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tients undergoing robotic versus laparoscopic treatment of adnexalmasses during pregnancy, except for a significantly shorter length ofhospital stay in the robotic cohort.

817 In vivo microendoscopic confocal imaging for opticaliopsy of visceral adipose tissue in CD-1 mice

Kathleen Vincent1, Fernanda Vergara1, Egle Bytautiene1,ingna Wei1, Igor Patrikeev1, Elena Sbrana1,eorge R. Saade1, Massoud Motamedi1

1The University of Texas Medical Branch, Galveston, TXOBJECTIVE: Maternal obesity is associated with obesity in offspring. A

ethod to noninvasively evaluate adipose tissue would increase ournderstanding of morphologic features of adipose tissue in these off-pring. Endoscopic in vivo fluorescence confocal imaging provides annabling tool for optical biopsy by allowing for high resolution visu-lization of tissue morphology. In this project, we demonstrate the usef in vivo confocal imaging to quantify morphological features ofdipose tissue in CD-1 mice.

STUDY DESIGN: Visceral adipose tissue (VAT) of CD-1 mice (n�21)was evaluated using a CellVizio confocal microendoscopy system. Asmall abdominal incision was made, fluorescein contrast agent wasapplied topically, and the 1.8 mm confocal probe was used for directimaging of VAT. Five frames were captured for each mouse and cellareas for all cells within a field were measured using Image J software.Twenty percent of images were re-evaluated to determine test retestreliability. The measured cell area was compared to total body andVAT weight. Linear regression, Pearson correlation, and student’s t-test were utilized for analysis (p�0.05).RESULTS: Confocal imaging revealed good detail of adipose cell shapend borders (Figure 1) and cell area measurement test retest reliabilityas good (r�0.9). Confocal measurement of cell area ranged from554 to 16,106 �m2 and was larger for males than for females9475�1011 vs. 6899�1794 �m2). The cell area significantly corre-ated with body weight (r�0.9) and VAT weight (r�0.7).

CONCLUSIONS: In vivo confocal imaging is feasible in a mouse modelor evaluation of VAT cell area. The described method will be used tovaluate VAT in the offspring of obese and normal weight mothers.onfocal imaging of adipose tissue is a powerful tool which will in-

rease our understanding of obesity and has the potential to be used inlinical studies.

818 Which criteria are the best for screening and diagnosisf gestational diabetes? A decision analysis

Lorie Harper1, Alison Cahill1, George Macones1, Anthony Odibo1

1Washington University in St. Louis, St. Louis, MOOBJECTIVE: A one-hour glucose challenge test (GCT) followed by ahree-hour glucose tolerance test (GTT) is an accepted method of

creening for gestational diabetes (GD); however, the optimal cut-off d

Supplem

criteria for abnormal tests is unclear. We sought to determine thecriteria most effective for preventing brachial plexus injuries in thenewborn.STUDY DESIGN: We created a decision analytic model to compare 5strategies for screening and diagnosis of GD: (1) no screening, (2) aGCT with a cut-off of 130 mg/dL followed by a GTT with NationalDiabetes Data Group (NDDG) criteria, (3) a GCT with a cut-off of 130mg/dL followed by a GTT with Carpenter-Coustan (CC), or modifiedNDDG, criteria, (4) a GCT with a cut-off of 140 mg/dL followed byGTT with NDDG criteria, and (5) a GCT with a cut-off of 140 mg/dLfollowed by a GTT with CC criteria. The primary outcome was bra-chial plexus injury. The five strategies were compared using the prob-ability estimates of events and utilities assigned to the outcomes asobtained from a review of the literature. One-way and multi-way sen-sitivity analyses were performed to address uncertainties in our base-line assumptions.RESULTS: Within our baseline assumptions, the model identified acreening cutoff of 130 followed by the CC diagnostic criteria as theptimal strategy. For a theoretical cohort of 4 million pregnancies, thisethod would prevent 28 brachial plexus injuries. The model was

obust to a wide range of probabilities with the exception of the sen-itivity of each cutoff. As the sensitivity of the 130 mg/dL cutoff falls, autoff of 140 followed by the CC criteria becomes the most effectiveethod. As the sensitivity of the CC criteria falls, a cutoff of 130 fol-

owed by NDDG criteria becomes the preferred method.CONCLUSIONS: The most effective method of screening and diagnosis

iabetes for preventing brachial plexus injuries is a screening cutoff of30 followed by the Carpenter-Coustan criteria for diagnosis.

819 Differences in methadone maintenance requirementsor pregnant women with illicit prescriptionpioid use versus heroin use

Matthew Brennan1, Brittany Albright1, Sylviarice1, Betty Skipper1, William Rayburn1

1University of New Mexico School of Medicine, Albuquerque, NMOBJECTIVE: To determine any differences in daily methadone mainte-

ance doses between pregnant women who used either illicit prescrip-ion opioids or intravenous heroin as a guide for better informederinatal care

STUDY DESIGN: This observational study was performed on consecu-ively-chosen women who sought continual prenatal care before 20eeks between January 2003 and August 2009 at our multidisciplinaryethadone program. Changes in the single daily methadone dose

fter initial in-hospital stabilization were according to a standard opi-te withdrawal scale. Patients were divided into two groups based onllicit prescription opioid use (e.g., hydrocodone, oxycodone, Vico-in, Percocet) or heroin use.

RESULTS: A total of 163 women enrolled in our methadone program,ith 31 (19.0%) being addicted to prescription opioids and 132

81.0%) to heroin. The only significant difference in demographicsetween the two groups was a decreased percentage of Hispanic sub-

ects in the prescription opioid group compared with the heroin group45% vs. 72%, p� 0.005). The median doses of methadone were in-

istinguishable between the two groups at initial stabilization (p �

ent to JANUARY 2011 American Journal of Obstetrics & Gynecology S319

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Poster Session V Academic Issues, Antepartum Fetal Assessment, Genetics, Hypertension, Medical-Surgical Complications, Ultrasound-Imaging www.AJOG.org

0.50), delivery (p � 0.46), and 6 weeks postpartum (p � 0.17). Thedoses increased gradually during pregnancy and did not decrease dur-ing the first six postpartum weeks.CONCLUSIONS: Pregnant women with an addiction to prescription

pioids required daily methadone doses that were as much as thoseddicted to heroin.

820 Hysterectomy at cesarean or beyondMeredith L Birsner1, Alice J Cootauco2, Jessica L Bienstock1,

ancy Hueppchen1, Andrew J Satin1, Cynthia H Argani1

1Johns Hopkins University School of Medicine, Baltimore,D, 2St. Joseph’s Medical Center, Towson, MD

OBJECTIVE: Peripartum hysterectomy is a morbid procedure resultingost commonly from hemorrhage and abnormal placentation. The

rocedure may be planned if abnormal placentation is diagnosed an-enatally but is more often due to uncontrollable postpartum hemor-hage. We sought to determine whether maternal outcomes differedetween peripartum hysterectomies done at the time of cesarean sec-ion versus those done later.

STUDY DESIGN: Retrospective case control study of all cases of peripar-um hysterectomy at our tertiary care institution between 1988 and

ay 2010. A hysterectomy was defined as peripartum if it occurredithin 30 days of delivery; a cesarean hystectomy (CH) was done at the

ime of cesarean delivery, and a postpartum hysterectomy (PH) wasone after vaginal delivery or after skin closure of cesarean. Chi squarenalysis was done for discrete variables and the Student’s t-test forontinuous variables with p�0.05 considered significant.

RESULTS: We identified 73 peripartum hysterectomies in 53,781 de-iveries (0.14%); 57 were done at time of cesarean, and 16 were donefter vaginal delivery (n�10) or after skin closure of cesarean (n�6).s expected, delivery-to-decision interval was shorter in CH than PH.

ntraoperative complications included bladder serosa injury, cystot-my, ureteral transection or obstruction, stool spillage into the oper-tive field, pulseless electrical activity and ventricular fibrillation;hese did not differ significantly between groups. Intraoperative vari-bles were similar between groups, but PHs had higher rates of DIC,CU admission, and several postoperative complications (transfusionequirement, organ failure, death).

CONCLUSIONS: Hysterectomy done after vaginal delivery or after com-letion of cesarean section is associated with more maternalorbidity.

Table. Perioperative variables for cesarean and postpartum hysterectomies

CH (n�57) PH (n�16) P-value

Delivery to decisioninterval (mins)

54 �/- 39 359 �/- 501 <0.01

..........................................................................................................................................................................................

Length of surgery (mins) 231 �/- 81 209 �/- 61 0.34..........................................................................................................................................................................................

EBL (mL) 4491 �/- 4576 3375 �/- 1966 0.35..........................................................................................................................................................................................

Intraoperativecomplications

10 (17.5%) 1 (6.3%) 0.25

..........................................................................................................................................................................................

Change in hematocrit(%)

9.5 �/- 4.9 9.2 �/- 6.0 0.86

..........................................................................................................................................................................................

DIC 14 (24.6%) 13 (81.3%) <0.001..........................................................................................................................................................................................

ICU admission 25 (43.9%) 13 (81.3%) 0.01..........................................................................................................................................................................................

Postop fever 26 (45.6%) 10 (62.5%) 0.23..........................................................................................................................................................................................

Postop ileus/SBO 5 (8.8%) 2 (12.5%) 0.64..........................................................................................................................................................................................

Postop cuff infection 4 (7.0%) 2 (12.5%) 0.49..........................................................................................................................................................................................

Postop transfusion 18 (31.6%) 11 (68.8%) <0.01..........................................................................................................................................................................................

Postop organ failure 2 (3.5%) 3 (18.8%) 0.03..........................................................................................................................................................................................

Maternal death 0 2 (12.5%) <0.01..........................................................................................................................................................................................

Postop length of stay 5.6 �/- 3.1 5.3 �/- 2.9 0.71

(days)..........................................................................................................................................................................................

S320 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2

821 Obstetric and medical risks in pregnancy after stillbirthKeren Ofir1, Anat Kalter1, Orit Moran1, Eyal

ivan1, Eyal Schiff 1, Michal J. Simchen1

1Sheba Medical Center, Ramat GanOBJECTIVE: To evaluate obstetric outcome after stillbirth with specificmphasis on placental and pro-thrombotic risk factors.

STUDY DESIGN: Obstetric outcomes of women with prior stillbirth1999-2009) with a subsequent pregnancy were reviewed. Data wasollected on the immediate subsequent pregnancy, including fetaloss, repeat stillbirth, obstetric pregnancy complications, gestationalge and birth weight at delivery, mode of delivery, thrombophilia, andedical therapy, if prescribed. The cohort was compared with unse-

ected women who gave birth at our center during 2007 (N�10,370),nd factors influencing recurrence risks were estimated. Results: 73ubsequent pregnancies after stillbirth were identified; with 77% takeome baby rates. 5/73 (6.8%) women had a repeat stillbirth, signifi-antly higher than 0.3% in the control group (RR 22.2, 95% CI 8.9-5.4). 4/5 repeat stillbirth cases occurred �37 wks gestation. Thereere significantly higher risks of hypertensive complications (x4), di-

betes (x2) and placental abruption (x7) compared with controls.estational age and birth weight at delivery were lower, probably due

o labor induction. Prior placental stillbirth was associated with a 7.5igher risk of IUGR in the subsequent pregnancy compared with prioron-placental stillbirth (OR 7.5, 95% CI 1.4; 41.0). 42/73 (57.5%)tudy group women had a positive thrombophilia screen (12 com-ined thrombophilias). All 5 repeat stillbirth cases occurred in throm-ophilic women, with the risk of recurrence 6.3 times higher than inon-thrombophilic women (OR 6.3, 95% CI 1.02; 39.1), despite 74%nticoagulant treatment.

CONCLUSIONS: Women with prior stillbirth face an increased risk ofregnancy complications in the subsequent pregnancy, and an in-reased risk of recurrence. Most repeat stillbirth cases occur preterm.oncurrent thrombophilia places these women at a greater risk of

ecurrence, notwithstanding anticoagulant treatment.

822 Cross sectional study to identify normalanges for D-Dimers in pregnancy

Nicolai Murphy1, David Broadhurst1, W.N.Ezyani.Jabarudin1, Ali Khashan1, Brid Wallace1,

ouise Kenny1, Keelin O’ Donoghue1

1Anu Research Centre, Department of Obstetricsnd Gynaecology, University College Cork, Cork

OBJECTIVE: Venous thromboembolism (VTE) is a major cause of ma-ernal morbidity and mortality. Outside pregnancy D-Dimer levelsre used to screen for VTE. This test is ineffectual in pregnancy be-ause D-dimer levels increase progressively from conception untilirth. The aim of this cross sectional study was to establish referenceanges for D-Dimer levels during pregnancy and compare theseanges to the normal non-pregnant range using the Bio-pool Autoimer assay.

STUDY DESIGN: D-Dimer measurements were carried out on a total of94 low risk women carrying singleton pregnancy to term. Samplesere taken from 164 women in the first trimester, 167 women whoere 19-21, 98 women who were 28-36,102 women who were 38-40

nd 164 women day two postpartum. Data from a previous studystablishing normal (non-pregnant) ranges of D-Dimer using theame assay was compared with data obtained from these pregnantomen (1).

RESULTS: Figure 1 shows the relationship between D-dimer levels andestation. D-Dimer levels peaked in the last two weeks of pregnancynd began to drop again as early as two days postpartum. Analysis ofhe population distributions shows that the D-Dimer 95th percentile

diagnostic cut-off point for normal non-pregnant women (224 ng/ml) is not applicable at any of the pregnancy time-points studied. Infact, by 28 weeks’ gestation �95% of the sample population have

D-Dimer levels exceeding the normal cut-off values.

011