Maternal diabetes and neonatal macrosomia. I. Postpartum maternal hemoglobin A1c levels and neonatal hypoglycemia.

Hemoglobin A1c (HgbA1c) levels were determined within 24 hours after delivery in 88 nondiabetic and 73 diabetic women belonging to White's classes A to D. Diet-controlled gestational diabetic women had mean (+/- SE) Hgb A1c levels similar to those of nondiabetics (5.8 +/- 0.18% vs 5.7 +/- 0.08%). Mean Hgb A1c levels were higher in insulin-requiring gestational (6.4 +/- 0.20%, P less than .05) and permanent (6.5 +/- 0.27%, P less than .05) diabetics than in nondiabetics. The proportions of subjects with levels above the normal range were also larger in the insulin-requiring groups. Mean Hgb A1c levels and the proportions of abnormally high levels were similar for mothers of macrosomic and of normally grown neonates in the nondiabetic as well as in the various diabetes groups. There was no correlation between maternal Hgb A1c level and neonatal birth weight, either real or relative. There were also no statistically significant differences in mean Hgb A1c levels between mothers of neonates with or without hypoglycemia within four hours of birth. Hgb A1c measurement did not permit differentiation between those mothers of macrosomic neonates who were diabetic and those who were not. In conclusion, although Hgb A1c level has been shown to reflect diabetic control, our data suggest that it may not be reliable as an indicator of fine tuning during the third trimester of pregnancy or as a predictor of the effects of diabetes on the fetus.

Prenatal diagnosis of partial trisomy 1q using fluorescent in situ hybridization.

We report the use of fluorescent in situ hybridization (FISH) with a DNA library of chromosome 1-specific probes to confirm the karyotype, 46,XY,15+der15,t(1;15)(q32.1; q26.3), obtained by prenatal periumbilical blood sampling from a fetus who exhibited multiple abnormalities by ultrasound examination. GTG-banding of chromosomes obtained from the mother showed a normal karyotype, while the father was unavailable for study. The propositus was born at 37 weeks gestation and survived for several weeks. Cytogenetic analysis performed after the birth of the male infant with multiple anomalies verified partial trisomy 1q. This patient is compared with other partial trisomy 1q patients reported in the literature. The usefulness of FISH is demonstrated in situations where fetal abnormalities are present with de novo chromosomal rearrangements where paternal chromosomes are unavailable for study.

Short-limb dwarfism and hypertrophic cardiomyopathy in a patient with paternal isodisomy 14: 45,XY,idic(14)(p11).

Uniparental disomy (UPD) has been shown to result in specific disorders either due to imprinting and/or homozygosity of mutant alleles. Here we present the findings in a child with paternal UPD14. Ultrasound evaluation was performed at 30 weeks of gestation because of abnormally large uterine size. Pertinent ultrasound findings included polyhydramnios, short limbs, abnormal position of hands, small thorax, and nonvisualization of the fetal stomach. Post-natally the infant was found to have a low birth weight, short birth length, contractures, short limbs, and a small thorax with upslanting ribs. Assisted ventilation and gastrostomy were required. At age 6 months, the infant required hospitalization for hypertrophic cardiomyopathy which responded to Atenolol. Initial cytogenetic studies demonstrated an apparently balanced de novo Robertsonian translocation involving chromosomes 14 and a karyotype designation of 45,XY,t(14q14q). No indication of mosaicism for trisomy 14 was observed in metaphase spreads prepared from peripheral blood lymphocytes or skin-derived fibroblasts. C-band and fluorescence in situ hybridization results demonstrated that the chromosome was dicentric. DNA analyses showed paternal uniparental isodisomy for chromosome 14. Based on the cytogenetic and DNA results a final karyotype designation of 45,XY,idic(14)(p11) was assigned to this infant with paternal isodisomy of chromosome 14.

Management of premature rupture of membranes and unfavorable cervix in term pregnancy.

One hundred thirty-four indigent patients at term who had premature rupture of membranes and a cervix unfavorable for induction of labor (80% effacement or less, 2 cm dilation or less) were randomized to compare expectant with intervention management. Women with any medical or obstetric condition warranting immediate intervention were excluded from the study. Patients treated expectantly were placed at bed rest and observed for labor or infection. Patients managed by intervention were given oxytocin if labor did not ensue within 12 hours of rupture of the membranes. Patients in the intervention protocol had longer labor (P less than .02) and a higher incidence of both cesarean delivery (P less than .05) and intraamniotic infection (P less than .05). There was only one case of proven neonatal sepsis, and this occurred in a patient managed by induction of labor. There was no statistically significant difference between groups in mean length of maternal hospitalization.

Asthma in pregnancy.

The main pregnancy-induced changes in respiratory physiology are increased minute-ventilation, due primarily to an increase in tidal volume; a 20 per cent decrease in the functional residual volume; and a decrease in the arterial pCO2 resulting from increased alveolar ventilation. The management of acute asthma is changed very little by pregnancy. Beta-adrenergic agonists, theophylline, and glucocorticoids are all as safe as they are in the nonpregnant state; they are not teratogenic. Iodides are contraindicated in pregnancy. Ephedrine and combination products containing theophylline are best avoided during pregnancy, not because they are dangerous but because better preparations are available.

Fetal hydronephrosis: selection and surgical repair.

Newly developed diagnostic techniques allowed us to select a fetus with potentially reversible renal damage from the usually fatal group with bilateral hydronephrosis and severe oligohydramnios early in gestation. Fetal surgery to marsupialize the fetal bladder at 24 weeks gestation restored normal amniotic fluid dynamics and allowed sufficient pulmonary and renal development to insure survival after delivery near term.

Antibiotic prophylaxis for puerperal endometritis following premature rupture of the membranes.

The incidence of intrauterine infections following premature rupture of the membranes is high in indigent populations. In 1970 a prospective study was carried out to determine the value of prophylactic antibiotics in preventing puerperal endometritis in such patients. Penicillin and kanamycin were administered when the patients went into labor or when a move was made toward delivery by induction of labor or cesarean section. Antibiotics were continued for two days postpartum. Puerperal endometritis was significantly decreased. Six-year follow-up has shown no problems with masked infections, superinfections or changes in the antibiotic resistance patterns of cultured pathogens.

Recurrent stillbirth. Significance and characteristics.

We sought to identify the significance of recurrent stillbirth and to determine the contributory etiologic factors for this phenomenon. Data were analyzed and retrospective chart review conducted for all stillbirths occurring during a 13-year period. Subjects were divided into two groups: those for whom the current stillbirth was the first and those who had had a previous stillbirth. The study included 48,479 consecutive multiparous women, of whom 403 had delivered stillborn infants (8.31/1,000 live births). For 34 of these subjects, this represented a recurrent stillbirth (84.36/1,000 live births). The recurrent-stillbirth group had a 10.15-fold higher risk for stillbirth. Additionally, this group had a twofold higher incidence of diabetes and hypertensive disease than did those women experiencing their first stillbirths; furthermore, the gestational age and birth weight of the stillborn infants were significantly lower in the recurrent-stillbirth group (P < .0004 and < .007, respectively). Such factors as socioeconomic class, chorioamnionitis and erythroblastosis fetalis, traditionally cited as contributing to repeated fetal loss, were not significant. Although recurrent stillbirth remains an unsolved problem, improving health care to specific groups within high-risk populations may reduce fetal loss.

Double-blind comparison of maternal analgesia and neonatal neurobehaviour following intravenous butorphanol and meperidine.

Butorphanol (1 mg and 2 mg) and meperidine (40 mg and 80 mg), given intravenously, were evaluated for analgesic efficacy and safety in a double-blind randomized study employing 200 consenting pre-partum patients in moderate to severe pain during the late first stage of labour. Both drugs provided adequate relief of pain to the mothers. There was no significant difference in the rate of cervical dilation, the foetal heart rate, the Apgar score, pain relief or neonatal neurobehavioural scores betweeen those receiving butorphanol and those receiving meperidine. Twenty-two mothers who received butorphanol and eleven who received meperidine nursed their infants with no adverse effects observed. Side-effects were generally infrequent in this study; however, more side-effects were reported by the patients and observed by the investigator in the meperidine-treated cases (13%) than in the cases treated with butorphanol (2%).

Intrapartum management of the fetus with idiopathic hydrocephalus.

Intrapartum management of fetal idiopathic hydrocephalus (IH) diagnosed late in pregnancy is controversial. Normal intellectual development is possible in many of these infants when neurosurgical intervention is undertaken in the neonatal period. Aggressive intrapartum management is indicated in most of these cases regardless of cortical mantle thickness. However, routine abdominal delivery is associated with increased maternal morbidity without proven fetal benefit. Transvaginal cephalocentesis for fetuses with IH in the cephalic presentation, followed by spontaneous vaginal delivery, lessens maternal morbidity and is compatible with good neonatal outcome.

Cefamandole therapy of endomyometritis following cesarean section.

Sixty women with endometritis following cesarean section were treated with cefamandole (12 gm/day) alone. Specimens for culture were obtained by endometrial lavage and from peripheral blood. Minimum inhibitory concentrations were performed on anaerobes and enterococci by an agar dilution technique. Anaerobic organisms were isolated in 55 of 60 (91.7%) endometrial specimens. Bacteremia was documented in 12 patients (20%). Of 387 isolates from uterine cultures, 20 (5%) were resistant or had MIC's greater than or equal to 32 micrograms/ml. Ten patients (17%) were judged clinical failures and responded to additional antibiotics. Of 19 patients with Bacteroides fragilis or related species isolates in the uterus, three (15%) were judged as failures. Cefamandole was well tolerated and appears to be useful in the initial treatment of endomyometritis.

Shoulder dystocia: should the fetus weighing greater than or equal to 4000 grams be delivered by cesarean section?

A total of 75,979 women who were delivered vaginally in the period 1970 to 1985 were stratified into diabetic and nondiabetic groups. Overall, the incidence of macrosomia (greater than or equal to 4000 gm) was 7.6% (5674/74390) in the nondiabetic group and 20.6% (328/1589) in the diabetic group. Patients were further subdivided by weight categories at 250 gm intervals. Eight percent of shoulder dystocia occurred in the diabetic group when fetal weight was greater than or equal to 4250 gm. In contrast, 20% of shoulder dystocia in the nondiabetic group could have been prevented by elective cesarean section when the fetal weight was greater than or equal to 4500 gm. Furthermore, logistic regression analysis demonstrated that birth weight, diabetes, and labor abnormalities were the principal contributors to shoulder dystocia. Elective cesarean section is strongly recommended for diabetics with fetal weights greater than or equal to 4250 gm, and trial of vaginal delivery for nondiabetic fetuses with weights greater than or equal to 4000 gm is recommended. In all cases the clinician must be watchful for labor abnormalities in macrosomic fetuses.

Severe neonatal alloimmune thrombocytopenia caused by antibodies to human platelet antigen 3a (Baka) detectable only in whole platelet assays.

BACKGROUND: Maternal antibodies that cause neonatal alloimmune thrombocytopenia are commonly identified by solid-phase assays that detect the causative antibodies on the basis of their reactions with specific PLT glycoproteins. Two cases of severe neonatal alloimmune thrombocytopenia caused by maternal antibodies specific for human PLT antigen 3a (HPA-3a [Baka]) that failed to give the expected reactions in some solid-phase assays were recently encountered. STUDY DESIGN AND METHODS: PLT-reactive antibodies were characterized by three different solid-phase assays and by flow cytometry. RESULTS: The two maternal antibodies gave negative reactions in the antigen capture ELISA, modified antigen capture ELISA, and MoAb immobilization of PLT antigens tests but reacted strongly in flow cytometry with intact PLTs that were HPA-3a+. Other sera samples specific for HPA-3a reacted equally well in all assays. CONCLUSIONS: The two antibodies appear to recognize an epitope on the HPA-3a+ form of glycoprotein IIb that is lost when PLTs are solubilized in detergent, as required for solid-phase assays. The diagnosis was made in these cases because no HLA antibodies were present, allowing an HPA-3a-specific reaction to be identified with intact PLTs as targets. Such antibodies are likely to be overlooked when HLA antibodies are also present.

Fetal growth: a comparison of growth curves with mathematical modeling.

This study compared the use of fetal growth curves with the Rossavik mathematical model in predicting third trimester fetal growth in 27 Hispanic patients. The parameters tested were BPD, HC, AC, and FL. The growth curve method of predicting third trimester fetal growth was significantly more accurate than the mathematical model for three of the four fetal parameters tested: BPD, HC, and FL. We conclude that the mathematical model method offered no advantage over the more commonly used growth curve method for predicting third trimester fetal growth. In addition, growth curves do not require complex calculations and are conceptually simpler and easier to use.

Perinatal mortality in a large perinatal center: five-year review of 31,000 births.

The perinatal mortality rate for 30,928 babies born at Medical Center Hospital, San Antonio, Texas, between 1978 and 1982, was 20.3/1,000 births. Neonatal and fetal mortality rates were, respectively, 10.1/1,000 live births and 10.4/1,000 births. Exclusion of babies who weighed less than 500 gm yielded adjusted fetal, neonatal, and perinatal mortality rates of, respectively, 9.2, 9.8, and 17.9. Birth weight-specific mortality rates were calculated by groups of 250 gm birth weight for all neonates and by increments of 100 gm for babies who weighed 500 to 1,499 gm. Male infants, intrauterine growth-retarded babies, and babies whose mothers were less than 15 years old contributed more deaths than would be expected from the characteristics of the obstetric population. Presumptive cause of fetal death was unknown in 32%, fetal anoxia in 21%, maternal pathologic conditions in 20%, inappropriate fetal growth in 13%, congenital malformations in 8%, and systemic fetal infections in 6%. Leading presumptive causes of neonatal death were immaturity (29%), congenital malformations (18%), hemorrhages (16%), and systemic infections (10%). Hyaline membrane disease and necrotizing enterocolitis contributed, respectively, 7% and 6% of deaths. Past and future trends of perinatal mortality are discussed.

Prenatal diagnosis and investigation of a fetus with chondrodysplasia punctata, ichthyosis, and Kallmann syndrome due to an Xp deletion.

We report the prenatal diagnosis of a male fetus with X-linked recessive chondrodysplasia punctata (CDPX), steroid sulphatase (STS) deficiency, X-linked Kallmann syndrome (KAL), and a chromosome deletion at Xp22.31. Biochemical analysis of bone from this case indicates that CDPX is not a defect of vitamin K metabolism. Immunocytochemical study of the brain suggests that KAL is a defect in neuronal migration.