417 ADVERSE NEONATAL OUTCOMES IN GRAVIDAS REQUIRING METHADONEMAINTENANCE ALYSSA MILLS1, JULIA NOETHER2, RENEE BOBROWSKI3, 1DukeMedical Center, Obstetrics and Gynecology, Durham, North Carolina,2Hartford Hospital, Maternal-Fetal Medicine, Hartford, Connecticut,3Hartford Hospital, Hartford, Connecticut

OBJECTIVE: To examine neonatal outcome in women requiring methadonemaintenance during pregnancy.

STUDY DESIGN: Gravidas receiving methadone maintenance and delivering atHartford Hospital between January 1, 1995, and December 31, 2002 wereretrospectively identified from our perinatal database. Maternal and newborncharts were reviewed for methadone and additional substance use, fetal demiseand neonatal complications including NICU admission, congenital anomalies,incidence of withdrawl/neonatal abstinence syndrome (NAS), need for paragoricand maximum dosage.

RESULTS: Medical records were available for 102/107 neonates. Fourstructurally normal fetuses (3.7%) died in utero: 1 with evidence of pnuemoniaat autopsy and 3 with chorioamnionitis and/or villitis. Twenty-two babies wereadmitted to the NICU. Thirteen (12%) newborns were diagnosed with a majorcongenital anomaly either prior to delivery or at birth. Five of the 13 mothersonly had methadone exposure reported while 8/13 used cocaine and/or heroin.Cardiac anomalies were most common with 5 affected neonates (5/107 or 4.7%of the study population). The incidence of documented withdrawl symptoms orNAS was 87% (83/95 newborns) with 41/95 (43%) requiring paragoric forsymptomatic treatment. The maximum dosage required was 0.45 mL/kg.Maternal methadone dosage at delivery ranged from 15 mg to 205 mg in babiesexhibiting withdrawl symptoms.

CONCLUSION: Women requiring methadone maintenance during pregnancyare at increased risk for fetal demise, NICU admission and congenital anomalies.NAS occurs in the majority of neonates, even with lower maternal methadonedosages at delivery. Nearly half the newborns require treatment to control theirsymptoms.

418 NEONATAL OUTCOMES IN VERTEX-NONVERTEX SECOND TWINS ACCORDING TOMODE OF DELIVERY QIUYING YANG1, SHI WU WEN2, YUE CHEN3, DANIEL KREWSKI1,KAREN FUNG, KEE FUNG4, MARK WALKER5, 1University of Ottawa, Institute ofPopulation Health, Ottawa, Ontario, Canada, 2University of Ottawa, OMNIResearch Group, Division of Maternal-Fetal Medicine, Faculty of Medicine,Ottawa, Ontario, Canada, 3University of Ottawa, Department of Epidemiologyand Community Medicine, Ottawa, Ontario, Canada, 4University of Ottawa,Maternal-Fetal Medicine, Ottawa, Ontario, Canada, 5University of Ottawa,Medicine, Ottawa, Ontario, Canada

OBJECTIVE: The optimal mode of delivery (caesarean versus vaginal delivery)for a second twin in breech position is controversial. The objective of our studywas to assess the risk of neonatal mortality and morbidity in vertex-nonvertexsecond twins according to mode of delivery.

STUDY DESIGN: A retrospective cohort study was conducted based on all twinbirths in the United States, 1995-1997. A total of 15,185 vertex-nonvertex secondtwins were classified into three groups: both twins delivered by cesarean section(C-C) (37.7%), both twins delivered vaginally (V-V) (46.8%), and the secondtwins delivered by cesarean section after vaginally delivery of the first twin (V-C)(15.5%). The adjusted odds ratios (OR) and 95% confidence interval (CI) ofneonatal mortality and morbidity for different modes of delivery were calculatedby unconditional logistic regression models, using the C-C group as the referencegroup.

RESULTS: The neonatal mortality and morbidity were significantly increasedin V-V group for asphyxia-related neonatal deaths (OR 7.99, 95% CI: 1.47-148.28), newborn injury (13.90 [5.71-45.87]), low Apgar score (2.42 [1.98-2.97]),mechanical ventilation use (1.38 [1.23-1.54]) and occurrence of seizure (4.61[1.24-29.77]) as compared to C-C group. The neonatal mortality and morbiditywere also increased in V-C group for asphyxia-related neonatal deaths (10.1[1.57-197.3]), newborn injury (5.53 [1.76-20.73]), low Apgar score (3.40 [2.70-4.28]) and mechanical ventilation use (1.33 [1.14-1.55]), but not increased in theoccurrence of seizure (4.44 [0.82-33.08]) as compared to C-C group.

CONCLUSION: Neonatal mortality and morbidity were increased in twinsboth delivered vaginally and the second twins delivered by cesarean section aftervaginally delivery of the first twin. Routine cesarean delivery in vertex-nonvertextwin gestations may be beneficial to the second twin.

419 A SISTER’S RISK: FAMILY HISTORY AS A PREDICTOR OF HYPERTENSIVE DISORDERSOF PREGNANCY DARCY CARR1, MEIRA EPPLEIN2, CATHERINE JOHNSON2, THOMASEASTERLING1, CATHY CRITCHLOW2, 1University of Washington, Obstetrics andGynecology, Seattle, Washington, 2University of Washington, Epidemiology,Seattle, Washington

OBJECTIVE: To determine if women with gestational hypertension (gHTN) orpreeclampsia (PE) are more likely to have a sister with a history of hypertensionin pregnancy.

STUDY DESIGN: A population-based case-control study was performed usingdata from WA State birth certificates linked to maternal and infant dischargerecords from the birth hospitalization. 10,723 nulliparous women (gHTN,N = 1611; PE, N = 1071; normotensive, N = 8041) who delivered their firstchild between 1987 and 2002 and had a sister with a prior delivery in WA Stateduring the same time period were studied. Stratified analyses with Mantel-Haenszel procedures were used to obtain odds ratio (OR) estimates and 95%confidence intervals (95%CI).

RESULTS: Women with any hypertensive condition in pregnancy were 1.7times (95% CI 1.5-2.0) more likely to have a sister who was hypertensive duringpregnancy. Women who had gHTN were 1.6 times (95% CI 1.3-2.0) more likelyto have a sister who had a history of gHTN and were 1.5 times (95% CI 1.2-2.0)more likely to have a sister who had PE. Women with PE were 1.8 times (95% CI1.4-2.3) more likely to have a sister with a history of gHTN and 2.3 times (95%CI 1.8-2.9) more likely to have a sister with PE. Similar results were obtainedfollowing stratification by the sisters degree of relation (full sisters, N = 9513:gHTN OR 1.6, 95%CI 1.2-2.0; PE OR 2.4, 95% CI 1.8-3.1; half sisters,N = 794: gHTN OR 2.1, 95% CI 0.9-4.8; PE OR 2.0, 95% CI 0.9-4.8). None ofthese associations were significantly altered after adjusting for age, race, smokingstatus or body mass index.

CONCLUSION: The greater likelihood of a hypertensive pregnancy amongsisters of women with gestational hypertension or preeclampsia supportsa pathophysiologic role for genetic and/or behavioral factors that cluster infamilies.

SMFM Abstracts S121

420 FETAL PONDERAL INDEX IS MORE SENSITIVE THAN BIRTHWEIGHT-TO-GESTATIONAL AGE TO PREDICT FETAL AND NEONATAL MORTALITY PERCYPACORA1, WILFREDO INGAR2, 1San Marcos University, Maternal-Fetal Division,Lima, Peru, 2Hospital San Bartolome, Dept. Pediatrics, Lima, Peru, Peru

OBJECTIVE: To establish whether the fetal ponderal index (PI) is moreeffective than neonatal birthweight-for- gestational age (BGA) to predict fetaland neonatal outcome.

STUDY DESIGN: A retrospective analysis of our perinatal database wasperformed from January 1, 1992 to December 31, 1999. The ponderal index (PI)was defined as birthweight in grams !100/ Crown- heel length3. SGA-infantwas defined as less than 10th percentile of BGA and LGA-infant, as more than90th percentile of BGA according to Fetal Peruvian Growth Charts (Hernandezet al, Annals UNMSM 1976).

RESULTS: During the study period, the rate of fetal death was 70,3 ! 1000(3617/51439) and neonatal death was 11.6 ! 1000 (555/47673). Among 47773neonates, PI was 2.75 G 0.50 g/cm3 (mean G SD). Normal PI was consideredbetween 2.41 and 3.07 (10th and 90th percentiles). Fetal undernourishment (FU)was defined as PI less than 241 and Fetal Obesity (FO) as PI greater than 3.07.

CONCLUSION: Fetal ponderal index is more sensitive than birthweight-to-gestational age to predict fetal and neonatal death.

PI and BGA as predictors of perinatal outcome

Outcome Sensitiv Specific PPV NPV

Fetal death FU/SGA 0.46/0.36 0.90/0.92 0.03/0.03 0.99/0.99Fetal death FO/LGA 0.17/0.03 0.89/0.93 0.14/0.21 0.99/0.99Neonatal death FU/SGA 0.47/0.32 0.90/0.93 0.05/0.05 0.99/0.99Neonatal death FO/LGA 0.11/0.02 0.89/0.93 0.01/0.004 0.98/0.98Morbidity FU/SGA 0.19/0.20 0.91/0.94 0.27/0.41 0.86/0.87Morbidity FO/LGA 0.10/0.10 0.93/0.89 0.14/0.21 0.85/0.85