Plurality and contemporary infant mortality risks

Plurality and contemporary infant mortality risks

S114 SMFM Abstracts 379 THE RELATIONSHIP BETWEEN AMNIOTIC FLUID WHITE BLOOD CELL COUNT AND FUNISITIS AT TERM SI EUN LEE1, ROBERTO ROMERO2, SOON-SUP SH...

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S114 SMFM Abstracts 379 THE RELATIONSHIP BETWEEN AMNIOTIC FLUID WHITE BLOOD CELL COUNT AND FUNISITIS AT TERM SI EUN LEE1, ROBERTO ROMERO2, SOON-SUP SHIM1, KYUNG CHUL MOON3, CHONG JAI KIM3, BO HYUN YOON1, 1Seoul National University College of Medicine, Department of Obstetrics and Gynecology, Seoul, South Korea, 2Wayne State University, Detroit, Michigan, 3Seoul National University College of Medicine, Department of Pathology, Seoul, South Korea OBJECTIVE: Funisitis is the histologic counterpart of the fetal inflammatory response syndrome, which is a multisystem disorder associated with impending preterm delivery and adverse short- and long-term neonatal outcome (i.e., cerebral palsy). However, this association was described in preterm gestation and there are questions whether this applies to term gestation, particularly in medico-legal cases of cerebral palsy at term. The objective of this study was to determine if there is a relationship between AF white blood cell (WBC) count and funisitis in term pregnancies. STUDY DESIGN: This study included 832 patients who delivered term singleton neonates within 72 hours of amniocentesis. AF was cultured for aerobic and anaerobic bacteria, as well as for mycoplasmas. Funisitis was diagnosed in the presence of neutrophil infiltration into the umbilical vessel walls or Wharton’s jelly. AF WBC count was determined with a hemocytometer chamber. RESULTS: 1) Funisitis was present in 3.6% (30/832) of patients; 2) A positive AF culture was more common in cases with funisitis than in those without funisitis (17% vs 5%; p!0.05); 3) Patients with funisitis had a higher median AF WBC count than those without funisitis (median, O1000 cells/mm3; range, 0- O1000 cells/mm3; vs median, 2 cells/mm3; range, 0-O1000 cells/mm3; p!0.001); 4) The diagnostic indices of AF WBC (cutoff, 18 cells/mm3) in the identification of funisitis were: a sensitivity of 70%, a specificity of 81%, a positive predictive value of 12%, and a negative predictive value of 99%. CONCLUSION: 1) An elevated AF WBC count is associated with funisitis in term gestations; 2) Funisitis is associated with AF infection. We propose that the diagnosis of funisitis in the placenta is evidence of prior exposure of the fetus to an inflammatory stimulus and can have medico-legal value in the defense of cases of cerebral palsy at term.

381 RISK OF MATERNAL MORBIDITY IN MULTIPLE PREGNANCY BARBARA LUKE1, MORTON B. BROWN2, 1University of Miami, Coral Gables, Florida, 2University of Michigan, Biostatistics, Ann Arbor, Michigan OBJECTIVE: The incidence of multiple births has risen dramatically since 1980, with an 83% increase in twins and a 453% increase in triplet and higherorder births. Our objective was to calculate nationally-representative, population-based estimates of maternal morbidity associated with multiple pregnancy. STUDY DESIGN: The study population included all singleton pregnancies from the 1995-2000 Birth Cohort Linked Birth/Infant Death Data Set and all multiple pregnancies from the 1995-2000 Matched Multiple Birth Data Set: 22,991,306 singleton (SI), 316,696 twin (TW), 12,193 triplet (TR), and 778 quadruplet (QU) pregnancies. Adjusted odds ratios (AORs) and 95% confidence intervals calculated the plurality-specific risk of complications compared to singletons, controlling for maternal age, race, parity, and smoking status. RESULTS: Mothers of multiples were significantly more likely to have preexisting medical risk factors (cardiac disease, AOR 1.26, 1.20-1.32; lung disease, AOR 1.35, 1.30-1.40; renal disease, AOR 1.17, 1.09-1.26), a previous preterm or small-for-gestational infant (AOR 1.25, 1.21-1.29), or to have diabetes or chronic hypertension prior to or during pregnancy (AOR 1.26, 1.24-1.29, and AOR 1.29, 1.24-1.34, respectively). Mean gestation was 38.9 weeks for SIs compared to 35.5 weeks for TWs, 32.0 weeks for TRs, and 30.1 weeks for QUs. Nearly every risk factor was increased for multiples, including incompetent cervix (TW-AOR 3.47, 3.33-3.62, TR-AOR 18.57, 16.93-20.38, and QU-AOR 39.72, 30.44-51.84), pregnancy-associated hypertension (TW-AOR 2.33, 2.30-2.36, TR-AOR 2.79, 2.62-2.96, QU-AOR 2.89, 2.283.67), premature rupture of membranes (TW-AOR 2.39, 2.35-2.43, TR-AOR 3.36, 3.15-3.59, QU-AOR 3.86, 3.02-4.94), and tocolysis (TW-AOR 4.54, 4.474.60, TR-AOR 13.27, 12.65-13.92, QU-AOR 24.00, 20.42-28.22). CONCLUSION: Women pregnant with multiples have significantly more risk factors both before and during pregnancy than their singleton counterparts. These risks should be considered in counseling infertility patients, and in the antenatal management of multiples.

380 PLURALITY AND CONTEMPORARY INFANT MORTALITY RISKS BARBARA LUKE1, MORTON B. BROWN2, 1University of Miami, Coral Gables, Florida, 2University of Michigan, Biostatistics, Ann Arbor, Michigan OBJECTIVE: During the 1990s major changes occurred in medical practice, clinical guidelines, and national recommendations in the US, paralleling the rise in multiple births. Our objective was to quantify infant mortality risks using national vital statistics data. STUDY DESIGN: The study population included all live births of 20 weeks gestation or more from the 1995-2000 US Birth Cohort Linked Birth/Infant Death Data Sets. This included 23,674,816 live births (LBs) and 157,358 infant deaths (IDs). Infant mortality rates (IMRs) were deaths per 1,000 LBs. Adjusted odds ratios (AORs) and 95% confidence intervals were calculated to evaluate the change in risk between 1995-97 and 1998-00 by plurality and compared to the change for singletons. RESULTS: The IMR decreased from 6.03 to 5.68 for singletons, 29.00 to 27.22 for twins, 63.58 to 56.33 for triplets, but increased from 80.54 to 94.01 for quadruplets and quintuplets. The risk of infant mortality decreased significantly overall and for births less than 25 weeks, respectively, for singletons (AOR 0.96, 0.95-0.97 and AOR 0.93, 0.90-0.96), twins (AOR 0.95, 0.93-0.98 and AOR 0.86, 0.80-0.93), and triplets (AOR 0.89, 0.81-0.97 and AOR 0.71, 0.57-0.89). At weeks 25-28, only triplets had a significant decrease (AOR 0.79, 0.66-0.96). At weeks 29-32, only twins had a significant decrease (AOR 0.89, 0.81-0.98). Beyond 32 weeks, only singletons had a decrease (weeks 33-36, AOR 0.89, 0.86-0.92; weeks 37-40, AOR 0.94, 0.92-0.96; and over 40 weeks, AOR 0.93, 0.90-0.97). Compared to singletons, very premature triplets experienced the greatest risk reduction (less than 25 weeks, AOR/AOR 0.76, 0.61-0.96, and 25-28 weeks, AOR/AOR 0.80, 0.66-0.97). CONCLUSION: The medical advances in the 1990s have improved infant survival rates for nearly all children, particularly those born at less than 28 weeks gestation. Improved survival at increasing earlier gestations, though, has important implications for subsequent physical and mental disabilities.

382 MATERNAL MORBIDITY IN TWIN VS TRIPLET & QUADRUPLET PREGNANCIES BARBARA LUKE1, MORTON B. BROWN2, 1University of Miami, Coral Gables, Florida, 2University of Michigan, Biostatistics, Ann Arbor, Michigan OBJECTIVE: Over the past 25 years the incidence of multiple births has risen dramatically. In higher-order pregnancies, fetal reduction to twins is often recommended to potentially reduce perinatal risks. Our objective was to calculate nationally-representative, population-based estimates of maternal risks among triplet and quadruplet pregnancies compared to twins. STUDY DESIGN: The study population included 316,696 twin, 12,193 triplet, and 778 quadruplet pregnancies from the 1995-2000 Matched Multiple Birth Data Set. Adjusted odds ratios (AORs) and 95% confidence intervals estimated the risk of complications for triplets and quadruplets compared to twins, controlling for maternal age, race, parity, and smoking status. RESULTS: Twin pregnancies averaged significantly longer gestations and higher mean birthweights compared to triplets and quadruplets (35.5 weeks and 2,376 g vs 32.0 weeks and 1,706 g and 30.1 weeks and 1,320 g). Mothers of triplets or quadruplets were more likely to have preexisting medical factors (cardiac disease, AOR 1.30, 1.08-1.58; lung disease, AOR 1.57, 1.35-1.82), or to have diabetes or chronic hypertension prior to or during pregnancy (AOR 1.66, 1.53-1.80, AOR 1.21, 1.02-1.44, respectively). Mothers of triplets or quadruplets were more likely to be diagnosed with an incompetent cervix (AOR 5.00, 4.54-5.52), anemia (AOR 1.32, 1.19-1.47), pregnancy-associated hypertension (AOR 1.23, 1.15-1.30), uterine bleeding (AOR 1.49, 1.28-1.74), or eclampsia (AOR 1.69, 1.47-1.93). During labor and delivery, mothers of triplets or quadruplets were more likely to require tocolysis (AOR 2.97, 2.833.11), or to experience premature rupture of membranes (AOR 1.55, 1.45-1.65) or other complications (AOR 1.57, 1.51-1.64), and to be delivered by cesarean (AOR 6.60, 6.21-7.01). CONCLUSION: Compared to twins, triplet and quadruplet births average 20-70% higher risks for the majority of antenatal and intrapartum complications. Maternal nutritional and lifestyle factors may be particularly important in improving outcomes in higher-order multiple births.