Breastfeeding following bariatric surgery among obese women with and without diabetes mellitus.

BACKGROUND: Information on exclusive breastfeeding (BF) and BF initiation following bariatric surgery (BS) among obese women with diabetes mellitus (DM) and without DM (non-DM) is limited. METHODS: Retrospective cohort study. Obesity was defined by BMI (kg/m2) as grade 1 (30-34.9), grade 2 (35-39.9) or grade 3 (≥40). The 65 women in the DM group (40 women with gestational, 19 with Type 2 and 6 with Type 1) was similar to 84 with non-DM in BS type: Roux-en-Y (51 vs 55%), sleeve gastrectomy (32 vs 35%), laparoscopic gastric banding (17 vs 7%) and gastro-duodenal anastomosis (0 vs 4%). RESULTS: Women with DM were older (35 vs 33y), of advanced age (54 vs 27%), with higher prevalence of grade 3 obesity (66 vs 46%), chronic hypertension (31 vs 10%), delivery of late-preterm infants (23 vs 10%) and neonatal hypoglycemia (25 vs 12%). Although infant feeding intention was similar: BF (66 vs 79%), partial BF (9 vs 7%) or formula (25 vs 14%), at discharge women with DM had lower exclusive BF (29 vs 41%) and BF initiation rates (68 vs 76%) than those with non-DM. Women with grade 3 obesity (52% were DM) differed from those with grades 1-2 (34% were DM) in exclusive BF (27 vs 52%), and BF initiation rates (66 vs 86%). CONCLUSION: After BS, women with DM, especially those with grade 3 obesity, had higher rates of chronic hypertension and preeclampsia and lower rates of exclusive BF and BF initiation than those who had DM but had less severe obesity.

Prediction of large-for-gestational-age infant by fetal growth charts and hemoglobin A1c level in pregnancy complicated by pregestational diabetes.

OBJECTIVES: To compare the ability of three fetal growth charts (Fetal Medicine Foundation (FMF), Hadlock and National Institutes of Child Health and Human Development (NICHD) race/ethnicity-specific) to predict large-for-gestational age (LGA) at birth in pregnant individuals with pregestational diabetes, and to determine whether inclusion of hemoglobin A1c (HbA1c) level improves the predictive performance of the growth charts. METHODS: This was a retrospective analysis of individuals with Type-1 or Type-2 diabetes with a singleton pregnancy that resulted in a non-anomalous live birth. Fetal biometry was performed between 28 + 0 and 36 + 6 weeks of gestation. The primary exposure was suspected LGA, defined as estimated fetal weight ≥ 90th percentile using the Hadlock (Formula C), FMF and NICHD growth charts. The primary outcome was LGA at birth, defined as birth weight ≥ 90th percentile, using 2017 USA natality reference data. The performance of the three growth charts to predict LGA at birth, alone and in combination with HbA1c as a continuous measure, was assessed using the area under the receiver-operating-characteristics curve (AUC), sensitivity, specificity, positive predictive value and negative predictive value. RESULTS: Of 358 assessed pregnant individuals with pregestational diabetes (34% with Type 1 and 66% with Type 2), 147 (41%) had a LGA infant at birth. Suspected LGA was identified in 123 (34.4%) by the Hadlock, 152 (42.5%) by the FMF and 152 (42.5%) by the NICHD growth chart. The FMF growth chart had the highest sensitivity (77% vs 69% (NICHD) vs 63% (Hadlock)) and the Hadlock growth chart had the highest specificity (86% vs 76% (NICHD) and 82% (FMF)) for predicting LGA at birth. The FMF growth chart had a significantly higher AUC (0.79 (95% CI, 0.74-0.84)) for LGA at birth compared with the NICHD (AUC, 0.72 (95% CI, 0.68-0.77); P < 0.001) and Hadlock (AUC, 0.75 (95% CI, 0.70-0.79); P < 0.01) growth charts. Prediction of LGA improved for all three growth charts with the inclusion of HbA1c measurement in comparison to each growth chart alone (P < 0.001 for all); the FMF growth chart remained more predictive of LGA at birth (AUC, 0.85 (95% CI, 0.81-0.90)) compared with the NICHD (AUC, 0.79 (95% CI, 0.73-0.84)) and Hadlock (AUC, 0.81 (95% CI, 0.76-0.86)) growth charts. CONCLUSIONS: The FMF fetal growth chart had the best predictive performance for LGA at birth in comparison with the Hadlock and NICHD race/ethnicity-specific growth charts in pregnant individuals with pregestational diabetes. Inclusion of HbA1c improved further the prediction of LGA for all three charts. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Changing patterns in medication prescription for gestational diabetes during a time of guideline change in the USA: a cross-sectional study.

OBJECTIVE: To define patterns of prescription and factors associated with choice of pharmacotherapy for gestational diabetes mellitus (GDM), namely metformin, glyburide and insulin, during a period of evolving professional guidelines. DESING: Cross-sectional study. SETTING: US commercial insurance beneficiaries from Market-Scan (late 2015 to 2018). STUDY DESIGN: We included women with GDM, singleton gestations, 15-51 years of age on pharmacotherapy. The exposure was pharmacy claims for metformin, glyburide and insulin. MAIN OUTCOMES: Pharmacotherapy for GDM with either oral agent, metformin or glyburide, compared with insulin as the reference, and secondarily, consequent treatment modification (addition and/or change) to metformin, glyburide or insulin. RESULTS: Among 37 762 women with GDM, we analysed data from 10 407 (28%) with pharmacotherapy, 21% with metformin (n = 2147), 48% with glyburide (n = 4984) and 31% with insulin (n = 3276). From late 2015 to 2018, metformin use increased from 17 to 29%, as did insulin use from 26 to 44%, whereas glyburide use decreased from 58 to 27%. By 2018, insulin was the most common pharmacotherapy for GDM; metformin was more likely to be prescribed by 9% compared with late 2015/16, but glyburide was less likely by 45%. Treatment modification occurred in 20% of women prescribed metformin compared with 2% with insulin and 8% with glyburide. CONCLUSIONS: Insulin followed by metformin has replaced glyburide as the most common pharmacotherapy for GDM among a privately insured US population during a time of evolving professional guidelines. Further evaluation of the relative effectiveness and safety of metformin compared with insulin is needed. TWEETABLE ABSTRACT: Insulin followed by metformin has replaced glyburide as the most common pharmacotherapy for gestational diabetes mellitus in the USA.

Breastfeeding initiation among women with chronic hypertension superimposed on pregestational diabetes mellitus.

OBJECTIVE: To compare breastfeeding (BF) initiation among 317 women with chronic hypertension (CHTN) and 106 women with CHTN superimposed on pregestational diabetes (CHTN-DM) who intended exclusive or partial BF. METHODS: Retrospective cohort study of women who delivered at≥34 weeks of gestation. At discharge, exclusive BF was defined by direct BF or BF complemented with expressed breast milk (EBM) while partial BF was defined by formula supplementation. RESULTS: CHTN and CHTN-DM groups were similar in prior BF experience (42 vs 52%), intention to BF exclusively (89 vs 79%) and intention to partially BF (11 vs 21%). Women in the CHTN group were younger (31 vs 33y), more likely primiparous (44 vs 27%), and delivered vaginally (59 vs 36%) at term (85 vs 75%). Women in the CHTN-DM group had higher repeat cesarean rates (32 vs 18%), preterm birth (25 vs 15%), neonatal hypoglycemia (42 vs 14%) and NICU admission (38 vs 16%). At discharge, exclusive BF rates among CHTN was higher (48 vs 19%), while rates of partial BF (34 vs 44%) and FF (18 vs 37%) were lower than in the CHTN-DM group. BF initiation (exclusive plus partial BF) occurred in 82%of CHTN and in 63% of CHTN-DM. CONCLUSION: Although intention to BF was similar, BF initiation rates were higher for the CHTN compared to the CHTN-DM group. Exclusive BF was low in the CHTN and even lower in the CHTN-DM group signaling the need for targeted interventions if BF initiation rates are to be improved.

Breastfeeding initiation among women with preeclampsia with and without severe features.

BACKGROUND: Timely delivery and magnesium sulfate (MgSO4) are mainstay in the treatment of preeclampsia with severe features (PWSF). Premature delivery, severity of illness and mother-infant separation may increase the risk for breastfeeding (BF) initiation failure. OBJECTIVE: To compare BF initiation among women with late-onset PWSF treated with MgSO4 to women with late-onset preeclampsia without severe features (WOSF) who did not receive MgSO4. METHODS: Retrospective study of 158 women with PWSF and 104 with WOSF who delivered at ≥34 weeks. Intention to BF, formula feed (FF) or partially BF was declared prenatally. At discharge, exclusive BF included direct BF or direct BF with expressed breast milk (EBM). RESULTS: PWSF and WOSF groups were similar in age, race, and obstetric history. PWSF and WSOF differed in primiparity (65 & 51%), late preterm births (73 vs 15%), admission to NICU (44 &17%) and mother (5 & 4d) and infant (6 & 3d) hospital stay. Both groups were similar in intention to BF (80 & 84%), to FF (16 & 13%) and to partially BF (5 & 5%). At discharge, exclusive BF (37 & 39%), partial BF (33 & 31%) and FF (30 & 30%) were similar. Exclusive BF in the PWSF group was 43% direct BF, 28% direct BF and EBM and 29% EBM alone whereas in the WOSF group exclusive BF was 93% direct BF and 7% direct BF and EBM. CONCLUSION: BF initiation rates for women with PWSF and WOSF were similar. EBM alone or with direct BF enabled infants in the PWSF group to exclusively BF at discharge.

In-hospital formula supplementation and breastfeeding initiation in infants born to women with pregestational diabetes mellitus.

OBJECTIVE: To ascertain the rate of in-hospital supplementation as it relates to early breastfeeding (BF) and early formula feeding (FF) and its effects on BF (exclusive and partial) at the time of discharge for infants born to women with pregestational diabetes mellitus (PGDM). METHODS: Retrospective cohort investigation of 282 women with PGDM who intended to BF and their asymptomatic infants admitted to the newborn nursery for blood glucose monitoring and routine care. Early feeding was defined by the initial feeding if given within four hours of birth. RESULTS: Of the 282 mother-infant dyads, for 134 (48%) early feeding was BF and for 148 (52%) early feeding was FF. Times from birth to BF and FF (median 1 hr, 0.3-6) were similar, while the time to first BF for those who FF and supplemented was longer (median 6 hr., 1-24). Ninety-seven infants (72%) who first BF also supplemented. Of these, 22 (23%) BF exclusively, 67 (69%) BF partially and 8 (8%) FF at discharge. One hundred seventeen (79%) who first FF also supplemented. Of these, 21 (18%) BF exclusively, 76 (65%) BF partially and 20 (17%) FF at discharge. CONCLUSION: Regardless of the type of first feeding, the majority of infants born to women with PGDM require supplementation. Even when medically indicated, in-hospital supplementation is an obstacle, albeit not absolute, to exclusive BF at discharge. Parents should be reminded that occasional supplementation should not deter resumption and continuation of BF.

Early feeding, hypoglycemia and breastfeeding initiation in infants born to women with pregestational diabetes mellitus.

OBJECTIVE: To examine the effects of early breastfeeding (eBF) or early formula feeding (eFF) on hypoglycemia and on BF initiation in infants born to women with pregestational diabetes mellitus (PGDM) who intended to BF. METHODS: Retrospective cohort investigation of 554 women with PGDM and their infants (IDMs) who delivered during 2008-2016. The first feeding (BF or FF) was considered early if given within 4 hours from birth. RESULTS: 282 (51%) IDMs were admitted to the Well Baby Nursery. Of the 134 IDMs whose early feeding was BF, hypoglycemia affected 30% which was corrected with oral feedings in 78% of the cases. At discharge, 49% BF exclusively while 45% BF partially. Of the 148 IDMs whose early feeding was FF, hypoglycemia affected 40% which was corrected with oral feedings in 69% of the cases. At discharge, 14% BF exclusively while 48% BF partially. There were 272 (49%) IDMs admitted to the NICU. Their early feeding was BF (14%) and FF (86%). Hypoglycemia developed in 50% and 43% of these groups, respectively. Benefits of early feedings on hypoglycemia were masked by the routine use of IV dextrose infusions. At discharge, early BF led to exclusive BF in 45% and partial BF in 50% of the cases. Early FF led to exclusive BF in 17% and partial BF in 42% of the cases. CONCLUSIONS: Early and continued feeding (BF preferably or FF if BF is not feasible) should be the first line of treatment for hypoglycemia. Early BF is paramount for BF initiation. Early FF is an obstacle, albeit not absolute, to BF initiation, thus it should not deter continued efforts to start or resume BF.

Decreasing NICU admissions of asymptomatic infants of women with pregestational diabetes mellitus improves breastfeeding initiation rates.

BACKGROUND: Asymptomatic infants born to women with pregestational diabetes mellitus (PGDM) are usually admitted to the well baby nursery (WBN) while those who are symptomatic or in need of specialized care are admitted to the neonatal intensive care unit (NICU). OBJECTIVE: To determine if changes in the NICU admission rate of asymptomatic infants born to women with PGDM during two different epochs affected breastfeeding (BF) initiation rates. DESIGN/METHODS: Retrospective cohort investigation of 386 women with PGDM and their infants who delivered in 2008-11 (epoch 1) and 457 who delivered in 2013-16 (epoch 2) at a single institution. RESULTS: NICU admissions: Comparison between epoch 1 and epoch 2 showed a decrease in the number of admissions from 243 (63%) to 175 (38%) *(chi square *p < 0.05). Respiratory distress (39 and 43%) and prematurity (28 and 23%) as admission diagnoses remained unchanged. Admissions for prevention of hypoglycemia declined (32% to 21%)*. At discharge from the NICU, exclusive BF (12 to 19%)* and any BF increased (41 to 55%)* while formula feeding (FF) decreased (59 to 45%)*. Admission to the NICU remained a strong predictor of BF initiation failure (a OR 0.6, 95% , CI 0.4-0.9, p 0.005).WBN admissions: Comparison between epoch 1 and epoch 2 showed an increase in the number of admissions from 143 (37%) to 282 (62%)*. The incidence of hypoglycemia (31% and 38%) and its correction with oral feedings (76% and 71%) remained unchanged. At discharge from the WBN, exclusive BF (15 to 27%)* and any BF (52 to 62%)* increased while FF decreased (48 to 38%)*. CONCLUSIONS: A decrease in the number of NICU admissions of asymptomatic infants born to women with PGDM is associated with improvements in BF initiation rates.

An evaluation of fetal heart rate characteristics associated with neonatal encephalopathy: a case-control study.

OBJECTIVE: We sought to identify fetal heart rate (FHR) characteristics that are associated with neonatal encephalopathy (NE). DESIGN: Retrospective case-control study. SETTING: A single medical centre in Shanghai, China, 2006-2015. SAMPLE: Women delivering a singleton, non-anomalous infant at ≥36 weeks' gestation diagnosed with NE (cases, n = 109) were compared with a group of women with unaffected infants (controls, n = 233). METHODS: Two physicians blinded to the outcome independently reviewed FHR tracings during the last 30 minutes of tracing prior to delivery. FHR characteristics were compared in the two groups and multivariable logistic regression was used to adjust for confounding. MAIN OUTCOME MEASURES: Adjusted odds ratio (aOR) and 95% confidence interval (CI) for the presence of specific FHR categories and characteristics. RESULTS: Category II FHR tracings were observed in 89% of women prior to delivery and were not independently associated with NE. Notably, a category III FHR was observed in 17.4% of women in the NE group compared with 0.9% of women in the control group (aOR 44.99, 95% CI 7.23-279.97). Bradycardia, minimal/absent variability, late decelerations and prolonged decelerations were independently associated with NE, whereas accelerations were protective. Similar findings were found when the cases were limited to NE with arterial cord pH <7.1 and in a subgroup analysis of women with category II tracings. CONCLUSIONS: Category III tracings, while infrequent, are not uncommon prior to delivery among fetuses who develop NE. In contrast, most FHR tracings are category II prior to delivery; however, individual FHR characteristics within this category are associated with NE. FUNDING: This research was supported by the Interdisciplinary Programme of Shanghai Jiao Tong University. TWEETABLE ABSTRACT: Category III tracings are not uncommon prior to delivery among fetuses who develop neonatal encephalopathy.

Failure to initiate breastfeeding among high risk obstetrical patients who intended to breastfeed.

BACKGROUND: In the US, at the time of discharge from the hospital, 79% of women had initiated breastfeeding. Intention to breastfeed is a strong predictor of breastfeeding initiation; however, we reported initiation failure in 45% of women with pregestational diabetes who intended to breastfeed. Information regarding intention and initiation among women with other high risk obstetrical conditions (HROB) remains scarce. OBJECTIVE: To ascertain demographic and clinical factors associated with breastfeeding initiation failure among women with HROB conditions who intended to breastfeed. METHODS: The study population is comprised of 89 women with diabetes (DM), 57 who were receiving treatment for substance abuse (SA), 51 women diagnosed with miscellaneous (MISC) conditions and 32 with history of preterm labor/delivery (PTL/D). Intention to exclusively breastfeed or in combination with formula (breastfed/FF) was ascertained prenatally. Breastfeeding was considered initiated if at discharge ≥50% of their infant feedings were maternal milk. Statistics include chi-square, Wilcoxon's and logistic regression (p < 0.05). RESULTS: Of all women, 59% initiated any breastfeeding. Intention to breastfeed/FF, lack of mother-infant contact during the first hour following birth and limited lactation consultation were predictive of initiation failure. The odds of initiation failure were 2.3 times higher among women who wished to breastfeed/FF as compared to those who wished to exclusively breastfeed. Women from the SA group had lower rates of initiation failure than the other three HROB groups. CONCLUSION: Intention to breastfeed among women with diverse HROB conditions is similar to that of the general population; however, initiation rates are disappointingly low. Intention to exclusively breastfeed results in fewer initiation failures. Prenatal intention to combine breast and formula feeding characterize women who may benefit from specific educational programs.

Lowering the high rate of caesarean delivery in China: an experience from Shanghai.

OBJECTIVE: To examine the trends of caesarean delivery (CD) after an intervention to lower the high rate of CD at a Chinese maternity hospital. DESIGN: Retrospective cohort study. SETTING: A large tertiary obstetric centre in Shanghai, China, from 2007 to 2014. SAMPLE: 81 459 nulliparous women who delivered a term singleton infant. METHODS: Logistic regression was used to calculate the odds of CD while adjusting for confounders. MAIN OUTCOME MEASURE: Rate of CD before and after the intervention. RESULTS: The rate of CD decreased from 51.5% in 2008 to 36.1% in 2014, mostly due to a reduction in non-indicated antepartum CD from 27.9% in 2010 to 11.9% in 2014. After adjustment, a period effect remained with delivery between 2011 and 2014 associated with a 31% reduction in the odds of CD compared with delivery between 2007 and 2010 [odds ratio (OR): 0.69, 95% CI: 0.66-0.71)] and a 33% reduction in the odds of antepartum CD (OR: 0.67, 95% CI: 0.64-0.69). The frequencies of perinatal mortality (0.5 versus 0.4/1000), hypoxic ischaemic encephalopathy (0.9 versus 1.2/1000), meconium aspiration syndrome (0.5/1000), birth trauma (0.6/1000), respiratory distress syndrome (0.5% versus 0.4%) and necrotising enterocolitis (0.9 versus 0.6/1000) were similar. The frequency of neonatal infection increased slightly (0.6% versus 0.8%), although this could be explained by other factors. CONCLUSIONS: A marked reduction in CD has occurred at an urban tertiary care centre as a result of efforts to reduce the high rate of caesarean delivery. No notable differences in neonatal outcomes were observed. TWEETABLE ABSTRACT: High rates of caesarean delivery can be lowered without increases in neonatal morbidity and mortality.

Neonatal outcomes of macrosomic infants of diabetic and non-diabetic mothers.

OBJECTIVE: To compare neonatal outcomes (including breastfeeding (BF) initiation) of 170 macrosomic IDM with that of 739 macrosomic nIDM. DESIGN/METHODS: Retrospective cohort investigation of all macrosomic infants born consecutively over a four-year period (2008-2011). Macrosomic (birth weight ≥4000 g) IDM included 100 infants whose mothers had gestational diabetes and 70 whose mothers had pregestational diabetes. RESULTS: IDM were more likely to be delivered by cesarean to obese women while nIDM were more likely to be delivered vaginally to younger women with a higher level of education. Ethnic distribution (60% white, 20% black, 10% Hispanic and 10% Asian or African) was similar in each group. Forty-nine percent of IDM and 7% of nIDM required NICU admission. Respiratory disorders (mainly TTNB) affected 21% of IDM and 3% of nIDM while hypoglycemia was observed in 36% of IDM and 15% of nIDM. Of the 35 IDM delivered vaginally, 10 were complicated by shoulder dystocia without injury. Conversely, 70 of the 458 nIDM delivered vaginally experienced shoulder dystocia that resulted in 6 limb fractures and 3 brachial plexus injuries. On arrival to labor and delivery, 75% of all women intended to BF; however, at the time of discharge, 65% of women with diabetes and 92% of those without diabetes who intended to BF had initiated BF. CONCLUSIONS: Both macrosomic IDM and macrosomic nIDM are at risk for significant morbidities. Macrosomic IDM carry a higher risk for NICU admissions, leading to maternal-infant separation, and lower BF initiation rates.

Breastfeeding initiation in women with gestational diabetes mellitus.

BACKGROUND: In the United States, breastfeeding initiation (BFI) is reported for 75% of all live births; however, little information is available regarding mothers affected by gestational diabetes mellitus (GDM). OBJECTIVE: To examine feeding practices and factors associated with BFI in women with GDM and their infants. METHODS: A total of 303 GDM (58 late preterm and 245 term) pregnancies were studied. Infant feeding preference was ascertained on admission to labor and delivery. Variables known to influence BFI including maternal age, smoking, obesity, racial and educational characteristics were assessed. RESULTS: On admission 188 women intended to BF, 60 intended to feed formula and 55 were undecided. None of the women who wished to feed formula and 27% of the originally undecided later initiated BF. Regardless of feeding preference 163 (54%) of all mothers initiated BF. Similar BFI rates were found for 176 Class A1 and 127 class A2 women. Logistic regression analysis showed that intention to BF was the most significant predictor of BFI. Factors associated with BFI failure included African American race, lower education, smoking, obesity and admission to NICU. Following delivery 264 (87%) infants received well baby care while 39 (13%) were admitted to the NICU. Among 188 women who intended to BF, BFI involved 81% of 160 infants receiving well baby care and 61% of the 28 admitted to the NICU. CONCLUSIONS: More than half of women with GDM, who intended to BF, initiated BF. BFI failure remains associated with race, lower education level, smoking, obesity, preference for formula feeding and admission to NICU.

Disseminated intravascular coagulation following selective termination in a twin pregnancy. A case report.

OBJECTIVE: Coagulation abnormalities after single fetal demise are well described, but similar cases had not been previously reported following therapeutic selective termination. CASE: A 23-year-old G(3) P(2001) with a monochorionic-diamnionic twin pregnancy underwent selective termination at 20 4/7 weeks for severe twin-twin transfusion syndrome. Her fibrinogen thereafter decreased and she developed disseminated intravascular coagulopathy with pathological bleeding during a cesarean section. The maternal coagulopathy resolved postpartum. CONCLUSION: Coagulation disorders can follow selective termination. Recommendations to serially follow coagulation parameters after these procedures, however, cannot be based upon a single case.

Differentiation-dependent regulation of the cyclooxygenase cascade during adipogenesis suggests a complex role for prostaglandins.

AIM: A thorough understanding of the mechanisms of adipocyte differentiation and metabolism is important for the prevention and/or treatment of obesity and its complications, including type 2 diabetes mellitus. A complex role for prostaglandins (PGs) in adipogenesis is suggested. We examined the expression and cellular localization of enzymes in the cyclooxygenase (COX) cascade that synthesize PGs as well as the PG profile as a function of differentiation status in 3T3-L1 cells. METHODS: Murine 3T3-L1 preadipocytes were used as a model for studies of adipocyte differentiation induced by a hormone cocktail and compared with the parental fibroblastic line NIH 3T3. Both cell lines were incubated in maintenance medium or differentiation medium. Nine days after differentiation, the expression of enzymes in the COX cascade was evaluated by immunoblot analysis, reverse transcriptase-polymerase chain reaction (RT-PCR) and immunocytochemistry, and PG formation was examined using enzyme immunoassay. RESULTS: A differentiation-dependent diminution of COX-1 and COX-2 mRNA and cognate proteins in 3T3-L1 cells was observed. PG release, including PGE(2), 6-keto PGF(1alpha), PGD(2) and 15d-PGJ(2), significantly decreased following differentiation in 3T3-L1 cells (anova/Tukey, p < 0.05). However, microsomal PGE synthase (mPGES) and lipocalin-type PGD synthase (L-PGDS) were selectively upregulated. Immunocytochemistry revealed that COX-1 and COX-2 became intracellularly more diffuse upon differentiation, whereas mPGES was redistributed to the nuclear compartment. CONCLUSIONS: Regulation of PG formation and COX-2 expression in 3T3-L1 cells is differentiation-dependent and involves changes in the levels of gene expression of the individual isoforms as well as redistribution of the enzymes within cellular compartments.

A planned randomized clinical trial of treatment for mild gestational diabetes mellitus.

OBJECTIVE: A planned study is described which will determine whether a benefit exists for the treatment of mild carbohydrate intolerance during pregnancy. METHODS: A randomized clinical trial of women with mild gestational diabetes will compare perinatal outcomes in those receiving diet therapy and insulin as required versus those randomized to no specific treatment. RESULTS: The primary outcome of this study will be a composite of neonatal morbidity in the treatment and control groups. CONCLUSIONS: A randomized treatment trial of mild gestational diabetes mellitus will clarify whether identification and treatment of mild gestational diabetes mellitus reduces perinatal morbidity. This information will aid in selecting appropriate thresholds for the treatment of gestational diabetes mellitus.

Fetal surveillance in pregnancy complicated by diabetes mellitus: is it necessary?

This article provides a literature review and opinion concerning the need for fetal surveillance in diabetic pregnancy. Low rates of intervention for suspected fetal jeopardy accompany well-controlled diabetic pregnancies in the absence of vascular disease or hypertension. The clinical utility of routine tests of fetal surveillance in uncomplicated type 1 and type 2 diabetic and gestational diabetic pregnancy has not been established. A randomized trial designed to establish whether a benefit exists to fetal testing in this population is not feasible, largely owing to sample size considerations.

Functional urinary tract obstruction developing in fetuses with isolated gastroschisis.

OBJECTIVE: To evaluate the frequency and natural history of urinary tract abnormalities developing in fetuses presenting with initially isolated gastroschisis. METHODS: Serial ultrasounds were performed prospectively on fetuses identified by our prenatal diagnosis program as having a gastroschisis. When abnormalities in the urinary tract were identified prenatally, newborns were evaluated by a pediatric urologist. RESULTS: Over a 1-year period four out of 12 fetuses with gastroschisis developed deformations of the urinary tract. In three fetuses the bladder herniated through the abdominal wall defect. Two also had upper tract dilatation. A fourth fetus developed bilateral hydronephrosis with a normally situated bladder. Once the gastroschisis was repaired none of the newborns had evidence of structural obstruction of the urinary tract, however, hydronephrosis with or without reflux persisted for several months. CONCLUSIONS: Deformations of the fetal urinary tract can develop secondary to gastroschisis. They do not appear to represent separate malformations and evaluation with fetal karyotyping may not be indicated. When hydronephrosis is present ongoing urologic evaluation of the neonate is indicated.