 mg/kg during five days. The through concentrations of caffeine were determined in the saliva and serum samples, collected simultaneously, by EMIT, Siemens. Clinical Cases or Summary Results: We included thirteen preterm infants with an average term of 32.2 weeks ‘gestation (+/-0.72) and an average birth weight of 1707g (+/-312.8g). The concentration of caffeine ranged between 1.2 and 35.8 mg/ml and between 0.4 and 36.8 mg/ml respectively in the serum and in the saliva, respectively. The saliva and the serum caffeine concentration increased proportionally to the administered dose. We noted a variability of the caffeine kinetic among patients in both serum and saliva matrix. Saliva and serum kinetics were comparable and the saliva caffeine concentrations were correlated to those in serum (r = 0.76). Conclusions: Saliva caffeine monitoring is a valid, useful and harmless alternative to serum in preterm infants.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Keywords: Preterm infant- Caffeine- Enzyme multiplied immunoassay technique (EMIT) Plasma-Saliva. Presenter: FZ. Chioukh

ID 699

CHORIOAMNIONITIS AND MULTISYSTEM IMPAIRMENT TO A PREMATURE WITH GA UNDER 32 WEEKS M. Tunescu1, G. Olariu1, O. Man1, S. Olariu1, & L. Olariu1 1

NICU Department, City Emergency Hospital/ Obstetrics&Gynecology, Timisoara, Romania Brief Introduction: Chorioamnionitis remains an important risk factor for prematurity, influencing neonatal mortality and morbidity. Clinical chorioamniotita is associated with damage to prematurely multisystem respectively sever sepsis, PVL, ROP, IVH greater than grade 2, BDP, EUN and perinatal death. Materials & Methods: The datas were collected from the National Registry of Respiratory Distress Sindrom in Romania. To carry out statistical processing we used SPSS Version 17.The period covered is 2010–2013, the study was retrospective, the category included infants with gestational age less than or equal to 32 weeks., born or brought by transfer in our NICU/neonatology service of Timisoara Municipal Hospital.We enrolled all consecutive VLBW(GA 32 weeks) newborn born to a clinical chorioamnionitis.Newborn without chorioamnionitis were controls. Clinical Cases or Summary Results: Study included a total of 442 VLBW, and 42 infants with clinical chorioamnionitis (9.5%), 400 (90.5%) infants controls. A significantly higher percentage of cases than controls required prolonged neonatal resuscitation (37.7% vs. 4.3%), from single gestations (34.9% vs.7.1%), and cesarean section (64.2% vs.35.7% of those with chorioamnionitis), showed a lower Apgar score at 5 min, and presented a higher rate of early-onset sepsis (64.2% vs. 35.7% of those with chorioamnionitis). In our study intraventricular intraventricular grade 2 and 3 were significantly more frequent among cases than controls. Conclusions: Clinical chorioamnionitis was associated with neonatal depression, intraventricular intraventricular grade 2 and 3, early sepsis but not with other prematurity-related complications. Keywords: damage

Clinical

chorioamnionitis,

prematurity,

multisystem

Presenter: Tunescu Mihaela

ID 426

THE EFFECTIVENESS OF INTERVAL CERCLAGE IN PATIENTS HAVING PRETERM LABOR M.I. Park1, HY Boo2, & J.K. Hoh2 1

Department of Obstetrics and Gynecology, Dongtan Cheil Women’s Hospital, Gyeonggi, Korea, and 2Department of Obstetrics and Gynecology, College of Medicine, Hanyang University, Seoul, Korea Brief Introduction: The aim of this study was to determine whether an interval cerclage (IC) reduced preterm delivery in those women who had undergone an emergency transvaginal cerclage due to dilated cervix and/or protruding fetal membrane with labor.

399

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DOI: 10.3109/14767058.2014.924236

Materials & Methods: We selected 16 cases underwent a transvaginal cerclage. They composed of 7 cases of IC group, and 9 cases having elective cerclage due to bad obstetric history. The IC was performed to patients who previously had emergency cerclage due to symptoms of impending preterm delivery at a distance of time. Antibiotics and prophylactic tocolysis were given to all patients. Neonatal outcomes and perinatal complications were analyzed between two groups. Clinical Cases or Summary Results: Mean initial cervical length before the first surgery was 0.07cm in IC group and 4.3cm in elective cerclage group. Cervical length before second surgery in IC groups was 1.94cm. Of all 16 cases, no fetal loss was found during present pregnancy. Mean delivery weeks was 35 + 0 weeks in IC group while 35 + 1 weeks in elective cerclage group (p = 0.4981). Mean birth weight in IC group was 1920.0 g and 2145.0 g in elective cerclage group (p = 0.2901). Apgar score (1/5 min) was 6/8 in IC group and 6/8 in elective cerclage group (p = 1.000). Other neonatal outcomes and perinatal complications were not different between two groups as well. Conclusions: It is thought that IC might be a good emergent surgical procedure that can be used in preventing preterm delivery in patients with incompetent internal os of cervix having preterm labor. Keywords: Preterm labor, Transvaginal cerclage Presenter: Jeongkyu Hoh

ID 398

CERVICAL LENGTH AND PHOSPHORILATED INSULIN LIKE GROWTH FACTOR BINDING PROTEIN-1 AS A PREDICTORS OF SPONTANEUS PRETERM DELIVERY IN SYMPTOMATIC WOMEN M. Hadzi Lega1, A. Daneva Markova1, M. Micevska1, A. Atanasovska Bosku1, & V. Gjirevski1 1

University Clinic of Gynecology and Obstetrics Skopje, r of Macedonia Brief Introduction: Preterm delivery is the leading cause of neonatal mortality and morbidity. Consequently, women presenting with threatened preterm labor are often treated with hospitalization and the administration of tocolytics to avoid preterm delivery. Randomized studies on the use of tocolytics in threatened preterm labor have demonstrated a significant prolongation of pregnancy by about 7 days but no significant reduction in the incidence of preterm delivery, perinatal morbidity or mortality. Objective: To assess the combined use of cervical length and cervical phosphorylated insulin-like growth factor binding protein-1 (phIGFBP-1) in the prediction of preterm delivery in symptomatic women in next 14 days Materials & Methods: 58 pregnant women were eligible to join the study if they attended the University Clinic for Gynecology and Table 1. Demographic characteristics of study population (n = 58) Mean ± SD (range) Maternal age (years) Gestation age at examination BMI n (%) Parity Nuliparous Multiparous Previous preterm delivery

30,12 ± 4.82 (20–40) 31,55 ± 3.95 (22–36) 27.54 ± 4.93 (18,7–43,8) 13 (22,41) 45 (77,59) 10 (17,24)

Obstetrics, Skopje and were admitted to Department of High Risk pregnancy Unit with symptoms of preterm labor (symptoms of uterine activity judged by the assessing physician to be indicative of preterm labor) at 24 to 36 weeks gestation. They were recruited in period of 6 months from September 2013 till March 2014 Clinical Cases or Summary Results: Some recent studies evaluated a combination of cervical length and phIGFBP-1 in the prediction of preterm delivery in symptomatic women. Eroglu et al. assessed 51 cases between 24 and 35 weeks of gestation. These authors reported an increase in specificity and positive predictive value by combining phIGFBP-1 with cervical length. PhIGFBP alone is not a good predictor for delivering in next 14 days but combination of cervical length(15 mm,25mm) with phIGFBP is a good predictor. It means that probability for delivery in the following 14 days in patients with positive phIGFBP and cervical length15 mm is 0.88 or probability for not delivering in those patients is 0.12.In 88% patients with positive phIGFBP and cervical length 15 mm will deliver in the following 14 days. Conclusions: Finally, testing the value of the combination of phIGFBP1 and cervical length allow us to find prediction model based on logistic regression analysis. Again, our study population was too small to allow such an approach. However, the combined use of phIGFBP-1 and cervical length with symptomatic women might have the potential for decreasing the false positive diagnoses of impending preterm delivery, allowing therefore to reduce the biological and economic costs of inappropriate treatment. Other demographic data (history of previous preterm delivery, history of spontaneous abortion, parity, BMI, Orthodox or Muslims, vaginal Ph) are not good predictors for delivery in the following 14 days. Keywords: Preterm labor, transvaginal ultrasound, phIGFBP-1 Presenter: Marija Hadzi Lega

ID 739

MORBIDITY AND MORTALITY IN EXTREMELY LOW BIRTH WEIGHT NEWBORN A.M. Manea, M. Boia, D. Iacob, & M. Dima University of Medicine and Pharmacy, Neonatology Department, Timisoara, Romania Brief Introduction: Introduction: Extremely low birth weight (ELBW) newborn are more susceptible to all of the possible complications of premature birth due to plurivisceral immaturity. Materials & Methods: Objectives: The authors aim to study a lot of newborns with extremely low birth weight and to determine the morbidity and mortality at this newborn category till discharge from a Neonatal Intensive Care Unit. Material and method: the study was carried out in the Neonatal Intensive Care Unit during two years, on a group of 24 premature newborns with birth weight under 1000 grams (800 grams–1000 grams), with gestational age 27–30 weeks. Clinical Cases or Summary Results: Results: Different stages of respiratory distress syndrome was present in all cases. In 15 cases (62.5%) mechanichal ventilation was need, in 6 cases (25%) nasal CPAP, and in 3 cases (12.5) just oxygen theraphy under head hood. It was diagnosed a case of necrotizing enterocolitis. Intraventricular haemorrhage of several degrees revealed with transfontanelar ultrasound in a ratio of 58.33% - 14 newborns. In 5 cases was associated with periventricular leukomalacia. The neonatal sepsis was present in 20 cases (83.33%), early-onset sepsis in 12 cases, and late- onset sepsis in 8 cases. The number of dead premature was 5 and the causes were, in order, neonatal sepsis with intravascular disseminated coagulation, intraventricular haemorrhage and pulmonary haemorrhage.

400 Conclusions: Conclusions: Extreme prematurity is an important risk factor in increasing neonatal morbidity and mortality, premature with very low birth weight being the most exposed to all major complications of prematurity. Neonatal sepsis, intraventricular haemorrhage and pulmonary haemorrhage are the common causes of death. Keywords: Extreme prematurity, complications. Presenter: A.M Manea

ID 611

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

PREVALENCE AND CAUSES OF LOW BIRTH WEIGHT BABIES BORN IN JAHROM MOTAHARI HOSPITAL IN 2013 S. Abdollahifard Faculty member of Nursing and Midwifery, Dept. Jahrom University of Medical & Health Sciences. Jahrom. Iran. Brief Introduction: One of the most important factors in infants ’ birth weight them. Underweight infants at birth has an important role in virulence and mortality in this group is 40 times higher than normal weight infants to families and communities is very costly task year 2013 has been paid Materials & Methods: This cross-sectional study using data on 2,418 infants born within 10 months of the Persian date Farvardin 1392 till December 1392 were arranged in Motahari Hospital City. Information using the form and evaluate maternal and neonatal records were collected. Then, using chi-square tests and logistic regression analysis was performed with SPSS 16 software and the level of p50.05 was considered significant. Clinical Cases or Summary Results:: 2418 neonates {(5/8 percent), CI 5/ 9% -5/7%)] and 80 had a birth weight less than 2500 g. The odds ratio (OR) for low birth weight infants in singleton multiple of about 20 times (p50.0001), in newborn infants with gestational age less than 37 weeks, about 10 times more than 37 weeks (p50.0001), the baby girls 5/2 times the boys (p = 0.04), maternal age less than 20 years of 75/2 to 20 years old (p = 0.04) and first pregnancy 69/3 times as far along the pregnancy (p = 0.01) to come. Assessed by logistic regression analysis showed that the combination of variables, multiple pregnancy, prematurity and infant sex were the most important risk factors for low birth weight Conclusions: In conclusion, it seems that the prevalence of underweight babies in the hospital - Motahari treatment is arranged similar to other parts of the country. The results showed that the main causes of low birth weight infants, intrauterine growth restriction, premature birth, birth rank, maternal age, multiparity, post Mchvryty baby was unknown. Prevention of preterm deliveries, educational intervention programs for high risk groups, especially young mothers aged 20 years and older primiparous and fifth pregnancies and increase the quality of prenatal care in multiple pregnancies, which can have an effective role in preventing low birth weight infants

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

M. Boia1, I. Bacos2, A. Manea1, & L. Portaru2 1

Clinic of Neonatology, University of Medicine and Pharmacy "Victor Babes" Timisoara, and 2Clinic of Neonatology, Clinical Emergency Hospital for Children "Louis Turcanu", Timisoara Brief Introduction: Introduction: being in its essence a metabolic disorder related to hyperamonemmia, recurrent convulsions are extremely rare in the medical practice, hard to diagnose and treat. Objectives: clinical and biological assessment of a neonate with frequent convulsions that are resistant to treatment. Materials & Methods: Material and methods: 2 weeks old female neonate, originated from G IV, P II, born naturally at 38 weeks gestation, weight at birth 2 900 g, height at birth 48 cm and Apgar index 10/1 minute, presents with fever starting with her third day of life, respiratory distress, impaired general status, tachypnea, dyspnea, SaO2 = 95%, heart rate = 120 b/min, frequent tonic and clonic seizures accompanied by a low saturation and resistance to the treatment, with further deterioration of the neurologic status. Clinical Cases or Summary Results: Results: serum ion, glycaemia, CSF glucose were all normal. Creatin kinase (325 UI/L), LDH (247 UI/L) and the serum amino acids were within the reference range for age. A high serum level of glutamic acid (3.3 mg/dl, reference range: 0.3- 2.5 mg/dl) and a dynamic increase of amonemmia: 117.9 umol/L, respectively 143.9 umol/L (reference range: 11–51 umol/L) were detected. The urine orotic test was normal for the patience’s age. The imagistic investigations (transfonatanelle ultrasound, MRI and angioMRI with contrast) found no pathological modifications. The EEG results showed ‘‘suppression burst’’. The anticonvulsant therapy was started with Valproic acid 30 mg/kg/day and Phenobarbital, without any reduction of the convulsive episodes. The treatment was further continued with Keppra 50 mg/day and Phenitoin 5 mg/kg/day, the patience showing resistance in this case as well. Discussions: hyperamonemmia is involved in the severe neurologic deterioration of the neonate, having repeated seizures, although the anticonvulsive medication has been promptly started: repeated i.v. perfusions with glucose, arginine sorbitol, lipids. The normal levels of orotic acid and the increase levels of glutamic acid rise the suspicion of a N-acetyl glutamate syntetase deficit, which is a autosomal recessive disorder and also extremely rare. Conclusions: Conclusions: the management of hyperamonemmia is a laborious one, needing an interdisciplinary approach and the prognostic is reserved, with frequent seizures, resistant to the classic anticonvulsant treatment. Keywords: neonatal seizures, therapeutic management Presenter: A. Manea

ID 895

GENOMIC DNA METHYLATION RESULTS IN PREMATURE INFANTS DEPENDING ON BIRTH WEIGHT.

Keywords:: intrauterine growth restriction, pregnancy, birth, low birth weight

E. Volyayuk1, & A. Safina2

Presenter: Sareh Abdollahifard

Kazan State Medical Academy, Kazan, Russia, and 2Kazan State Medical Academy, Kazan, Russia 1

ID 741

NEONATAL HYPERAMMONEMIACLINICAL AND BIOLOGICAL IMPLICATIONS IN RECURRENT CONVULSIONS

Brief Introduction: The aim of our study was to investigate DNA methylation indices of blood cells in preterm infants with different periods of gestation. Materials & Methods: The observation of 150 preterm infants. Genome DNA isolation was perfomed using K-SORB kits (Synthol, Moscow), restriction was performed using restriction enzymes MspI and HpaII (Fermentas)/Separation of fragmented genome DNA was performed in 1% agarose gel. Densitometric analysis was performed using TotalLab software (v.2.01).

401

DOI: 10.3109/14767058.2014.924236

Clinical Cases or Summary Results: The observation of 150 preterm infants, 42 with birth weight less than 1500 grams (1201 ± 194.9), weighing more than 109 in 1500 (2042 ± 457.7). Gestational age of the first group of children was less than 32 weeks, the second group of 32 or more weeks. We found that the values of total genomic DNA methylation were lower in the group of children born with very low and extremely low birth weight-52, 4 ± 18.9%, whereas in preterm infants over 1500 grams of 60.1 ± 23.9. Conclusions: It seems promising to further study gene methylation indices of antioxidant defense enzymes that are pathogenic factors in the development bronchopulmonary complications in preterm infants with very low body weight. Keywords: preterm infants, DNA methylation

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Presenter: Elena Volyayuk

pulmonic embolism underwent splenectomy 42 days after delivery (9 days after leaving our Clinic in a good condition) in the other clinic, for abdominal surgery. PH review showed necrosis in the tissue, due to the rupture of the capsule. The patient had a CS delivery. No further exams were made due to the patient decline. Conclusions: The conclusion is that the increased rate of EA did not lead to the statistically increase of forceps or VE use in DM pregnancies, and deliveries in EA The increase of CS is statistically significant. The reason was not EA, but other obstetric and metabolic complications, expected in those cases. Introducing low-dose or walking EA can lead to even less use of instrumentation in labor, as it provides lesser motor block with sufficient analgesia. Our experience is that only about 3% of cesarean sections in labors with initial EA were related to the possible effect of local anesthetic, while all the other were performed due to the obstetric/endocrine indication solely. This is the proven case also in the diabetes mellitus complicated pregnancies.

ID 286

Keywords:

THE MODE OF DELIVERY IN PATIENTS WITH DIABETES MELLITUS COMPLICATED PREGNANCIES, CONSIDERING THE USAGE OF THE EPIDURAL ANALGESIA IN THE PROCESS

Presenter: Aleksandar Curkovic

D. Sokolovic1, A. Curkovic2, S. Brankovic3, S. Babic7, N. Karadzov Orlic4, I. Pesic Stevanovic5, J. Djukic6, S. Jankovic Raznatovic7, V. Soldo7, J. Stankovic7, D. Jeremic3, Dj. Cecez8, & T. Mitrovic Lazic8 EUROMEDIK, Belgrade, Serbia, 2Preoperative care unit, Conservative Gynecology Department, 4High Risk Pregnancies Ward, 5Transfusiology Ward, 6Anaesthesia Department, and 7Maternity Ward, G/O Clinic Narodni front, Belgrade, Serbia 1

3

Brief Introduction: In past decades epidural analgesia (EA) in labor was used mostly in prolonged labor. Rarely, it was used in diabetes mellitus (DM) pregnancies. On the contrary, it was considered a major medical mistake, suspecting complications facing during the delivery, could become more dubious. Today the picture is rapidly changing all over the world. That trend was observed in our Clinic, also, mainly by the introduction of new technologies, both in the treatment of DM during pregnancy, conducting intrapartal monitoring, and the last but not the least in admittance and the follow up of the EA during labor. Materials & Methods: Objective was to analyze impact of EA on mode of delivery in DM pregnancies during the 12 month period, as a retrospective study. MATERIALS AND METHODS At the G/O Clinic ‘‘Narodni front’’ Belgrade, Serbia, the number of EA admitted during labor has increased significantly in the last 15 years, from 2.9% in 1998 to 47.17% in 2012. In 2012. there were 6799 deliveries and 3207 EA, 151 with DM (4.71%). Control group was found of 200 pregnant women in delivery, admitting EA, but not having DM, and other connecting metabolic problems. All the results were statistically tested and compared with the up to date literature. Clinical Cases or Summary Results: In general population that was admitted in our Clinic for delivery, 9.8% of all deliveries in EA underwent the Cesarean Section (CS). Indications were in 97.3% obstetric. In DM patients 41.72% (63) and indications in them were 81.3% obstetric. In the rest metabolic indication were in the lead. Use of forceps in EA was 0.9%, in DM-EA 1.3%. Vacuum extractor (VE) was used in control group in 4.3% cases, in test EA-DM group 9.21% (14). In control none of the major complications were observed. Test group EA-DM had two (one postpartal hysterectomy, and one pulmonic embolism, both in the first 72 hours after delivery). Patient with

ID 172

POSSIBLE APPLICATION OF NATURALLY ORIGINATED ESSENTIAL OILS IN POSSIBLE TREATMENT OF PATIENTS WITH CERVICAL BACTERIAL INFECTION AND SYMPTOMS OF IMMINENT PRETERM DELIVERY M. Bogavac1, M. Karaman2, Z. Novakovic3, Janjusevic Lj2, B. Radovanovic3 1

University of Novi Sad, Faculty of Medicine, Clinical Centre of Vojvodina, Department of Obstetrics and Gynecology, Novi Sad, Serbia, 2University of Novi Sad, Faculty of Sciences, Department of Biology and Ecology, Novi Sad, Serbia, and 3 University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia Brief Introduction: Preterm delivery remains one of the major problems around the world. The etiology of preterm delivery is not clarified yet, but last data indicate that infection in general, and cervical bacterial infection in particular, can be one of the causes of preterm contraction, preterm rupture of amniotic membrane and preterm delivery. Naturally originated substances mostly derived from plants including their essential oils have been already proved to be one of major agents with antibacterial activity. The aim of the study was to investigate in vitro the possible application of essential oils as antimicrobial agents in the treatment of bacterial cervical infection in pregnant women with the clinical symptoms of the imminent preterm delivery. Materials & Methods: The experiment was based on analysis of pregnant women (from 24 to 32 weeks of gestation) with clinical symptoms of imminent preterm delivery (25 randomly chosen). It was found that five women were infected by Gram positive bacteria including multiresistant strains: Staphylococcus aureus E.coli and P. mirabilis. Microbiological diagnosis was performed by using direct cervical swab preparation including Gram staining with standard susceptibility assay. The antimicrobial assay was carried out by a 96 well microdilution method for two pure natural commercial essential oils derived from Organum minutiflorum and Mentha piperita (Probotanic, Baltik Junior d.o.o., Belgrade, Serbia). Clinical Cases or Summary Results: The highest antibacterial effect was reached with oregano essential oil on S. aureus strain with minimal

402 inhibitory concentration (MIC) and minimal bactericidal concentration (MBC) at 300 mg/mL, respectively, while M. piperita oil showed almost six times lower activity (MIC and MBC at 2600 mg/mL). The most resistant bacterium was P. mirabilis followed by E. coli and S. aureus. The oregano oil tested proved to be similarly efficient against the S. aureus strain compering to the positive control applied (streptomycin, MBCs 120 mg/mL and "120 mg/mL, respectively). Conclusions: Since essential oils are already present in the form of vaginalettes, it is reasonable to promote further investigations of essential oils and their pure components bioactivity due to its possible application in obstetric practice, especially among pregnant women where the use of convenient therapy (vaginalettes and antibiotics) is limited. The alternative based therapy could be promising in patients with clinical symptoms of imminent preterm delivery as well.

operative delivery. 2) New styles of perinatal infection diagnostics, prophylaxis and treatment are to be developed to reduce the rate of extremely preterm birth and long-term neurological impairment for extremely premature newborns. 3) The use of modern medical technologies can reduce organic pathology of central nervous system in extremely preterm babies. Currently the neurological impairment cannot be avoided completely, particularly at 22–25 weeks’ gestation.

Keywords: preterm delivery, bacterial cervical infection, essential oils

TRENDS IN PRETERM BIRTHS AND ITS SUBTYPES FOR SINGLETONS IN AN ASIAN OBSTETRIC POPULATION: A PICTURE DIFFERENT FROM THE WEST?

Presenter: Bogavac Mirjana J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

ID 747

CENTRAL NERVOUS SYSTEM DISEASES FOLLOWING EXTREMELY PRETERM BIRTH: OPTIMAL DELIVERY METHOD R. Shalina1, & D. Spiridonov1 1 Obstetrics and gynecology Dept., Pirogov Russian National Research Medical University, Moscow, Russia

Brief Introduction: Central nervous system pathology remains a significant problem especially if associated with extremely preterm birth, leading to decreased survival. There is no agreement among specialists regarding causes, pathogenesis and methods of prophylaxis for central nervous system diseases following extremely preterm birth. Therefore obstetricians are of great interest to decrease the rate of significant neurological impairment in extremely preterm babies. Materials & Methods: The study of 135 singleton obstetrical history forms (91[67.4%] – vaginal delivery [VD], 44[32.6%] – C-section [CS]) with gestational age 22–26 was performed. Children clinical examination included: neurosonography, radiography, echography; consultation of neonatologist, neurosurgeon, ophthalmologist, pediatric surgeon. The technique for cesarean delivery included: the leading role of an experienced obstetrician, regional anesthesia, fetal extraction in intact vesica fetalis, use of respirators and care equipment for extremely immature infants, postnatal treatment with surfactant. All the born alive babies were admitted to neonatal intensive care unit. Clinical Cases or Summary Results: Indications for CS at 22–25 weeks: 6(66.7%) preeclampsia, 3(33.3%) vaginal bleeding. At 26–27 weeks: 10(43.5%) intrauterine hypoxia, 13 (56.5%) amnionitis. The rate of neonatal mortality at 22–25 weeks: CS – 3(15.8%), VD – 9(45%); at 26– 27 weeks: CS – 2(8%), VD – 10(14.1%). Intraventricular haemorrhage (IVH) was the main cause of perinatal morbidity and mortality: I grade 9(6.67%)(7-VD,2-CS), II grade – 23(17.0%)(17-VD,6-CS), III grade – 17(12.6%)(8-VD,9-CS). Grade III IVH was diagnosed only in babies after CS at 22–25 weeks. 56.2% of children suffered from perinatal infection (PI). In 75% of this cases PI matched IVH. 33 (24.4%) neonates developed bronchopulmonary dysplasia followed by 3(2.2%) lobectomy. Surgical operations in neonates: 9(6.7%) laser photocoagulation for retinopathy of prematurity, 8(6.0%) closures of ductus arteriosus, 3(2.2%) shunt insertion for posthemorrhagic hydrocephalus. 17% reduction of long-term morbidity was achieved due to invasive procedures listed above. Conclusions: 1) Neonates head trauma being one of the main causes of IVH can be avoided through cesarean delivery use. Other causes of IVH such as hypoxia and perinatal infection cannot be eliminated by

Keywords: Extremely preterm birth, intraventricular haemorrhage, modern medical technologies Presenter: Dmitry Spiridonov

ID 105

A.S.Y. Hui1, T.T. Lao1, T.Y. Leung1, J.M. Schaaf2, & D. S. Sahota1 1

Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, 2Academic Medical Centre, Department of Medical Informatics, Amsterdam, the Netherlands Brief Introduction: This study examined the trends of preterm births among singletons, and its relationship with perinatal mortality, at a university teaching hospital in Hong Kong. Materials & Methods: 103364 singletons delivered between 1995 and 2011 were reviewed, 95.5% were Chinese. The trends in preterm births and its contribution to perinatal mortality, as well as the subtypes including spontaneous, iatrogenic, and preterm births following premature rupture of membranes were examined using linear regression model. Clinical Cases or Summary Results: Of the 6722 (6.50%) preterm births, 1835 (1.78%) were 534 weeks, and 4887 (4.73%) were 34–36 weeks. Spontaneous preterm births declined by 25% (beta = -0.83, p50.001) from 4.52% to 3.80%, while preterm births following premature rupture of membrane increased by 135% (beta = 0.82, p50.001) from 0.71% to 1.66%. Overall perinatal mortality was 4.77/1,000 births and it decreased from 56.7 to 37.0 per 1,000 births before 37 weeks (beta = -0.16, p = 0.54). Early preterm births contributed to 16% of all deaths. Conclusions: Although the overall preterm birth rate remained constant, trends of the underlying subtypes were changing. Decline in spontaneous preterm births was offset by simultaneous increase in those following premature rupture of membranes. The overall perinatal mortality was gradually declining, yet early preterm birth was still the major contributor. Keywords: preterm births; iatrogenic, spontaneous, premature rupture of membranes, perinatal mortality Presenter: Annie S.Y. Hui

ID 090

ACUPUNCTURE REFLEXOTHERAPY OF THE PREGNANSI REMAINS IN THE III TRIMESTER.

403

DOI: 10.3109/14767058.2014.924236

O. Romanova1, V. Linde2, T. Botascheva3 1

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Department of Obstetrical, Research Institute of Obstetrics and Pediatrics, Rostov-on-Don, Russia, 2Department of Obstetrical, Research Institute of Obstetrics and Pediatrics, Rostov-on-Don, Russia, and 3Department of Obstetrical, Research Institute of Ob Brief Introduction: Incomplete pregnancy remains a major problem in today’s health worldwide. In order to decrease the frequency of preterm birth conducted randomized controlled clinical trial of the efficacy and safety the acupuncture therapy threat of abortion in primigravidae in the III trimester. Materials & Methods: Included 299 pregnant women with regular complaints of abdominal pain, uterine contractile activity. In group 1 (n = 145) acupuncture not performed. In group II (n = 154) 10 days stimulate points MC-7, RP-6, TR-5, R-6 on the side of placenta, 30 minutes. Randomization was performed by the method of envelopes. At admission and on day 10 were studied: uterine activity (mehanogisterografiya, CTG, "Sonomed-200", Russia), blood flow in the arteries of the uterus, the umbilical cord, fetal middle cerebral artery (ultrasound and Doppler, «Toshiba SSA- 340", Japan); plasma levels of estriol, placental lactogen and cortisol (enzyme immunoassay, Victor, Finland). Statistical power of 80%. Clinical Cases or Summary Results: On admission, the patients in both groups noted: uterine artery vasospasm ipsilateral placenta and umbilical and fetal middle cerebral artery, low level of estriol, placental lactogen, high levels of cortisol. On day 10 the negative dynamics was observed in 12% of women in group I for all parameters (p50.05). In group II, 90% of patients showed normalization of uterine tone, blood flow in the arteries of the umbilical cord, uterus, fetal middle cerebral artery, levels of cortisol, estriol and placental lactogen (p50.05). There was no negative effect of acupuncture on the pregnant woman and the fetus. Births 38–42 weeks gestation have occurred: group I - 53.1%, in II - 81.1% of women (p50.05). Conclusions: Stimulation of acupuncture points with MS-7, RP-6, TR-5, R-6 on the side of the placenta is an effective and safe method of nonmedicamentous of therapy threat of pregnancy interruption. Keywords: acupuncture, threat of pregnancy interruption Presenter: O. Romanova

ID 679

HYPERGLYCEMIA IN AN EXTREMELY LOW- BIRTH- WEIGHT (ELBW) PREMATURE INFANT – CASE REPORT N. Ionita1, M. Dima2, A. Agoston-Vas1, C. Ilie2, A. Badoi1, & R. Tanase1 1

County Emergency Hospital Timisoara, Romania, and university Of Pharmacy And Medicine "V. Babes" Timisoara, Romania 2

Brief Introduction: Hyperglycemia in an ELBW infant is defined as glucose blood levels 4180 mg/dl, or by other authors 4250 mg/dl. In this presentation we want to emphasize the importance of preventing hyperglycemia and the importance of a correct treatment. Materials & Methods: We are presenting the clinical case of a premature newborn, gestational age 25 weeks, birth weight 500g. She comes from a twin pregnancy, biamniotic, monochorial, born by cesarean section. The other twin having a birth weight of 400g lived for only 48 hours. Family history: the mother was diagnosed with Patent ductus arteriosus (PDA) and acute pulmonary edema. In the delivery room the newborn needed cardiopulmonary resuscitation,

oral intubation and surfactant administration followed by mechanical ventilation. Apgar score: 1/10 -50 -100 . We are interested in the raised blood glucose levels. To determine the values we used a rapid method: dextrostix and we confirmed the results with serum glucose levels. Clinical Cases or Summary Results: 24 hours after birth we had a blood glucose level of 450 mg/dl (dextrostix). First we decreased the concentration of glucose administered in infusion. We determined the blood glucose levels every 4/6 hours, and we had levels of 548 mg/dl. Guidelines recommend to administer Insulin if the levels persist 4250 mg/dl. We chose HumulinR, first loading dose of 0.1 UI/Kg intravenous over 20 minutes, then maintenance 0.05 UI/Kg by continuous intravenous infusion. We determined blood glucose levels every 30/60 minutes until a stable level of 85%. We administered Insulin for 4 days. We had no adverse effects like hypokalemia. We considered all the risk factors, pathological aspects or medical errors which could lead to hyperglycemia. The clinical evolution of the ELBW premature infant was threatened by the cardiac pathology: PDA and Atrial septum defect with two important levels of left to right shunt. Conclusions: Hyperglycemia is very common in ELBW premature infants (60–80%). A correct treatment of it decreases mortality Keywords: ELBW, premature, hyperglycemia, insulin Presenter: N. IONITA

ID 735

RISK FACTORS AMONG LOW BIRTH WEIGHT INFANTS, BORN WITH ASSISTED REPRODUCTIVE TECHNOLOGY R. Maslarska, M. Kalaidjieva, V. Konstantinova, S. Deneva, S. Kontilska, V. Alexandrova, E. Igova, & B. Ivanova Neonatology Department; Tokuda-Hospital Sofia; Sofia; Bulgaria Brief Introduction: The development of the assisted reproductive technology methods in the last few years has massively drown the attention to the increased rate of inborn malformations among infants, born with an IVF (in vitro fertilization)/ICSI (intracytoplasmic sperm injection). It has not been clearly proved if this is a direct result of the assisted reproductive technology method or a consequence of the primary cause for infertility. According to different clinical cases the incidence of inborn malformations after IVF/ICSI varies between 4 and 10%. Materials & Methods: A summary of the risk factors among low birth weight infants, born with assisted reproductive technology from various scientific sources and materials has been made. A higher rate of multifetal pregnancies und infants with extremely low birth weight in combination with the consequent diseases and complications has been detected. All infants born in Tokuda Hospital-Sofia after an assisted reproductive technology for a time period of 5 years, their disease progress, diagnosis, treatment and screening methods for prophylaxis of complications have been included and presented in our data basis. Clinical Cases or Summary Results: The clinical report presents the case of a high-risk newborn girl with a low birth weight. The infant has been born from a third in vitro pregnancy accompanied by an oligohydroamnios, a detected with a sonographic examination retardation of the fetus in the 26th g. w and a cardiotopographic evidence for fetal distress. The baby has been born with an emergency Cesarean section in the 26th- 27th g.w, with birth weight of 650 g and a note of 1–5 according to the Apgar scale. A primary reanimation has been performed in the delivery room. At the 3rd minute the child has been intubated and neonatal mechanical

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404 ventilation has been started. At the 15th minute after the birth a prophylactic surfactant doses of 200mg/kg has been insufflated. In the following hours the consequent therapy methods have been prescribed: an epicutaneous central catheter, inotropic assistance, parenteral feeding and an antibiotics therapy. The microbiological sample of a tracheal aspirate show Candida- the hemoculture examination is also positive for Candida at the 10th day. Therefore, a treatment with Vfend for 2 months has been conducted. The hemoculture shows negative results at the 4th week of the therapy. The clinical evidence at an age of 30 days presents a oxygen- and ventilation machine dependence. The x-ray examination indicates a pulmonary dysplasia. The mechanical ventilation continued up to the age of 14 days, but the ventilation assistance with CPAP c FiO2 0.25%. has been applied up to the end of the 2nd month. A treatment with diuretics, Vitamin A and inhalation therapy with Pulmikort has been performed. The child experienced a sudden injury of the right femur bone- the biochemical and roentgen examination show evidence for a severe degree of rickets. This clinical case is presented as an example of a rare and severe disease with a positive outcome- Candida sepsis in the neonatal period. The symptoms of the pulmonary dysplasia have been relieved with an early enough therapy with diuretics and a later inhalation treatment with corticosteroid medications. Despite the early prophylactic with Vitamin D, infants with an extremely low birth weight have complication of the Ca-P metabolism and, therefore, require a biochemical and roentgen screening and therapy. Conclusions: The screening techniques for infants born with an assisted reproductive technology require a multidisciplinary method.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

effect so after gaining all lab and other test normal, we started to search metabolic or other genetic disorders and sweat test was positive so we have got the diagnosis as early as at 5 weeks of age and the child got regular therapy/Creon/and automatically gain on weight It is important to be aware that preterm delivery can be sign of fetus disease and if some problem, even failure to thrive appears in neonatal period it can itself be the sign of genetic disease Conclusions: It is important to be aware that preterm delivery can be sign of fetus disease and if some problem, even failure to thrive appears in neonatal period it can itself be the sign of genetic disease Keywords: Presenter: Svetlana Stefanovic´

ID 825

PARENT-STAFF COMMUNICATION AND BREASTFEEDING SUPPORT IN NICU: A QUALITATIVE STUDY A. Concheiro-Guisa´n, D. Can˜izo Va´zquez, M.L. Gonza´lez Dura´n, E. Gonza´lez Colmenero, C. Dura´n Ferna´ndez-Feijo´o, & J.R. Ferna´ndez Lorenzo Neonatology Dept., Hospital Xeral-Cı´es (EOXI), Vigo, Spain.

Keywords: Presenter: R. Maslarska

ID 690

CYSTIC FIBROSIS -CLINICALY DIAGNOSED IN NEONTAL PERIOD S. Stefanovic´, Ð. Tenjovic´, V. Stefanovic´, V. Stefanovic´ 1

Medical Faculty University of Novi Sad, Serbia, 2Institute for Childrens and Youth Health Care of Vojvodina, Novi Sad, Serbia, 3Health Care Center, Novi Sad, Serbia, and 4Students Health Care Center, Novi Sad, Serbia Brief Introduction: Cystic fibrosis is a very rare disease as due to the literature data one of 25 children is a carrier of the CF gene. It is hereditary, autosomal recessive disease with progression The cause of cystic fibrosis is a mutation on chromosome 7 causing defect in a protein which regulates the transport of chloride ions through the cell membrane(TRCF). so the secretion of various glands is very dense and easily results with blockage of excretory ducts with tissue damage. Diagnosis can be set before birth, if there is family history by using a genetic analysis of amniotic fluid cells, or in a newborn without signs of disease usinig neonatal screening or later on with pathological sweat test and PCR diagnosis Materials & Methods: We will present our case of preterm newborn child hospitalized due to failure to thrive Clinical Cases or Summary Results: We have hospitalized a male newborn at age of 4 weeks, P 160/min, O2 sat 95%. weight 2880 e.g. even 70 gr under b birth weight, length 49 cm, aspect of chronic ill neonate patient, with signs of extreme reduction of fat tissue, neurological assessment showed mild lethargy and axial hypotonia Laboratory and other findings: negative CRP Le 11.7 g/l, RBC 3.48 T/l, 112 g Hb/l, Pl237 g/l. Glucose, serum electrolytes and gas analyses within normal range Radiological findings -lungs, abdomen, brain -normal Bacteriological finding normal, IgM nonspecific and specific toward TORCH negative We started with breastfeeding at 3 hours intervals but child did not get on weight properly so we tired to add formula but with no

Brief Introduction: The experience of the admission of a premature baby in NICU is a stressful event for the family. An adequate level of communication with the staff could alleviate this discomfort and ensure proper transmission of medical information. The first contact in the unit is a key moment. The establishment of breastfeeding can be a complex process, good advice in the early days relieves stress and presumably increases the success rate. The evaluation of the adequacy of communication in the neonatal units is a key point in quality of care surveillance. Materials & Methods: Prospective qualitative study. Survey to mothers/ fathers (separately) of premature children 532 weeks GA admitted to our unit during one year period. Survey was performed at the first control after discharge. Questionnaire consists in 3–4 points Likert scale or open-ended questions and grouped according to admission in the unit (3 items), breastfeeding counseling (11 items) and clinical information by physicians and nurses (8 items). Statistical analysis SPSS v.19. Clinical Cases or Summary Results: 53 out of 72 eligible subjects completed the survey (73%). 70% mothers. Median age: 32 years. Mean days of hospitalization were 44 (21–112). On admission 50% of parents reported feeling nervous. In 81% of cases they received the first information from medical staff. 94% reported that this person was clearly identified and introduced him/herself correctly. Concerning the explanation of the rules of the unit, 69% reported have been clearly informed. There were no significant differences between the level of understanding and the mood of the parent at admission. Regarding breastfeeding counselling, the mother was the first person to receive this information in 47% of cases and usually received the first information the day of admission, although 26.4% also received it prior delivery (from midwife or neonatologist). Breastfeeding information was given by NICU nurses (28%), medical staff (24%), midwives (20%) or maternity ward nurses (17%). 67% of parents said they have been well-informed. 87% of them have received writing information about breastfeeding and found it useful in all cases but suggest an improvement in further instruction on breast pumping. 74% have received information about breast pumping mostly at maternity ward. Breastfeeding counselling was considered appropriate by 71% of parents, although 21% considered it totally inadequate. In relation to health information of the premature, 98% reported it has been enlightening (68% extremely clear) and 89% said it has been granted enough time for it. Only 64% of parents reported have received information about all tests and

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DOI: 10.3109/14767058.2014.924236

procedures performed to his/her child. Concerning nursing care, 85% said that this information was clear and complete. 22% of parents said they have received conflicting information between doctors, nurses and primary care. 85% received information at any time they have demanded it and 73% have been able to make telephone consultation. 77% reported have received information in a kind and respectful way with few exceptions by staff poorly involved in child care. The overall rating of communication has been very good (74% respondents). There were no differences between fathers and mothers about satisfaction with medical care information. Parents of children with a longer admission (460 days) complained about a reduction in time for medical information but further explanations about the care of the newborn. Conclusions: In view of our results, we can highlight some weak points of parent-staff communication in our unit like lack of information about breastfeeding (late onset, incomplete in the case of the extraction technique or lactation, uncoordinated between several professionals involved on it) or about clinical information (contradictory between different members of staff, inadequate in the patient with prolonged hospitalization or in relation with complementary testing). On the other had we can include as strengths: the usefulness of print media in support of breastfeeding instruction, professionalism and politeness of most of the staff, the explanatory clarity (no abuse of medical terminology), the accessibility to information and time employed, all aspects to be improved. An adequate family-staff communication facilitates the integration process of the parents into the care of the newborn on NIDCAP care, increases the rate of breastfeeding, attenuates emotional strain and prevent conflicts. In order to this staff should be trained in communication skills.

STRUCTURED ASSESSMENT AND/ OR PRAGMATIC CRITERIA? N. Goel1, S. Mohinuddin1,2, N. Ratnavel1,2, & A. Sinha2,3 1

Neonatal Transfer Service, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom, 2Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom, and 3Centre for Paediatrics, Blizard Institute, Barts and the London School of Medicine & Dentistry, London, United Kingdom Brief Introduction: Identification of suitable infants requiring therapeutic hypothermia needs careful clinical assessment. The major cooling trials (References - 1, 2) which informed the clinical practice had specific entry criteria to select infants with moderate or severe encephalopathy, before recruitment into the study occurred. With the proven efficacy of hypothermia, there is a concern that in everyday clinical practice there may be a ’therapeutic drift’ and clinicians may choose to start treatment in borderline cases where the trial criteria are not fulfilled. The long term effects and risks or benefits of cooling outside the published trial criteria are not yet known.

Keywords: parent-staff communication, breastfeeding Presenter: A. Concheiro-Guisa´n

ID 659

NEUROLOGICAL ASSESSMENT IN INFANTS REFERRED FOR THERAPEUTIC HYPOTHERMIA: IS THERE A NEED FOR MORE

Figure 1. Encephalopathy assessment in babies referrred for cooling

Figure 2. Documentation of neurological assessment in babies who did not meet the criteria used by the TOBY study group {Azzopardi et al (1)}

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406 Materials & Methods: Aim: To assess if infants referred for therapeutic hypothermia meet the published criteria for encephalopathy, as used by either the TOBY group or Shankaran et al (1, 2). Methodology: All infants referred for therapeutic hypothermia between 1st July 2011 to 30th June 2013 to the London Neonatal Transfer Service (NTS) were included. NTS provides stabilisation and transfer of infants from approximately 20 referring neonatal units to the 9 cooling centres in London. The neurological state of the baby documented by the referring centre and/or on evaluation by the transfer team, prior to administration of sedative or muscle relaxant, were obtained and analyzed. The study was approved by Barts Health Clinical Effectiveness Unit. Clinical Cases or Summary Results: 156 infants (data available on 145 infants) were transferred to a cooling centre. The documentation of neurological assessment for encephalopathy prior to cooling treatment included (% of all infants) - tone (97%), posture (69%), spontaneous activity (69%), suck (54%) and pupillary reflex (73%) (Table 1). Hypertonia was more commonly used as a referral criteria rather than the trial criteria of hypotonia. Suck reflex was not mentioned in 50% of ventilated babies as compared to 25% of nonventilated babies. When measured against the encephalopathy assessment criteria published by the TOBY group (1), only 86/145 infants fulfilled the criteria. The remaining 59/145 (40%) infants did not have documented evidence of moderate to severe encephalopathy (Table 2). Normal neurological examination was documented in 36/145 (24.8%) infants. In 23/145 cases, there was evidence of mild encephalopathy. We also measured cases against the encephalopathy assessment criteria as published by the Shankaran et al group (2). In 24/145 infants the criteria was not met fully and 36 others had normal neurology. Cerebral function monitoring (CFM) was available at the referral centre in 47/145 (32%) cases. The CFM trace was documented as normal in 14/47, of which 8 had normal neurology as well, while 6 had abnormal tone with no seizure activity. Conclusions: In 40% of infants referred for cooling, the documentation of neurological assessment did not show any evidence of moderate to severe encephalopathy and cases did not meet the entry criteria for the therapeutic hypothermia trials. This has important clinical and medico-legal implications and may represent a significant additional workload. There is a need for structured neurological examination training with appropriate documentation for referring clinicians, alongwith pragmatic guidance for referring infants for cooling treatment. Keywords: neonatal, hypothermia, neonatal transport, cooling criteria Presenter: Nitin Goel

ID 251

THERAPEUTIC HYPOTHERMIA DURING NEONATAL TRANSFER: COMPARISON OF PASSIVE VS ACTIVE COOLING N. Goel1, S. Mohinuddin1,2, N. Ratnavel1,2, & A. Sinha2,3 1

Neonatal Transfer Service, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom, 2Neonatal Unit, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom, and 3Centre for Paediatrics, Blizard Institute, Barts and the Lo Brief Introduction: Therapeutic hypothermia commenced within 6 hours results in improved neuro-developmental outcomes in infants with moderate to severe hypoxic ischaemic encephalopathy. In the UK, neonatal units where active hypothermia is not available, infants are passively cooled until transfer to a cooling centre. Recently, with the

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

availability of servo-controlled cooling equipment on transport, it is now possible to commence active cooling at the referral unit. Materials & Methods: All infants referred for therapeutic hypothermia between 1st July 2011 to 30th June 2013 to the London Neonatal Transfer Service (NTS) were included. Active hypothermia during transfer using servo-controlled cooling mattress (Tecotherm) was introduced at NTS from September 2012. We compared the outcomes in the two groups, i.e., passively cooled vs actively cooled, to evaluate the effectiveness of this treatment modality. Outcome measures included stabilization time, temperature stability at different stages of transfer and time to reach target temperature. Analysis was performed using SPSS software. This project was approved by Barts Health Clinical effectiveness unit. Clinical Cases or Summary Results: 156 infants (data available on 145 infants) were transferred to a cooling centre. 76 infants were passively cooled during the transfer and 69 were actively cooled. 15 infants were actively cooled by the referring units. Median (Interquartile range) age of infant at referral was 140 (96–200) minutes. Dispatch time i.e. time from referral to the team mobilization was median of 25 (15–60) minutes. Median age of infant at the time of arrival of the transfer team was 230 (177–300) minutes. The stabilization time was significantly longer for active cooling group compared to passive cooling (median time 110 vs 90 min, Mann Whitney U test, p = 0.034). There was a significant difference between the temperature at arrival of NTS to the temperature during stabilization, during transfer and at the receiving hospital for both passive and active cooling groups (Fig 1). The proportion of newborns cooled to within the ideal temperature range was higher in active cooled group at all stages of transfer. Median time to achieve target temperature was 30 (95%CI 23–37) minutes in babies actively cooled, significantly shorter in comparison to 130 (95%CI 83–177) minutes in passively cooled babies (Fig 2) (Log rank Mantel Cox chi sq = 29.8, p50.001). Conclusions: Infants actively cooled during transfer achieve target temperature for therapeutic hypothermia in a significantly shorter time period and achieve better temperature stability during transfer. Although the stabilization times were longer, active cooling should become standard of care for achieving therapeutic hypothermia during neonatal transfer. Keywords: neonatal, hypothermia, neonatal transport, active cooling Presenter: Nitin Goel

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DOI: 10.3109/14767058.2014.924236

ID 802

PULSE OXIMETRY SCREENING FOR CRITICAL CONGENITAL HEART DISEASE (CCHD) IN ASYNTOMATIC NEWBORN BABIES IN A SPANISH HOSPITAL: ANALYSIS BEFORE AND AFTER SCREENING IMPLANTATION L. Serrano Lo´pez1, F. Perin2, C. Carreras Blesa2, L. Zamorano Bonilla1, M.V. Jimenez Cabanillas1, M.M. Rodriguez Vazquez del Rey2, & J.A. Hurtado Suazo1 Neonatology Dept., and 2Cardiology Dept., Paediatric Dept., University Hospital "Virgen de las Nieves", Granada, Spain 1

Brief Introduction: Several studies have shown that critical congenital heart diseases (CCHD) can be missed by prenatal ultrasound and physical examination, being discharged up to 30% newborns with unrecognized CCHD. This fact entails a high risk of cardiogenic shock, neurological damage and death. Since 2012, the American Pediatric Association supports the universal screening of CCHD by pulse oximetry. In the Spanish Health system there is no available information neither about the rate of missed CCHD diagnosis nor about the pulse oximetry usefulness. The objective of this study is to evaluate the rate of unrecognized CCHD in newborn before the universal pulse oximetry was stablished in our center, and to describe the initial results after its implantation, with special focus on false-positive rate. Materials & Methods: We define CCHD as those which cases which caused death or intervention in the first 28 days of life. We report

2 analyses: the first, retrospective, showing the incidence of CCHD and late detection rate before pulse oximetry screening implantation, and the second, prospective, after its recent introduction. We assessed pulse oximetry in the right hand (preductal) and in one foot (postductal) after the first 24 hours of life. A screen result was considered positive (abnormal) if 1): any oxigen saturation 590%, 2) oxygen saturation 595% in both extremities on 3 measures or (3) 43% absolute difference in oxigen saturation between right hand and foot on 3 measures Clinical Cases or Summary Results: The incidence of CCHD in 18 months before the pulseoximetry (September 2011 - February 2013) was 1,8:1000. There were 10 CCHD diagnosed out of 5500 newborn: 3 (30%) prenatally, 4 (40%) by physical examination before discharge and 3 (30%) after hospital discharge. Since the use of pulse oximetry as a screening method at our center (May 2013-March 2014), there have been4 patients (out of 3068 deliveries) with CCHD, all of them diagnosed previously to the hospital discharge (2prenatally and 2 by physical examination and pulseoximetry). There were 2 false positives (0.06%). One of the 2 newborns with false positive result, was diagnosed by echocardiography of situs inversus totalis (without CCHD), probably related to Kartagener syndrome and needed oxygen during the first week of life. Conclusions: Conventional screening for congenital heart disease, based on prenatal ultrasound and physical examination, can lead to a significant rate of unrecognized CCHD. Pulse oximetry may be a useful screening test. Furthermore, it does not imply an increase of referrals to cardiology being false-positive rate was particularly low (50.1%). The study of false positive can be useful to detect significant anomalies (different from CCHD) that can need additional analyses and treatments. More studies are needed to assess its long-term real value and economic impact in our heath system. Keywords: Pulse Oximetry Screening, Congenital Heart disease, Asyntomatic newborn Presenter: Laura Serrano Lo´pez

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ID 552

ID 709

CRITICAL CARE EQUIPMENT AND UNINTERRUPTED POWER SUPPLY CIRCUITS (UPS) IN NEONATAL INTENSIVE CARE UNITS – A SAFETY AND QUALITY REVIEW

NEONATAL RESUSCITATION: A SURVEY ON TRAINING OF JUNIOR DOCTORS IN THE SOUTH WEST OF ENGLAND, UNITED KINGDOM

A. McClean, K. Courtenay, C. McFeely, M. Anandarajan, & R. Tubman

Musgrove Park Hospital, Taunton, United Kingdom

1

Brief Introduction: Uninterrupted power supply (UPS) circuits provide back up power supply in the event of the loss of mains electricity to critical care equipment in NICU. Although some equipment has internal battery backup, the duration that these provide emergency power varies widely, depending on the battery capacity and its lifespan. This study investigated whether or not critical care equipment was connected to UPS circuits in all occupied spaces in Northern Ireland’s five NICUs. Materials & Methods: Data were collected from each of the five NICUs in Northern Ireland over a six-month period (Royal Maternity, Ulster, Altnagelvin, Craigavon and Antrim Hospitals). These included the number of sockets per cot space, the type of circuit, and whether or not critical care NICU equipment was connected to UPS circuits. Equipment included incubator, ventilator, CPAP, NIPPV, vital signs monitor, critical and other infusion pumps. Clinical Cases or Summary Results: There was wide variation in the number of UPS circuits available per cot space, ranging from 1- 28 sockets per cot space. Critical care equipment was connected to UPS circuits in 75–100% of spaces (apart from one hospital that only had one UPS socket per cot space at that time). See Table 1 for Summary of Results. Conclusions: There is wide variation in the number and proportion of UPS circuits in different neonatal units in Northern Ireland. The review has resulted in the following recommendations being made:  Continuing staff education in use of UPS  Labels on power plugs to remind staff to use UPS circuits appropriately.  Include UPS use in safety check documentation.  Review of provision of UPS circuits in units to the level recommended by Intensive care network (minimum 16 sockets per cot space).

Brief Introduction: All junior doctors undertaking paediatric rotation are expected to attend deliveries and provide at least the basic level of neonatal resuscitation. This is quite daunting especially to junior doctors at the foundation level. This survey looked into the training available to the junior doctors in neonatal resuscitation prior to and during their paediatric rotation in the South West Hospitals. Materials & Methods: Junior doctors doing their first paediatric rotation requiring neonatal resuscitation were included in the survey. They include foundation level doctors (F1/F2), junior paediatric trainees (ST1/ST2) and trust grade doctors. Unfortunately, GP trainees could not be included due to the lack of support for the survey. The online-based survey was sent to them through Severn and Peninsula Deanery (UK Paediatric Training Deaneries). The survey was carried out from February 2014 to March 2014. Clinical Cases or Summary Results: 31 doctors responded to the survey from hospitals in the South West region. 29% of doctors were not aware that they had to provide neonatal resuscitation in their rotation. 77.4% of them have not attended Neonatal Life Support course. 9.68% of doctors did not receive formal training in neonatal resuscitation prior to attending deliveries. 53.3% of doctors attended55 deliveries under supervision initially. A concerning 63.3% of juniors doctors have been put in a situation where they felt not competent in attending neonatal resuscitation independently. Conclusions: The survey has identified the need for continued training and support in neonatal resuscitation for junior doctors. This is extremely important if we are to deliver safe and good care to newborn babies. In response to this, the following measures are in place or in progress: 1) Follow-up training in addition to induction, focusing on neonatal resuscitation 2) System to improve information given for the paediatric delivery calls (LAMDA) 3) Project in progress to video neonatal resuscitation as training aid

Keywords: Equipment and Patient Safety

Keywords: Neonatal Resuscitation Training, Junior Doctors

Presenter: Anne Marie McClean

Presenter: J Parasuraman

Paediatric Depart., Ulster Hospital Dundonald, Belfast, Northern Ireland, and 2Neonatology Depart., Royal Jubilee Maternity Hospital, Belfast, Northern Ireland. J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

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J. Parasuraman

ID 143

INTERACTIVE MEDICAL INTELLIGENCE-THE FUTURE IS NOW G. Pregenzer Somerset Medical Center; Somerville, New Jersey, USA

Table 1 Showing the Percentage of UPS Sockets Available per Cot Space for Emergency Equipment in Five NICUs in Northern Ireland

Brief Introduction: The application of the computer and Information Technology had the promise of dramatically improving the the care of medicine world wide for over a decade now. The landmark report in the United States by the Institute of Medicine in 2000, "To Err is Human, building a safer Heath System" indicated that up to 90,000 Americans die from medical errors largely attributed to illegibility of

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DOI: 10.3109/14767058.2014.924236

medical orders and directives. The current electronic medical record systems used world wide certainly solve the illegibility concerns. But the question remains, what about truly quality of care? The vast majority of systems today are used for tracking billing, and check on inventory issues. None of the systems evaluated by the authors have a check and balance system to assist the clinician in identifying if a mistake has taken place. A system was developed which we believe has taken Information Technology in medicine to the next level and has compared it to traditional systems. The new system is not a medical record system but rather an interactive medical intelligence system.. Such a system has the ability to assist the clinician to accurately, efficiently and rapidly obstetrical care and dramatically, if not eliminate medical errors. Materials & Methods: Seven busy obstetrical practices were selected to transfer the information in their system, both paper and electronic based, into the Interactive Medical Intelligence system. Over a 1,000 pregnancies were followed until delivery. The risks identified by the Interactive Medical Intelligence system were tabulated. These were compared to the risks identified by the traditional methods and some of the standard EMR’s. Clinical Cases or Summary Results: Twenty categories were identified that the Interactive Medical Intelligence system identified risks that were missed by the obstetrical practices. Missed were: (1) 7 cases of LEEP, a risk for PTL(preterm labor) (2) 8 History of Herpes not acted upon (3) Maternal blood type not obtained (4) 7 cases of IVF not appreciated as high risk for PTL (5) Three cases of myomectomy not recognized as risk (6) Sickle cell trait missed in one patient (7) USG measurement of the cervix not measured in 8 patients at high risk for PTL (8) A missed GBS in 6 (9) For cases of family history or autism and Fragile X not being ordered (10) a short inter pregnancy interval not noted as risk for PTL (11) Low MCV recorded but no action taken in 8 patients (12) multiple abortions as possible risk for PTL not noted in 7 patients (13) missing fields in 106 charts (14) No height noted 90 (15) No fundal height noted in flow sheet, 64 (16) elevated BP on initial exam not acted on in 15 patients (17) an elevated BMI not appreciated as risk for dystocia (18) an elevated BMI not appreciated as risk factor for PTL (19) short stature not noted as risk for dystocia in 5 patients and (20) 12 high risk patients for gestational glucose intolerance not offered early glucose screening. Conclusions: As the Institute of Medicine has indicated, humans are human and are prone to mistakes. When mistakes occur in obstetrics, the results can be catastrophic and lifelong for the neonate. The dream has been to utilize the computer technology to help humans catch mistakes and take corrective actions, but this has not happened until now with the promise of Interactive Medical Intelligence. In this system, data is collected during the history and physical exam. Risks are identified and diagnostics are suggested. The results of these diagnostics may further identify additional or refine the noted risks. The system never forgets, and continues to remind the clinician of outstanding results or if another test needs to be ordered. All abnormalities are noted on the front page so the clinician does not need to search the chart, especially in an emergency situation. The Interactive medical Intelligence system integrates with the commercial labs and interprets the data and does not depend on the commercial lab to identify abnormal labs. We have identified at least 7 situations when the commercial lab reported an abnormal result but did not flag the result and the result was not in red. Unfortunately, in three situations, permanent harm occurred to the baby and litigation followed. We believe all clinicians should use an Interactive Medical Intelligence system to act as a "check and balance" system to help protect the baby, mother and clinician. This new system is an interactive medical intelligence system. Such a system has the ability to assist the clinician to accurately, efficiently and rapidly deliver obstetrical care and dramatically reduce, if not eliminate, medical errors. Keywords: Presenter: G. Pregenzer

ID 196

CENTRALIZED PREPARATION AND BAR CODE SCANNING OF BREASTMILK REDUCES BREASTMILK ADMINISTRATION ERRORS C. Steele1, S. Kukreja2, & C. Bixbie3 1,2,3

Department of Neonatology, CHOC Children’s Hospital, Orange, California USA Brief Introduction: Safe handling and preparation of breastmilk within the hospital setting is often taken for granted and, as with many performance improvement initiatives, the process is not scrutinized until problems arise. Historically, the handling of infant feedings has not received the same level of attention as that of medication; however, the potential for error does exist. Children’s Hospital of Orange County (CHOC) administers approximately 7,000 individual breastmilk feeds per month hospital-wide. In the NICU, a nurse may handle breastmilk 12 times per shift creating the risk of confirmation bias and reduced sensitivity to the potential risks. Materials & Methods: Between May 2010 and May 2012, CHOC reported 34 breastmilk handling errors: 3 which involved the wrong breastmilk reaching the wrong patient, 16 labeling errors, and 26 breastmilk storage errors (where correctly labeled breastmilk was placed in the wrong patient’s bin, increasing risk of misadministration). A breastmilk performance improvement initiative was then launched to evaluate breastmilk handling and implement change. An analysis of potential breastmilk handling failure points determined that of the top 85, 55% were unlikely to be detected. The two primary program changes implemented to reduce the risk of breastmilk handling errors were the centralization of breastmilk preparation and the use of a breastmilk bar code scanning system to confirm proper identity at each step of the process. Clinical Cases or Summary Results: Centralization of breastmilk handling reduced total errors from 34 to 7: 4 labeling errors and 3 storage errors with no incidents of the wrong milk reaching the wrong patient. During the first 4 months of breastmilk bar code scanning, total breastmilk errors dropped to 3—all breastmilk storage errors (correctly labeled breastmilk placed in the wrong patient’s bin). There were no incidents where the wrong breastmilk reached the wrong patient. However, during that time frame, the bar code system prevented 38 near misses where the wrong breastmilk may have been fed to the wrong baby, highlighting the importance of such a system. If the same rate of near misses were to continue, the system would be preventing an estimated 123 wrong breastmilk administration incidents per year. Conclusions: Centralized preparation and bar code scanning of breastmilk reduce errors. The frequency of near-misses highlights the importance of automated systems to prevent breastmilk misadministration. Keywords: Presenter: Sudeep Kukreja, MD

ID 689

QUALITY AND SAFETY REVIEW OF POSTNATAL WARD RADIOLOGICAL INVESTIGATIONS M. Campbell1, K. Courtenay2, R. Verma3, & M. Anandarajan Ulster Hospital, Belfast, United Kingdom

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Brief Introduction: Follow up, management and communication of results of postnatal ward radiological investigations is a conundrum, especially in district general hospitals. The Ulster hospital postnatal ward has more than a thousand postnatal radiological investigations requested every year. The organizational strategies, stated below, following a review of the requesting and communication process had resulted in change in practice. (Image 1)  Radiological investigation register for postnatal ward  Scan results checked by neonatal outreach team  Named consultant in charge of post natal care and follow up  Ongoing teaching and training  All investigations results communicated to parents within 4 weeks of scan and incorporated in the Electronic care record Materials & Methods: Aim: The aim of audit was to review the improvement of communication of radiological investigation results to parents and General

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practitioners (GP), ensuring accountability, efficient, safe and effective care. Methods: A retrospective study looking at the radiological investigation requesting process, documentation, review and communication of results before and after introduction of organizational strategies Clinical Cases or Summary Results: Prior to the introduction of the organizational strategies in April 2013 there had been delay of more than 26 weeks in communication of normal scan results and scans not being organized/requested. This had resulted in parenteral anxiety and distress. There were 60 scan requests in April 80 in May, 61 in June, 108 in July 2013, 67 in August, 68 in September and 82 in October 2013 (Image 2). All the normal scan results were communicated to parents and GP within 4 weeks, and abnormal results acted upon within a day of the result (Image 3). Conclusions: The organizational strategies have resulted in effective communication, accountability and delivery of safe and high quality care to babies requiring post natal radiological investigations. These strategies can be implemented in other hospitals with modifications to suit the individual unit’s risks and priorities. Keywords: Presenter: M. Campbell

ID 376

THE IMPACT OF IMPROVED STAFF EDUCATION AND PERINATAL CARE ON NEONATAL MORTALITY IN ALBANIA A. Hoxha1, N. Kolici2, E. Jazexhiu2, G. Mullalli2, D. Bujari2, E. Kreka2, D. Lushi2, & E. Tushe3 1,2

Neonatology Department, University Hospital for Obstetrics and Gynecology’’Koco Gliozheni’’, Tirana, Albania, and 3Chief of Neonatology Department, University Hospital for Obstetrics and Gynecology, Tirana, Albania Brief Introduction: The infant mortality rate (IMR) remains a significant public health concern. The perinatal death is one of the main indicator representing the status of perinatal care. Evidence based knowledge in our neonatal care unit has substantially increased during the last 5 years. Aim To asses the impact of improving staff education and perinatal care on neonatal mortality in our country. Materials & Methods: This is a retrospective study including all neonatal deaths during January 2008 to December 2013, from birth to 28 first days of live, 24weeks and 500g. Data was collected at Neonatal Unit ‘‘ Koco Gliozheni’’ Maternity of Tirana, inborned at this maternity, divided into three groups: 2500gr. There was 25933 deliveries in totally. We compared the neonatal deaths related to two periods 2008–2010 versus 2011–2013. Causes of deaths were described according to ICD 10 classification. Clinical Cases or Summary Results: There were significant differences according to the number of births for the group 2500gr, odds ratio was 0.99, CI 95% 0.96–1.03. There were siginificant differences related to neonatal mortality according to the groups: 2500g odds ratio was 0.42, CI 95% 0.22–0.78.There were significant differences related to three major causes of neonatal mortality, prematurity, asphyxia and infection. Conclusions: These results suggest that, to decrease neonatal mortality, improved staff education and perinatal care quality is crucial.

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Keywords: Neonatal mortality, perinatal care, staff education, improving health service. Presenter: ALKETA HOXHA

ID 672

USING "BABIES" MATRIX FOR REASONS ANALYSIS OF INFANT MORTALITY IN KYRGYZSTAN S. Abduvalieva, C. Rakhmanova, & A. Askerov

Conclusions: Thus, the introduction of the matrix BABIES in Kyrgyzstan since 2004 for evaluation the quality of services to the mother before pregnancy, during pregnancy, childbirth, newborns and infants up to 1 year, show a decline in health status indicators of women before pregnancy, pregnant and woman in labor compared with 2012, which requires immediate effective interventions to women of reproductive age pregnancy, during pregnancy and childbirth. Tendency in improving the neonatal and infant care during the same period reflecting the integration of effective neonatal and infant programs, requires a close intersectoral public support, based on effective practices. Keywords: Presenter: SAGYNBU ABDUVALIEVA

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1

Neonatal Department, The Natinoal Centre of Maternity and Childhood, Bishkek City, Kyrgyz Republic, 2Neonatal Department, The Natinoal Centre of Maternity and Childhood, Bishkek City, Kyrgyz Republic, and 3The Department of Obstetrics and Neonatologists of Kyrgyz Medical Academy, Bishkek City, Kyrgyz Republic Brief Introduction: In accordance with the Government enactment of the Kyrgyz Republic from 2004 at the country level is collecting an information on births and deaths of children under the criteria of WHO live births and stillbirths. For a complete analysis and improvement the quality of services, choosing the most effective interventions, monitoring and evaluating the effectiveness of interventions in the field of maternal and child health integrated the matrix BABIES. Materials & Methods: To determine liability for foetus-infant loss used BABIES matrix, in which were entering the data of the National Health Information Center about the number of births and deaths of newborns, infants and stillbirths according to birthweight for 2004 and 2012. We calculated proportional indicators of foetus-infant loss, depending on body weight at birth and time of death. We aggregated the finding data in the matrix in accordance with BABIES, that determines the responsibility of stillbirth, the death of a newborn and baby. Clinical Cases or Summary Results: The main responsibilities for the foetus-infant loss in 2004 depend on the health of women before pregnancy (14.2% o), from the care of pregnant before and during labor (6.8% 0), the organization of neonatal care in maternity clinics (about 10.3%), from baby care up to 1 year (10.4% o). The range of factors by type of interventions, affecting on foetus-infant loss of 100% in 2004 are as follows: 50.35% - women’s health before pregnancy, during pregnancy and childbirth (34.05% and 16.3%, respectively), 24.7% - newborn care, 24.95% - baby care. Considering that in 75.05% of cases the responsibility for foetusinfant loss depends on the health of the mother before pregnancy, during pregnancy, childbirth and newborn care, was designed "The program of improving perinatal care in Kyrgyz Republic on 2008– 2017 years.". Integrated the programs effectively perinatal and neonatal care, antenatal care, newborn resuscitation, from 2011 is being implemented the program IMCI stationary level. In 2012 compared with 2004, there is a gradual decrease in the proportional index from 41.7% to about 33.5% of that is about 8.2%. 12.1% of these (in 2004, 14% of 2) - due with the health of the mother. The quality of health services in the antenatal and intrapartum level remains at the same level - about 6.8% (2004) and 6.2% of (in 2012), a decrease of 0.6%. There has been gradual improvement in the quality of early neonatal newborn care from 10.3% to about 7.8% of (a decrease of 2.5% o), and also reductions in baby care by 3% o (from 10.4% to about about 7.4% respectively). Analysis of the range of factors affecting on the fuetas-infant loss in 2012 evidence about the deterioration in the health of women before pregnancy, during pregnancy and childbirth by 3.27% compared with 2004, it means that in 2014 - was 54, 62% (36.12% and 18.5%, respectively). There is a tendency in improving services in the neonatal and infancy, as evidenced by the data in 2012, a decrease of 1.42% in the care of the newborn - (24.7% -23.28%) and 2.85% decrease in the care of the baby (24.95%–22.1%).

ID 111

ITALIAN BIRTH CENTERS EXPERIENCE: A MERGER LEADING FROM PRIMARY TO TERTIARY CARE LEVEL E. Barbolini1, P. Lombardi2, R. Zanini3, & F. Quaglia4 1

Obstetric Obstetric 3 Obstetric 4 Obstetric 2

Unit, Unit, Unit, Unit,

Poliambulanza Poliambulanza Poliambulanza Poliambulanza

Hospital, Hospital, Hospital, Hospital,

Brescia, Brescia, Brescia, Brescia,

Italy, Italy, Italy, Italy.

Brief Introduction: Patient volume and level of NICU care at the hospital of birth both had significant effects on maternal/neonatal morbidity and mortality. Our obstetric unit began his activity in 1997 with 51 deliveries. As a primary level care center, none of these had a gestational age less than 34 weeks. In 2012, for health policy reasons, two different hospitals with their own delivery rooms located in the same city and once fully independently managed, were merged and a NICU was built. In order to support this human and structural hard process, during previous 6 months, joint discussions twice-weekly have been arranged. Materials & Methods: This is a retrospective study on 2615 deliveries in our unit from January to December 2012. Mode of delivery, maternal and neonatal outcomes were reviewed and compared to 2011. Data were compared using Chi square statistics and continuous data by T-tests by parity. Missing data were excluded from the analyses. Results were considered statistically significant if p50.05 in a twotailed test. Data were analysed using SPSSX version 19. Clinical Cases or Summary Results: Out of 2615, mode of delivery was vaginal in 74.1% of cases (of which 14.9% by operative vaginal delivery). Patients were nulliparous in 51.4% of cases. Cesarean section (CS) rate remained stable compared to 2011 (25.9% vs 25.8% overall) but we noticed an evident decrease, although not statistically significant (95% CI; p = 0.073) from first to second half year (27.6% vs 25.5%). Elective CS and intra-partum CS were performed in 70.9% and 29.1% of cases, respectively, with no difference comparing to 2011. Induction of labor and VBAC rates were even improved in 2012 comparing to 2011. (24% vs 21.2%, p = 0.061; 18% vs 30.5%, p = 0.001* respectively; see table 1). No statistical differences were noted in neonatal outcomes(see Table 2). Preterm births were 127 (4.9%), 14 of these before 32 weeks. In 2012 we had 3 neonatal deaths but all were preterm infants. Conclusions: In our knowledge, this is the first report about a merger of two different primary care delivery units in order to built a tertiary care level unit. Considering different protocols, high level of psychological stress and personal conflicts, a significant worsening in maternal and neonatal morbidity/mortality was expected in the first year. Our experience demonstrated that different medical, obstetric and paramedical teams can be merged maintaining a high

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Table 1.

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Total No. deliveries Gestational age (weeks) median (IQR) Age (years) median (IQR) Nulliparous Cesaresan sections (CS) – Planned – Emergent/urgent Operative vaginal deliveries Epidural anesthesia Induction of labor (/labors) VBAC (/patients with previous CS) VBAC intrapartum CS Post-partum haemorrhage (41000 ml)

2011

2012

1817 39.5 (39–40.2) 31 (29–35) 901/1817 (49.6%) 469/1817 (25.8%) 314/469 (67%) 155/469 (33%) 192/1817 (10.5%) 265/1817 (14.6%) 360/1508 (24%) 23/125 (18%) 11/23 (49%) 74/1817 (4.1%)

2615 39.4 (38.5–40.3) 31 (28–35) 1344/2615 (51.4%) 676/2615 (25.9%) 479/676 (70.9%) 197/676 (29.1%) 251/2615 (9.8%) 402/2615 (15.4%) 458/2155 (21.2%) 88/289 (30.5%) 32/88 (36.4%) 91/2615 (3,5%)

p Value

OR [95% CI]

0.727 0.382 0.246 0.977 0.159

[0.464–0.664] [0.328–0.128] 0.930 [0.824–1.050] 0.998 [0.868–1.147] 0.833 [0.641–1.083]

0.292 0.470 0.061 0.011* 0.315 0.305

1.112 [0.908–1.363] 0.940 [0.792–1.116] 1.162 [0.99–1.364] 0.525 [0.297–0.889] 1.604 [0.577–4.410] 1.178 [0.851–1.629]

Table 2.

Total No. deliveries Birthweight median [IQR] (grammes) Adimission to NICU Tranfer to another hospital (1st level care) Gestational age from 34.1 to 37 weeks Gestational age from 32.0 to 34 weeks Gestational age 532.0 weeks pH 57.00 at birth pH 57.15 at birth Apgar 57 at 1 minutes Apgar 57 at 5 minutes Neonatal deaths Maternal deaths

2011

2012

p Value

1817 3260 [2985–3540] n.a. 12/1817 (0.7%) 69/1817 (3.8%) 1/1817 (0.05%) 0/1817 (0%) 12/1817 (0.7%) 106/1817 (5.8%) 74/1817 (4.1%) 5/1817 (0.3%) 0 0

2615 3280 [3000–3575] 52/2615 (2%) n.a. 96/2615 (3.7%) 17/2615 (0.9%) 14/1817 (0.8%) 24/1817 (1.3%) 133/2615 (5.1%) 137/2615 (5.2%) 15/2615 (0.6%) 3 0

0.432 n.a n.a 0.827 0.002* 0.002* 0.348 0.278 0.073 0.145 0.149

level of maternal and perinatal care. Therefore, despite the numerous management issues, VBAC rates were improved in 2012. We hope this report will be useful and encouraging. Keywords: Delivery room, merger, fusion, primary care, tertiary care Presenter: E. Barbolini

ID 328

THE EFFECT OF PRIMAPARA MOTHERS’ POSTNATAL CARE ON ENVIROMENTAL COMFORT H. Aygor1, K. Altuntug2, & E. Ege3 1

Lecturer, Faculty of Health Sciences, Necmettin Erbakan University, Konya, Turkey, 2Assist. Prof. Faculty of Health Sciences, Necmettin Erbakan University, Konya, Turkey, 3 Assoc. Prof. Faculty of Health Sciences, Necmettin Erbakan University, Konya, Turke Brief Introduction: Comfort is an expected result in a physical, psychospritual, social and environmental context to cope with the assistance, peace and challenges related to individuals’ needs. The provision of comfort in postnatal period may contribute to individuals’ quality of care, satisfaction and postnatal quality of life. The study was

OR [95% CI]

1.036 0.084 0.0 0.718 1.156 0.768 0.478 0.0

n.a n.a [0.747–1.436] [0.004–0.596] [0.0–0.524] [0.338–1.502] [0.882–1.516] [0.569–1.035] [0.152–1.435] [0.0–3.204]

performed to determine to the effect of postnatal care on enviroment comfort in primapara mothers. Materials & Methods: The descriptive study was performed with 275 primara mothers. The data were collected with face-to-face interviews between 1st May and 1st September 2014. A questionnaire including the features related to socio-demography, fertility, postnatal period and environmental comfort, were used to collect the data. In the analysis, percentage, mean and chi-square tests were used. Clinical Cases or Summary Results: It was found that mean age rate of mothers was 22.02 ± 3.30 years, and many were primary school graduates (81.5%), and housewives (95.3%). In the evaluation of environmental comfort features of postpartum unit, of all mothers, 92.4% were reported to feel in secure, 79.3% to find beds comfortable, 64.7% to have enough space for their personalty, 63.3% to be pleased with their wards (heating, lightening, etc.), 81.8% to be easily visited by their relatives/friends and to have good communication facilities, and 63.3% not to feel disturbed with the existence of other patients and caregivers in the same ward. While a significant difference was observed between postnatal care, and those reporting to feel self-secure, a comfortable bed, satisfied with the ward (heating, lightening, etc.), being easily visited by relatives/ friends and good communication facilities (p0.05). Conclusions: Postnatal period is an important time in maternal life. Regulatory efforts in hospital settings as to postnatal comfort of mothers may ease and shorten the adaptation to the new roles to be experienced by mothers and the period after the hospital discharge. Keywords: primipara, comfort, postnatal period Presenter: Hamide AYGOR1

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ID 665

A THREE-YEARS EVALUATION OF PARAMETERS ASSOCIATED WITH PERINATAL OUTCOME IN THE DEPARTMENT OF OBSTETRICS AND GYNECOLOGY, UNIVERSITY HOSPITAL OF HERAKLION, CRETE, GREECE

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A. Pontikaki, I. Kritsotakis, M. Volosyraki, P. Hatzivasileiou, & S. Sifakis Department of Obstetrics and Gynecology, University Hospital of Heraklion, Crete, Greece Brief Introduction: To evaluate parameters associated with the perinatal outcome of 3955 births in the Department of Obstetrics and Gynecology of the University Hospital of Heraklion during the years 2010–2012. Materials & Methods: We included birth certificate data from deliveries the Department of Obstetrics and Gynecology, University Hospital of Heraklion, Crete, Greece during the years 2010–2012. Specifically we performed a record of the number of stillbirths (intra-uterine and perinatal deaths), the rate and the distribution of preterm labor, the mode of delivery (normal delivery or cesarean section, CS) and the number of multiple gestations. Clinical Cases or Summary Results: 3955 labors were recorded during the 3-year interval (2010–2012). The total number of still-born were 36 (0.91%). From the remaining 3919 live births, 3240 (82.6%) were delivered after the 37th week of gestation. The percentage of preterm labors was 17.3% (676 newborns) with the following distribution according to the weeks of gestation: 34–36 + 6–13%, 32–33 + 6–1.8%, 28–31 + 6–1.7%, 23–27 + 6–0.6% (percentage of the total number of live births). The estimated rate of vaginal delivery was 52.6% (2061 newborns) compared to 47.4% of CS (1858 newborns). The incidence of multiple gestation was 3.33% (128 pregnancies, 122 twin & 6 triple pregnancies); the incidence of newborns from multiple gestations was 6.68% (262/3919 live births). Conclusions: Our data was collected from a tertiary hospital with a large number of high-risk pregnancies & many referrals of complicated pregnancies. The rate of stillborn is relatively low (9%0), indicative of adequate antenatal and perinatal care. The incidence of preterm labor is high (approximately 17.3%), probably due to the high rate of the ‘‘iatrogenic’’ induction of labour. The rate of CS is high and is only partially justified by the large number of high-risk pregnancies followed or referred to our tertiary health center. The high rate of multiple gestations is mainly due to the use of ART techniques. The record, evaluation and publication of these data are useful in the interpretation & assessment of antenatal care patterns and may improve the perinatal care and outcomes. Keywords: perinatal outcome, preterm labor, ceasarean section, stillbirth, multiple pregnancy Presenter: A. Pontikaki

ID 043

WHY DO ADOLESCENTS GO TO THE GYNECOLOGYST? C. Garo`1, E. Calvi2, & C. Paolini3 Department of Obstetrics and Gynecology, San Paolo Hospital Medical School, Universita` degli studi di Milano, Milano, Italy.

Brief Introduction: The aim of our study was to evaluate reasons for young women to consult gynecologist in an outpatient clinic in San Paolo Hospital in Milano. A total of 322 patients came to our Outpatient Clinic for their first gynecological visit. Materials & Methods: We retrospectively analysed the indication to the first access to our Obstetric and Gynecological Clinic specifically dedicated to young women (21 years old) in the period from January 2011 through August 2013. To analayze data we divided our population into two groups: prepuberal patients (PRE-P) were 88 and post-puberal patients (POST-P) were 234. Among POST-P patients, 43 came for pregnancies and 191 for gynecologycal indications. Into each subgroup we identified different clinical categories that justify the first access at our adolescents’ ambulatory. Clinical Cases or Summary Results: Considering PRE-P patients (8 y.o.), the great majority of patients come for menstrual irregularities or dismenorrhea (30.3%) and polycystic ovary syndrome follow-up (12.5%). 25 (10.7%) patients need a consultation for contraception. A frequent reason that induce pediatricians to ask for a gynecologycal control is for young patients with alimentary disease (anorexia or bulimia, above all) (15 patients, 6.5%). The less frequent indications are genito-urinary infections and post-IVG controls. Conclusions: Due to our clinical experience we have observed that dismenorrhea and PCOS follow-ups are the most frequent indications for gynecologycal controls in POST-P patients, followed by contracception request. PRE-P patients are more frequently sent to us for suspected early puberty onset and genito-urinary infections. Keywords: young women, first access, gynecology Presenter: Chiara Garo`

ID 028

BENEFITS OF CORD BLOOD COLLECTION IN THE PREVENTION OF POST-PARTUM HAEMORRHAGE: A COHORT STUDY A. Guillaume1,2, N. Sanane`s1,2, V. Poirier2, A. Gaudineau1,2, G. Fritz1, E. Boudier1, B. Viville1, G. Aissi2, R. Favre2, I. Nisand1,2, & B. Langer1 1

Hoˆpital de Hautepierre Department of Gynaecology & Obstetrics, Hoˆpitaux Universitaires de Strasbourg, 67098 Strasbourg Cedex, France, and 2CMCO Schiltigheim Department of Gynaecology & Obstetrics, Hoˆpitaux Universitaires de Strasbourg, 67098 Strasbourg Cede Brief Introduction: Post-partum haemorrhage (PPH) is the first cause of maternal mortality worldwide. Recent studies indicate an increase in the incidence of PPH. The prevention and management of PPH has therefore gained major attention. The aim of this study was to assess the benefit of umbilical cord drainage through cord blood collection (CBC) for the prevention of post-partum haemorrhage (PPH). Materials & Methods: This is a cohort study based on data collected prospectively including all vaginal delivery of singletons pregnancies after 37 weeks of gestation between July 2011 and May 2013. We performed an univariate comparison of PPH risk factors with 2 tests and then we built multivariate logistic regressions to predict PPH, severe PPH (41000cc), retained placenta over 30 min and manual removal of the placenta. Clinical Cases or Summary Results: A total of 7 810 vaginal deliveries were analysed, among which 1957 benefited from CBC (25%). In the CBC group, 71 PPH (3.6%) were observed vs. 260 (4.4%) in the control group (p = 0.12). In multivariate analysis, after adjustment on PPH risk factors, CBC revealed to be a protective factor of PPH: OR = 0.69 (95% CI 0.50–0.97 p = 0.03). CBC is not a significant predictive factor of

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severe PPH, time to placental delivery nor rate of manual removal of the placenta. Conclusions: In our study, CBC and thus umbilical cord drainage was a protective factor against PPH but it did not reduce neither retained placenta nor the need for artificial placental delivery. Keywords: umbilical cord drainage; third stage of labor; active management; retained placenta; severe post-partum haemorrhage Presenter: Anne Guillaume

ID 323

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

SIMULATING EMERGENCY IN DELIVERY ROOM: NEXT STEP FROM NINA CENTER IN ITALY D. Panizza1, F. Moscuzza2, M. Ciantelli2, S. Ciuti2,3, E. Sigali2, A. Cuttano2, & A. Boldrini2,3 Scuola Superiore Sant’Anna, Pisa, Italy, 2Centro ‘‘NINA’’ di Formazione Avanzata e Simulazione Neonatale, U.O. Neonatologia, AOUP, Pisa, Italy, and 3Universita` di Pisa, Pisa, Italy 1

Brief Introduction: Simulation is worldwide recognized as an effective strategy for training and education also in Neonatology (1). The ‘‘NINA’’ Center for Neonatal Simulation and Advanced Training in Pisa has been the first center in Italy to use high-fidelity simulation in Neonatology, with the aim of a better education and continuous training of both new and expert health staff. The experience of NINA has started in 2009 with the ICU part of the project (2). In these few years, courses to several classes of health staff have been being organized: neonatologists, pediatricians, nurses, obstetricians, anesthetists. Moreover, management of simulated emergency situations has promoted the experimental development of new devices, in order to improve chances to their solution (3). Materials & Methods: The new part of NINA center consists of a simulating delivery room with Laerdal SimMom and Laerdal SimNewB advanced simulators, a control room and a large hall for plenary lectures, briefings and debriefings. All the rooms are connected with audio and video wiring. It is important to underline the fact that the simulating delivery room is located nearby the real delivery room: simulation and reality are in this way strictly connected. This is important for giving to the emergency scenarios the same importance of a real situation: in this way, training should be stronger. On the other hand, it gives the health staff the chance to train inside the department. We can choose emergency scenarios which include critical situations for several health staff categories: management of a post-partum hemorrhage involves both gynaecologists and anesthetists; otherwise, management of shoulder dystocia, as possible origin of neonatal asphyxiation, includes both gynaecolgists and neonatologists. Clinical Cases or Summary Results: The delivery room part of NINA center has already engaged gynaecologists, anesthetists,

neonatologists, nurses and obstetricians in emergency scenarios that can occur during labour. The simulation in delivery room focuses on CRM (Crisis Resource Management) and underlines problems that can occur between people who are unknown to each other or different specialists in emergency management: our necessity in training health staff is stressing the point of communication, which is of primary importance in the resolution of an unexpected event, which is not rare in Neonatology. Conclusions: This part of NINA center projects underlines the importance of simulation in delivery room. Training in simulating delivery room allows the skill improvement of health staff, improving consequently patient safety. Simulation permits to focalize latent problems and visualize some their solutions which difficultly appear in emergency, but can emerge in briefings: in fact, simulation and briefings occur in a more serene mood, apart from legal problems. We have already organized courses with several categories of health staff, and our next plan will be trying to analyze the problems of communication in emergency, studying the psychological dynamics that characterize people who deal with these situations. Keywords: simulation, neonatology, technology, skill improvement Presenter: D. Panizza

ID 045

THE IMPACT OF MATERNAL AGE ON VAGINAL DELIVERY C. Garo`1, E. Calvi2, & C. Paolini3 Department of Obstetrics and Gunecology, San Paolo Hospital Medical School, Universita` degli Studi di Milano, Milano, Italy. Brief Introduction: The aim of the study was to evaluate the impact of maternal age on vaginal delivery in our Ob/Gyn Department. Materials & Methods: We recruited all primiparous women (n = 1853) with singleton pregnancies who delivered at San Paolo Hospital in Milano between January 2011 to December 2012. Our population was divided into four distinct maternal age groups: 20 years old (N1 = 109), 21- 30 (N2 = 839), 31–40 (N3 = 847) and 440 (N4 = 58). In each age group we considered the rate of pregnancy pathology (gestational diabetes, intrauterine growth restriction, preeclampsia and pregnancy induced hypertension), pre-pregnancy maternal BMI, gestational age, fetal weight at birth, placental weight, umbilical arterial pH, Apgar score. Data are presented as mean ± standard deviation. Significativity was tested with t-test for independent groups and Chi square. Clinical Cases or Summary Results: All age groups were not significantly different comparing the rate of pregnancy pathology, pre-pregnancy maternal BMI, fetal weight at birth, placental weight, gestational age at delivery, umbilical arterial pH, Apgar scores (Table 1).

Table. The impact of maternal age on vaginal delivery

maternal age (years) BMI (kg/m2) pregnancy complications (%) gestational age at delivery (weeks) fetal weight (g) placental weight (g) Apgar score at 5 minutes umbilical arterial pH

N1: 20 years old

N2: 21–30 years old

N3: 31–40 years old

N4: 440 years old

18,9 ± 1.17 22.66 ± 3.7 22.02 39.1 ± 2 3090 ± 498.3 540 ± 136 9.85 ± 0.6 7.268 ± 0.08

26.2 ± 2.4 23.50 ± 4.6 16.68 39.3 ± 1.9 3287 ± 434.4 545 ± 124 9.89 ± 0.5 7.262 ± 0.3

34.8 ± 2.7 23.35 ± 4.3 18.65 39.3 ± 1.5 3291 ± 395.2 549 ± 134 9.84 ± 0.8 7.252 ± 0.2

42 ± 1.55 23.71 ± 4.1 15.51 39.2 ± 1.2 3263 ± 380.2 546 ± 126 9.85 ± 0.3 7.301 ± 0.07

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DOI: 10.3109/14767058.2014.924236

The rate of vaginal delivery decreased significantly (p50.01) in primiparae with advancing maternal age: 89% vaginal delivery in group 1, 83.2% in group 2, 74.1% in group 3, 58.6% in group 4, it did not differ between N1 and N2. Conclusions: The study suggests that maternal age does have an impact on the rate of vaginal delivery of primiparae in our Department. Keywords: pregnancy, maternal age, delivery Presenter: C. Garo`

ID 078

LIVE BIRTHS IN BRAZIL IN 2001. A.A. Cunha1, & M.I. Nascimento2 J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

1

Hospital Central do Exe´rcito, Universidade do Estado do Rio de Janeiro., and 2Epidemiology and Biostatistics Dept, Universidade Federal Fluminense. Brief Introduction: Introduction. Brazil is a huge country (8,500,000 km2) with a population of 170,000,000 inhabitants in 2000. It is divided in five big regions (North [N], Northeast [NE], with less resources, and Southeast [SE], South [S] and Midwest [MW] with more resources. The obstetrics care model is the hospital. Objective. The aim is to assess the live babies according to the different Brazilian regions. Materials & Methods: Methods. This is a cross sectional study of secondary data from the National Information System, the part dedicated to living babies (SINASC). The place of birth (hospital vs others), the gestational age (37 weeks), the identification of congenital anomalies, the Apgar score at 1 and 5 min (7 vs 8–10), the birth weight (500–2499 g vs 2,500–4,000+), the type of birth (vaginal vs cesarean section) and the type of pregnancy (single vs multiple) were compared within the region. The analysis was made using the chi square test at a level of significance of p50.05. Clinical Cases or Summary Results: Results. There were 3,105,189 live births in Brazil in 2001. All the results were statistically significant (p50.001). The place of birth was the hospital with 98.3%, 99% and 99.3%, respectively in SE, S, MW. The highest prevalence was in percentages: prematurity in SE (6.9), congenital anomalies in SE and S (0.7),1 min Apgar score 7 in N (24.8), 5 min Apgar 7 in NE (6.1), low birth weight in SE (9.9), cesarean section in SE (47.2) and multiple pregnancy in SE and S (1.9). Conclusions: Conclusions. In 2001, in Brazil, the obstetric model was the hospital care. The suboptimum results found among the Brazilian regions suggest difference in access to the available resources. Keywords: Deliver, birth, prematurity, anomaly, asphyxia, low birth weight, cesarean section, multiple pregnancies. Presenter: A. A. Cunha

ID 202

MATERNAL AND CHILD HEALTH CARE IN LATVIA: HOW POLICY CAN MAKE IT BETTER I. ZileI1,3, I. Smate3, I. Gavare3, & D. Rezeberga2,3 1 Riga Stradins University, Public Health and Epidemiology Department, Riga, Latvia, 2Riga Stradins University, Department of Obstetrics and Gynecology, Riga, Latvia, and 3 The Centre for Disease Prevention and Control, Riga, Latvia

Brief Introduction: Maternal and child health is one of the main priorities in public health. The health of the mother before, during

and after pregnancy has a direct impact on the health of the child. Due to high perinatal and neonatal mortality rates it should be paid more attention on this issue in Latvia. Objective. To estimate policy changes in maternal and child health care (MCHC) and analyze perinatal and early neonatal mortality trends within last five years in Latvia. Materials & Methods: We reviewed the policy documents in MCHC field, analyzed collaboration between the Ministry of Health (MH), Centre for Disease Prevention and Control (CDPC) and other institutions related to health care organization in Latvia. Clinical Cases or Summary Results: Main political documents about MCHC and activities were: - Public Health strategy for 2011 – 2017. The strategy was developed in close collaboration with WHO Regional Office for Europe. Improvement of MCHC and decrease of infant mortality are the main goals of this strategy. - Plan for Improvement of Mother and Child Heath for 2012 – 2014 was developed by the MH. Plan includes changes in antenatal care screening program, including first trimester genetic screening, screening for gestational diabetes and other additional examinations. - Regular Maternal and child health council meetings initiated by MH, MH chief specialist in gynecology, CDPC and other nongovernmental institutions as collaborators. It is estimated that perinatal mortality in 2009–2013 decreased by 21.9% (9.6 vs 7.5/1000 respectively). The reduction occurred due to decrease in early neonatal death rate - decline was achieved by 50% (1.8 in 2013 vs 3.6/1000 in 2009). Conclusions: Effective interventions for improving health of mothers and newborns are implemented in cooperation between policy makers and health care practitioners during last five years. For further improvement of perinatal outcomes confidential enquiries into perinatal deaths has to be introduced in Latvia. Keywords: Maternal and child health, policy documents, perinatal mortality, neonatal mortality Presenter: I. Zile

ID 079

PERINATAL MORTALITY RATE AND ITS COMPONENTS IN BRAZIL IN 2001 ACCORDING TO PLACE OF BIRTH A.A. Cunha1, & M.I. Nascimento2 1

Hospital Central do Exe´rcito, Universidade do Estado do Rio de Janeiro, and 2Epidemiology and Biostatistics Dept, Universidade Federal Fluminense Brief Introduction: Introduction. The model of the health system to obstetric care adopted in Brazil is the medical one, based in hospital, which is supposed to have the best quality of care, but it is not the same all over the country. Objective. The aim was to evaluate perinatal mortality in Brazil in 2001 according to places of birth. Materials & Methods: Methods. It is a cross sectional study of secondary data from the National Information System, which included births in 2001 from the data base dedicated to all living births (SINASC = System of Living Births) and the one dedicated to mortality (SIM = System of Information on Mortality). The places of birth are coded as hospital, other health services (primary care), street, home delivery and ignored. Only the two first places were considered in this study. The data included fetal death (from 28+ weeks), neonatal death (less than 7 days and 28+ weeks of gestational age) and the living babies. Late fetal mortality, early neonatal mortality and perinatal mortality rates were computed.

416 Clinical Cases or Summary Results: Results. There were 3,062,212 living births, 21,619 fetal deaths and 17,564 early neonatal deaths with a gestational age of 28+ weeks. The perinatal mortality rate was 12.43/ 1,000 births (hospital) and 8.99/1,000 (other health services). According to the place of birth, the fetal mortality rate was 7.04/ 1,000 (hospital) and 5.29/1,000 (other); the neonatal mortality rate was 5.40/1,000 living births (hospital) and 3.72/1,000 living births (other). Conclusions: Conclusion. Perinatal mortality rate and its components were higher in hospital, probably, to the high risk pregnancy cared in hospital. We see that both indexes can be reduced, what demands health polices in all levels. Keywords: Perinatal Mortality; Fetal Death; Early Neonatal Death; Health System; Model of Obstetrics Care.

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Presenter: A. A. Cunha

ID 007

TO REDUCE NOISE IN THE NEONATAL INTENSIVE CARE UNIT (NICU) BY 20% WITHIN 4 MONTHS – A DEVELOPMENTAL CARE INTERVENTION I. Ereno, Y.Y. Tay, & D. Lam Singapore General Hospital

Brief Introduction: Seventy to eighty eight percent of NICU admissions are preterm infants who lack the maturity to cope with noise, one of the most polluting physical agents in newborn intensive care. It causes physiologic instability, excessive crying, disturbed sleep and poor overall development. Noise is a major risk factor for deafness and developmental disabilities. We aimed to reduce operational sounds by 20% within 4 months. Materials & Methods: The team performed Cause & Effect analysis of root causes, plotted the Pareto Diagram, used Prioritization Matrix and Run chart. Clinical Cases or Summary Results: Leq was reduced by 23%. L10 was reduced from 61.2dBA to 57.1dBA. However, there was no improvement in the maximum sound level occurring per day as measured by 1-second Lmax, which were contributed mainly by equipment alarms, certain ventilator modes, accidental banging of instruments and metal trolleys and things dropping on the floor. Conclusions: A calmer and quieter intensive care environment together with low ambient light exposure provided a more consistent and age-appropriate neuro-sensory maturation for these vulnerable groups of infants. Babies are calmer, have less physiologic instability and have more optimal sleep cycles. It facilitated parent-infant attachment and interaction as well as more effective communication between staff and parents. Keywords: Presenter: I. Ereno

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

FOR ATTENDING DELIVERIES ON LABOUR WARD R. Hayward Prince Charles Hospital, Merthyr Tydfil, South Wales, UK Brief Introduction: Attendance at neonatal deliveries is an essential role in paediatrics. A recent survey of junior doctors revealed high levels of anxiety when attending deliveries due to the limited information provided by midwifery staff when requesting the attendance of a paediatrician at deliveries. As a result, a risk stratification tool, LABOUR, was developed to improve communication between midwifery staff and paediatricians, to ensure the attendance of paediatric staff at deliveries with the necessary experience and skills to optimise neonatal outcome Materials & Methods: This audit aimed to identify limitations in the information provided by midwives regarding the progression of labour and the potential for neonatal compromise at delivery. A prospective audit was conducted recording the information volunteered by midwifery staff when requesting the attendance of a Paediatric SHO at deliveries. The audit criteria included: Location Age (gestational) Birth type Ongoing concerns (e.g. CTG abnormalities) Urgency Risk factors (e.g. Group B Streptococcus, meconium, maternal pyrexia/tachycardia). These were deemed important in conducting a risk assessment prior to attending a delivery to determine whether senior assistance would be required. Clinical Cases or Summary Results: The information from a total of 50 calls was documented. Of these, 98% provided the location, 82% the birth type and 48% the urgency. Detailed information regarding gestation, CTG traces and risk factors for neonatal compromise were 16%, 18% and 24% respectively. Following the initial audit, the LABOUR risk-stratification tool was implemented on the delivery suite. The acronym was placed above phones and attached to patient notes. One month after implementation a re-audit of calls to the Paediatric SHO was conducted. The information provided from 50 calls included: location 94%, gestation 60%, birth type 86%, ongoing concerns 57%, urgency 71%, risk factors 60%. Conclusions: The LABOUR tool has improved communication of essential information from midwives to junior paediatricians enabling them to determine the potential risk for neonatal compromise at delivery and to ask in advance for senior assistance. The initial study also suggests a reduction in the number of admissions of term babies to SCBU from the delivery suite. Keywords: LABOUR, delivery, risk factors, resuscitation Presenter: R.Hayward

ID 064

RECOGNITION OF BILE COLOUR IN NEONATES IN A DISTRICT HOSPITAL HI. Abdelrhim, & P. Heaton

ID 191

THE DEVELOPMENT AND IMPLEMENTATION OF A RISK ASSESSMENT TOOL (LABOUR)

1

H. Abdelrhim: The Neonatal Unit, Southmead Hospital, Bristol, United Kingdom, and 2P. Heaton: Paediatric Department, Yeovil District Hospital, Yeovil, United Kingdom

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DOI: 10.3109/14767058.2014.924236

Brief Introduction: Neonatal bilious vomiting is a surgical emergency until proved otherwise, and requires prompt investigation. Health workers who are unfamiliar with the colour of bile may over or underdiagnose the presence of bile in vomit or gastric aspirates. The aim of this study was to assess whether the nursing staff, midwives and doctors at a district general hospital, where the exposure to newborns with bilious vomiting is less common than in tertiary hospitals, are able to identify the colour of bile accurately. Materials & Methods: Design A total of 163 participants of both parents and health workers were asked to identify bile colour from a colour-chart of 8 green/ yellow colour options. Setting At Paediatric Department in Yeovil District Hospital from the first of April, 2013 to the end of July, 2013. Main outcome measures Chi-Square goodness-of-fit tests and Kolmogorov-Smirnov twosample tests were conducted to compare different groups and answers. Clinical Cases or Summary Results: Showed that the colour of bile was correctly identified by 95.5% of medical staff, 91% of nurses, midwives 72% and only 16.5% of parents. Whereas 16% of doctors, 30.5% of nurses, midwives 28% and 34% of parents wrongly identified the yellow colours as being that of bile. Our results are not significantly different from reports of similar studies done in tertiary neonatal units. Conclusions: Using bile colour posters and charts might be of value in recognizing the bile colour accurately. We suggest checking the colour by 2 professionals to reduce the possibility of incorrect recognition of bile.

Table 2. (Breakdown of the ability to identify the true bile colour by gender) Per cent of correct response

Gender Female staff (90) Male staff (9) Mothers (59) Fathers (5)

74% 88% 45% 35%

Table 3. (Breakdown of doctor’s response) Correct identification of bile colour

Grade Consultant paediatricians (4) Middle grade paediatricians (7) GP trainees at SHO level (10) FY doctors (2)

100% 85% 80% 85%

Table 4. The results of Kolmogorov-Smirnov two sample tests to determine if the frequency distributions of the correct answers for the four groups of hospital staff (excluding the parents) were significantly different from each other are presented in Table 4

Keywords: bile vomiting, newborn, intestinal obstruction

Groups

Presenter: Hisham Abdelrhim

Doctors vs. SCBU nurses Doctors vs. Paediatric nurses Doctors vs. Midwives SCBU Nurses vs. Paediatric nurses SCBU nurses vs. Midwives Paediatric nurses vs. Midwives

KolmogorovSmirnov Z

p

2.296 2.149 1.948 0.603 0.701 0.577

50.001 50.001 0.001 0.860 0.692 0.893

ID 016

CLAVICULAR FRACTURES IN HEALTHY TERM NEWBORN INFANTS Z. Zakanj University Hospital "Sestre milosrdnice", Zagreb, Croatia Brief Introduction: Birth injuries are a common cause of neonatal morbidity in otherwise healthy infants, with the incidence from 0.2% to 37%. Clavicular fracture is the most common birth bony injury in neonate. The aim of this retrospective analyze is to determine the incidence of clavicular fracture in our maternity ward department Table 1 Frequencies of Correct Identification of Bile Colours among Five Groups of Participants Correctly Identified as Not Bile Groups Doctors SCBU nurses Paediatric nurses Midwives Parents ChI-Square p

Correctly Identified as Bile

Colour 1 Colour 2 Colour 4 Colour 6 Colour 3 Colour 5 Colour 7 Colour 8 N Milky yellow Yellow-Green Mustard Yellow Lemon Yellow Avocado Green Spinach Green Lime Green Wanasabi Green 23 26 30 20 64 163

23 (100.0%) 26 (100.0%) 29 (96.0%) 20 (100.0%) 49 (77.0%) 0.67 0.163

17 (73.9%) 6 (23.1%) 15 (50.0%) 11 (55.0%) 45 (71.0%) 8.37 0.079

23 (100.0%) 17 (65.4%) 15 (50.0%) 12 (60.0%) 28 (43.8%) 34.40 50.001

23 (100.0%) 19 (73.1%) 29 (96.0%) 19 (95.0%) 46 (71.9%) 3.364 0.499

23 (100.0%) 26 (100.0%) 26 (89.7%) 16 (80.0%) 12 (18.8%) 34.40 50.001

23 (100.0%) 26 (100.0%) 26 (89.7%) 16 (80.0%) 12 (18.8%) 34.40 50.001

23 (100.0%) 26 (100.0%) 26 (89.7%) 16 (80.0%) 7 (10.9%) 34.40 50.001

19 (82.6%) 24 (92.3%) 22 (73.3%) 20 (100.0%) 10 (15.6%) 34.77 50.001

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418 during one year and present the perinatal circumstances in which we observed this injuries. Materials & Methods: In one-year long period (from 01.01.-31.12.2010.), in our maternity ward, we registered 19 newborn infants with clavicular fracture. Both maternal data and neonatal data were analyzed. Clinical Cases or Summary Results: The incidence of neonatal clavicular fracture in our study was 0.68%. Right side clavicle was more likely to be fractures than the left side (61.16%: 36.84%). There are no statisticaly significant difference between males and females birthweight (2 = 3,753, p40.05). Only one newborn with a clavicular fracture was born by caesarean section, and all the rest was born vaginally (94.74%). In two newborn infants (10.53%) we observed the greenstick fracture, and in 17 (89.47%) it was a complete fracture. One child with a fracture of clavicle had also a fracture of scapula. In other participants we didn’t found other fractures or bone abnormalities. No child had associated Erb’s paralysis. All of the fractures healed without complications. Conclusions: Fractures of the clavicle in newborns in our maternity ward are at the threshold of appearance in relation to the results of previous studies, and present a good prognostic form of birth injury. Keywords: Presenter: Z. Zakanj

ID 649

CEREBRAL INJURY IN MONOCHORIONIC TWINS AFTER SINGLE FETAL DEMISE: INCIDENCE, RISK FACTORS AND PATTERNS OF INJURY J. van Klink1, A. van Steenis1, S. Steggerda1, M. Sueters2, D. Oepkes2, & E. Lopriore1 1

Division of Neonatology, Department of Pediatrics, and Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands 2

Brief Introduction: Single fetal demise in a monochorionic twin pregnancy is associated with an increased risk of perinatal morbidity and mortality in the co-twin due to acute exsanguination through placental vascular anastomoses. The aim of our study was to evaluate the incidence, risk factors, type and severity of cerebral injury in the surviving co-twin after single fetal demise in a large single center cohort. Materials & Methods: We included all monochorionic pregnancies with single fetal demise evaluated at our center between 2002 and 2013. We recorded perinatal characteristics, neonatal outcome and presence of cerebral injury on neuroimaging in all survivors. Clinical Cases or Summary Results: A total of 50 monochorionic pregnancies, including one triplet, with single fetal demise were included in the study. Median gestational age at single fetal demise was 25 weeks. Single fetal demise was due to twin-twin transfusion syndrome (17/50, 34%), selective intrauterine growth restriction (14/ 50, 28%) orand monoamnionicity (4/50, 8%). Intrauterine death of the co-twin after single fetal demise was recorded in two cases (4%). Median interval between single fetal demise and live-birth was 61 days. Median gestational age at birth was 36 weeks. Severe cerebral injury was detected in 13 (26%) of the 51 co-twins and was detected antenatally in 8% (4/51) and postnatally in 18% (9/51) of cases.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Cerebral injury was mostly due to severe hypoxic-ischemic injury leading to cystic periventricular leukomalacia or cystic encephalopathy, middle cerebral artery infarction or injury to basal ganglia, thalamus and/or cortex. Conclusions: Single fetal demise in monochorionic twins is associated with severe cerebral injury in 1 in 4 of surviving co-twins. Routine antenatal and postnatal neuroimaging, followed by standardized long-term follow-up, is mandatory. Further research into preventive measures is urgently required. Keywords: monochorionic twins; single fetal demise; cerebral injury Presenter: Enrico Lopriore

ID 030

FETOSCOPIC LASER COAGULATION FOR TWIN-TWIN TRANSFUSION SYNDROME BEFORE 17 WEEKS’ GESTATION: LASER DATA, COMPLICATIONS AND NEONATAL OUTCOMES. L. Lecointre1, N. Sananes1, AS. Weingertner1, M. Kohler1, F. Guerra1, G. Fritz2, B. Viville2, B. Langer2, I. Nisand1, & R. Favre1 1

Fetal Medicine, CMCO-HUS, 19 Rue Louis Pasteur, 67300, Schiltigheim/Strasbourg, France, and 2Department of Gynaecology & Obstetrics, Hoˆpitaux Universitaires de Strasbourg, 1 Avenue Molie`re 67098 Strasbourg Cedex, France. Brief Introduction: Objective: The purpose of this study was to compare laser data, complications and neonatal outcomes of pregnancies that undergo "early" (17 weeks’ gestation) fetoscopic laser ablation of placental vascular anastomoses for twin-twin transfusion syndrome (TTTS) with "conventional" cases treated after 17 weeks’ gestation (WG). Materials & Methods: This is a cohort study on data collected prospectively between January 2004 and December 2012. Inclusion criteria were monochorionic diamniotic twin pregnancies complicated by TTTS and treated by fetoscopic laser coagulation. Clinical Cases or Summary Results: Forty ‘‘early’’ and 138 ‘‘conventional’’ pregnancies with TTTS underwent laser therapy. On multivariate analysis, we did not find any significant difference between conventional lasers and early lasers regarding the risk of PPROM before 32 WG (OR 12.06, 95% CI 0.21–700.14, p = 0.23) and the risk of delivery before 32 WG (OR 0.94, 95% CI 0.36–2.48, p = 0.90). Moreover, there was no difference between the 2 groups with regard to the probability of losing both twins (OR 0.35, 95% CI 0.02–5.52, p = 0.46), of having at least one living twin (OR 2.85, 95% CI 0.18– 44.71, p = 0.46) or having both twins alive (OR 0.91, 95% CI 0.27–3.05, p = 0.88). Conclusions: In the event of early TTTS, fetoscopic laser coagulation is technically feasible before 17 WG and obstetric outcomes and neonatal survival are comparable with those of laser performed after 17 WG. Keywords: fetoscopic laser therapy, twin-twin transfusion syndrome, monochorionic twins. Presenter: Lise LECOINTRE

419

DOI: 10.3109/14767058.2014.924236

ID 631

ID 836

ULTROSONOGRAPHIC ESTIMATION OF FETAL WEIGHT AND PREDICTION OF BIRTH WEIGHT DISCORDANCY IN TWIN PREGNANCIES

PERINATAL OUTCOME AND PSYCHOMOTOR DEVELOPMENT IN SPONTANEOUS VERSUS ASSISTED CONCEPTION MULTIPLE BIRTHS: A 12-MONTH FOLLOW-UP

K.E.A. Hack1, R.J. Rijpma2, M.K. van de Waarsenburg2, & J.B. Derks2

P. De Liso1, S. De Angelis2, C. Dosi3, B. Caravale4, A. Castronovo5, & A. Casadei6

1

1

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Department of Obstetrics and Gynecology, Diakonessen Hospital, Utrecht, The Netherlands, and 2Department of Obstetrics, University Medical Centre Utrecht, Utrecht, The Netherlands Brief Introduction: Twin pregnancies carry a higher risk of perinatal mortality and morbidity as compared to singleton pregnancies. Fetal growth restriction, birth weight discordance and prematurity are considered to be mainly responsible for this higher risk of adverse fetal and neonatal outcome. Prenatal recognition is therefore important in order to plan appropriate antenatal monitoring as well as timing and mode of delivery. The aim of this study was to assess the accuracy of ultrasound in predicting birth weight and birth weight discordancy in twin pregnancies. Materials & Methods: We retrospectively studied variables of ultrasonographic biometry and outcome of 255 twin pregnancies, that had their antenatal care and delivery at the University Medical Centre Utrecht between 2006 and 2011. Clinical Cases or Summary Results: On average, estimated fetal weight (EFW) differed 6.7% (range: 0%-88.6%) from actual birth weight. Sixtynine percent of newborns had an actual birth weight within 10% of estimated fetal weight by ultrasound. Inaccurate weight estimations occurred more frequently in pregnancies with anterior location of the placenta and birth weight 42500 gram. Sonographically discrepancy in EFW as well as an increased ratio of the fetal abdominal circumference (AC) were correlated with actual weight discordance at birth. It was best predicted by an intertwin EFW discordance at 34 weeks of gestation, but was often underestimated. Sensitivity of the prediction of birth weight discordancy however was rather low at all gestational ages. Chorionicity did not influence ultrasonographic measurements. Severe birth weight discordance occurred more frequently in the presence of a growth restricted cotwin and abnormal Doppler findings during pregnancy. Conclusions: Mean percentual error in individual weight estimations is comparable to singleton data. If intertwin birth weight discordance is not suspected by ultrasound (either by EFW discordance or increased AC-ratio) the vast majority has no birth weight discordance, whereas correctly diagnosing true birth weight discordance by use of ultrasound is difficult. It is best predicted by an intertwin EFW discordance at 34 weeks of gestation. In case of severe birth weight discordance the presence of at least one growth restricted twin is very likely. However, since around 10% of concordantly grown twin pairs comprises at least one small infant, one cannot rely on weight discordance alone. Furthermore, birth weight discordance is often underestimated, wrongly reassuring the clinician of being a low-risk pregnancy. Keywords: twins, ultrasound, fetal weight, birth weight, birth weight discordancy Presenter: K.E.A. Hack

Pediatrics and Child Neuropsychiatry Dept, Sapienza University, Rome, Italy, 2Pediatrics and Child Neuropsychiatry Dept, Sapienza University, Rome, Italy, 3Developmental and Social Psychology Dept, Sapienza University, Rome, Italy, and 4 Developmental and Brief Introduction: In the last years, a strong increase in Assisted Reproductive Technology (ART) procedures was registered in Italy. Several medical studies performed in Europe demonstrate that most of the children conceived after ART are normal; nevertheless, there is an increasing evidence that ART-conceived children are at higher risk of poor perinatal outcome. Furthermore, compared to women who conceive naturally, those who undergo ART procedure are more likely to deliver multiple-birth infants, which are associated with more complications compared with natural singleton pregnancies. Then, it is important to follow up these children, evaluating whether they have elevated developmental risks compared to naturally conceived children to address them to the best therapeutic intervention as soon as possible.

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420 Materials & Methods: This is a 12-month follow-up study, which has been conducted on all twins and triplets delivered between 2010 and 2013, who arrived to our service. We included 9 couples of twins and 2 triplets born after ART (4 ICSI, 4 IVF, 2 IVF with egg donation and 1 with embryo donation) and 8 couples of twins and a triplet after natural conception (NC). All are prematures. The study variables were parents’ age, perinatal outcome items (gestational age, chorionicity, IUGR, type of delivery, presence of congenital anomalies, birth weight and head circumference), brain ultrasound performed at birth and psychomotor development at 12 months of corrected age, using clinical assessment and the Bayley Scale of Infant Development (mental scale). Clinical Cases or Summary Results: ART group parents are older than those of NC one. No differences concerning perinatal items, except for congenital anomalies, which seem to occur more often in NC (ART: 17%; NC: 32%). Above all, no difference in head circumference, which has not been studied in previous papers. Brain ultrasound at birth showed a higher number of anomalies in ART group: ventricular asymmetry in 32% of infants and periventricular hyperechogenicity in 45%, while 5% and 32% respectively in NC group. At 12-month follow-up, we have diagnosed 2 motor delays in ART group and a PCI, a global developmental delay and 2 language delays among NC infants. No significant differences were found in the psychomotor development between the cohorts, even if the Bayley scale shows ART group minimal better outcome than NC one (Image 1, 2, 3). Both groups performs better with respect to cognitive scores, language and motion respectively. 6 children from ART group and 3 from NC group have been incorporated into a rehabilitation program. Conclusions: This is the first italian follow-up study. It’s important the monitoring of transient disturbance up to a longer period that allows to evaluate the evolution of disturbances and to find out other. Keywords: twins, ART Presenter: C. Dosi

ID 249

DIAGNOSTIC CRITERIA, MANAGEMENT AND PROGNOSIS OF TAPS (TWIN ANEMIA POLYCYTHEMIA SEQUENCE) M. Veujoz1, N. Sananes1, F. Severac2, N. Meyer2, B. Langer1, & R. Favre1 1

Obstetric and Gynecology Dept, University Hospital of Strasbourg, Strasbourg, France, and 2Public Health Dept, University Hospital of Strasbourg, Strasbourg, France Brief Introduction: Our main objective was to analyse TAPS ’s pre and postnatal diagnostic criteria. Secondary objective was to study interest of in utero intervention. Materials & Methods: We performed a monocentric prospective cohort study, including all pregnancies complicated by TAPS between 2006 and 2013 in our hospital (Obstetric and Gynecology Dept, University Hospital of Strasbourg, Strasbourg, France)

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Clinical Cases or Summary Results: Twenty patients were included, 10 presented spontaneous form of TAPS and 10 developped iatrogenic TAPS (after laser therapy for twin to twin transfusion syndrom). PSV measurement correlated significantly with hemoglobin level (r = 0.78, p50.0001). Sensitivity and specificity of prenatal diagnosis were 71.4% and 50%. Prenatal stadification corresponded to postnatal stadification in 22.2% of cases. No link between TAPS severity and placental architecture was found. Laser therapy or IUT (in utero transfusion) were performed in 9 cases. Time between TAPS diagnosis and delivery was longer in case of in utero intervention (57 vs 21 days), with a smaller cesarean rate (64.3 vs 100%). Hemoglobin difference at birth between twins was smaller in case of prenatal treatment (6.2g/dL vs 13.3g/dL), with less recourse to blood transfusion within first month of life (57.1 vs 88.9%). Mortality (in utero and neonatal until D30) rate were 16.7% in case of in utero intervention and 22.7% in the other group. Conclusions: PSV is reliable for TAPS diagnosis providing rigorous measurement. Pre and posnatal classification do not correlate well between each other. In utero intervention, specially laser therapy, seems to improve obstetrical and neonatal prognosis, but other studies are needed to specify indications and modalities of treatment. Keywords: monochorial biamniotic pregnancy, TAPS, diagnosis, laser therapy, IUT Presenter: Marine VEUJOZ

ID 235

PLACENTAL SHARE AND HEMOGLOBIN LEVEL IN RELATION TO BIRTH WEIGHT IN TWIN ANEMIA-POLYCYTHEMIA SEQUENCE O.D. Zhao1, F. Slaghekke2, J. Middeldorp2, D. Oepkes2, & E. Lopriore1 Neonatology Department, and 2Obstetrics Department, Leiden University Medical Center, Leiden, The Netherlands 1

Brief Introduction: The purpose of this study was to investigate if birth weight share in monochorionic (MC) twins with twin anemiapolycythemia sequence (TAPS) is determined by placental share or hemoglobin level at birth Materials & Methods: Retrospective cohort of all MC twin pregnancies with two live-born twins with and without TAPS. Hemoglobin levels were routinely measured at birth in all twins and individual placental shares were determined after colored-dye injection. We excluded MC pregnancies with twin-twin transfusion syndrome. Clinical Cases or Summary Results: A total of 270 MC twin pregnancies (TAPS twins, n = 20; uncomplicated MC twins, n = 250) were included in this study. In the group of uncomplicated MC twins, birth weight share was positively correlated with placental share (p50.01), but this correlation was not present in MC twins with TAPS (p = 0.54). In MC twins with TAPS, birth weight share was positively correlated with hemoglobin level (p50.01), but this correlation was not detected in the group with uncomplicated MC twins (p = 0.13).

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DOI: 10.3109/14767058.2014.924236

421

422 Conclusions: Birth weight in MC twins with TAPS is determined primarily by the hemoglobin levels rather than placental share.

Wang Ying, Wei Yuan, Yuan Pengbo, Wang Xueju, Zhao Yangyu1

Keywords: Twin anemia-polycythemia sequence, hemoglobin, placenta share, birth weight

1

Presenter: E. Lopriore

ID 114

PREDICTIVE VALUE OF CARDIOVASCULAR PARAMETERS IN TWIN-TO-TWIN TRANSFUSION SYNDROME J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

E. Gapp-Born1, N. Sananes1,2,3, A.S. Weingertner1, F. Guerra1, M. Kohler1, G. Fritz1, B. Viville1, A. Gaudineau1, B. Langer1, E. Sauleau2, I. Nisand1, & R. Favre1 1

Department of obstetrics and gynaecology, Strasbourg University Teaching Hospital, France, 2Department of biostatistics, Strasbourg University Teaching Hospital, France, and 3 INSERM, UMR-S 1121, "Biomate´riaux et Bioinge´nierie", Strasbourg, France Brief Introduction: Quintero staging provides an incomplete evaluation of twin-to-twin transfusion syndrome (TTTS) because it doesn’t include cardiovascular parameters. The principal aim of this study is to evaluate the prognostic value of the Children’s Hospital Of Philadelphia score (CHOP) and modified myocardic performance index (MPI), described by Hernandez-Andrade et al., on the risk of recipient fetal loss. Materials & Methods: Cohort Study is based on data collected prospectively between May 2008 and February 2013 in a population of TTTS. Comparisons between groups were carried out using Student’s t-test and c2 test. A multivariate logistic regression model was then built. Clinical Cases or Summary Results: 105 pregnancies in stage I to IV of Quintero’s classification were treated with laser. Rates of recipient fetal losses were significantly higher when CHOP score was above 3 (39.5% versus 12.9%, p = 0.002) as when MPI z-score was above 1.645 (34.5% versus 10.6%, p = 0.004). After adjustment on Quintero stages, risk of recipient fetal loss was significantly higher according to CHOP score (OR 3.09: 95% CI 1.035–9.21). We found a positive correlation between CHOP score, MPI and Quintero stage. Conclusions: The CHOP score and MPI value are predictors of recipient fetal loss in TTTS and may be used to supplement Quintero’s classification. Keywords: twin-to-twin transfusion syndrome, Quintero’s classification, CHOP score, Tei index, MPI, Prognostic factors Presenter: GAPP-BORN Elodie

ID 180

EVALUATION OF THE RISK FACTORS OF TWIN PREGNANCY COMPLICATED WITH SINGLEINTRAUTERINE FETAL DEMISE AND ITS IMPACT ON MATERNAL AND CO-TWIN PROGNOSIS

Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China Brief Introduction: To analyze the risk factor and maternal-fetal prognosis in twin pregnancies complicated with single intrauterine fetal demise (sIUFD). Materials & Methods: Retrospectively analyzed the twin pregnancy cases admitted in Peking University Third Hospital between Jan 2008 and Mar 2013. 854 cases were found, including 59 sIUFD cases, other 795 cases were control group. Clinical Cases or Summary Results: Results (1) The incidence of natural sIUFD was 10.93%(59/854). The risk of sIUFD in McT was significantly higher than that in DcT (12.1% vs 5.0%, p50.05, OR 2.634, 95% CI 1.542–4.499). But the fetal prognosis had no difference between McT and DcT. (2) According to the diagnosis gestational age of sIUFD, research group was divided into three groups: group A (12–26 weeks, n = 22), group B (26–32 weeks, n = 20), group C (32 weeks, n = 22). The ratio of co-twin term birth in group A is significant higher than that in group B and group C. The group B had the worst perinatal prognosis. (3) According to the location of demised-fetus in the uterine, those cases were divided into the lower group (n = 24) and the higher group (n = 35). The lower group had the worse perinatal prognosis, gestational week (30.57wk vs 36.14wk), birthweight (1715 ± 556g vs 2424 ± 663g) (4) None of these mothers got coagulation dysfunction after sIUFD. Conclusions: McT were closely related to the occurrence of sIUFD. The outcomes of co-twin were related to the location of the demisedfetus, and the time of sIUFD occorred. sIUFD didn’t increase the maternal risk of complication. Keywords: twin pregnancy, single intrauterine fetal demise, risk factor, perinatal outcome Presenter: Zhao Yangyu

ID 844

TEN YEAR EXPERIENCE IN THE MANAGEMENT OF MONOCHORIONIC TWINS COMPLICATED BY DISCORDANT ANOMALY M.M. Lanna1, S. Livio2, G. Cavenaghi3, S. Faiola4, V. Schena5, L. Spaccini6, M.A. Rustico7, & E.M. Ferrazzi8 Fetal Therapy Unit ‘‘U. Nicolini’’, V. Buzzi Children’s Hospital, University of Milan, Milan (Italy) Brief Introduction: An excess of structural anomalies is observed in twins compared to singletons. The frequency of malformations in dizygotic twins is thought to be similar to that of singletons (2–3%), while it has been reported to be two to three times higher in monozygotic (MZ) pairs. Altough they share the same genotype, 1– 2% of MC twins are complicated by discordant anomalies, since one twin has a chromosomal/structural defect while the other is normal. The management of these pregnancies is not standardized, since selective termination of the affected twin is up to the parents, and in some cases expectant management is the primary choice. The aim of this study is to analyze the management options and pregnancy outcome in a large cohort of MC twins complicated by discordant anomaly. Materials & Methods: This is a retrospective study of MC twin pregnancies complicated by major discordant anomalies referred at the Fetal Therapy Unit ‘‘U. Nicolini’’, V. Buzzi Children’s Hospital, Milan (Italy) between April 2004 and April 2014. Major anomalies were

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DOI: 10.3109/14767058.2014.924236

defined as lethal anomalies, or anomalies requiring postnatal surgical intervention or caused by functional/neurologic impairment. Pregnancies with TTTS or sIUGR with one anomalous twin were excluded. After evaluation of fetal anatomy, amniocentesis of both twins was offered. Parents had detailed counselling regarding the anomaly detected. Options included expectant management (EM), selective termination by bipolar cord coagulation (BCC), or termination of pregnancy (TOP). Pregnancy and perinatal outcome was available for all cases. Clinical Cases or Summary Results: Out of 1422 MC pregnancies referred in 10 years, 103 were complicated by major fetal anomalies. Of these, 95 had discordant fetal anomaly which involved central nervous system (31.6%), heart (13.7%), gastroenteric tract (10.5%). Multiple anomalies were detected in 17.9% of cases, while urinary tract, skeleton, lymphatic, chromosomal and other malformations in 7.4%, 5.2%, 5.2%, 6.3%, and 2.1% of cases. The EM group (48 cases, 42 BA, 6 MA) was complicated with 5 IUFD of both twins and 3 miscarriages. Delivery was at 35 weeks (IQR 33–36 wks), with a weight of 2000 grams (IQR 1610–2322 gr). The BCC group (38 cases, 36 BA, 2 MA) was treated at 21 weeks of GA. 5 IUFD (13%) of the co-twin occurred after the procedure, PPROM was found in 11 cases. Delivery was at 36 weeks (IQR 32–38 wks), with a weight of 2555 grams (IQR 1972–3025 gr). In 9 cases parents decided for TOP. All 9 neonatal deaths were in fetuses with anomalies in the EM group; 14 babies had surgery within first 18 months of life. Conclusions: In presence of a discordant anomaly in MC twins, the possible options are termination of the whole pregnancy, expectant management or selective feticide. In deciding whether to choose selective feticide, the clinician must balance the prognosis for both the normal as well the anomalous twin, risks of preterm delivery and PPROM, and maternal risks. The expectant management can be complicated with miscarriage or foetal loss. Once the diagnosis is clear and its severity established, the highly individualized options for management and parental choice are to be considered. Keywords: monochorionic twins, discordant anomaly, bipolar cord coagulation Presenter: M.M. Lanna

ID 429

A SYSTEMATIC REVIEW OF BIRTH WEIGHT DISCORDANCE AND PERINATAL OUTCOMES AMONG TWIN GESTATIONS S. Jahanfar School of Population and Public Health, University of British Columbia Brief Introduction: This paper reviews both incidence and association of birth weight discordance (BWD) with adverse fetal and neonatal outcomes. Materials & Methods: Searches were conducted using eleven databases inclusive of Medline, Cochrane Central Register of Controlled Trials, EMBASE, CINHAL, Database of Abstracts of Reviews of Effects, Web of Science, EBSCO, Paper First, Proceeding First, Web of Science, and Pro Quest Digital. More than 2,500 studies were screened, describing BWD specific to twin gestation, as a risk factor associated with fetal and neonatal outcomes. Forty-one articles, containing approximately 1.2 million twin-data, were selected and assessed for quality. Twelve meta-analyses were performed and their heterogeneities (I2) were tested. A fixed model was generated if I2525%, while a random-effect model was adopted if I2450%. Results were computed as relative risk and 95% confidence interval.

Clinical Cases or Summary Results: BWD was found to be common among twin gestations, ranging from 8.0% to 58.2%. It was found to be associated with nine outcomes, including stillbirth, early and late neonatal mortalities, length-of-stay greater than two days in neonatal intensive care unit, congenital anomalies, fifth minute Apgar score57, newborn septicaemia, hypoglycaemia, and respiratory distress syndrome. The association between BWD and three other neonatal morbidities (neonatal anemia, intraventricular haemorrhage and overall neonatal mortality) were found to be insignificant. Conclusions: A wide range of incidence rate was found for the BWD. It was concluded that exposure to growth discordance in twin gestation is significantly associated with perinatal mortality and morbidity. Keywords: Twin, Birth weight discordance, Incidence, Fetal and neonatal mortality, Morbidity Presenter: S. Jahanfar

ID 860

DELIVERY MODE IN TWIN PREGNANCIES WITH FIRST TWIN IN BREECH: A RETROSPECTIVE STUDY IN A TUNISIAN MATERNITY LEVEL III OVER A PERIOD OF 12 YEARS H. Laajili1, F.Z. Chioukh2, A. Hajji1, D. Toumi1, E. Korbi1, K. Monastiri2, & M. Sakouhi1 Department of gynecology and obstetrics and 2Department of reanimation and neonatal medicine – Maternal and neonatal Center of Monastir 5000 Tunisia 1

Brief Introduction: The birth of twin pregnancies with first twin in breech presentation is deemed at risk because it is associated with more important neonatal morbidity and mortality than first twin in cephalic presentation. Materials & Methods: We conducted a retrospective single-center study of 815 twin pregnancies over 34 weeks and 224 which come with a first twin in breech over a period of 12 years. We aim to analyze neonatal morbidity and mortality of twin and maternal morbidity and whether if the presentation of the first twin in breech is a factor that exacerbates the neonatal or maternal outcome, comparing the group with first twin in breech at a control group of twin pregnancies with first twin in cephalic. Clinical Cases or Summary Results: Frequency of first twin in breech presentation in twin pregnancies is estimated at 27.4%. Sixty-five parturient with first twin in breech underwent a planned caesarean section (29%) and 159 underwent an attempted of vaginal delivery (71%). Among these 51 women have undergone a cesarean during labor (32.1%) and 108 were eventually delivered vaginally (67.9%). The indications for cesarean section before labor are dominated by scarred uterus (33.8%), breech presentation of the first twin (27.7%) and vascular disease (preeclampsia 15.4%). The indications for secondary cesarean section are dominated by stagnation of dilatation (33.3%) and premature rupture of membranes 12h (37%). We don’t observed statistically significant differences in neonatal mortality and morbidity or maternal morbidity according to mode of delivery. We also didn’t notice significant differences depending on presentation of first twin. Conclusions: A careful selection and proper care of twin pregnancies with the first twin in breech candidates to vaginal delivery are reasonable alternative to routine cesarean section. Keywords: Twin Pregnancy - Breech – Vaginal Delivery - Neonatal Morbidity - Maternal Morbidity

424 Presenter: FZ Chioukh

ID 890

THE EPIDEMIC OF MULTIPLE BIRTHS: DATA FROM A TERTIARY CENTER FOLLOW UP PROGRAM OF HIGH RISK NEONATES E. Tsekoura1, E. Sdona1, E. Kotsia1, I. Orfanidou1, A Matziota2, & E. Alexopoulou2

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1

Developmental follow up clinic of preterm and high risk neonates, 3rd Department of Pediatrics National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece, and 22nd Radiology Department National and Kapodistrian University of Brief Introduction: Multiple births rate has risen significantly over the last years due to assisted reproductive techniques (ARTs). Data from mortality, morbidity and neurodevelopmental outcome are sparse. The aim of the study was to register all twins and triplets attending our tertiary follow up program from its initiation in 2008 to date. Analysis was carried out in view of ART, mortality-morbidity and neurodevelopmental outcome. Materials & Methods: We retrospectively collected data from the medical records of all multiple births and follow-up program evaluations from 2008 up to date. Total 137 children born from multiple births were studied. Male n = 85 (62%), female n = 52 (38%). Twins n = 113 (82%), Triplets n = 24 (18%). Inborn 97/137 (70.8%), extra uterine transfer 2/137 (1.5%), 38/137 (27.7%) born in private hospitals. ART data collected from 88/137. Clinical Cases or Summary Results: IVF n = 67/88 (76%), normal conception n = 18/88 (24%), hormonal therapy 3/88 (3.4%). Extremely preterm  29 wks: n = 7 (5.1%), moderate preterm (30–33 wks): n = 69 (50.4%), late preterm (34–37 wks): n = 53 (38.7%), term (38 wks): n = 8 (5.8%). Mortality 1/137 (0.7%). Any respiratory support n = 53/137 (38.7%). IUGR: n = 18/137 (13.1%). Abnormal head scann at the exit 45/137 (32.8%). Severely abnormal head scan (PVL, hydrocephalus) 7/137 (5.1%). Triplets: IVF 21/24 (87.5%) Mean GA = 33 wks (r = 31–35). Mean BW = 1752 gr. Mild RDS (CPAP) n = 6/24 (25%). PVL = 3/24 (12.5%). Negative neurodevelopmental outcome at 5 yrs n = 8/24 (33%). From these severe was one case with global developmental delay, moderate one case with mobile diplegia and mild 6 cases with either mild hemiplegia, mild ADHD, language delay and writting skills. Twins: IVF (75%). Mean GA = 33 wks (r = 24–38). IPPV n = 20/113 (17.7%), CPAP 20/113 (17.7%), HOOD 4/113 (3.5%). Negative neurodevelopmental outcome 34/113 (30%). Moderate-severe n = 9/ 113 (7.9%). Autism n = 3, ADHD n = 1, CP n = 1, mild delay n = 2, learning difficulties n = 2. Conclusions: Multiple births are mainly of moderate prematurity. Multiple preterm births of extreme prematurity are mainly twins. Triplets have milder RDS compared to twins. Total mortality is low. IUGR complicates more than 1/10 of neonates from multiple preterm births. One third of either triplets or twins will make use of health care system resources due negative neurodevelopmetal outcome of various severity. Keywords: multiple births, preterm birth, twins, triplets, neurodevelopmental outcome Presenter: Effrossine Tsekoura

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

ID 199

COMPARISON BETWEEN THE USE OF THE CERVICAL LENGTH AND THE CHANGE IN THE CERVICAL LENGTH FOR PREDICTION OF SPONTANOUS PRETERM BIRTH IN ASYMPTOMATIC TWIN PREGNANCIES M. Khalil Mohamed Ibrahim KHALIL, MD, MRCOG, Consultant, Department of Obstetrics and Gynecology, Security Forces Hospital, Riyadh, Kingdom of Saudi Arabia, and Professor of Obstetrics and Gynecology, Faculty of Medicine, Menoufiya University, Egypt Brief Introduction: The twin birth rate has risen 70% from 1980 (18.9 per 1000 live births) through 2006 (32.1 per 1000 live births), with a correlated rise in preterm births (PTBs) Preterm birth (PTB) continues to be a significant problem worldwide and is one of the most significant contributors to the elevated morbidity and mortality rates observed in multiple gestations. Overall, twin pregnancies compose 15% of all PTBs which is a disproportionate share. Identifying which women are at risk for PTB remains challenges. The objective was to assess the association between cervical length (CL), and the change of CL over 2 measurements and preterm birth (PTB) 532 weeks in asymptomatic twin pregnancies. Materials & Methods: This study was undertaken in the multiple pregnancies antenatal clinic at Security Forces Hospital (SFH), a tertiary care hospital in Riyadh, Saudi Arabia, between November 2005 and October 2010, This study involved 420 women with asymptomatic twin gestations, only 209 unselected patients were completed the study and met the inclusion criteria. All patients had a CL measurement by transvaginal ultrasound at 20–23 weeks, a second CL measurement had done within 3–5 weeks from the initial measurement. Patients classified into two groups, group A with significant shortening of CL, and group B without significant shortening of CL. Comparisons between the groups were performed using a chisquare test or a Fisher exact test for categorical variables, whereas Student’s T test or Wilcoxon’s rank-sum test was used for continuous variables. We employ ROC curves to compare the diagnostic accuracy of actual cervical length and percent change in cervical length in predicting preterm birth events. Clinical Cases or Summary Results: There were 35 (16.7%) patients whose CLs shortened by 25% (group A), and 174 (83.3%) patients whose CLs either did not shorten or shortened by 525% (group B). Preterm birth at528, 530, 532, and 25 mm. The use of CL shortening was superiorthan the use of CL for the prediction of PTB at 532 (p = 0.0424), and at 534 weeks (p = 0.028); however, CL was preferred for the prediction of PTB 528 (p = 0.037), and 530 weeks (p = 0.0457). Conclusions: The test of 2 CL measurements, starting between 20–23 weeks gestation and followed by another CL measurement 3–5 weeks later, with a difference of 25% is a good predictor for preterm birth in asymptomatic twin pregnancies, even if the CL is 425 mm Keywords: Presenter: Mohamed Ibrahim KHALIL

425

DOI: 10.3109/14767058.2014.924236 1,2,4,5,6

ID 583

DELAYED-INTERVAL DELIVERY IN DICHORIONIC TWIN PREGNANCIES: A SINGLE CENTER EXPERIENCE M. Cozzolino, V. Seravalli, L. Pasquini, & M. Di Tommaso

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Department of Health Sciences, University of Florence, Florence, Italy Brief Introduction: The most important complication of twin pregnancies remains preterm delivery. Delayed delivery is a relatively new term used to describe the delivery of one fetus after premature delivery of the first fetus. Delayed delivery could prolong pregnancy for a sufficient amount of time to achieve good prognosis for the second baby. Materials & Methods: We report two cases of delayed-interval delivery in dichorionic diamniotic twin pregnancies Clinical Cases or Summary Results: Two women with dichorionic diamniotic twin pregnancies were admitted to our emergency department at 17 + 5 and 22 + 1 weeks of gestation, respectively, because of regular contractions and cervical modification. Rupture of the amniotic sac and spontaneous delivery of the first twin occurred a few days after admission, before 24 weeks. The second twin was left in utero, and uterine contractions ceased. Patients received antibiotics for seven days. Tocolytic therapy combined to steroid therapy for Table 1. pregnancy and delivery characteristics in the two cases Case Mode of Conception GA at admission GA at delivery, 1st twin Birth-weight (g), 1st twin GA at delivery, 2nd twin Birth-weight (g), 2nd twin nterval (days) Mode of delivery

Case1

Case2

ICSI 17+5 18+1 135 g 27+2 1,070 57 Vaginal delivery

ICSI 22+1 23+1 510 g 25+3 542 16 Cesarean section

fetal lung maturation was administered when needed, after 24 weeks. This management prolonged pregnancy for 57 and 16 days, respectively, with excellent fetal outcome (delivery at 27 + 2 and 25 + 3) (see Table); during this period, a careful fetal and maternal monitoring was carried out. Conclusions: Delayed delivery after abortion of the first fetus can be successful if there are no contraindications. However, there is currently no accepted protocol for the treatment of this condition, as no randomized controlled trials are reported in literature. In our experience, delayed delivery prolonged pregnancy for enough time to achieve a good outcome for the second baby. Keywords: Twins, preterm birth, delayed delivery Presenter: Mauro Cozzolino

Division of neonatology, University Hospital of Pisa, Pisa, Italy, and 3CNR-IFC, National Research Council, Institute of Clinical Physiology

Brief Introduction: Twin pregnancies are increasingly common due to growing popularity of fertility treatments. Studies have shown that the larger twin of a pair is at greater risk of respiratory distress syndrome (RDS); furthermore the incidence of RDS is higher in males than in females (Canpolat et al. 2006, Webb and Shaw 2001). Our aim was to determine whether there is a relation between birth-weight discordancy (Bwd), twins’ gender and neonatal morbidity. Materials & Methods: We included in our retrospective study all consecutive twin births with severe BWD (20%) delivered at our center from January 2007 to January 2014 (n = 130 twin pairs). We excluded triplets and stillborn births. Discordance was calculated as the difference between twins’ weights divided by the heavier weight. We analyzed the influence of sex, size and sibling’s gender on the outcome measures. As primary outcome measures we enclosed: a) RDS, which was defined as respiratory failure requiring mechanical ventilation (including nCPAP) and oxygen supplementation for the first 24 hours, and typical radiological findings. We included in our study all apneas that required caffeine citrate therapy; b) Hypocalcemia, that was considered clinically relevant if requiring 10% Calcium gluconate administration; c) the occurrence of severe CNS lesions on echographic exploration featuring intraventricular hemorrhage (IVH) grade III+ (Papile L. et al, 1978) and/or periventricular leucomalacia (PVL) grade II+ (De Vries et al,). Genitourinary defects (including cryptorchidism, incomplete fusion of the foreskin, hydrocele, hypospadias, renal ptosis and multicystic kidney) were also considered as factors possibly affecting the outcome. Likelihood Ratio chi-squared test or Fisher one-tail exact test and odds ratio (when appropriate) were used to explore the link between dependent and independent variables. Clinical Cases or Summary Results: Smaller females of same-sex twins had a higher incidence of RDS than those with a male sibling (OR 2.8, p50.03). Furthermore, in the same group apneas occurred more frequently (20.6%& vs. 0%, p50.004). No difference was observed in the incidence of RDS between the larger and smaller twins (46.92%% vs 43.85% respectively, p = 0.32). We also found that heavier males with a male twin, as compared to those with a female sibling, were more likely to be diagnosed with apneas (15% vs 0%, p50.0149;), serious CNS-lesions (7.5% vs 0% p50.0424;) or genitourinary malformations (7.5% vs 0% p50.0424;). Finally, within same gender male-twins, larger newborns experienced a higher incidence of hypocalcemia than their brothers (14.29% vs 0% respectively, p50.0362) Conclusions: In conclusion, we cannot confirm that RDS is more common in the larger twin or in males. In fact, in our series RDS was significantly more frequent in small females of same-sex pairs. Moreover, it appears that larger males of same sex pairs had a significantly higher incidence of CNS lesions, GU defects and apneas. Last but not least, hypocalcemia was more common in large males of same-gender pairs. We suggest that both gender concordance and gender mismatch may play a prognostic role in the setting of BWD. Further studies are warranted to verify this preliminary data. Keywords: discordant twins, gender, RDS, hypocalcemia, CNS lesions, genitourinary defects

ID 687

IMPACT OF SIBLING’S GENDER ON MORBIDITY IN GROWTHDISCORDANT TWINS. L. Leuzzi1, F. Moscuzza2, G. Rossi3, G. Ferri4, A. Boldrini5, & P. Ghirri6

Presenter: Livia Leuzzi

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ID 019

TWIN PREGNANCY AND DELIVERY IN WOMEN BETWEEN 35 AND 50 YEARS OF AGE: A RETROSPECTIVE COHORT STUDY A. Garcia-Faura, C. Zabau, C. Catlla, & L. Marques

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Department of Obstetrics and Gynaecology. Institut Marque`s, Barcelona. Brief Introduction: INTRODUCTION: Perinatal mortality and intrauterine growth restriction (IUGR) have been extensively described as the major complications of twin pregnancies. However, very little has been published referring to maternal perinatal morbidity, and how maternal risks could increase in patients between the ages of 35 and 50. OBJECTIVE: To compare the perinatal and obstetric outcomes of twin pregnancies in three groups of different maternal age between 35 and 50 years. Materials & Methods: MATERIALS & METHODS: We included 162 twin pregnancies in patients 434 years old, delivered in our Department beyond 20 weeks of gestation, and we reviewed them in a retrospective cohort study divided into three groups according to maternal age: 35 to 39, 40 to 44, and over 44 years. Using Chi2 and Fisher Test, we searched for significant differences (p50.05) in obstetric and perinatal outcomes: the occurrence of premature labor, premature rupture of membranes, gestational age at delivery, intrauterine growth restriction, perinatal mortality, maternal and fetal need for Intensive Care, gestational diabetes, preeclampsia, cholestasis, post-partum blood transfusion and hysterectomy, and Csection rates. Clinical Cases or Summary Results: RESULTS: When comparing the 35– 39 and 40–44 age groups, no significant differences were found for any obstetric or perinatal outcome. Similarly, no differences were found for any antenatal maternal or fetal outcome in the three age groups. It was found that only postnatal severe maternal morbidity indicators were significantly different in the 444 age group, with a higher rate of post-partum hysterectomy (p50.0001), maternal need for intensive care (p50.0001) and blood transfusion (p50.015) Conclusions: CONCLUSIONS: For women aged between 35 and 50 years and carrying twin pregnancies, the risks of fetal mortality and morbidity and antenatal maternal morbidity seems to remain stable; no significant differences were found between groups of increasing maternal age. Severe maternal post-partum morbidity remains stable up to the age of 44, but increases significantly in the 45–50 year age group. Reproductive medicine specialists should try to avoid creating multiple pregnancies in patients over 44 years of age, and obstetricians should attend to these high risk deliveries in tertiary medical centers due to their risk of significant morbidity.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Brief Introduction: We performed comparative clinical and hemostasiological examination of coagulation parameters in 100 women (group I) with a physiological uncomplicated multiple pregnancy and in 100 women (group II) with complicated multiple pregnancy after IVF. Materials & Methods: The criteria for thrombophilia were: factor V Leiden mutation, prothrombin G20210A mutation, deficiency of antithrombin III, protein C, 3 homozygous thrombophilic polymorphisms or 5 heterozygous polymorphisms, moderate and severe hyperhomocysteinemia and antiphospholipid antibodies. Clinical Cases or Summary Results: In the group I (control) thrombophilia was diagnosed 14 women (5 heterozygous polymorphisms without other forms of a thrombophilia). In the group II in 96% (n = 96) the thrombophilia was revealed: factor V Leiden mutation in 16%, prothrombin G20210A mutation in 12%, hyperhomocysteinemia in 34%, APS in 11%, homozygous polymorphisms – 11%, heterozygotic polymorphisms in 64%. The combined forms of thrombophilia (inherited thrombophilia assotiated with antiphospholipid syndrome- in 15% of cases). In women with multiple pregnancy after IVF (96 of 100 in the II group) pregnancy was complicated with threatened abortions in I and II trimesters (17.5%); moderate preeclampsia developed in 17% of women; placental abruption with antenatal death of both fetuses in 50 women; placental abruption with antenatal death of one fetus – in 10 women; chorionic abruption in early terms of pregnancy was observed in 10 women; premature birth on term of 29–32 weeks occurred in 30 women; thrombosis (thrombosis of a jugular vein, ileofemoral thrombosis) – in 4 women (4%) during the I trimester of pregnancy. In the postpartum period ileofemoral thrombosis was diagnosed in 4 women with factor V Leiden mutation. In the group I (control) 200 alive children, from them 96 were born prematurely. In 76 women was performed cesarean section. In the group II were born 140 alive children. Fetal losses were associated with antenatal fetal death in 24 women (28 children), early abortions in 8 women (16 children), early neonatal death – 8 women (16 children). Conclusions: We suggest that thrombophilia is of high importance in pathogenesis of complications of multiple pregnancy after IVF. Anticoagulant, antioxidant treatment and vitamins support are recommended in preparation to IVF, during pregnancy and in postpartum period. Keywords: Multiple pregnancy, IVF, thrombophilia, anticoagulants Presenter: N. Makatsariya

ID 781

PERINATAL OUTCOMES OF TRIPLET PREGNANCIES IN KOREA H. Nam1, K.S. Kyung1, J.Y. Shim1, & S.Y. Oh2 1

Keywords: Twin pregnancy, advanced maternal age, maternal morbidity Presenter: A. Garcia-Faura

ID 663

COMPLICATIONS OF MULTIPLE PREGNANCY AFTER IVF IN WOMEN WITH THROMBOPHILIA N. Makatsariya, G. Abramian, V. Bitsadze, & Z. Gadaeva I.M. Sechenov First Moscow State Medical University, Department of obstetrics and gynecology, Russian Federation

Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea, and 2Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. Brief Introduction: This study was conducted to evaluate the trends and changes in the perinatal outcomes of triplet pregnancies to provide information with the times for the counseling and the management of triplets. Materials & Methods: Medical records of triplet delivery at Asan Medical Center and Samsung Medical Center from 1992 to 2012 were retrospectively reviewed with respect to their maternal and neonatal outcomes. The study period was divided into the following two groups for trend analysis: 1992–2005 and 2006–2012. Pregnancy loss before 20 weeks was excluded from the study population. Composite outcome was defined as combination of death or any of five neonatal morbidities (BPD, RDS, severe IVH, ROP, or sepsis).

427

DOI: 10.3109/14767058.2014.924236

Clinical Cases or Summary Results: Over a 21-year period, a total of 65 cases of triplet pregnancies were analyzed with respect their perinatal outcomes (29 cases for 1992–2005, and 36 cases for 2006–2012). There were no significant differences in the gestational age at delivery and neonatal birth weight between two periods. The antenatal corticosteroid use also significantly increased over the time period. Neonatal BPD, RDS, and severe IVH decreased significantly. The unadjusted composite outcome rate was significantly lower in the recent period [32.1% vs. 12.1%, p = 0.001; OR 0.29 (95% CI 0.10, 0.85)]. Also, when adjusted for confounders, the difference between groups was statistically significant [OR 0.18, 95% CI 0.04, 0.79]. Conclusions: Due to technological advances in obstetrical and neonatal care, there was a significant improvement in the outcomes of triplet pregnancies during the observed periods. Keywords: triplet pregnancy, neonatal outcomes Presenter: Hyoun Nam

No difference was found in gestational age at delivery (35 weeks for cases and 34weeks + 6 days for controls. In the population of women exposed to amniocentesis we found 3 pregnancy loss: 1 spontaneous abortion before 20 weeks (0.61%), 1 between 20 and 24 weeks (0.61%) and 1 pPROM before 20 weeks (0.61%). The frequency of unfavourable outcomes was the same in the control group: 3 pPROM before 20 weeks (0.92%). Conclusions: Despite the sample size and the retrospective nature of the study, we found no difference in pPROM and spontaneous abortion in dichorionic twin pregnancies exposed to genetic amniocentesis compared with a similar population of dichorionic twin pregnancies who underwent sonographic scans only. This data agree with a recent prospective observational study (Lenis-Cordoba, 2013) on fetal loss risk following amniocentesis in twin pregnancies: this favourable results can be helpful for the clinician who faces counselling to the couples deciding to undergo invasive prenatal diagnosis with amniocentesis.

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Keywords: twin pregnancy, amniocentesis

ID 831

AMNIOCENTESIS IN DICHORIONIC TWIN PREGNANCIES: WHICH RISK OF FETAL LOSS? A. Pertusio2, E. Viora1, S. Bastonero1, A. Sciarrone1, P. Gaglioti1, G. Errante1, E. Gullino1, S. Sdei1, B. Inaudi2, E. Peano2, R. Mellano2, E. Volpi2, & T. Todros1 1

Ultrasound and Prenatal Diagnosis Unit Sant’Anna Hospital, Turin (Italy), 2Obstetrics and Gynecology Santa Croce e Carle Hospital, Cuneo (Italy) Brief Introduction: The literature about abortion risk following amniocentesis in twin pregnancies is unclear: some authors identify a risk almost double in twin versus single pregnancies, while others argue that post-amniocentesis foetal loss rate is similar in twin and single pregnancies (about 1%). The articles assessing the risk in dichorionic and monochorionic pregnancies are rare: aim of our study is to evaluate the pPROM risk (524 weeks), the abortion rate and the total foetal loss rate in a population of 163 dichorionic twin pregnancies compared with 164 controls (dichorionic twin pregnancies undergoing ultrasound scans only). Materials & Methods: The study was retrospectivelly carried out at the Prenatal Diagnosis Center of S.Anna Hospital (Torino) and S.Croce Hospital (Cuneo), considering all dichorionic twin pregnancies who underwent diagnostic amniocentesis between 01/01/2008 and 31/10/ 2013: we excluded triplets, patients exposed to selective termination of pregnancy, all pathologic karyotype and all pregnancies with precoce miscarriage of one twin. The control group was selected between dichorionic twin pregnancies exposed to exclusive sonographic scans. All data concerning amniocentesis was collected by our database (Echoplus), and the follow-up was carried out by using the computerized database Echoplus, Trakcare (Torino) and Ippocrate (Cuneo). Clinical Cases or Summary Results: We examined 163 cases and 164 controls: the mean age was 36.82 ± 3.9 (19–46) years for cases and 36.10 ± 5.1 (20–46) years for controls, with no statistically significative difference. The mean gestational age at the time of amniocentesis was 16.6 ± 1.38 (15–22) weeks. Indications for performing amniocentesis was: 75.5% maternal age; 12.8% abnormal first trimester screening; 4.9% growth restriction of one or both foetuses; 3.5% suspicion of mosaicism at CVS; 3.3% fetal malformation. The technique of amniocentesis was the same for both centres, and performed by skilled perinatologist.

Presenter: Annasilvia Pertusio

ID 341

UPDATE: TWIN-TO-TWIN TRANSFUSIO´N SYNDROME: EXPERIENCE IN 56 CASES M. Yamamoto, B. Walker, C. Fernandez, R. Latorre, J. Astudillo, D. Pedraza, J. Fleiderman, G. Hidalgo, A. Insunza, & M. Gonzalez Unidad de Medicina Materno Fetal, Clı´nica Alemana, Faculta de Medicina Clı´nica Alemana – Universidad del Desarrollo, Santiago, Chile. Brief Introduction: The demonstration of an enhanced benefit of fetoscopy and laser photocoagulation in comparison to amnioreduction was published in 2004, which showed that survival at 6 months after birth was 76%, compared with only 51% with recurrent amnioreduction. In 2009 the perinatal outcome of the first cases of twin-to-twin transfusion syndrome treated in Clı´nica Alemana, with a survival of at least one of the fetuses of 72.8% was reported. The aim of this publication is to update the results for national knowledge. The results have proven that it is feasible to perform complex treatments at national level. The main concern at the time was to establish whether this therapy could favorably impact the Chilean public health. The results of survival will allow to obtain conclusions. Materials & Methods: Retrospective review of databases. Patients confirmed their participation by written informed consent. The procedure was performed taking the described form, with local anesthesia, direct view of the anastomosis and laser photocoagulation seeking the ablation of the placental vascular anastomoses. The full track was revised, in order to know the rate of complications and survival at birth. There have been 3 cases of TAPS in the series. Clinical Cases or Summary Results: 56 cases, the pregnancy rate with at least one living child reaches 80% in the entire series, with excellent results. In 44% of cases both fetuses are alive, number that can be improved. Conclusions: The results are appropriate in relation to international numbers, and has been possible to orderly include a therapeutic process for the country. Keywords: Presenter: Fernandez C

428

ID 273

THE EFFECT OF IN VITRO FETILIZATION ON MULTIPLE GESTATION AND PRETERM BIRTH. ASSESSMENT IN 55.725 DELIVERIES A. Perez-Mun˜uzuri, A. Iglesias Deus, J.R. Cervilla, A. Ban˜a Souto, A. Urisarri Ruiz de Cortazar, M.L. Couce Pico

J Matern Fetal Neonatal Med Downloaded from informahealthcare.com by University of Laval on 07/08/14 For personal use only.

Neonatal Unit. Pediatric Assistance Area. Hospital Clinico Universitario (CHUS). Santiago de Compostela (SPAIN) Brief Introduction: The first human birth after ‘‘in vitro fertilization‘‘ technique (IVF) was born in 1978, and its use has been increased steadily. This event has brought about a raise rates of multiple gestations (MG) as well as preterm birth (PTB) on a average of 36 wks of GA in the twins and 32 wks in the triplets. Higher prematurity rates with their increased risk of perinatal morbidity and mortality, are seen almost inevitable. Our goal was to review in the last 22 years (1992– 2013) the practice of IVF and its relationship with both, PTB 37 wks GA and MG rates. Materials & Methods: We reviewed our records in Maternal and Neonatal Unit about number of birth, IVF, PTB and MG rates between 1992 and 2013. AS the practice of IVF has been increased especially in the last ten years, we divided the entire period into two subperiods (1992–2002) and (2003–2013) to assess if there was relevant differences among them. Total deliveries (DLV) in the entire 21 years period were 56.725. Clinical Cases or Summary Results: In the entire period the overall number of succeeded conceptions by IVF were 405 (0.7% of DLV), twins rate was 993 (1.7% DLV), triplets number 27 (0.5% DLV) and PTB 6.322 rate 11.1%. Between the two subperiods data found were as follow: 1st overall DLV were 27.122 vs. 29.603 (9% increment); 2nd IVF 29 (median frequency 1.0 % DLV, range 2.9 % – 0) vs. 376 (median frequency 12.6 % DLV, range 21.7 % – 5.9 % (1.197% increase); 3rd twins DLV 320 rose to 673 (110% increment); 4th triplets DLV 9 (0.3 % DLV rose to 18 (0.6 % DLV), an increase rate of 100%. There was only one case of cuadruple DLV by IVF in 1993. 5th PTB deliveries 2.409 (median 8.9%) rose to 3.913 (median rate 13.2%) an increase of 54.1% between the two subperiods analyzed. Conclusions: Our rate of twins DLV doubled in the period (2003–2013) (1:145) vs. (1:75) those twins conceived spontaneously according to Hellin’s law (1:80). The use of IVF rose considerably in a 1.197% as well as PTB rate, a 54.1% (from 8.9% to 13.2%) between the two periods. The latter a PTB rate higher than 10.6% found in a control group of 405 DLV conceived naturally in our maternity in the period 2008– 2012). As a conclusion, the best reliable way to reduce PTB rate and its consequences may be the reduction of MG rate.

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Brief Introduction: Our aim was to study adaptive changes of hemostasis system in women with spontaneous multiple pregnancy and multiple pregnancy after IVF. Materials & Methods: In 92 women with multiple pregnancy that were included to the study 42 were after stimulation of ovulation and 50 with multiple pregnancy after IVF. The control group consisted of 46 women with uncomplicated bichorial biamniotic twin pregnancy in I, II and III trimesters of pregnancy and in the postpartum period. The age of women was 20–32 years old. The hemostasis parameters: cell blood count, thromboelastogramm, APPT, fibrinogen level, thrombocyte aggregation, FM, fibrin monomers soluble complex (FMSC), Ddimers, lupus anticoagulant. Clinical Cases or Summary Results: Earlier development of plasmatic and thrombocytic hyperactivity have been noted in both groups. Hypercoagulation was detected from the II trimester; thrombocytic hyperactivity to 55–70% (normal level 30–50%) was developed in the I trimester, in the II and the III trimesters thrombocytopathy occurred in 25–40% of cases. There was high thrombocytic aggregation (ADPaggregation - 60–70%) and decreased functional activity of thrombocytes (adrenaline-aggregation - 20–27%). In the majority of cases it was detected thrombocytopathy and excessive hyperactivity. From the I trimester increased fibrin formation (D-dimer more than 0.5–1.0 mkg/ml) without thrombinemia (FM, FMSC tests - negative) was detected. We found increased D-dimers level (to 1–3 mkg/ml) which was combined with thrombinemia (FM, FMSC - positive tests) at 20– 35% of pregnant women in II and III trimesters (pregnancy after IVF). Activation of coagulation allowed us to predict risks of thrombophilia manifestation. We used antithrombotic treatment to prevent pregnancy complications (preeclampsia, placental insufficiency and placental abruption). LMWH were used in cases when D-dimers levels were more then 1–3 mkg/ml or D-dimer levels were more than 1 mkg/ml accompanied with FM and FMSC positive tests. After antithrombotic treatment adaptive changes in hemostasic system were characterized by stabilization of blood coagulation, by stabilization of thrombocytes aggregation and by absence of thrombinemia. In the majority of cases the level D-dimer was more than 1 mkg/ml that was the indication for use antithrombotic treatment to prevent pregnancy complications. As control tests we used the estimation of combination of D-dimer level and FM-tests. All pregnant women after IVF were delivered by cesarean section. In cases of non-complicated multiple pregnancy 40% of women had normal vaginal delivery and 60% cesarean section. In women who received anticoagulants and which did not have ovarian hyperstimulation recovery of hemostasiological system was observed in 5–7 days in the postpartum period. Conclusions: In women with multiple pregnancy occurs early excessive hyperadaptation of hemostasic system, especially in the women with APS, genetic thrombophilia, somatic diseases and ovarian hyperstimulation syndrome. Anithrombotic treatment during multiple pregnancy is a treatment of a choice which is based on prediction of changes of gestational adaptation of hemostasic system. Keywords: Multiple pregnancy, IVF, hemostasis, thrombophilia

Keywords: in vitro fertilitation, twins, preterm Presenter: N. Makatsaria Presenter: JR Cervilla

ID 666

MULTIPLE PREGNANCY AND CHANGES IN HEMOSTASIS SYSTEM N. Makatsaria, A. Mischenko, V. Bitsadze, & G. Abramian I.M. Sechenov First Moscow State Medical University, Department of obstetrics and gynecology, Moscow, Russia

ID 647

CHORIONIC VILLUS SAMPLING IN ASSISTED CONCEPTION VERSUS SPONTANEOUSLY CONCEIVED TWINS G. Daskalakis, M. Theodora, P. Antsaklis, A. Ntomali, M. Sindos, S. Mesogitis, & N. Papantoniou 1st Department of Obstetrics and Gynecology, Athens University, Athens, Greece

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DOI: 10.3109/14767058.2014.924236

Brief Introduction: This study evaluates the impact of chorionic villus sampling (CVS) in twins conceived with assisted reproduction technology (ART) versus spontaneously conceived (Sp) twins regarding obstetric outcome. Materials & Methods: Case control study of 162 consecutive twin pregnancies that underwent CVS at a single centre (Alexandra hospital, Athens, Greece). From 01.01.2000 to 30.6.2013 we recruited 32 ART and 130 Sp twin pregnancies. Patients having undergone multifetal reduction or chorionic villus sampling and those with fetal anatomic or chromosomal anomalies, discordant growth, death, or a monoamniotic sac detected at ultrasonography were excluded. Clinical Cases or Summary Results: The mean maternal age was not significantly different between the two groups. The fetal loss rate was also similar (6.3 vs 4.2% for the ART and Sp twins, respectively). The admissions to NICU were higher in the ART (29.7%) than in the Sp group (9.2%) (p50.001). The proportion of neonatal deaths was not significantly different between the two groups and was equal to 3.1% for ART twins group and 0.4% for the spontaneous twins group. Delivery before the 28 week was more frequent in the ART group compared to the spontaneous twins group (18.8% vs 1.5%, p = 0.001). The preterm delivery rate before 37 weeks was similar in the two groups (50% vs. 47.7%). The mean birth weight for the ART group was 2162 g (SD = 750 g), and for the spontaneous twins group was 2501g (SD = 485 g), (p = 0.004). Conclusions: First trimester CVS in ART and Sp twins carries a similar fetal loss rate and has the same impact on perinatal outcome. Keywords: CVS, twins, fetal loss rate, assisted reproductive technology Presenter: G. Daskalakis

consider that optimal gestational age for establishing the risk for preterm delivery for twins using TVC measurement of cervical length is 19–21 weeks. In our study MC twins are more likely to exhibit fetal growth restriction of one of twins (70%) and DC- growth restriction of both (50%). We found the strong correlation between growth restriction and total maternal weight gain in multiple pregnancy. As for the severity of intrauterine growth restriction the incidence of babies with birthweight55 percentile was higher in MC multiples (80% vs. 56% in DC). In MC pregnancies 50% of newborns with mild form and 67% with severe form of IUGR required hospitalization in special care units, whereas in DC group continuous treatment required only 46% of newborns with severe IUGR. Neonatal morbidity was non significantly higher in MC newborns. Conclusions: Thus, twin pregnancies with IUGR and MC type of placentation are associated with higher rates of complications (including early preterm delivery) and much higher rates of adverse perinatal outcome than DC twins. The consequences of IUGR in MC twins are more complex to manage and appear to be influenced by the territorial division of the single placenta and the vascular anastomoses. Keywords: twins, IUGR Presenter: K. Gamsakhurdiya

ID 431

FETAL ORIGIN HYPOTHESIS AND REPRODUCTIVE HEALTH OF TWINS S. Jahanfar

ID 674

INTRAUTERINE GROWTH RESTRICTION AND PERINATAL OUTCOME IN TWINS L. Sichinava1, K. Gamsakhurdiya2, & O. Panina2 1

Russian National Research Medical University, and Lomonosov Moscow State University, Moscow, Russia

2

Brief Introduction: Because of the presence of two or more fetuses, the intrauterine growth restriction and intertwine growth discordance are unique considerations in multiple gestations and significant contributors to poor perinatal outcome. The aim of the study was to ascertain the nature of the relationship between fetal growth, chorionicity and perinatal outcome in twin pregnancies. Materials & Methods: Our study included 77 twin pregnancies complicated by IUGR of one/both fetuses. Accurate dating of the pregnancy in the 1st trimester was essential along with designation of chorionicity. We excluded patients with twin–twin transfusion syndrome in monochorionic diamniotic pregnancies, congenital anomalies or chromosomal defects and monochorionic monoamniotic twins. Clinical Cases or Summary Results: We have found different rates of pregnancy complications in DC and MC twin gestations: cervical insufficiency (33% vs. 15%), threatened abortion (23% vs. 41%), preeclampsia (20% vs. 15%). Anemia – complication that makes great input in perinatal morbidity and mortality of multiples, was significantly more frequent in MC (50%) twins than in DC (27%)(p50.05). Significant difference was also revealed in rate of oligohydramnios: 46% in MC twins group and 14% in DC group (p50.05). The most serious contributor to adverse perinatal outcome was preterm birth, in our study preterm birth rate was 45% in DC pregnants and 65% in MC twins. Significantly higher in MC group was also the incidence of early preterm birth (before 34 weeks of gestation) – 23% and 16% respectively in MC and DC twins. We

School of Population and Public Health, University of British Columbia, Vancouver, Canada Brief Introduction: The fetal origins hypothesis suggests that conditions such as nutritional status during fetal life, program the fetus for the development of chronic diseases in adulthood. Since low birth weight is the general manifestation of twining, it is logical to hypothesize that twins may suffer from ill health. This study aimed at testing the hypothesis that low birth weight twins and normal birth weight twins differ with respect to reproductive events and anthropometric measurements. Materials & Methods: This is a cross sectional and observational study. The sample consisted of identical and non identical Asian twins who participated in the volunteer reproductive health study. Twins were interviewed to obtain their birth weight and reproductive history. They were then divided into two groups of low birth weight (n = 87) and normal birth weight (n = 43). Menstrual history for female twins included age of menarche (year); duration (day), interval (day), irregular menstrual bleeding, clinical symptoms of premenstrual symptoms (PMS) inclusive of physiological and psychological symptoms a week prior to menstrual flow. Clinical symptoms for polycystic ovary syndrome (PCOS) were considered positive if subjects were suffering from hyper-androgenemia (hirsutism, acne), and chronic anovulation (amenorrhea, oligomenorrhea or irregular menstruation). Clinical Cases or Summary Results: Normal birth weight group had a significantly higher mean of adulthood weight (59.77 ± 10.69) when compared with low birth weight group(52.78 ± 7.64) (p = 0.001). Premenstrual symptoms were found more frequently among normal birth weight group (25% vs. 16.7%; p = 0.03). No other reproductive health variable was found to be significantly different within the two groups. Conclusions: Our data does not support the fetal origin theory as none of the reproductive illnesses was found to be higher among low birth weight twin infants. Keywords: Low birth weight, reproductive health, twins

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J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

Presenter: S.Jahanfar

Table 1. Maternal socio demographic profile and antenatal complications in relation to twin gestation.

ID 863

Sr. No

OBSTETRIC AND PERINATAL OUTCOMES IN MONOCHORIONIC MONOAMNIOTIC TWIN PREGNANCIES

1

S. Barras1, M. de la Calle1, P. Tobı´as1, M. Sancha1, & J.L. Bartha1

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Obstetrics and Gynecology Dept. University Hospital La PAZ, Madrid, Spain. Brief Introduction: OBJECTIVE: To evaluate the obstetric and perinatal outcomes in a large series of monochorionic monoamniotic twin pregnancies Materials & Methods: We conducted a descriptive study by reviewing the cases of monochorionic monoamniotic twin prenancies attended at our Hospital between the years 1997 and 2013. 29 patients were obtained. Mean gestational age at diagnosis was 15.8 ± 4.5 weeks. Mean maternal age was 31.9 ± 3.5 years. Obstetric complications and perinatal outcomes were recorded. Data was analysed using binary logistic regression. Clinical Cases or Summary Results: In 4 cases (13.8%) invasive prenatal diagnostic techniques were performed (2 amniocentesis and 2 chorionic biopsies). There were 3 cases of fetal malformations (10.3%). Fetal transfusion syndrome was diagnosed in 1 case (3.4%). There were 10 intrauterine deaths (17.2%), 4 cases affecting both twins. In 7 patients cord entanglement was diagnosed by ultrasound (24%). In two of the cases of cord entanglement the death of one twin occurred postnatally. There was premature rupture of membranes in 4 cases (13.8%) and preterm labor in 13 (45%). Inatruterine growth restriction was observed in any of the two twins in 6 cases (21%). The gestational age at delivery was 32.3 ± 6.3 weeks, 7 of them by vaginal delivery (24%), 2 of them single twins. There were four cases of neonatal deaths, with both twins affected in one patient (neonatal mortality 4/48, 8.3%). Overall perinatal mortality was 14/58 (24.1%). Binary logistic regression analysis failed to prove any correlation between the data recorded and perinatal mortality. Conclusions: Monoamniotic monochorionic twin pregnancies present high perinatal morbidity and mortality, although our results are better than those reported in the literature. No variable was predictive for perinatal death in our study, including cord entanglement prenatal sonographic diagnosis. Even though, elective delivery at 32 weeks has demonstrated to reduce antenatal mortality despite prematurity. Keywords: Presenter: Silvia Barras

ID 109

STUDY OF MATERNAL AND FETAL OUTCOME IN TWIN GESTATION AT TERTIARY CARE REFERRAL CENTRE M. Vijayasree Obstetrics and Gynaecology Department, Mamata Medical College, Khammam, Andhra Pradesh, India Brief Introduction: Twin gestation is considered as high risk pregnancy due to associated high maternal morbidity and perinatal mortality in

5

Maternal profile Age distribution 520 years 20–30 years 430 years Parity distribution Primi Multi Registration status Booked Unbooked Gestational age 534 weeks 34–37 weeks 437 weeks Common antenatal complications Preterm labour PIH Malpresentations First babySecond babyAnemia Hydramnios APH PROM

Number (n=50)

%

6 43 1

12 86 2

25 25

50 50

38 12

76 24

16 25 9

32 50 18

42 9

84 18

3 16 33 6 4 8

6 32 66 12 8 16

Table 2. Showing mode of delivery and perinatal outcome in twin gestation Sr. No

Perinatal outcome Mode of delivery– Spont.Vaginal –Caesarean -Instrum. Vaginal Fetal Birth weight51500 grams 1500–2000 grams 42000 grams Sex of the baby–Male –Female Fetal outcome at birth– Livebirth –Stillbirth Neonatal outcome–NICU Admission –Neonatal morbidity –Neonatal mortality Causes of neonatal deaths–RDS –Septicemia –Pul.Hemorrhage –DIC

Number

%

32 16 02

64.00 32.00 04.00

67 71 62

33.50 35.50 31.00

124 76

62.00 38.00

185 15

92.50 07.50

102 42 20

51 21 10

09 12 04 09

– – – –

comparison with singleton pregnancies.Overall, the rate of twin gestation is on rise due to inadvertent use of ovulation induction drugs and assisted reproductive techniques.This study was carried out to find out the maternal and perinatal outcome in diagnosed cases of twin gestation Materials & Methods: 50 antenatal mothers with twin gestation delivered at Mamata general hospital, khammam, Andhra Pradesh, India from January 2012 to july 2013 which is a tertiary care referral centre were included in the study. Clinical Cases or Summary Results: It was observed that the incidence of twins was 1.49%.thirty eight percent cases were booked and attended antenatal clinic on regular basis.Preterm labour (42%) was

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the commonest obstetric complication, whereas, nutritional anemia (33%) and pregnancy induced hypertension (9%) were the commonest medical complications encountered.The rate of caesarean section was 16.5%.There was no serious maternal morbidity or mortality. Extreme prematurity (18.5%) and very low birth weight (16.5%) were the major causes of perinatal deaths. The common causes of neonatal deaths were respiratory distress, fulminant septicemia, pulmonary hemorrhage and Disseminated Intravascular Coagulation. Conclusions: Judicious use of ovulation induction drugs can reduce the incidence of twin gestation. Early diagnosis of twin gestation with its chorionicity, careful monitoring for fetal well - being throughout the pregnancy, regular antenatal checkups, adequate rest, good diet, cervical encirclage in selective cases, maternal gluco-corticoid therapy in pre - term labour, short term tocolysis and institutional delivery having good neonatal facilities can improve the maternal and perinatal outcome in twin gestation. Keywords: Twin gestation, Perinatal outcome, Preterm labour, Low birth weight Presenter: dr.m.vijayasree

ID 340

PREMATURITY PROFILE IN TWIN PREGNANCY M. Yamamoto, C. Fernandez, R. Latorre, J. Carrillo, F. Avila, F. Jorda´n, J. Rojas, & A. Insunza Hospital Padre Hurtado, Facultad de Medicina Clı´nica Alemana-Universidad del Desarrollo, Santiago, Chile Brief Introduction: Twin pregnancies are considered high risk for prematurity, being the reason of important preventive behaviors. To validate these potential therapies, we need to know their prematurity profile Materials & Methods: A retrospective evaluation of delivery protocols was conducted from May 2005 to December 2012. The GA at birth, how the labor were started, chorionicity and background of prematurity were taken in consideration. Clinical Cases or Summary Results: 375 twin pregnancies were delivered at the Hospital Padre Hurtado in this 7 years and fraction period, during which there were 42,498 registered pregnancies, accounting the 0.88% of the total. Median GA at birth was 36 weeks [21–39], showing a no-normal distribution as expected (D’Agostino Pearson p50.001). There were 7,358 preterm births at singleton pregnancy and 244 preterm twins that corresponded to 488 newborns, corresponding to 6% of premature. tabla 1. Conclusions: The prematurity rate exceeds 50%, reaching 78% in monochorionic diamniotic. Data do not include pregnancies referred to the center that delivers babies under 32 weeks, so the actual rate may be higher, but not lower. The burden of premature infants is at least 6%. The twin pregnancy is a group with high risk of prematurity and much effort should concentrate on your treatment.

Presenter: Fernandez C

ID 478

PREGNANCY OUTCOME OF TWIN PREGNANCIES IN WOMEN OF ADVANCED MATERNAL AGE M. Kim, J.H. Sung, J.Y. Kuk, J.Y. You, S.J. S.Y. Choi, C.R. Oh, J.H. Roh, & Kim Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Brief Introduction: The aim of this study is to compare the pregnancy and perinatal outcomes of twin pregnancies between women aged 35 years or older and women aged less than 35 years. Materials & Methods: We conducted a retrospective cohort study of twin pregnancies delivered after 24 weeks of gestation in Samsung Medical Center between 1995 and 2010. Subjects were categorized into two groups by maternal age (35 and 535 years of age). Pregnancy and neonatal outcomes were compared between the two groups using the Student’s t-test and chi square test. Clinical Cases or Summary Results: A total of 1,240 women with twin pregnancy were included, of which women in the 35 year of age group were 247 (19.9%) and women in the 535 year of age group were 993 (80.1%). The rate of twin births increased over the 16 years of study period (from 1.60% in 1996–1998 to 4.14% in 2007–2010), as well as women with twin pregnancy aged 35 years or older (linear-bylinear association, p = 0.027). Women in the 35 year of age group had a higher parity, and higher rates of assisted reproduction technique pregnancies and dichorionic twins than women in the 535 year of age group. There was no significant difference between two groups regarding the incidence of preterm delivery, preterm labor, preterm premature rupture of membranes, preeclampsia, placenta previa, placenta abruption, intrauterine death or major anomaly of one or more twin pairs. The incidence of gestational diabetes was higher in women in the 35 year of age group than the 535 year of age group (7.3% vs 2.9%, p = 0.001). Neonatal outcome including Apgar scores, incidences of respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, neonatal sepsis and neonatal mortality were comparable between the two groups, except for a higher rate of NICU admission in women in the 535 year of age group (45.0% vs. 38.3%, p = 0.008). Conclusions: In this study, advanced maternal age, defined as age 35 year and older, was not significantly associated with the pregnancy and perinatal outcomes of twin pregnancies. Keywords: Twin pregnancy, advanced maternal age, pregnancy outcome, perinatal outcome Presenter: Mina Kim

Keywords: twin pregnancies, prematurity rate

ID 462

MATERNAL AGE AND PREGNANCY COMPLICATIONS IN WOMEN WITH TWIN PREGNANCY S. Ferna´ndez-Prada1, A. Leal2, M. de la Calle3, J.L. Bartha4, & N. Martinez5 1

Obstetrics Dept., University Hospital La Paz, Madrid, Spain, Obstetrics Dept., University Hospital La Paz, Madrid, Spain, 3 Obstetrics Dept., University Hospital La Paz, Madrid, Spain, 2

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Obstetrics Dept., University Hospital La Paz, Madrid, Spain, and 5 Brief Introduction: To evaluate the relationships between maternal age and pregnancy complications as well as perinatal and obstetrics outcomes in women with twin pregnancy. To find the cut-off level to define a higher risk for those complications. Materials & Methods: In total 197 women with twin pregnancy (82.7% (163/197) dichorionic diamniotic and17.3% (34/197) monochorionic diamniotic) were analysed. Clinical records were reviewed. Rates of pregnancy-induced-hypertension (PIH), preeclampsia (early and lateonset, mild and severe), gestational diabetes (on diet and under insulin therapy), mild carbohydrate intolerance (abnormal O’Sullivan’s test), preterm labor (classified according gestational age), caesarean section (elective and emergency) and low birthweight (51500 and 52500 g) were evaluated. Spearman’s correlation coefficient and ROC curves were used to analyse correlations with maternal age and to find the best cut-off level. Clinical Cases or Summary Results: Maternal age was significantly positively associated to the rate of pregnancy-induced hypertension, severe preeclampsia, mild carbohydrate intolerance and elective caesarean section. On the contrary it was significantly but negatively associated to the rate of preterm labor, specifically under 32 weeks of pregnancy. ROC curves demonstrated that the best cut-off level for pregnancy complications was 35 years. Conclusions: Pregnancy complications in women with twin pregnancy increases with maternal age and the best cut-off level to determine the higher risk is 35 years. Keywords: twins, maternal morbidity, age cut-off, pregnancy complications Presenter: S. Ferna´ndez-Prada

ID 816

AN UNUSUAL CASE OF SUCCESSFUL DELIVERY OF TWIN GESTATION IN A SINGLE HORN OF A BICORNUATE UTERUS A. Martinelli1, E. Grossi2, M. Crivelli3, C. Personeni4, & I. Cetin Unit of Obs and Gyn, L.Sacco Hospital, Center for Fetal Research Giorgio Pardi, University of Milan, Italy Brief Introduction: Mu¨llerian duct anomalies occur in 0.1% to 3% of women. In women with congenital malformations of the uterus, pregnancy may be associated to obstetric complications, such as preterm birth and lower birth weights. In particular, bicornuate uterus is mainly associated to spontaneous abortion, premature rupture of the membranes, or fetal malpresentation. Twin gestation in a case of bicornuate uterus is extremely rare. We report a successful case of a twin pregnancy in a single horn of a bicornuate uterus. Materials & Methods: Clinical Cases or Summary Results: A 34-year-old woman with a previous miscarriage at nine weeks of gestational age conceived a dichorionic diamniotic twin gestation. A 3-D ultrasound exam performed after miscarriage had previously revealed a suspected bicornuate uterus with a single cervix (Figure 1). A diagnostic hysteroscopy was programmed when she reported a positive pregnancy test. In the first ultrasound exam, a viable twin dichorionic pregnancy was seen (Figure 2). Both gestational sacs were located in the same uterine cavity. Down syndrome screening was performed at eleven weeks of gestational age. Prophylactic cervical cerclage was performed at fourteen weeks of gestation. Patient was regularly examined in 2–3-weeks interval. Anatomical survey by ultrasound was normal for each fetus. Pregnancy had no complications up to 29

weeks of gestational age when in both twins umbilical artery (UA) pulsatility index 42SD with normal end diastolic flow were found. Middle cerebral artery (MCA) pulsatility index, ductus venosus (DV), fetal heart rate monitoring and fetal growth were normal. Fetal lung maturation was performed with betamethasone 12 mg repeated after 24 hours. Next ultrasound examination evidenced fetal growth restriction of a twin. The other twin had a regular growth. UA pulsatility index was 42DS with normal end diastolic flow in both twins. Patient was hospitalized in order to monitor fetal wellbeing. Fetal-placental velocimetry was evaluated every 48 hours and fetal heart monitoring every day. At 32.4 weeks of gestation both twins showed UA pulsatility index 42 DS with reduced end diastolic flow, normal MCA pulsatility index and DV and normal fetal heart rate monitoring. At 33.1 weeks we performed an emergency ceasarean section for suspected fetal distress indicated by short term variability 55 bpm and presence of a single-prolonged deceleration for both twins. Neonates were delivered successfully by one single lower segment transverse incisions. Birth weights were 1440 and 1145 g, respectively. Apgar scores were 10/10 and 7/9 at 1 and 5 minutes, respectively. There were no complications in the early and late postoperative periods. Total blood loss did not exceed 500 cc. No neonatal complication occurred. Patient was discharged from the hospital four weeks after delivery with two healthy babies. Conclusions: Uterine anomalies have been associated with an increased incidence of spontaneous abortion, malpresentation, placental abruption, preterm delivery, intrauterine growth restriction, and the need for operative delivery. There are no guidelines about the follow-up of the pregnancy or the mode of delivery, because the incidence is very low. To date, there are only few reported cases of twin pregnancy in bicornuate uterus. The management of twin pregnancy in uterus bicornis should

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DOI: 10.3109/14767058.2014.924236

be individualized because of the possible risk and the rare occurrence of these cases. Moreover, prophylactic cerclage could be a key step in the prevention of prematurity Keywords: twin pregnancy, uterus bicornis Presenter: E. Grossi

ID 280

MINIMALLY CONJOINED MONOCHORIONIC DIAMNIOTIC TWINS K. Kosinska-Kaczynska, D. Bomba-Opon, I. Szymusik, &M. Wielgos 1st Department of Obstetrics nad Gynecology, Medical University of Warsaw Brief Introduction: The incidence of conjoined twins is approximately 1/50000 to 1/100000 births. The hypothesis of their development concludes that conjoined twins form after incomplete fission of germinal disc after the 12th day of embryogenesis and create monochorionic monoamniotic twin pregnancy. According to this theory it would be impossible for diamniotic conjoined twins to occur. We present the sixth documented case of diamniotic conjoined twin pregnancy. Materials & Methods: case report Clinical Cases or Summary Results: A 28-year old woman, presented at 27th week of her second pregnancy, diagnosed as monochorionic

diamniotic twin gestation. The twins, however, were conjoined by a tissue bridge probably containing bowel and vessels. MRI scan revealed male conjoined omphalopagus twins in breech presentation. Both fetuses were almost identical in size and shared a common omphalocele sac containing bowel, both had a suspicion of ileal atresia and twin b also of persistent urachus. After a spontaneous onset of regular uterine contractions at 34 weeks of gestation, a cesarean section was performed. The pregnancy was confirmed to be diamniotic. Both fetuses together weighing 4715 g were born in good general condition. A separation procedure was conducted in the first day of life. Both twins had a shortened small intestine passing into a common short colon, which ended in a single extrophic cloaca. Both had separate bladders and two kidneys, twin b with obstructed urethra. Both twins also had imperforate anuses. Newborns were separated successfully. Conclusions: Monochorionic diamniotic conjoined twins with omphalocele, urachal anomaly, conjoined ilea and anorectal/cloacal malformation indicate that the fusion of two separate embryonic discs in the area around the allantois and caudal portions might be a better hypothesis of their development than the incomplete fission. Keywords: conjoined twins, omphalopagus, anorectal malformation Presenter: K. Kosinska-Kaczynska

ID 473

NEONATAL OTCOME OF PRETERM NEWBORN TWINS B. Miljkovic´, M. Jonovic´, G. Jovanovic´, N. Stojanovic´, S. Stamenovic´1, & M. Stojanovic´2

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Clinic for Gynecology and Obstetriton, Clinical Centre Nisˇ, and 2Public Health InstituteNisˇ Brief Introduction: Twin pregnancies are appearing with frequency of 3%. Such pregnancies are followed by a great number of maternal complications and a larger degree of perinatal morbidity and mortality. The aim of our stady is to examine the frequency of delivering preterm newborn twins and their neonatal outcome. Materials & Methods: In the Clinic for Ginecology and Obstretition in Nisˇ we have done a prospective study for newborn twins in 2013.We analised the data of pregnancy and delivery, Apgar score, clinical examination, laboratory analysis, intracranial ultrasound, echocardiography examination, ultrasound abdomen and Ro-graphia where it has been indicated.The data were statistically examined. Clinical Cases or Summary Results: There were 3109 deliveries in 2013., of which 60 were twin pregnancies (1.93%). There were 40 preterm twin pregnancies, 30% of preterm twins were IVF pregnancies.The mode of delivery: 65% was born by SC, the rest was per vias naturalis. Twins from IVF pregnancies in 91.66% was born by SC. Mean birth weight was 2183.12g (twins from IVF pregnancies 2091.66g) and mean gestational age at birth 34.97 weeks (from IVF pregnancies 34.00 weeks). Apgar scor of the preterm twins was 7.67, Apgar score of preterm twins from IVF pregnancies was 7.62. The most frequent neonatal complications in all preterm twins were: RDS 36.25%, asphyxio 23.75%, hyperbilirubinemia 43.75%, metabolic complications 40.0%, infections 11.25%, anaemia 3.75%, congenital anomalies 3.75%, etc. Two babies died in the first day of life. 29 babies had a need for intensive care in the third level hospital care. Conclusions: The incidence of preterm delivery within twin pregnancies was 1.28%. Preterm newborn twins make 27.12% of all premature infants. There was no significant difference in morbidity between preterm twins from spontaneus pregnancies and those from IVF pregnancies. Keywords: twin preterm babies, neonatal outcome Presenter: Biljana Miljkovic

ID 900

MORBIDITY OF NEWBORNS FROM MULTIPLE PREGNANCIES M. Markovic Gynecological Clinic, Clinical Centre of Montenegro, Podgorica Brief Introduction: Introduction: Multiple pregnancy belongs to a group of high-risk pregnancies. Their frequency varies and is about 3%. Twin pregnancies are associated with many complications (low birth body weight of newborn, prematurity, congenital anomalies etc.) resulting in an increase in the pathology of the newborn. Goal: Analysis of the structure of morbidity of newborns from multiple pregnancies. Materials & Methods: Methods: Retrospective analysis includes the twins born in maternity hospital (Gynecological Clinic, Clinical Centre of Montenegro) in the period 1.01.2007.–31.12.2008. In the study following parameters are monitored and analyzed: maternal age and parity, delivery mode, gestational week, body weight, Apgar score and newborn morbidity. Clinical Cases or Summary Results: Results: During this period of time, there were 5959 deliveries and 113 pairs of twins were born, which makes 1.9% of the total number of births. Total number of newborns delivered during this time period was 6033 including 223 newborns from multiple pregnancies (3.7% of the total number of newborns). 39.8% of the deliveries were completed surgically. The average maternal age was 29 years and through parity analysis it was found that 56.6% were primiparous. More than 50% of newborns were male

J Matern Fetal Neonatal Med, 2014; 27(S1): 1–437

and the average gestational age was 35.8 ± 2.5. The rate of prematurity in the study group is 27.8%, while the overall rate of prematurity is 7.75%. Body weight between 2000 and 3000 g was registered in 63.7% of the newborns, while the average body weight was 2510.8 ± 487.5. Analysis of the average Apgar score value at 1 and 5 min. was 7.7 ± 0.8/8.6 ± 0.9. The morbidity structure was dominated by perinatal asphyxia with 26%, RDS 19.7%, jaundice 13.5%, anemia 8.5%, infection 4.8%, intracranial hemorrhage 2.2%, IUGR 3.6%, congenital anomalies 0.9%. Conclusions: Conclusions: The analysis of the obtained data showed significant dominance of primipara and frequent presence of surgical delivery. The dominant sex is male. Gestational age is about 36 weeks which indicates that premature newborns are dominant and that affects morbidity of analyzed group. Our results confirm that newborns from multiple pregnancies are highly risky and require adequate treatment from the neonatal team. Keywords: multiple pregnancies, asphyxia, prematurity Presenter: M. Markovic

ID 875

DELAYED INTERVAL DELIVERY OF THE SECOND TWIN IN A WOMAN WITH ALTERED MARKERS OF INFLAMMATION G. Daskalakis, A. Ntomali, V. Pergaliotis, M. Theodora, P. Antsaklis, S. Mesogitis, N. Papantoniou, & D. Loutradis 1st Department of Obstetrics and Gynecology, Athens University, Athens, Greece Brief Introduction: An increasing number of studies and reports are published DURING the last years, reporting delayed interval delivery of twins. Although these cases aren’t something new in obstetrics, improved antenatal surveillance rendered imperative their surveillance, in order to investigate the causes that lead to delayed delivery of the second twin and improve its intrauterine growth. We report a case of delayed interval delivery of the second twin 34 days after the delivery of the first one. Materials & Methods: A 34-year old woman P1G2 was admitted in our high risk pregnancy Clinic at 23 + 4 weeks of gestation due to premature prelabor rupture of the membranes (PPROM) in one of her dichorionic twins. Her personal history revealed hypothyroidism under supplementation with T4 175mcg twice a day, an appendectomy performed 12 years ago and cervical cryotherapy for HPV treatment one year ago. During physical examination she was normotensive, without fever and she had a Bishop score of 0. Laboratory examinations revealed increased white blood cells (12.300/ml) and elevated CRP (40.98mg/L with upper normal laboratory limit of 1.0 mg/L), while both dipstick urine examination and urinary cultures were normal. The patient was started on amoxicillin and metronidazole regimen for ten days and she was administered betamethasone 12mg intramuscularly with a repeated dose 24 hours after the initial one. Ultrasound examination revealed the presence of two embryos with positive cardiac function that weighted 535 and 606 grams respectively. The first of them had an amniotic fluid index (AFI) of 5 cm and the latter an AFI of 14 cm. Clinical Cases or Summary Results: One week after admission (24 + 4) the patient delivered vaginaly a female infant weighing 550 grams. Manual extraction of the placenta failed and we decided to ligate the umbilical cord just above the level of the external cervical os. The next day the delivered twin died due to respiratory distress syndrome. Blood samples were obtained from the patient that revealed again raised WBCs (12.400/ml) and an increased CRP (13.14 mg/L). The patient remained in our high risk pregnancy CLINIC and one five days later she had a new blood and urine examination along with urine

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cultures that revealed elevated WBCs (13.900/ml) an even higher CRP (31.78 mg/L) and presence of enterobacteriae. An expert in infectious diseases was advised and the patient started cefuroxime 750mg three times a day for a period of seven days. A repeated dose of corticosteroids was administered to the patient during her 26th and 27th day of hospitalization (28th week of gestation). The second female fetus was finally delivered 34 days after the first one (29 + 2) with cesarean section due to an abnormal NST. The neonate weighed 1150 grams and had an Apgar score of 7 at the first minute and 9 at five minutes. It remained in the neonatal ward for 4 more weeks. Conclusions: Even modest intervals of deliver can improve neonatal outcome, in cases of delayed delivery of the second twin. Keywords: twins, pprom, delayed delivery Presenter: g. daskalakis

A significant percentage of the patients (75.59%) had preterm delivery which is reportedly the most important complication of multiple pregnancies and the single greatest contributor to the high perinatal mortality rate in twin pregnancy.The average gestational age at delivery for twins is 37 weeks and about half of twins deliver preterm. Prematurity is associated with an increased incidence of respiratory distress syndrome, intracranial haemorrhage, cerebral palsy, blindness, low birth weight and neonatal morbidity and mortality. Conclusion: The incidence of twin pregnancy and its attendant perinatal mortality is high on our center. In addition, caesarean section is the most common mode of delivery with malpresentation of the first twin. Various measures have been used in attempt to reduce the incidence of prematurity including bed rest, oral tocolytics and cervical cerclage all of which unfortunately have failed to significantly improve gestational age at delivery.

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Keywords: twins, pregnancy, delivery, cesarean section Presenter: Aleksandar Curkovic

ID 423

HIGH LEVEL OF CEASAREAN SECTION IN TWIN PREGNANCY: OUR EXPERIENCE . SoldoV1, N. Cutura2, A. Curkovic3, S. Jankovic-Raznatovic4 1

University Clinic of Obstetrics and gynaecology GAK "Narodni front", Medical faculty University of Belgrade, department of delivery, 2Private clinic of gynaecology, Belgrade, and 3 University Clinic of Obstetrics and gynaecology GAK "Narodni front", Medic Brief Introduction: Twin pregnancy continues to be a focus of interest the world over due to its increasing incidence and also the high maternal and perinatal mortality and morbidity associated with it.The most optimally safe mode of delivery remains a challenge and a subject of controversy among obstetricians. Materials & Methods: A retrospective rewiew of twin deliveries at the University Clinic of obstetrics and gynaecology‘‘ Narodni front‘‘, Belgrade, Serbia between 1 st January 2013 and 31st December 2013. Clinical Cases or Summary Results: There were 6 662 deliveries out of which 254 were twin deliveries resulting in an incidence of 3.81%.Their ages ranged from 20–47 years with modal age group of 31–40 years (69.29%). Majority (67.71%) were primiparous. The number of patients delivered by Caesarean section were 216 (85.04%), 206 of them were elective caesarean and 10 started as a vaginal delivery but some complications have occured and they have finished by ceasarean section. Malpresentation of the first or second twin (34.64%) and preterm membranae rupture (16.53%) were the most common indications. The number of patients delivered vaginally were 38 (14.96%). In seven of them the second twin was in a breech presentation and situs transversus of second twin was in 7 cases (delivered by inversio internal et extractio fetus ad pedem). Apgar score was high in both groups, delivered vaginally or by ceasarean section for both twins. The perinatal mortality rate was 21.16/1000 and there was not maternal death. Conclusions: Discussion: The incidence of twin deliveries in our center is 3.81%. Twin pregnancies are documented to occur more commonly among older women due to rising follicle stimulating hormone levels and also grandmultips.In our study most of patients were over 30 years.The caesarean section rates for twins are documented to be 2–3 times higher than for singleton pregnancy. This is reflected in this study by the high caesarean section rate (85.04%). Malpresentation of the first or second twin and preterm membranae rupture were the most common indications for caesarean section.Most obstetritian advocate delivery by caesarean section when the leading twin is breech and the second cephalic.

ID 245

STUDY ON THE ROUTE OF DELIVERY AND PREGNANCY OUTCOME IN TWIN PREGNANCY Ding Hong Juan1, Chen Min2 Nanjing Maternity and Child Health Hospital, Nanjing, China Brief Introduction: To observe the relationship between delivery route and pregnancy outcome in twin pregnancy. Materials & Methods: We randomly assigned women between 32 weeks and 36 weeks 6 days of gestation and with the first twin in the cephalic presentation. 598 women were divided into two groups, 300 women planed cesarean delivery and 298 women planed vaginal delivery.The primary outcome was a composite of fetal or neonatal death or serious neonatal morbidity. Clinical Cases or Summary Results: The rate of cesarean delivery was 86.3% in the planed cesarean delivery group and 56.2% in the planned vaginal delivery group. There was no difference in pregnant week and postpartum hemorrhage of two groups (p40.05); neonatal weight of cesarean section was higher than that of vaginal delivery (P0.05), however the incidence of neonatal asphyxia of second fetal in cesarean section is much lower than that in vaginal delivery (p50.05). Conclusions: Planned cesarean delivery significantly decrease the risk of fetal or neonatal asphyxia morbidity of second fetal, as compared with planned vaginal delivery. The right route of delivery can lower the incidence of cesarean section and neonatal asphyxia. Keywords: Twin pregnancy Delivery route Pregnancy outcome Presenter: Ding Hong Juan

ID 713

TWIN PREGNANCY WITH A PARTIAL HYDATIDIFORM MOLE AND A COEXISTENT VIABLE FETUS: A CASE REPORT I. Rato, M. Centeno, S. Susana, L. Pinto, & L. Grac¸a 1

Obstetrics Dept., CHLN- Hospital de Santa Maria, Lisbon, Portugal, 2Faculdade de Medicina da Universidade de Lisboa, Obstetrics Dept., CHLN-Hospital de Santa Maria, Lisbon,

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Portugal, 3Faculdade de Medicina da Universidade de Lisboa, Obstetrics Dept., CHLN-Hospital de Santa Maria, Lisbon, Portugal, 4Faculdade de Medicina da Universidade de Lisboa, Obstetrics Dept., Hospital de Santa Maria, Lisbon, Portugal, and 5Faculdade de Medicina da Universidade de Lisboa, Obstetrics Dept., Hospital de Santa Maria, Lisbon, Portugal Brief Introduction: Twin pregnancy with a healthy fetus and an hydatidiform mole is extremely rare, occurring in 1:20.000–100.000 twin pregnancies. In the majority of cases it is associated with poor maternal and fetal outcomes. Materials & Methods: Clinical Cases or Summary Results: A 30-year-old, nulliparous woman underwent an intra-uterine insemination with donor sperm. At 13 weeks of gestation the ultrasound examination showed a dichorionic twin pregnancy; twin A had an omphalocele and the placenta was enlarged, with multiple cystic and hyperechogenic areas, suggesting a trophoblastic disease; twin B had no major abnormalities and the placenta looked normal. Detailed counseling concerning maternal and fetal risks was provided. An amniocenteses was performed at 15 weeks of gestation and the kariotype was normal for both fetuses. At 18 weeks of gestation death of the affected fetus occurred. At 35 weeks, twin B showed fetal growth restriction and two weeks later tlabour was induced because of severe pre-eclampsia. A 2280 g healthy newborn was delivered. Histology of the placenta of the death fetus confirmed a partial hydatidiform mole. Postpartum serial HCG follow-up showed a progressive decrease. Conclusions: In the rare event of a twin pregnancy with a partial hydatidiform mole coexisting with a viable fetus, proceeding the pregnancy may be an option although several complications such as pre-eclampsia and fetal growth restriction. Thus close surveillance is mandatory in order to detect early signs of maternal or fetal complications. Keywords: Twins; hydatidiform mole Presenter: I. Rato

syndrome is one such adverse effect characterised by gaseous bowel-distension in infants treated with nasal CPAP. The pressures transmitted from oropharynx to stomach during BCPAP are not known. Intra gastric pressures in babies receiving nasopharyngeal BCPAP have not been studied previously to the best of our knowledge. This study was done to study intra-gastric pressures in neonates receiving bubble CPAP by nasopharyngeal prong. Materials & Methods: 27 neonates were recruited for the study. Bubble CPAP pressure of 6 cm water was used in all the neonates. A pressure sensor (by sensoromedic Õ was attached to a 5V regulated power supply and the voltage drop across appropriate leads of the sensor was proportional to the pressure difference,) was attached to orogastric tube to measured the intra gastric pressure prior to starting bubble CPAP and again after 30 to 90 minutes of CPAP. The software for the data logging was provided by MECOÕ 81 K -TRMS. We routinely checked the calibration at different depths of water and found it accurate with an error of less than 2%. The clinical variables like Downe’s score, oxygen saturation, venous blood gas pH, pCO2 and abdominal girth were recorded alongside with pressure readings. Clinical Cases or Summary Results: In our study there was statistical improvement (p50.05) in parameters of respiratory distress like Downe’s score (DS), oxygen saturation (SpO2), venous blood gas parameters (pH, pCO2). The mean intragastric pressure before starting BCPAP was 12.422 cm H2O, (95% CI 8.65 to 16.18) and during BCPAP it was 12.88 cm H2O (95% CI 10.48 to 15.29). The intragastric pressure always remained positive and the overall change in intragastric pressure recordings (paired t test) was 0.464 cm H2O (95% CI -5.11 to + 4.18,) (p = 0.838). Conclusions: We found that nasopharyngeal Bubble CPAP at pressure of 6 cm water, decreased work of breathing, improved gas exchange and improved Downe’s score. We found no significant increase in intra gastric pressures and gastrointestinal complications such as abdominal distention, NEC, perforation during our study. Further multi centric studies with larger number of cases, are required for predicting accurate changes in intragastric pressures. Keywords:

ID 66

Presenter: Puliyel J.

INTRA GASTRIC PRESSURES IN NEONATES RECEIVING BUBBLE CPAP

Table 2. Pressure variance in recorded pressures before and after BCPAP

P. Tyagi1, N. Gupta1, A. Jain1, P. Upadhyay2, & J. Puliyel1 1

Department of Pediatrics, St Stephens Hospital, Delhi, India, and 2Indian Institute of Immunology, Delhi, India Brief Introduction: Although bubble CPAP is seen to be superior to continuous steady pressure CPAP, it is reported that its pressure delivery system can be highly variable and unpredictable. CPAP has been associated with gastrointestinal adverse effects – although rarely. The CPAP belly

Pressure Values after Pressure CPAP at 6 Values cmH2O before CPAP Mean cmH2O, Mean cmH2O, 95% C.I 95% C.I Variables

Difference in Mean, 95% C.I

p Value (Significant  0.05)

12.422 cmH2O, 12.88 cmH2O, 0.464 cmH2O, Intra Gastric (8.65 to 16.18) (10.48 to 15.29) (5.11 to 4.18) Pressures

0.8384

Table 1. Clinical Variables Before and After BCPAP

Variables DOWNE’S Score for Respiratory Distress Oxygen saturation (SpO2) Venous Blood GaspH Venous Blood Gas pCO2

Values before CPAP Mean , 95% C.I

Values after CPAP at 6 cmH2O Mean , 95% C.I

Difference in Mean, 95% C.I

p value (Significant  0.05)

4.37 /10, (3.60 to 5.13)

1.96 /10, (1.36 to 2.55)

2.40 /10, (1.92 to 2.88)

50.0001

92.74%, (90.50to 94.97)

98.4 %, (97.41 to99.39)

5.66 %, (7.37 to 3.95)

50.0001

7.259, (7.225to 7.294)

7.327, (7.302 to 7.352)

0.067, (0.101 to 0 . 033)

50.0004

44.72 mm Hg , (41.99 t o 47.44)

39.61 mmHg, (37.13 to 42.09)

5.10 mmHg, (2.95 to 7.26)

50.0001

437

DOI: 10.3109/14767058.2014.924236

60 minutes, respectively. Following oximetry readings, we ascertained that 87.72% of the infants required no resuscitation at birth, 10.73% needed basic resuscitation (tactile stimulation or free-flow oxygen) and only 1.55% required complex methods of resuscitation (positivepressure ventilation, chest compressions, medication). Conclusions: Routine use of pulse oximetry in the first hour after birth led to judicious use of oxygen in the delivery room. Pulse oximetry can be used as a standard method of monitoring infants in the delivery room, as it is simple, inexpensive and noninvasive. Keywords: pulse oximetry, oxygen administration, delivery room Presenter: Andreea Avasiloaiei

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ID 88

REDUCTION IN THE INCIDENSES OF BACTERIAL COMPLICATIONS OF INCHALET NITRIC OXIDE IN NEWBORNS WITH RESPIRATORI PATHOLOGY ON A VENTILATOR M. Puhtinskaya1, V. Estrin2, & M. Dudareva3 1

Pressure Transducer circuit

ID 399

LIMITING OXYGEN ADMINISTRATION IN THE DELIVERY ROOM THROUGH OXIMETRY MONITORING M. Stamatin1, A. Avasiloaiei1, M. Moscalu2, & M. Patriciu3 1

Division of Neonatology, Mother and Child Care Department, Gr.T.Popa University of Medicine and Pharmacy, Cuza-Voda Neonatal Intensive Care Unit, Iasi, Romania, 2Division of Medical Statistics, Interdisciplinary Sciences Department, Gr.T.Popa University of Medicine and Pharmacy, Iasi, Romania, and 3PhD student, Gr.T.Popa University of Medicine and Pharmacy, Iasi, Romania Brief Introduction: In spite of the overwhelming evidence of harmful effects of excessive administration in neonates, oxygen is still widely and liberally used in delivery rooms throughout Romania. The aim of this paper is to identify through oximetry newborns that require oxygen supplementation in the delivery room. Materials & Methods: We conducted a prospective study on 5406 neonates, born in the Cuza-Voda Maternity Hospital in Iasi, Romania, from December 2012 to December 2013. We assessed the following parameters: gestational age, birth weight, Apgar scores at 1, 5, 10, 20 minutes and preductal oxygen saturation at 1, 5, 15, 30 and 60 minutes. We used Nellcorä and Masimoä pulse oximeters. Data were collected and analyzed in order to assess the usefulness of oximetry monitoring in the delivery room. Clinical Cases or Summary Results: The mean gestational age in our lot was 38.18 weeks and the mean birth weight was 3175 grams. Apgar scores at 1, 5, 10, 20 minutes were between 1 and 10, with a median value of 9 at all moments. SpO2 values at 1 minute were between 40% and 90% in term newborns and between 50 and 82% in preterms. Mean SpO2 values throughout monitoring were: 65% at 1 minute, 80% at 5 minutes, 92% at 15 minutes, 97% and 98% at 30 and

Research Institute of Obstetrics and Pediatrics, Rostov-onDon, Russia, and 2Research Institute of Obstetrics and Pediatrics, Rostov-on-Don, Russia, and 3Research Institute of Obstetrics and Pediatrics, Rostov-on-Don, Russia. Brief Introduction: It is known, that infants with respiratory diseases with Mechanical Ventilation (MV), the development of bacterial complications is due including the activation of apoptosis of T lymphocytes and low-activated macrophages (CD14) [1]. Some clinical studies confirm the influence of inhaled nitric oxide (iNO) on anti-infectious resistance [2]. With the purpose reduce the incidence of bacterial complications studied the effects of iNO on subpopulation structure and apoptosis of T- Lymphocytes. Materials & Methods: In a controlled, randomized, blind clinical trial included 37 newborns on MV. Randomization was performed by the method of envelopes. Group I (n = 20) patients receiving inhalation of iNO in a concentration of 10 ppm for 24 hours («Pulmonox mini», «Messer II NO Therapeutics», Austria). In Group II (n = 17) did not receive iNO. At admission and at 3–5 day was studied subpopulations of lymphocytes in the venous blood: CD3, CD4, CD8, CD14, CD19, CD34, CD56, CD69, CD71, CD95 monoclonal antibody (Immunotech Beckman Coulter, USA); the relative content of Lymphocytes in apoptosis using AnneksinV + labeled FITK and propidium iodide (PL+), labeled with PE (Saltag, USA), with the results on the cytometer Beckman Coulter Epics XL (USA). The statistical power of the study was 80% (a  0.05). Clinical Cases or Summary Results: In Group I relative to group II on 3–5 day was registered an increase mature monocytes (CD14) 23.1 ± 0.8% (p50.05); reduction in the relative content of CD69 3.8 ± 0.21%, lymphocyte of apoptosis: Annexin V-FITC + PI7.12 ± 0.46% and Annexin V-FITC + PI + 0.79 ± 0.07% (p50.001). Duration of MV was 4.1 ± 1.4 days (18 ± 3.4 in Group II). All newborns survived and were not septic complications. None of the patients showed clinical or laboratory evidence of adverse effects of iNO. In Group II: fatai outcome - 7 newborns, the Incidence of Sepsis – 5. Conclusions: Inhaled Nitric Oxide in Newborns on M.V. increase in the relative content mature macrophages and decreased the lymphocytes in apoptosis; decreased the Incidence of Sepsis and Fatal Outcome, as well as the Duration of MV. Keywords: Inhaled Nitric Oxide, Newborn, Apoptosis Presenter: M. Puhtinskaya

Abstracts of the XXIV European Congress of Perinatal Medicine, June 4-7, 2014, Florence, Italy.

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