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RESULTS: Of 62,645 total patients, 7,083 (11.3%) were smokers. A to-al of 4,707 (7.5%) patients in the entire cohort developed preeclamp-ia. Smokers were younger and more likely to be nulliparous, white,verweight or obese, and have chronic hypertension, pregestationalr gestational diabetes, or renal disease. There were no differences inates of preeclampsia between smokers and non-smokers (0.98, 95%I 0.89-1.07). This lack of relationship persisted after controlling for

onfounders (aOR 0.97, 95% CI 0.88-1.07). In stratified analysis,here was no association between smoking and preeclampsia in anyeight category (Table 1).

CONCLUSIONS: In this large retrospective analysis, we did not find anssociation between smoking and decreased rates of preeclampsia,egardless of BMI category.

Table 1. Risk of Preeclampsia in Smokers by BMI Category

BMI CategoryPreeclampsia,n (%) OR (95% CI) aOR* (95% CI) P-value

ormal 1267 (4.5) 0.96 (0.80-1.15) 1.01 (0.84-1.23) 0.884..........................................................................................................................................................................................

Overweight 1209 (8.4) 1.00 (0.83-1.20) 0.99 (0.82-1.20) 0.935..........................................................................................................................................................................................

Obese 2142 (11.5) 0.93 (0.81-1.07) 0.94 (0.81-1.09) 0.395..........................................................................................................................................................................................

Underweight 35 (2.7) 0.86 (0.30-2.47) 1.03 (0.34-3.08) 0.951..........................................................................................................................................................................................

* Adjusted for age, race, parity, chronic hypertension, pregestational diabetes, and gestationaldiabetes

596 Gestational weight gain: will more stringent weightain recommendations improve obstetrical andeonatal outcomes among obese women?

Neil S. Seligman1, Cara Doherty1, Vincenzoerghella1, Matthew K. Hoffman2

1Thomas Jefferson University, Philadelphia,A, 2Christiana Hospital, Newark, DE

OBJECTIVE: The Institute of Medicine (IOM) recommends a gesta-ional weight gain (GWG) range of 11-20lbs for all obese women. Ourbjective was to determine if more stringent GWG recommendationsor class 2 and 3 obese women correlate with improved obstetrical andeonatal outcomes.

STUDY DESIGN: Class 2 (BMI 35.0-39.9kg/m2) and class 3 (BMI40kg/m2) obese women were selected from the Consortium on Safe

Labor database which contains retrospective electronic data from 12institutions (19 hospitals) on 233,844 deliveries which occurred be-tween 2002-08. Exclusion criteria were unknown pre-pregnancy BMIor delivery weight, multiple gestations, and preterm delivery. Class 2obese women with GWG of �9 to 9lbs and class 3 obese women withGWG of �15 to 0lbs (“strict” cohort; based on findings by Beyerlein etal. Am J Clin Nutr 2009 and Kiel et al. Obstet Gynecol 2007) werecompared to class 2 and 3 obese women with GWG of 11-20lbs (IOMcohort).The primary outcome was macrosomia �4000g. Secondaryoutcomes were shoulder dystocia, low birth weight, stillbirth, AP-GAR5 �7, NICU admission, cesarean section, hypertensive disorders,and gestational diabetes.RESULTS: Of 8,928 class 2 and 3 obese women, 3,303 (37%) had GWG

ithin the “strict” (n�1,282) or IOM (n�2,021) recommendedanges. Median BMI was 39.7kg/m2 (35.0-70.8kg/m2) in the “strict”

cohort and 40.3kg/m2 (35.0-72.3kg/m2) in the IOM cohort. The ratef macrosomia �4000g was 7.7% in the “strict” cohort compared to1.1% in the IOM cohort (OR 0.67, 95%CI 0.52-0.86). Other out-omes were not statistically significant, except for low birthweight andypertensive disorders.

CONCLUSIONS: More stringent gestational weight gain recommenda-ions, than those made by the IOM, were correlated with a lower

requency of macrosomia among women with a BMI �35kg/m2. m

S238 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2

Obstetrical and neonatal outcomes of class 2 and 3 obese womenwith GWG meeting more stringent recommendations comparedto women with GWG meeting the IOM recommendations.

Outcome“strict” IOM ORn � 1282 n � 2021 (95%CI)

acrosomia >4000g 99 (7.7) 225 (11.1) 0.67 (0.52-0.86)..........................................................................................................................................................................................

Macrosomia �4500g 16 (1.2) 43 (2.1) 0.58 (0.33-1.04)..........................................................................................................................................................................................

Shoulder Dystocia 19 (1.6) 28 (1.5) 1.09 (0.61-1.96)..........................................................................................................................................................................................

Low Birthweight 34 (2.7) 32 (1.6) 1.69 (1.04-2.76)..........................................................................................................................................................................................

Stillbirth 1 (0.1) 4 (0.4) 0.39 (0.04-3.53)..........................................................................................................................................................................................

APGAR5 �7 16 (1.2) 20 (1.0) 1.26 (0.65-2.45)..........................................................................................................................................................................................

NICU Admission 135 (10.5) 195 (9.6) 1.10 (0.87-1.39)..........................................................................................................................................................................................

Cesarean Sectiona 226 (22.0) 385 (24.9) 0.85 (0.71-1.03)..........................................................................................................................................................................................

Hypertensive Disordersb 85 (7.2) 178 (9.4) 0.75 (0.57-0.98)..........................................................................................................................................................................................

Gestational Diabetes 104 (9.8) 189 (11.1) 0.87 (0.68-1.13)..........................................................................................................................................................................................

Data presented as n (%); a) excluding repeat cesarean section; b) defined as gestationalhypertension, preeclampsia (or superimposed), HELLP syndrome, or eclampsia

597 Maternal super-obesity and perinatal outcomesNicole Marshall1, Camelia Guild2, Yvonne W.

heng3, Aaron Caughey1, Donna Halloran2

1Oregon Health & Science University, Portland, OR, 2Saint Louis University,Saint Louis, MO, 3University of California, San Francisco, San Francisco, CAOBJECTIVE: To determine the effect of increasing maternal BMI, in-luding morbid obesity (BMI �40 kg/m2) and super-obesity (BMI

�50 kg/m2), on perinatal outcomes.STUDY DESIGN: This is a retrospective cohort study of birth recordsinked to hospital discharge data for all live born singleton infants �37eeks gestation born to African American or Caucasian Missouri res-

dents from 2000-2006. We excluded major congenital anomalies andomen with diabetes or chronic hypertension.

RESULTS: There were 625,745 births meeting study criteria. 19,8943.2%) women were morbidly obese and 2,323 (0.37%) were super-bese. Super-obese women were significantly more likely than otherbese women (BMI 30-49.9 kg/m2) to have a cesarean delivery (aOR.68, 95% CI 1.47, 1.92), preeclampsia (aOR 1.62, 95% CI 1.41, 1.85),acrosomia (aOR 1.73, 95% CI 1.37, 2.18) and hypoglycemia (aOR

.85, 95% CI 1.36, 2.52) (table).CONCLUSIONS: Women with a BMI �50 kg/m2 are at significantly in-creased risk of perinatal complications compared to women in theother BMI classes, including other obese women with a BMI 30-49.9kg/m2.

Table. Perinatal outcomes by BMI

18.5-24.9 25-29.9 30-39.9 40-49.9 >50

30-49.9 vs.>50 aOR(95% CI) p-value

Cesarean delivery 19.7% 26.3% 33.4% 43.1% 49.7% 1.68 (1.47, 1.92) �.0001..........................................................................................................................................................................................Preeclampsia 3.2% 5.1% 7.4% 9.8% 11.2% 1.62 (1.41, 1.85) �.0001..........................................................................................................................................................................................Macrosomia 0.8% 1.5% 1.9% 2.7% 3.4% 1.73 (1.37, 2.18) �.0001..........................................................................................................................................................................................Hypoglycemia 0.6% 0.7% 0.9% 1.3% 1.9% 1.85 (1.36, 2.52) �.0001..........................................................................................................................................................................................

Adjusted for: smoking, Medicaid, age (18-34), average education, prenatal care, married,nulliparous, previous C/S, primary elective C/S, infant gender (male), and African Americanrace.

598 Eating for two: the effect of gestational weightain, maternal BMI, and race on birthweight

Nicole Marshall1, Camelia Guild2, Yvonne W.heng3, Aaron Caughey1, Donna Halloran2

1Oregon Health & Science University, Portland, OR, 2Saint Louis University,Saint Louis, MO, 3University of California, San Francisco, San Francisco, CAOBJECTIVE: To determine the effect of gestational weight gain (GWG),

aternal BMI, and race on birth weight (BW).

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STUDY DESIGN: This is a retrospective cohort study of birth recordsinked to hospital discharge data for all live born singleton infants �37eeks gestation born to African American or Caucasian Missouri res-

dents from 2000-2006. We excluded major congenital anomalies andomen with diabetes or chronic hypertension. Gestational weightain categories were chosen as �10 lbs and �40 lbs as these amounts

are outside of the 2009 Institute of Medicine guidelines for weight gainin pregnancy. GWG of 10-40 lbs served as the referent category.RESULTS: There were 625,745 births meeting study criteria. GWG �40bs was associated with an increased incidence of fetal macrosomia,egardless of race or maternal BMI (table). GWG �10 lbs was associ-ted with an increased risk of low birth weight and GWG �40 wasrotective against LBW for both Caucasian and African Americanomen of all BMI. Overweight and obese Caucasian women, but notfrican American women, with GWG � 10 lbs had significantly de-reased risk of fetal macrosomia and significantly increased risk ofBW.

CONCLUSIONS: Weight gain during pregnancy is significantly associ-ted with BW. All women, including normal weight women, whoained more than 40 lbs during pregnancy were significantly moreikely to deliver macrosomic infants. Further studies are needed toetermine the ideal weight gain during pregnancy for optimal fetalrowth.

Table. Risk of macrosomia for women who gain<10 lbs or > 40 lbs across BMI categories

Caucasian African AmericancOR (95% CI) cOR (95% CI) aOR

†(95% CI)

WG �10 lbs.................................................................................................................................................................................

18.5-24.9* 1.00 (0.54, 1.88) 5.18 (2.05, 16.46) 0.44 (0.38, 0.50).................................................................................................................................................................................

25-29.9* 0.41 (0.26, 0.65) 0.56 (0.14, 2.3) 0.48 (0.42, 0.54).................................................................................................................................................................................

� 30* 0.34 (0.27, 0.44) 0.36 (0.13, 1.00) 0.46 (0.40, 0.53)..........................................................................................................................................................................................

GWG �40 lbs.................................................................................................................................................................................

18.5-24.9* 2.95 (2.71, 3.20) 5.47 (3.62, 8.28) 0.48 (0.43, 0.53).................................................................................................................................................................................

25-29.9* 2.64 (2.41, 2.89) 3.97 (2.90, 5.42) 0.51 (0.46, 0.57).................................................................................................................................................................................

� 30* 2.18 (1.96, 2.42) 2.23 (1.57, 3.17) 0.49 (0.45, 0.54)..........................................................................................................................................................................................

* BMI (kg/m2)† Adjusted for maternal age, average education, nulliparous, Medicaid, adequate prenatal

care, smoking, maried, male gender, prior C-section, primary elective C-section.

599 The effect of race and maternalbesity on perinatal outcome

Nicole Marshall1, Camelia Guild2, Yvonne W.heng3, Aaron Caughey1, Donna Halloran2

1Oregon Health & Science University, Portland, OR, 2Saint Louis University,Saint Louis, MO, 3University of California, San Francisco, San Francisco, CAOBJECTIVE: To determine the effect of race and obesity on perinatal

utcomes.STUDY DESIGN: This is a retrospective cohort study of birth recordsinked to hospital discharge data for all live born singleton infants �37eeks gestation born to African American or Caucasian Missouri res-

dents from 2000-2006. We excluded major congenital anomalies andomen with diabetes or chronic hypertension. Obesity was defined asre-pregnancy body mass index � 30 kg/m2.

RESULTS: There were 625,745 births meeting study criteria. 28.1%25,727) of African American mothers and 20.0% (111,596) of Cau-asian mothers were obese. Infants of obese African American womenere significantly less likely to be macrosomic (1.2% vs. 2.5%, aOR.39, 95% CI 0.34, 0.45) and more likely to be low birth weight (3.4%s. 1.8%, aOR 2.26, 95% CI 2.14, 2.38) compared to infants of obeseaucasian women (table).

CONCLUSIONS: Obesity-related maternal and neonatal complicationsf pregnancy, especially birth weight, vary by race and should be con-

idered in counseling obese pregnant women.

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Table. Obstetric outcomes in obese women by race

AfricanAmerican CaucasianN % N % aOR

†(95% CI) p-value

esarean delivery 8294 32.2 41730 37.4 1.02(0.98, 1.05) 0.3953..........................................................................................................................................................................................Preeclampsia 1952 7.6 9163 8.2 1.11 (1.06, 1.16) �.0001..........................................................................................................................................................................................Macrosomia 309 1.2 2809 2.5 0.39 (0.34, 0.45) �.0001..........................................................................................................................................................................................Low Birth Weight 880 3.4 2006 1.8 2.26(2.14, 2.38) �.0001..........................................................................................................................................................................................Birth Trauma 430 1.7 2065 1.8 0.89 (0.83, 0.96) 0.0026..........................................................................................................................................................................................Hypoglycemia 367 1.4 1770 1.6 0.80 (0.70, 0.91) 0.0008..........................................................................................................................................................................................Length of stay� 5 days

2663 10.3 10779 9.7 1.07 (1.03, 1.10) 0.0003

..........................................................................................................................................................................................Low Apgar 266 1.0 713 0.6 1.47 (1.31, 1.62) �.0001..........................................................................................................................................................................................

† Adjusted for maternal age, average education, nulliparous, Medicaid, adequate prenatalcare, smoking, married, male gender, prior C-section, primary elective C-section.

600 Impact of number of cesareans on placentalbnormalities and maternal morbidity: a systematic review

Nicole Marshall1, Jeanne-Marie Guise1

1Oregon Health & Science University, Portland, OROBJECTIVE: To determine the impact of number of prior cesarean de-iveries upon placental abnormalities and maternal outcomes.

STUDY DESIGN: This study was performed as part of a systematic re-view conducted to inform the 2010 NIH Consensus DevelopmentConference on Vaginal Birth After Cesarean: New Insights. Publishedstudies were identified from searches of MEDLINE®, Cochrane Da-tabase of Systematic Reviews, National Centre for Reviews and Dis-semination (1980 to September 2009), reference lists, and nationalexperts. English language,general population studies from developedcountries of women with one or more prior cesarean were included.RESULTS: Women with a prior cesarean delivery had a statistically sig-

ificant increased risk of placenta previa compared with women witho prior cesarean at a rate of 12 per 1,000 (95% CI: 8 to 15 per 1,000).he incidence increased with increasing number of prior cesareaneliveries (Table). Similarly, the odds of adverse outcomes increasedith increasing number of cesareans: Hysterectomy OR 3.8-18.6 for 2r more cesareans compared with 1; adhesions OR 2.5 with 2 or moreompared with none.

CONCLUSIONS: Women with multiple cesareans suffer increasing mor-idity with increasing numbers of cesareans. Women consideringlective or repeat cesarean need to be counseled about the risks ofultiple cesareans. This increased morbidity is particularly concern-

ng for rural providers who may not have the resources (e.g. bloodupply and surgical staff) to respond to these life threatening condi-ions, yet according to limited evidence this is the very group who areerforming fewer VBACs.

Considerations Rate

Placenta Previa..........................................................................................................................................................................................

General population 800/100,000..........................................................................................................................................................................................

1 Prior Cesarean 1,000/100,000..........................................................................................................................................................................................

2 Prior Cesareans 1,700/100,000..........................................................................................................................................................................................

3 or more Prior Cesareans 2,700/100,000..........................................................................................................................................................................................

Placenta Accreta..........................................................................................................................................................................................

General population 240/100,000..........................................................................................................................................................................................

1 Prior Cesarean 319/100,000..........................................................................................................................................................................................

2 Prior Cesareans 570/100,000..........................................................................................................................................................................................

3 or more Prior Cesareans 2,400/100,000..........................................................................................................................................................................................

ent to JANUARY 2011 American Journal of Obstetrics & Gynecology S239