ajog.
org
753 Elevated unexplained alanine amniotransferase
and subsequent development of gestational diabetes
and preeclampsia
Seung Mi Lee1, Joong Shin Park1, You Jung Han2, Won Kim1,3,
Byoung Jae Kim1,3, Chan-Wook Park1, Moon Young Kim2
1
Seoul National University College of Medicine, Seoul, Korea, Republic of,
2
Dankook University College of Medicine, Seoul, Korea, Republic of, 3Seoul
Metropolitan Government Seoul National University Boramae Medical
Center, Seoul, Korea, Republic of
OBJECTIVE: Nonalcoholic fatty liver disease(NAFLD) is now consid-
ered as a hepatic manifestation of metabolic syndrome and elevated
alanine aminotransferase(ALT) is commonly related to NAFLD in
the absence of viral hepatitis or alcohol abuse. Previous studies have
indicated that elevated ALT is associated with diabetes or insulin
resistance in adults, but the clinical signicance of ALT or NAFLD in
pregnancy has not been well determined. The objective of this study
was to determine the association between elevated ALT in early
pregnancy and the development of gestational diabetes (GDM) or
preeclampsia in late pregnancy.
STUDY DESIGN: In this retrospective cohort study, pregnant women
who met the following inclusion criteria were included: 1) singleton
pregnancy; 2) ALT measured at 4-20 weeks of gestation; 3) screened
for GDM and delivered in Cheil General Hospital and Womens
Healthcare Center. Cases with viral hepatitis or other liver diseases
were excluded. The early ALT levels were divided into two groups
(normal ALT (95percentile) and elevated ALT (>95 percentile)),
and the frequency of GDM and preeclampsia was compared between
the two groups of cases. GDM was screened and diagnosed by two-
step procedure (50g oral glucose challenge test followed by 75g
glucose challenge test).
RESULTS: A total of 2224 women met the inclusion criteria. The
frequency of GDM and preeclampsia were 2.4% (by WHO criteria)
and 1.2%, respectively. Cases with elevated early AST lev-
els(>95percentile) had higher risk of subsequent GDM or pre-
eclampsia (GDM by WHO criteria, 2.1% in normal ALT vs. 7.4% in
elevated ALT, p<0.005; preeclampsia, 1.0% in normal ALT vs. 4.1%
in elevated AST, p<0.05). This relationship between elevated ALT
and increased risk of GDM /preeclampsia remained signicant after
adjustment for maternal age and pre-pregnancy BMI.
CONCLUSION: Elevated unexplained ALT in early pregnancy was
associated with the risk of subsequent development of GDM and
preeclampsia in late pregnancy.
Supplement to JANUARY 2017 American Journal of Obstetrics & Gynecology
Poster Session IV
* p<0.05 after adjustment
Normal ALT (95p) (n=2102) Elevated ALT (>95p) (n=122) p
GDM (WHO criteria) 44 (2.1%) 9 (7.4%) 0.002*
GDM (IADPSG criteria) 135 (6.4%) 17 (13.9%) 0.004*
Hypertensive disease in pregnancy 24 (1.1%) 7 (5.7%) 0.001*
Preeclampsia 23 (1.0%) 5 (4.1%) 0.014*
754 Gestational weight gain for women with twins:
are the IOM guidelines appropriate?
Lynn M. Yee1, Aaron B. Caughey2, William A. Grobman1,
Yvonne W. Cheng3
1
Northwestern University Feinberg School of Medicine, Chicago, IL, 2Oregon
Health & Science University, Portland, OR, 3California Pacic Medical
Center, San Francisco, CA
OBJECTIVE: The 2009 Institute of Medicine (IOM) gestational weight
gain (GWG) guidelines recommended specic ranges of GWG for
women with twin gestations, yet data to support these guidelines are
limited. Thus the aim was to utilize a population-based cohort to
examine differences in maternal and neonatal outcomes of twin
gestations based on GWG according to IOM guidelines.
STUDY DESIGN: This was a population-based retrospective cohort
study of women giving birth to twins in the United States (2012-
2014). Inclusion criteria were live births and available information
on GWG. Pre-pregnancy body mass index (BMI) was calculated
using reported weight and height. IOM GWG guidelines for twins
were examined as weight gain by week in order to account for
prematurity as a reason for less weight gain. Women were catego-
rized based on BMI as having had GWG below, within, or above
IOM guidelines. Multivariable logistic regression was utilized to
assess the independent association of GWG with adverse maternal
outcomes, whereas generalized estimating equation models were
used for neonatal outcomes to account for clustering. Signicance
was set at p<0.001.
RESULTS: Of 167,121 women meeting inclusion criteria, 33.6%
gained below, 39.7% within, and 26.7% above guidelines. Women
with GWG above guidelines were more likely to be non-Hispanic
white, married, college educated, obese, and nulliparous; women
with GWG below guidelines were more likely to be Asian or His-
panic. Women with GWG below guidelines were at decreased odds
of gestational hypertension or preeclampsia; however, their neonates
were at increased odds of preterm birth <34 weeks, very low
birthweight, 5-minute Apgar score <7 and NICU admission (Table).
Women with GWG above guidelines were at increased odds of
gestational hypertension/preeclampsia, eclampsia, and cesarean de-
livery; their neonates were at increased risk of preterm birth <37 and
<34 weeks but no other adverse events.
CONCLUSION: Twin GWG below IOM guidelines is associated with
adverse neonatal outcomes, whereas GWG above guidelines has few
associations with neonatal outcomes but is associated with adverse
maternal outcomes. Although further work is warranted to address
whether the IOM guidelines fully balance maternal and neonatal
risks, these data offer guidance for counseling women with twin
gestations.
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Poster Session IV ajog.org

755 A prediction model for severe maternal

morbidity at term in a modern cohort
Joshua I. Rosenbloom, Methodius G. Tuuli, Molly J. Stout,
Omar M. Young, Candice Woolfolk, George A. Macones,
Alison G. Cahill
Washington University in St. Louis, Saint Louis, MO
OBJECTIVE: The objective of this study was to determine factors
associated with severe maternal morbidity in a modern cohort of
women laboring at term and to create a prediction model.
STUDY DESIGN: This is a retrospective cohort study of all consecutive
live births at a single Midwest tertiary care center from 2004-2014.
The primary outcome was a composite of severe maternal mor-
bidities including cardiomyopathy, renal failure, respiratory com-
plications with ventilation, amniotic uid embolism, cardiac arrest,
heart failure, pulmonary edema, anesthesia complications, sepsis,
shock, thrombotic embolism, transfusion, or hysterectomy. Odds
ratios were calculated for composite morbidity based on presence or 756 Electronic fetal monitoring patterns on
absence of each risk factor, and multivariable logistic regression was admission and in the active phase associated with
used to identify independent risk factors. A scoring system was elevated umbilical cord arterial lactate at term
created and test characteristics were analyzed. Joshua I. Rosenbloom, Molly J. Stout, Methodius G. Tuuli,
RESULTS: Among 19,249 women delivering during the study period, Julia Lopez, George A. Macones, Alison G. Cahill
323 (1.68%) patients experienced severe morbidity. Not surprisingly, Washington University in St. Louis, Saint Louis, MO
risk was elevated among those with hypertension (adjusted odds OBJECTIVE: The purpose of this study was to determine if there are
ratio [aOR] 1.54 and 95% condence interval [CI] (1.05, 2.24), patterns of electronic fetal monitoring (EFM) on admission and in
advanced maternal age, nulliparity, and prior cesarean section, the active phase of labor associated with elevated umbilical cord
Bishop score <6 (aOR 1.40 95% CI (1.03, 1.89), prolonged second arterial lactate at term.
stage (aOR 1.51, 95%CI (1.02, 2.22), and delivery by cesarean (aOR STUDY DESIGN: This is a nested case-control study within an ongoing
7.54, 95%CI (5.76, 9.87)). A scoring system was created with cohort of >8000 consecutive term, vertex, nonamomalous singleton
weighted points for each of the risk factors; and the area under the pregnancies during labor. 119 neonates with elevated umbilical cord
curve was 0.77. Using a cutoff of  5, the scoring system had a arterial lactate and 119 temporally-matched, randomly chosen
sensitivity of 68.0% (95%CI 62.6, 73.1), specicity of 80.2% (95%CI controls were selected from the cohort. EFM patterns in the rst 60
79.7, 80.0), positive predictive value 5.5% (95%CI 4.9, 6.3), and minutes after admission and in active phase of labor (dened as 6 cm
negative predictive value 99.3% (95%CI 99.2, 99.4). dilation) were extracted by trained research nurses who were blinded
CONCLUSION: While the scoring system offered modest predictive to clinical data, using the National Institute of Child Health and
ability, currently none exist to help clinicians risk-stratify patients for Human Development system. The primary outcome was elevated
serious maternal morbidity. This risk scoring system can help cli- umbilical cord arterial lactate ( 4 mmol/L). EFM patterns were
nicians counsel patients and guide clinical decision making for compared between the two groups and multivariable logistic
anticipating severe maternal morbidity and necessary resources. regression was used to adjust for oxytocin exposure.

S438 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2017