377 ADAPTIVE IMMUNE PATHWAY ACTIVATION IN WOMEN UNDERGOING RESCUECERCLAGE FOR CERVICAL INCOMPETENCE (CI) KEUN-YOUNG LEE (F)1, HYUN-AHJUN1, YOUNG-HWA PARK1, SUNG-HO PARK1, HONG-BAE KIM1, CARL P. WEINER2,1Hallym University, Department of Obstetrics and Gynecology, Seoul, SouthKorea, 2University of Maryland at Baltimore, Baltimore, Maryland

OBJECTIVE: Cervical ripening requires inflammation, and intra-amnioticinflammation can cause midtrim. cervical ripening and dilation. 25% ofwomen who present for rescue cerclage have evidence of innate immuneactivation and 25% of decidual hemorrhage. We previously showed that some,but not all women with innate immune activation also have an elevated IL6,suggesting the 2 pathways worked independently. Thus, we sought othercomponents of the adaptive immune pathway.

STUDY DESIGN: CI was diagnosed in women (n=25) with cervicaldilationO2cm between 15-25w associated with intact bulging membranesand no detectable uterine activity. Each woman had an amniocentesis to aidsurgery. 32 other women undergoing amniocentesis for karyotyping between16-25w served as controls. All control women delivered chromosomallynormal infantsO37w. IL6, MMP8 and TNF-a were measured in the amnioticfluid (AF) sample by ELISA.

RESULTS: Amniocentesis was done at 20.7w (G2.7w) in cerclage (meandilation 3.2 cm) vs. 20.6w (G 2.8w) in control patients(p=NS). AF IL6,MMP8 and TNF-a were higher in CI compared to control (IL6, 291 pg/mL[range 132-452 pg/ml] vs. 37,698 pg/mL [range 10,771-48,599 pg/ml], p!0.001; MMP8, 2.1 mg/mL [range 1.3-5.0 mg/mL] vs 65.1 mg/mL [range 29.3-258.3 mg/mL]; p! 0.001; TNF-a, 7.0pg/mL [range 6.7-7.4 pg/mL] vs. 44.3 pg/ml [range 17-93 pg/mL], p! 0.001). ROC analyses showed significantrelationships between the AF IL6, MMP8 and TNF-a and CI (IL6 areaunder the curve 0.965; p!0.001: MMP8 area under the curve 0.909; p!0.001:TNF-a area under the curve 0.994, p!0.001). Correlation analyses withinterval from cerclage to delivery as the dependent variable and IL6, MMP8and TNF-a as independent variables revealed a significant inverse relationshipfor all (IL6, r= �0.432; p=0.03: MMP8, r= �0.483; p=0.001: TNF-a, r=�0.431 p=0.03).

CONCLUSION: CI in the modern obstetric era is often secondary to dysfunc-tional cervical ripening trigered by several mechanisms. These and priorstudies show that the inflammatory response causing CI is triggered by bothinnate and adaptive immune pathway activation.

SMFM Abstracts S113

375 WHERE DOES ALL THE MONEY GO? MALPRACTICE PAYMENT DESTINATIONSJAMES GREENBERG1, ANJALI KAIMAL2, JEFFREY ECKER3, ROBERT BARBIERI4,1Brigham and Women’s Hospital, Boston, Massachusetts, 2Harvard Univer-sity, Obstetrics and Gynecology, Boston, Massachusetts, 3Harvard University,Obstetrics, Gynecology & Reproductive Biology, Boston, Massachusetts,4Brigham and Women’s Hospital, Obstetrics, Gynecology & ReproductiveBiology, Boston, Massachusetts

OBJECTIVE: To determine against whose injuries malpractice premiumsinsure – mother’s or baby’s.

STUDY DESIGN: All obstetric liability claims from 1990 to 2000 werereviewed. Cases were reviewed to determine if the claim resulted from a babyinjury or a maternal injury and to determine if an alternate route of deliverymight have prevented a lawsuit. Indeterminate cases were considered unaf-fected. Costs were calculated by adding the cost of processing the claim, thelegal defense, the settlement payments and/or the actuarially derivedadjustments.

RESULTS: There were 205,241 births and 91 lawsuits with projected claims-costs totaling $53,731,903. 68 (75%) cases representing $51,233,086 (95%)were determined to be for an injured baby. Of these, 47 (51%) casesrepresenting $41,064,559 (76%) may have been prevented by a prophylacticcesarean section while 19 (21%) cases representing $10,168,527 (19%) wouldnot have had the outcome affected by a cesarean section. The remaining 23(25%) cases representing $2,498,817 (5%) of the cases were determined to befor a maternal injury. Of these, 5 (5%) cases representing $804,489 (1%) mayhave been prevented had a vaginal delivery been performed rather than acesarean section.

CONCLUSION: Based on the data, we believe that while medical decision-making in obstetrics can be difficult, the current malpractice environmentmakes this task even more daunting by placing such an overwhelming dollaremphasis on the baby’s health. By our calculations 95% of the malpracticecosts cover the baby’s health while only 5% covers mothers. Further, 76% ofthe baby-related injury costs ($41,064,559) may have been prevented by aprophylactic cesarean section. We believe this reality cannot help physiciansand midwives to ignore financial pressures and consistently make the bestmedical decision for their patients.

376 THE ASSOCIATION BETWEEN PLACENTAL ABRUPTIION AND MATERNAL THROM-BOPHILIA JESSICA LANDSBERG1, MICHAL LEVI1, JB LESSING1, MICHAELKUPFERMINC1, 1Tel-Aviv Sourasky Medical Center, Obstetrics and gynecology,Tel Aviv, Israel

OBJECTIVE: There is increasing evidence implicating congenital and ac-quired thrombophilia in the pathological processes underlying obstetricalvascular complications. Our objective was to asses the association betweenclinically-significant placental abruption and maternal thrombophilia.

STUDY DESIGN: The study group included 48 women, at least three monthsafter their last delivery, with a history of placental abruption that requiredimmediate delivery, in most cases by caesarean section. 49 healthy women whohad at least two normal pregnancies matched for ethnicity and smoking habitsserved as controls. All participants were tested for the mutations Factor VLeiden, MTHFR C677T, Prothrombin G20210A, deficiencies of protein C,protein S, antithrombin III, the presence of antipospholipid antibodies and thelevels of coagulation factors VIII, IX and XI.

RESULTS: we found a significantly higher incidence of thrombophilia inwomen with abruption. 21 out of the 48 women in the study group were foundto have thrombophilia (42%), compared to 7 women out of 49 in the controlgroup (14%). (P=0.002, OR=4.66, 95% CI 1.74-12.46). Two thrombophiliaswere found to be significantly higher in prevalence among women withplacental abruption- the prothrombin G20210A mutation and the presence ofantiphospholipid antibodies. Neonatal birth weight and gestational age atdelivery were significantly lower for women with abruption.

CONCLUSION: Thrombophilia was found to be a risk factor for placentalabruption. Prothrombin gene G20210A mutation and the presence ofanticardiolipin antibodies were found to be significantly higher in womenwith abruption.

378 THE FREQUENCY AND CLINICAL SIGNIFICANCE OF INTRA-AMNIOTIC INFLAMMA-TION IN PATIENTS WITH PAINLESS CERVICAL DILATATION SI EUN LEE1, BYOUNGJAE KIM1, ROBERTO ROMERO2, GILJA KIM1, JONG KWAN JUN1, BO HYUN YOON1,1Seoul National University College of Medicine, Department of Obstetrics andGynecology, Seoul, South Korea, 2Wayne State University, Detroit, Michigan

OBJECTIVE: The purpose of this study was to determine the frequency andclinical significance of intra-amniotic inflammation in patients with painlesscervical dilatation.

STUDY DESIGN: Amniocentesis was performed in 50 patients with painlesscervical dilatation (O1.5 cm), intact membranes, and without regular uterinecontractions (gestational age: 17-29 weeks). Amniotic fluid (AF) was culturedfor aerobic and anaerobic bacteria as well as for mycoplasmas, and assayed formatrix metalloproteinase-8 (MMP-8). MMP-8 was used because it is asensitive and specific index of inflammation. Intra-amniotic inflammationwas defined as an elevated AF MMP-8 concentration (O23 ng/mL). Non-parametric statistics and survival techniques were used for analysis.

RESULTS: 1) The prevalence of intra-amniotic inflammation was 82%(41/50) and that of a positive AF culture was 8% (4/50); 2) Intra-amnioticinflammation was present in all cases with a positive AF culture; 3) Bulging ofthe chorioamniotic membranes was present in 96% of cases; 4) Spontaneouspreterm delivery within 7 days occurred in 50% and delivery before the 34thweek occurred in 88% of cases with intra-amniotic inflammation; 5) 59% ofnewborns born to mothers with intra-amniotic inflammation expired imme-diately after birth (!1 day); 6) The amniocentesis-to-delivery interval wasshorter in patients with intra-amniotic inflammation than in those withoutintra-amniotic inflammation (p=0.05).

CONCLUSION: Intra-amniotic inflammation is present in approximately80% of patients presenting with painless cervical dilatation between 17–29weeks of gestation, and is a risk factor for impending preterm delivery andadverse outcome.