332 THE EFFECT OF TOBACCO EXPOSURE ON BIRTH OUTCOMES INDIABETIC PREGNANCIES SAMEER GOPALANI1, MICHELLE WILLIAMS2,1University of Washington, Maternal-Fetal Medicine, Seattle, WA 2Universityof Washington, Epidemiology, Seattle, WA

OBJECTIVE: Smoking increases insulin resistance (IR) and contributesindependently to microvascular disease. Microvascular injury in the placenta isimplicated in the pathophysiology of preeclampsia (PE) and other adverseoutcomes. We sought to determine if joint exposure to tobacco and diabetes(DM) increases the risk of these outcomes beyond that expected from eachexposure alone.

STUDY DESIGN: We conducted a population-based cohort study usingcomputerized records in WA State. Singleton births from 1992-2001 to diabeticwomen (gestational [GDM] and preexisting [PDM]) were selected, with non-DM subjects as controls. The cohort was stratified in order of hypothesizedincreasing risk of adverse outcome into six groups, with the first as the referencegroup: non-smoking non-diabetics (n = 78,071); non-DM smokers (n =13,862); GDM non-smokers (n = 17,587); GDM smokers (n = 2896); PDMnon-smokers (n = 2176); and PDM smokers (n = 391). Adjusted incidence rateratios (IRR) were calculated using a multivariable generalized linear model. Allreported IRR were statistically significant (P < .05).

RESULTS: Smoking increased the risk of preterm delivery (PTD) (IRR 1.4)and fetal/infant death (IRR 1.7) but was associated with reduced risk of PE (IRR0.7). The IRR for PE in nonsmokers and smokers with GDM were 1.8 and 1.5,respectively. The corresponding IRR for nonsmokers and smokers with PDMwere 2.6 and 2.3. This pattern of PDM subjects experiencing the highest risks wasalso evident for PTD and fetal/infant death.

CONCLUSION: Tobacco and DM act independently on adverse outcomesin subjects with joint exposure. The reduced risk of PE in diabetic smokerscompared to non-smokers suggests that the increased incidence of PE in DMmay not be solely attributable to insulin resistance (IR).

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334 RISK FACTORS AND SCORING SYSTEM FOR PATIENTS RECEIVINGOUTPATIENT PRETERM LABOR MANAGEMENT SERVICES SUNEETCHAUHAN1, NIKI ISTWAN2, DEBBIE RHEA2, GARY STANZIANO2,1Spartanburg Regional Healthcare System, Maternal Fetal Medicine,Spartanburg, SC 2Matria Healthcare, Dept. of Clinical Research, Marietta,GA

OBJECTIVE: To determine factors influencing pregnancy outcome inwomen receiving outpatient management (OM) of preterm labor (PTL) andcreate a scoring system to determine which patients will deliver < 32 wks.

STUDY DESIGN: Included in this retrospective analysis: non-anomaloussingleton pregnancies enrolled for OM (uterine contraction monitoring andnursing assessment) with PTL at < 30 wks, having non-indicated delivery. Oddsratios (95% CI) were calculated for factors present at start of OM (previouspreterm delivery [PTD], cervical dilation [CX], gestational age [GA], vaginalbleeding [VB], cerclage, maternal age, race, marital status, smoking, and pre-pregnancy body mass index), for incidence of spontaneous PTD (SPTD) < 32wks. A receiver-operating characteristic (ROC) curve was generated to de-termine if the scoring system could identify patients who will deliver < 32 wks.Data were analyzed with Pearson’s v2, Pearson’s rho, and likelihood ratio teststatistics (2-sided P < 0.05 considered significant).

RESULTS: In 4531 patients studied, each factor was individually associatedwith SPTD. A scoring system (0 if absent and 2 points if risk factor was present;maximum 10) was created using the five factors withOR$2.0 for SPTD< 32 wks:CX $2 cm, VB, cerclage, black race, and smoking. Incidence of SPTD < 32 wksincreased with increasing risk score (P < 0.001). Prevalence of SPTD <32 wks was7% in patients having a score of 0; 64% in patients with a score$6. With a scoreof $2, the sensitivity, specificity, and positive and negative predictive values forSPTD < 32 wks were 71.6%, 57.4%, 19.8%, and 93.2%. The ROC curve indicatesthat the risk score identified patients who will have SPTD < 32 wks (area undercurve 0.68; P < 0.001) better than chance alone.

CONCLUSION: Assessment of five risk factors available at admission forPTL identifies patients at greatest risk for SPTD < 32 wks. Using the proposedscoring system permits screening of patients who may optimally benefit fromOM services for PTL.

335 ADVERSE MATERNAL OUTCOMES IN MULTIFETAL PREGNANCIESMARK WALKER1, KELLIE MURPHY2, SAIYI PAN3, QIUYING YANG4, SHIWU WEN1, 1University of Ottawa, OMNI Research Group, Department ofObstetrics and Gynecology, Ottawa, Ontario, Canada 2University of Toronto,Department of Obstetrics and Gynecology, Toronto, Ontario, Canada3Health Canada, Surveillance and Risk Assessment Division, Centre forChronic Disease Prevention and Control, Population and Public, Ottawa,Ontario, Canada 4University of Ottawa, McLaughlin Centre for PopulationHealth Risk Assessment, Institute of Population Health, Ottawa, Ontario,Canada

OBJECTIVE: To assess the impact of multiple gestations on women’s healthoutcomes.

STUDY DESIGN: A population-based study.RESULTS: We assessed the impact of multiple gestation on women’s health

outcomes, using the 1984 to 2000 discharge data collected by the CanadianInstitute for Health Information. All women with a multiple gestation wereselected (n = 44,674) and their health outcomes were compared with womencaring a singleton gestation (n = 165188). The means of maternal age weresimilar between the two groups (28.9 years in multiples versus 28.8 years insingletons). Preeclampsia, thromboembolic disease, and postpartum hemor-rhage had relative risks of 2.7 or greater inmultiples. The increased risk for rarerbut potentially more serious morbidity such as pulmonary edema, venousthromboembolic disease, and myocardial infarction was even higher inmultiples. Maternal in-hospital death was increased in multiple gestations, butbecause of small numbers, the confidence interval crossed one. Surgicalinterventions, either cesarean section or operative vaginal delivery, occurred in75 percent of multiple pregnancies. These women were more likely to requirehysterectomy or receive a blood transfusion.

CONCLUSION: The last two decades, through assisted reproductive

Volume 189, Number 6Am J Obstet Gynecol

SMFM Abstracts S153

PRESCRIBER ERRORS: TIME, LOCATION, FREQUENCY IN OB-GYN AMYMITCHELL1, GAIL GOLDBERG1, CAMILLE KANAAN1, JEAN-CLAUDEVEILLE1, 1Albany Medical College, Ob/Gyn, Albany, NY

OBJECTIVE: To describe the ongoing nature and incidence of medicationprescriber errors (MPE) identified in our inpatient OB/GYN service of a tertiarycare hospital in relation to time of day and location.

STUDY DESIGN: An Ob/Gyn MPE database was started January 1, 2002.Each entry had information concerning date, time, prescriber, problemdescription, result of problem, drug class, problem code, service, severity index,and contributor factor. Severity index was defined as potentially ‘‘fatal orsevere,’’ ‘‘serious,’’ or ‘‘significant’’ and scored by one senior pharmacist. Servicewas further divided into antepartum/GYN, labor and delivery, and postpartum.Time was translated to day, evening, or night shifts. Incidence was calculated asnumber of errors per 1000 orders. Statistics were done using ranked ANOVAwith a Tukey correction for multiple comparison.

RESULTS: 73 prescriber errors were reviewed for 2002 (24 antepartum/GYN, 34 labor anddelivery, and 15 postpartum).Overall incidencewas 1.2 errorsdetected per 1000 orders. More errors were detected on labor and delivery ascompared to antepartum/GYN and postpartum (5.3 vs 0.5 and 1.5/1000 orders,respectively, P < 0.001). MoreMPE (51%) occurred during the day. MPE rate wassimilar during weekdays and weekends. Wrong dose (36%) and allergy (30%)were most common. Antimicrobials (44%), analgesics (20%) were the mostcommon MPE. Although most MPE were in the ‘‘significant’’ category (60%),5.5%MPE were ‘‘fatal’’ or ‘‘severe.’’ Patient (43%) and therapeutics (36%) werethe most common contributing factors.

CONCLUSION: Ongoing collection of MPE is warranted in Ob-Gynpractice. Focus-oriented strategies specific to services particular to antimicrobialand painmanagement should decrease the number ofMPE and increase patientsafety.

technologies, have seen an explosion in the number of multiple gestationpregnancies. The increased medical morbidity, obstetrical complications, andsurgical interventions have important implications for affected mothers, as wellas the health care system. These factors must be taken into consideration whencounseling women undergoing fertility treatment and in antenatal care ofwomen with multiple gestation pregnancy.