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the BQ and ESS in screening for SA during pregnancy, and to deter-mine whether a simpler screening method would be more accurate.STUDY DESIGN: High-risk women (women with chronic hypertension,pre-gestational diabetes, obesity, and/or a prior history of preeclamp-sia) were recruited to complete a sleep survey, comprised of the BQand ESS, and to participate in an overnight sleep evaluation with theWatch-PAT100 (WP100), a wrist-mounted, ambulatory device de-signed to diagnose SA. The presence of SA was defined as an apneahypoxia index (AHI) of �5. In addition to evaluating the BQ and ESS,we assessed the performance of a 2 question approach in which pa-tients were considered to be screen positive if their pre-pregnancyBMI was �25 and they reported snoring. The performance of the BQ,ESS, and a two-question approach (BMI and snoring) were assessedthrough the use of receiver operating characteristic (ROC) curves.RESULTS: Complete sleep survey and WP100 data was available for 86

omen. Area under the curve (AUC) data from the ROC for the BQ,Q�ESS and the two-question approach are shown in the Table. The

wo-question approach performed better than the BQ, the BQ �ESSombined, and performed better than the null hypothesisAUC�0.5). The sensitivity and specificity of the BQ were 35% (95%I 17%, 57%) and 69% (95% CI 55%, 79%), respectively. The two-uestion approach had a much better sensitivity 74% (95% CI 51%,9%) without sacrificing much specificity 59% (95% CI 46%, 71%).

CONCLUSIONS: Standard screening tools for SA are not adequate inregnancy. A simpler approach, using pre-pregnancy BMI and self-eported snoring, yields better results. Further studies are needed toesign and test the most appropriate screening tool for SA in pregnantomen.

Table: ROC data

AUC (95% CI) P (vs. null) P (vs. 2-question test)

2 question(BMI�snoring)

0.66 (0.54, 0.79) .02 —

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

BQ 0.52 (0.38, 0.66) 0.8 .02..........................................................................................................................................................................................

BQ�ESS 0.49 (0.36, 0.64) 0.9 .004..........................................................................................................................................................................................

564 The effect of customizing birth weight z scoresn the association with perinatal death at term

Gordon Smith1

1University of Cambridge, CambridgeOBJECTIVE: To determine the appropriateness of adjusting birth

eight z scores for maternal characteristics.STUDY DESIGN: The risk of perinatal death (stillbirth or neonatal

eath) due to any cause other than congenital abnormality was ana-yzed in two separate cohorts of term singleton births in Scotland: (1)39,114 births (2003-2008) with data on maternal weight, (2) 597,550irths (1992-2008) without data on maternal weight. Birth weight zcores for sex and gestational age were calculated using multiple linearegression and adjusted (“customized”) for other maternal character-stics. The association between different adjusted birth weight z scoresnd the risk of perinatal death (n�302 and 1,263; respectively) wasssessed by area under the receiver operating characteristic curveAUROCC) using Stata v10.1.

RESULTS: In the cohort with maternal weight data, the AUROCC forerinatal death associated with gestational age and sex adjusted zcores was 0.6378. The AUROCC was increased when the z score wasdjusted for maternal weight (�0.0205), body mass index (�0.016)r height (�0.0005). Correcting for maternal weight alone was asso-iated with the highest AUROCC (0.6583). The AUROCC was de-reased by correcting for parity (�0.0018), smoking (�0.0056) andhe combination of parity and smoking (�0.0116). In the secondohort, the AUROCC for gestational age and sex adjusted z scores was.6238 and it was again decreased by correcting for parity (�0.0071),moking (�0.0056) and the combination of parity and smoking

�0.0135). m

S226 American Journal of Obstetrics & Gynecology Supplement to JANUARY 2

CONCLUSIONS: Sex and gestational age corrected birth weight scoreshould be customized for maternal weight but not smoking and par-ty. Birth weight scores should not be adjusted for factors which aressociated with an increased risk of perinatal death through impairedetal growth.

565 Rate of change of lipid levels in pregnancy associatedith first trimester lipid levels and maternal factors

Heather Byers1, Jeffery C. Murray2, Bruce Bedell2,elli K. Ryckman2, Kristi S. Borowski2

1University of Iowa Carver College of Medicine, Iowa City,A, 2University of Iowa Hospitals & Clinics, Iowa City, IA

OBJECTIVE: To define average lipid levels and average rate of change ofotal cholesterol (TC), HDL, LDL and triglycerides (TG) during therst and second trimesters of pregnancy. To determine maternal de-ographic factors associated with lipid levels in pregnancy.

STUDY DESIGN: First and second trimester TC, HDL, LDL and TGevels were measured in 2054 women with singleton pregnancies in arospective cohort study. Lipid levels were adjusted for gestational agesing linear regression. Nonparametric statistical analysis was per-

ormed to assess association of maternal demographic factors andipid levels using Spearman’s Rho correlation test for continuous vari-bles and Wilcoxon rank-sum test for binary traits. Lipid levels weretratified into low (�10th% of cohort), average (25-75th%), and high�90th%); for additional analysis.

RESULTS: We confirmed previous studies that TC, HDL, LDL and TGevels increase with gestational age. Our study identified that the ratef TC, HDL and LDL increase is inversely related to the first trimesterC level (Table 1). Baseline maternal weight was highly associatedith change in TC (p��1E-4); heavier women had lower increases inC. Maternal age was weakly associated with change in HDL

p�0.03). Women �21years old had lower lipid levels in first trimes-er (TC, HDL p�1E-4; LDL, TG p�0.001) and lower TC and HDL inecond trimester (p�1E-4). Diabetic mothers had a smaller than av-rage increase in TC (p�2E-4) and HDL (p�0.003).

CONCLUSIONS: This study is unique in that it defines rate of lipid levelhange in pregnancy using the same woman in a larger study thanreviously done. Weight, maternal diabetic status and maternal agere associated with lipid level and need to be accounted for whennterpreting lipid levels in pregnancy. The rate of lipid level increasesre dependant on first trimester values. Further research is warrantedo determine if first trimester TC levels and rate of lipid change inregnancy are related to adverse obstetrical outcomes.

1st to 2nd Trimester Average Lipid Level Changes, grouped by 1st Tri TC levels

Groups according to 1st Tri TC levelsp-values comparing rate ofchange in subgroups

LOW (<10%)n�207

AVG (25-75%)n�1034

High (>90%)n�207 low-avg low-high avg-high

TC 35 23 18 �0.0001 �0.0001 0.01..........................................................................................................................................................................................�HDL 9 4 2 �0.0001 �0.0001 0.002..........................................................................................................................................................................................�LDL 21 17 15 0.001 0.001 0.4..........................................................................................................................................................................................�TG 34 30 30 0.3 0.4 0.9..........................................................................................................................................................................................

566 Patterns of pregnancy-associated death in Ohio: effectf the adoption of 2003 U.S. death certificate standard

Hugh Ehrenberg1, Courtney Lynch1, Cynthiahellhaas1, John Poulson2, Mark Landon1

1The Ohio State University, Columbus, OH, 2Thehio Department of Health, Columbus, OH

OBJECTIVE: In 2005, the US pregnancy-related mortality ratioPRMR) was 15.1 per 100,000 live births. African American womenad a PRMR greater than three times that of Caucasians. To assessow Ohio compares nationally, and evaluate the effect of the imple-

entation of the 2003 US Standard Death Certificate, data from 2003-

011