Diabetes in Pregnancy.

OBJECTIVE: This guideline reviews the evidence relating to the diagnosis and obstetrical management of diabetes in pregnancy. OUTCOMES: The outcomes evaluated were short- and long-term maternal outcomes, including preeclampsia, Caesarean section, future diabetes, and other cardiovascular complications, and fetal outcomes, including congenital anomalies, stillbirth, macrosomia, birth trauma, hypoglycemia, and long-term effects. EVIDENCE: Published literature was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary (MeSH terms "diabetes" and "pregnancy"). Where appropriate, results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. VALUES: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). SUMMARY STATEMENTS: Recommendations It is recognized that the use of different diagnostic thresholds for the "preferred" and "alternative" strategies could cause confusion in certain settings. Despite this, the committee has identified the importance of remaining aligned with the current Canadian Diabetes Association 2013 guidelines as being a priority. It is thus recommended that each care centre strategically align with 1 of the 2 strategies and implement protocols to ensure consistent and uniform reporting of test results.

Le diabète pendant la grossesse.

OBJECTIF: La présente Directive passe en revue les données probantes liées au diagnostic et à la prise en charge obstétricale du diabète durant la grossesse. ISSUES: Les issues évaluées étaient les issues maternelles à court et à long terme, dont la prééclampsie, la césarienne, le diabète éventuel et d'autres complications cardiovasculaires et les issues fœtales, dont les anomalies congénitales, la mortinaissance, la macrosomie, le traumatisme de la naissance, l'hypoglycémie et les effets à long terme. RéSULTATS: La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans PubMed et The Cochrane Library au moyen d'un vocabulaire contrôlé (termes MeSH « diabète ¼ et « grossesse ¼) appropriés. Le cas échéant, les résultats ont été restreints aux analyses systématiques, aux essais comparatifs randomisés / essais cliniques comparatifs et aux études observationnelles. Aucune limite n'a été imposée en matière de date, mais les résultats ont été limités aux articles publiés en anglais ou en français. VALEURS: La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau 1). DéCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Perinatal Outcome in 1515 Cases of Prolonged Second Stage of Labour in Nulliparous Women.

OBJECTIVE: To examine perinatal outcomes among nulliparous women with a second stage of labour lasting more than three hours. METHODS: We conducted a retrospective review of all nulliparous women over a 14-year period who had a term, live, singleton, cephalic fetus ≥ 2500 g and who had a second stage of labour lasting at least three hours. Outcome measures included five-minute Apgar score < 7, cord arterial pH < 7.10, admission to the NICU, neonatal seizures, and neonatal death. Rates of serious long-term neurologic morbidity were also analyzed. Outcomes were compared with those of a similar cohort of women who delivered after less than three hours in the second stage. RESULTS: During the study period, 1515 women met the inclusion criteria. The majority of women (67%) delivered vaginally, after up to 10 hours in the second stage of labour. The overall rate of Caesarean section was low (15.7%). The rate of permanent neurologic impairment was 2.6 per 1000 deliveries. CONCLUSION: Among nulliparous women, 84% were spared a possibly difficult Caesarean section in the second stage of labour or a potentially difficult operative vaginal delivery by allowing a longer second stage. However, surviving neonates had a higher risk of permanent neurologic handicap. Our study indicates that the optimal management of the second stage of labour remains controversial.

Objectif : Examiner les issues périnatales chez des nullipares ayant connu un deuxième stade du travail d'une durée supérieure à trois heures. Méthodes : Nous avons mené une analyse rétrospective, sur une période de 14 ans, portant sur toutes les nullipares qui ont accouché à terme d'un fœtus unique en présentation céphalique ≥ 2 500 g et qui ont connu un deuxième stade du travail d'une durée d'au moins trois heures. Parmi les critères d'évaluation, on trouvait un indice d'Apgar à cinq minutes < 7, un pH du sang artériel de cordon < 7,10, l'admission à l'UNSI, les convulsions néonatales et le décès néonatal. Les taux de morbidité neurologique grave à long terme ont également été analysés. Les issues ont été comparées à celles d'une cohorte semblable de femmes ayant accouché après un deuxième stade du travail d'une durée de moins de trois heures. Résultats : Au cours de la période d'étude, 1 515 femmes ont répondu aux critères d'inclusion. La majorité des femmes (67 %) ont connu un accouchement vaginal, et ce, même après un deuxième stade du travail dont la durée avait atteint jusqu'à 10 heures dans certains cas. Le taux global de césarienne était faible (15,7 %). Le taux de détérioration neurologique permanente était de 2,6 sur 1 000 accouchements. Conclusion : Quatre-vingt-quatre pour cent des nullipares ont pu, en permettant la prolongation du deuxième stade, éviter une césarienne qui aurait pu être difficile au cours du deuxième stade du travail ou encore un accouchement vaginal opératoire potentiellement difficile. Toutefois, les nouveau-nés ayant survécu ont été exposés à un risque accru de handicap neurologique permanent. Notre étude indique que la prise en charge optimale du deuxième stade du travail demeure un sujet controversé.

Does routine induction of labour at 41 weeks really reduce the rate of caesarean section compared with expectant management?

OBJECTIVE: It is contended that routine induction of labour at 41 completed weeks of gestation reduces, or at least does not increase, a woman's chance of Caesarean section (CS), compared with expectant management. We wanted to know if this was true in our own hospital. METHODS: We performed a retrospective review of 1367 nulliparous women who had reached 41+0 weeks undelivered with a live, singleton, fetus with a cephalic presentation. The women comprised two non-randomized contemporaneous cohorts: in one group, expectant management was planned, and in the second group the intention was to induce labour at 41 weeks. The primary outcome measure was the rate of CS in each group. RESULTS: Of 645 women in whom expectant management was planned, 17.7% delivered by CS. Of 722 women in whom induction of labour was planned, 21.3% delivered by CS (P = 0.09). Of the total of 907 women in whom expectant management was planned or who laboured spontaneously before planned induction could be carried out, 16.6% delivered by CS. Of 460 women in whom induction was planned and actually carried out, 25.4% delivered by CS (P = 0.001). CONCLUSION: The contention that routine induction of labour at 41 weeks reduces a woman's chance of delivery by Caesarean section was not supported by the findings of our study. Inducing labour may actually increase the nulliparous woman's risk of delivery by CS.

How often do perinatal events at full term cause cerebral palsy?

OBJECTIVE: To determine the contribution of perinatal events to cerebral palsy in children born at full term. METHODS: The delivery records of a cohort of babies born at full term in one tertiary care hospital over an 11-year period were reviewed. The obstetric history and neonatal chart of each baby admitted to the Neonatal Intensive Care Unit was then examined. For those babies whose stay in the NICU was because of encephalopathy, brain injury, asphyxia with organ dysfunction, serious infection, or prolonged respiratory support, a review of their medical records was undertaken to determine how many subsequently developed cerebral palsy. RESULTS: Of 36,368 babies born at term, 20 were later diagnosed as having cerebral palsy in which the causative insult likely occurred just before, during, or shortly after labour and delivery. This is an incidence of cerebral palsy arising from perinatal events of 0.55 per 1000 deliveries. Only six cases, however, were deemed to have been possibly preventable by better obstetric care. CONCLUSION: In our hospital, perinatal events are an important cause of cerebral palsy in children born at full term, but few cases are potentially preventable.

Amniotic fluid proteomic signatures of cervical insufficiency and their association with length of latency.

PROBLEM: Cervical insufficiency is a precursor of preterm birth. Treatment with emergency cervical cerclage is contraindicated in the presence of intra-amniotic infection. Detecting infection with Gram stain and culture of amniotic fluid lacks sensitivity. Proteomic profiling of amniotic fluid in cervical insufficiency may help identify pregnancies best suited for emergency cerclage. METHOD OF STUDY: Thirty-two pregnant women underwent amniocentesis for routine genetic testing (n = 22) or after diagnosis of cervical insufficiency (n = 10). The proteomic profiles of the amniotic fluid samples were compared in a cross-sectional fashion, including sub-analyses of women with cervical insufficiency and latency periods of <1 week and >1 week post-diagnosis. RESULTS: Mean gestational age at diagnosis of cervical insufficiency was 21.4 weeks (95% CI 20.6-22.1). Proteomic analysis yielded 40 (7.2%, P < 0.05) differentially expressed proteins between women with delivery <1 week (n = 6) vs. >1 week (n = 4). Women who delivered <1 week had activated inflammatory response (z = 2.3, P = 6.71E-09), chemotaxis of immune cells (z = 2.9, P = 2.01E-08), and inhibited bacterial growth (z = -2.2, P = 5.82E-05). A multivariate model of eight biomarkers positively associated with cases of <1 week latency and distinguished cases from controls (97.8%, cross-validation accuracy 92.7%, P = 0.0009). CONCLUSION: In this pilot study, significant differences in the amniotic fluid proteomic profiles in cases of cervical insufficiency compared to genetic amniocentesis were observed. Proteomic signatures were predictive of achieving latency > 1 week after diagnosis of cervical insufficiency. These preliminary findings suggest that proteomic analysis may be of value in predicting outcome following cervical insufficiency and warrants further validation in larger studies.

A modified technique to deliver the posterior arm in severe shoulder dystocia.

BACKGROUND: Posterior arm delivery resolves almost all cases of severe shoulder dystocia. However, if the posterior arm is extended or lies under the fetus's body, the usually described technique for its delivery may not be practicable. CASE: A young, multiparous woman with type II diabetes had a low-midcavity vacuum delivery. Severe shoulder dystocia was encountered. The usual maneuvers, including the usual technique described for delivery of the posterior arm, were unsuccessful. A modified technique for delivery of the posterior arm was used. CONCLUSION: Posterior axillary traction will deliver the posterior arm when it is not accessible by the usual technique.

Obstetrical and neonatal outcomes in obese parturients.

OBJECTIVE: Obstetrical risk is increased with maternal obesity. This prospective study was designed to simultaneously evaluate the outcomes in obese parturients and their newborns. METHODS: Patients with a body mass index (BMI) > or =35 were prospectively identified and compared to an equal number of normal weight parturients. Maternal and neonatal outcome measures were compared for the peripartum and neonatal period. RESULTS: We identified 580 obese parturients over a 6 month period and compared them to an equal number of normal weight parturients. The incidence of obesity in this population was 23%. Obesity was associated with increased rates of hypertension, diabetes, and cesarean section. Obese patients were more likely to develop postpartum complications. Neonatal outcomes were compared for infants > or =37 weeks gestation excluding multiple births (496 neonates in the obese group and 520 in the control group). The neonates of obese parturients were more likely to be macrosomic, have 1-minute Apgar scores of < or =7.0 and require admission to a special care unit. Sub-group analysis showed that negative outcomes for parturients and their neonates correlated with increasing BMI. Neonates born to obese diabetic parturients had the highest risk of poor outcomes. CONCLUSIONS: Maternal obesity confers increased risks for both the parturient and their newborn.