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144 Pregnancy-related deaths dueo hemorrhage in Florida, 1999-2007saac Delke1, Washington Hill2, Leticia Hernandez3,

illiam Sappenfield3, Deborah Burch4

University of Florida, Obstetrics & Gynecology, Jacksonville, Florida,Sarasota Memorial Hospital, Maternal-Fetal Medicine, Sarasota, Florida,Florida Department of Health, Office of Surveillance, Evaluation andpidemiology, Tallahassee, Florida, 4Florida Department of Health,nfant, Maternal and Reproductive Health, Tallahassee, FloridaBJECTIVE: To determine pregnancy-related deaths due to hemor-hage in Florida that were potentially preventable and the changeseeded to prevent them.TUDY DESIGN: The Florida Department of Health, Pregnancy-Asso-iated Mortality Review (PAMR) Committee reviewed all pregnancy-elated deaths that occurred in the state from January 1, 1999 to De-ember 31, 2007. For each death, the committee determined the causef death, identified potentially preventable gaps in quality of care, andeveloped recommendations for improvement in care. We analyzedregnancy-related deaths due to hemorrhage using this database. Liveirth data were used to calculate pregnancy-related mortality ratioue to hemorrhage (HPRMR), deaths per 100,000 live births, werebtained from published vital statistics. Deaths due to ectopic preg-ancy were included.ESULTS: There were 335 pregnancy-related deaths and, 47 (14.0%)ere due to hemorrhage. Women 35 years and older had higherPRMR (6.8) than women 24 years and younger (1.1). Black women

ad higher HPRMR (5.8) than Hispanic (2.4), and white (0.9)omen. Uterine atony (25.8%), placenta previa/accreta/increta/per-

reta (22.6%), and abruption placentae (16.1%) accounted for two-hirds of deaths in women with an intrauterine pregnancy at 20 weeksr more. Eighty four percent of these cases were determined to bessociated with potential gaps in quality of care. Ectopic pregnancyccounted for 25.5% of the deaths, but only 5/12 (41.7%), were asso-iated with gaps in quality of care.ONCLUSION: Hemorrhage was the second leading cause of pregnancy-elated death in Florida. Black women had six times the risk of deathf white women. The risk of pregnancy-related death increased withge. These deaths could potentially be prevented through improveduality of care and, patient/community education (LEVEL OF EVI-ENCE: III).002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.159

145 A prospective observational trial of history indicatederclage location and pregnancy outcomeslizabeth Platz1, Scott Sullivan1, Jeffrey Korte2, Roger Newman1

Society for Maternal-Fetal Medicine, Charleston, South Carolina,Medical University of South Carolina, Biostatisticsnd Epidemiology, Charleston, South CarolinaBJECTIVE: To determine if the anatomic location of history indicatederclages has an effect on the gestational age at delivery.TUDY DESIGN: We performed an IRB approved, prospective observa-ional trial of women receiving a history indicated cervical cerclageetween November 2007 and June 2009. All subjects underwent acDonald or Shirodkar cerclage at 15 weeks gestation. All partici-

ants had transvaginal sonograph of the cervix prior to and immedi-tely after cerclage placement. Transvaginal measurements includedotal cervical length, distance from cerclage to external and internal os,nd width of the cervix prior to cerclage placement. These measure-ents were then repeated on an outpatient basis at 18, 22 and 24eeks. The relationship of these measurements and gestational age atelivery were analyzed by multiple linear and logistic regression.ESULTS: A total of 56 patients were enrolled in the study. The meanotal cervical length post cerclage was 35.6 mm, the mean length prox-mal was 19.4 mm and the distal mean length was 16.2 mm. The meanestational age at delivery was 32.9 weeks (� 6.5) with a distance ofess than 15 mm from cerclage to the external os versus 37.4 weeks (�

.0) which was significant (p�0.01). This difference was seen in r

68 American Journal of Obstetrics & Gynecology Supplement to DECEMBER 2

omen with cervical lengths less than 20 mm with the mean gesta-ional age at delivery of 34.3 weeks (p�0.05). A logistic regression

odel, controlling for maternal age, race and parity demonstrated andds ratio of 11.0 (2.1, 56.6) (p�.004) for preterm delivery comparingomen with �15 mm vs. �15 mm distal cervical length. An OR of 6.4as observed for distal cervical lengths greater than 20 mm. In linearodels, every 1 mm increase in width of the cerclage was associatedith a 2 day longer gestation (p�0.04).ONCLUSION: A distance less than 15 mm from a history indicatederclage to the external os is associated with an increased risk of pre-erm delivery.002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.160

146 Application of a clinical risk stratification scoren pregnancy and the puerperium - can unnecessarynvestigations for pulmonary embolism be avoided?lare O’Sullivan1, John Moriarty2, Jennifer Walsh3,am Coulter-Smith4, William Boyd5

National Maternity Hospital, Dublin, Ireland, 2University of California,os Angeles, California, 3National Maternity Hospital, Ireland,The Rotunda Hospital, Dublin, Ireland, 5Mater Misericordiaeospital, Gynae-Oncology, Dublin, IrelandBJECTIVE: Pulmonary Embolism remains the number one cause ofirect maternal death in the developed world with an almost 10 fold

ncreased incidence in pregnancy versus the non-pregnant popula-ion.The diagnostic imaging tool of choice, CT Pulmonary Angiogra-hy, is costly and hazardous due to radiation and iodinated contrastdministration. Our aim was to retrospectively evaluate the efficacy ofhe Modified Wells score as a risk stratification tool in the antenatalnd post natal setting.TUDY DESIGN: This study was carried out in a large tertiary referralentre in Ireland. All pregnant or post-partum patients who wereeferred for CT Pulmonary Angiography (CTPA) over a 5 year periodere included in the study cohort. Developed by Wells et al in 2000,

he Modified Wells Score (MWS) combines clinical history and signso obtain a probability score (6 or more �high risk). Its use in adult

edicine is well validated. Patients records were used to retrospec-ively apply a MWS and hypothesis analysis was performed using thehi squared test.ESULTS: A total of 125 women were referred for CTPA over a 5 yearime period (97 pregnant, 28 post-partum). 5 positive for PE onTPA. MWS of 6 or greater (“High Risk”) � 100% sensitive, 90%

pecific, positive predictive value of 36% negative predictive value of00% for the diagnosis of PE. P��0.001. D-dimers, chest X-ray,lood gases and ECG data was also analysed.The sensitivity and spec-

ficity of these commonly used tests were found to be significantlyower than the MWS for the diagnosis of PE.ONCLUSION: The diagnosis of PE in pregnancy and the puerperiumepresents a significant diagnostic challenge. Risk stratification usinghe Modified Wells Score may allow safe and timely exclusion of PE, ast has been shown in this study to have a negative predictive value of00%.This may reduce the use of expensive and potentially toxic di-gnostic tools, such as CT Pulmonary Angiography, in a large major-ty of cases. To the best of our knowledge this is the first study to havesed the modified wells score in the maternity setting.002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.161

147 Fetal fibronectin for evaluation of pretermabor in the setting of cervical cerclageames Benson1, Alessandro Ghidini2, Helain Landy1,oridelle Gilo1, Daphnie Drassinower1, Sarah Poggi2

Georgetown University, Washington, District of Columbia,Georgetown University, Alexandria, VirginiaBJECTIVE: Previous studies have validated fetal fibronectin (FFN)esting in asymptomatic patients with cervical cerclage undergoing

outine surveillance. However, the efficacy of FFN has not been estab-

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ished for cerclage patients presenting with acute signs or symptoms ofreterm labor (PTL).TUDY DESIGN: This retrospective study evaluated the efficacy of FFNn a cohort of women with cervical cerclage presenting at two separateenters at risk for imminent delivery (based on PTL and cervicalhortening). A total of 71 FFN tests were performed in 48 womenetween 23 and 34 weeks= gestation. Excluded were patients with vag-

nal bleeding or ruptured membranes. The FFN tests were evaluatedor their ability to predict delivery within 2 weeks of testing or �34eeks (for which any positive FFN was considered positive and neg-

tive FFN if all testing had been negative). Diagnostic indices werealculated and Fisher=s exact test was used to compare outcomes ofositive vs negative FFN results.ESULTS: The sensitivity, specificity, positive predictive value, andegative predictive value for delivery within 2 weeks of fetal fibronec-

in testing were 100%, 77%, 28% and 100% respectively (P �0.001).o patients delivered within 2 weeks of a negative FFN test. For de-

ivery before 34 weeks sensitivity, specificity, positive predictive value,nd negative predictive value were 91%, 78%, 56% and 97% respec-ively. The relative risk of delivery �34 weeks with positive FFN was6.7 (P � 0.001).ONCLUSION: In the setting of cervical cerclage, FFN testing has similarccuracy for prediction of preterm delivery in the presence of pretermabor as reported in asymptomatic cerclage patients.002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.162

148 Post-cerclage ultrasound monitoring of cervicalength for predicting gestational age at deliverylison Cape1, Carol Benson2, Thomas McElrath1

Brigham and Women’s Hospital, Maternal Fetal Medicine,oston, Massachusetts, 2Brigham and Women’sospital, Radiology, Boston, MassachusettsBJECTIVE: It is unclear from the literature whether following cervical

engths after cerclage placement is predictive of gestational age at de-ivery and thus a useful practice.TUDY DESIGN: We included women with a singleton pregnancy overhe last 5 years and at least two transvaginal ultrasounds between 20nd 30 weeks after a vaginally placed cerclage. A linear regression wassed to determine the association between gestational age at delivery,

he initial cervical length and the change in cervical length of �5mmrior to 30 weeks.ESULTS: Complete information was available for 380 women. Meanestational ages at first and second measurements were 21.8 weeksSD�1.7) and 28.1 weeks (SD�1.9) respectively. For women withoutmm shortening, only those starting with cervical length �2cm weret risk of delivering at earlier gestation. Regardless of the initial cervi-al length category, however, any woman with shortening �5mm alsoelivered at earlier gestation. The combination of initial cervical

ength of �2cm and cervical change was associated with earliest de-ivery (Table).ONCLUSION: These results confirm that among women with cervicalerclage, cervical length �2cm at 21 weeks is associated with a shorterestation. More importantly, for all length categories, shortening5mm is associated with an earlier mean gestational age. Initial

ength and change in length may provide different perspectives on theuration of gestation in the cerclage population.

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ean delivery gestational age by initial cervical length (CL),ith and without change in length prior to 30 weeks

nitial CL Chg> 5mm N Mean Del GA 95% CI p- value

2cm No 60 35.8 27.1, 41.8 0.041..........................................................................................................................................................

Yes 22 31.5 21.1, 39.4 �.001.........................................................................................................................................................................................

2-3cm No 77 37.3 28.7, 43.3 0.171..........................................................................................................................................................

Yes 40 35.9 25.8, 43.0 0.049.........................................................................................................................................................................................

3cm No 136 38.5 29.9, 44.5 0.40..........................................................................................................................................................

Yes 45 36.4 26.6, 43.6 0.001.........................................................................................................................................................................................

002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.163

149 Inappropriate identification of MFM practices low quality by a NQF/LEAPFROG indicatorhomas Benedetti1, Suzan Walker2

University of Washington, Obstetrics and Gynecology, Seattle, Washington,University of Washington, Neonatology, Seattle, WashingtonBJECTIVE: To evaluate the “Elective Delivery Prior to 39 Weeks Ges-ation” National Quality Forum/ Leapfrog (NQFL) perinatal indica-or derived from hospital discharge data for benchmarking perinatalare on the practice assessment of MFM specialists.TUDY DESIGN: At one quaternary academic medical center the NQFLndicator algorithm for Elective Delivery Prior to 39 Weeks Gestationas applied to 12 months of administrative data linked with a supple-ental gestational age file. 100% of medical records from cases iden-

ified as elective delivery were reviewed.ESULTS: Among 2110 total live births during a 12 month period, 784ingleton deliveries �� 37 weeks gestation with specified conditionsxcluded by the algorithm were identified. Among these 89(11.4%)ases were identified as elective delivery prior to 39 weeks gestation.fter chart review cases fell into five categories of pertinent conditionsrior to admission. We found the following non-exclusive medical

ndications for delivery prior to 39 weeks gestation: Congenital anom-lies 21/89 (24%), labor and/or rupture of membrane 33/89 (37%),aternal medical conditions 32/89 (36%), previous cesarean 28/89

31%), and abnormal antepartum testing 6/89 (7%). Among thebove conditions 23/89 (25%) had two or more concurrent condi-ions. We identified 17 coding errors that should have received codesn the exclusion code list (1 case of diabetes and 16 with rupture ofembranes). The remainder of conditions were not on the exclusion

ist. Fifty of 89 cases ( 56%) represented appropriate MFM practiceecisions( delivery �37weeks with pulmonary maturity of maternaledical conditions, delivery of severe congenital anomalies � 37eeks with pulmonary maturity).ONCLUSION: Congenital anomalies and maternal medical conditionsould most likely be followed by MFM specialists. As currently used

he NQFL indicator “ Elective Delivery prior to 39 weeks” would in-ppropriately identify MFM specialists as providing low quality care.002-9378/$ – see front matter • doi:10.1016/j.ajog.2009.10.164

150 Can the final value of the 3 hour glucose tolerancee omitted without compromising sensitivity?anasi Patwardhan1, James Airoldi1

St. Luke’s Hospital, Bethlehem, PennsylvaniaBJECTIVE: The 3 hour glucose tolerance test (GTT) is a long, tediousnd exhausting test for pregnant women and needs to be simplified.he objective was to evaluate whether the final value (the 3 houralue) can safely be omitted without compromising detection. A sec-nd objective was to assess whether the prepregnancy weight couldelp discriminate which patients need the final blood draw.TUDY DESIGN: This is a case series study. An existing gestational dia-etes database was querried and all abnormal 3 hour GTT’s were iden-ified. An abnormal 3 hour GTT was defined as an elevated fasting

lucose only, or any combination of 2 out of the remaining 3 tests.

nt to DECEMBER 2009 American Journal of Obstetrics & Gynecology S69