Maternal and neonatal outcomes of women with gestational diabetes and without specific medical conditions: an Australian population-based study comparing induction of labor with expectant management.

BACKGROUND/AIMS: To evaluate maternal birth and neonatal outcomes among women with gestational diabetes mellitus (GDM), but without specific medical conditions and eligible for vaginal birth who underwent induction of labour (IOL) at term compared with those who were expectantly managed. MATERIALS AND METHODS: Population-based cohort study of women with GDM, but without medical conditions, who had a singleton, cephalic birth at 38-41 completed weeks gestation, in New South Wales, Australia between January 2010 and December 2016. Women who underwent IOL at 38, 39, 40 weeks gestation (38-, 39-, 40-induction groups) were compared with those who were managed expectantly and gave birth at and/or beyond the respective gestational age group (38-, 39-, 40-expectant groups). Multivariable logistic regression analysis was used to assess the association between IOL and adverse maternal birth and neonatal outcomes taking into account potential confounding by maternal age, country of birth, smoking, residential location, residential area of socioeconomic disadvantage and birth year. RESULTS: Of 676 762 women who gave birth during the study period, 66 606 (10%) had GDM; of these, 34799 met the inclusion criteria. Compared with expectant management, those in 38- (adjusted odds ratio (aOR) 1.11; 95% CI, 1.04-1.18), 39- (aOR 1.21; 95% CI, 1.14-1.28) and 40- (aOR 1.50; 95% CI, 1.40-1.60) induction groups had increased risk of caesarean section. Women in the 38-induction group also had an increased risk of composite neonatal morbidity (aOR 1.10; 95% CI, 1.01-1.21), which was not observed at 39- and 40-induction groups. We found no difference between groups in perinatal death or neonatal intensive care unit admission for births at any gestational age. CONCLUSION: In women with GDM but without specific medical conditions and eligible for vaginal birth, IOL at 38, 39, 40 weeks gestation is associated with an increased risk of caesarean section.

Options for screening for gestational diabetes mellitus during the SARS-CoV-2 pandemic.

The balance between avoiding severe acute respiratory syndrome coronavirus-2 contagion and reducing wider clinical risk is unclear for gestational diabetes mellitus (GDM) testing. Recent recommendations promote diagnostic approaches that limit collection but increase undiagnosed GDM, which potentially increases adverse pregnancy outcome risks. The most sensitive approach to detecting GDM at 24-28 weeks beyond the two-hour oral glucose tolerance test (OGTT) is a one-hour OGTT (88% sensitivity). Less sensitive approaches use fasting glucose alone (≥5.1 mmol/L: misses 44-54% GDM) or asking ~20% of women for a second visit (fasting glucose 4.7-5.0 mmol/L (62-72% sensitive)). Choices should emphasise local and patient decision-making.

Persistent occiput posterior: OUTcomes following digital rotation: a pilot randomised controlled trial.

AIM: To determine the feasibility of a multicentre randomised controlled trial (RCT) to investigate whether digital rotation of the fetal head from occiput posterior (OP) position in the second stage of labour reduces the risk of operative delivery (defined as caesarean section (CS) or instrumental delivery). METHODS: We conducted the study between December 2010 and December 2011 in a tertiary referral hospital in Australia. A transabdominal ultrasound was performed early in the second stage of labour on women with cephalic, singleton pregnancies to determine the fetal position. Those women with a fetus in the OP position were randomised to either a digital rotation or a sham procedure. In all other ways, participants received their usual intrapartum care. Data regarding demographics, mode of delivery, labour, post natal period and neonatal outcomes were collected. RESULTS: One thousand and four women were consented, 834 achieved full dilatation, and 30 were randomised. An additional portable ultrasound scan and a blinded 'sham' digital rotation were acceptable to women and staff. Operative delivery rates were 13/15 in the digital rotation (four CS and nine instrumental) and 12/15 in the sham (three CS and nine instrumental) groups, respectively. CONCLUSION: A large double-blinded multicentre RCT would be feasible and acceptable to women and staff. Strategies to improve recruitment such as consenting women with an effective epidural in active labour should be considered. This would be the first RCT to answer a clinically important question which could significantly affect the operative delivery rate in Australia and internationally.

Estimating the impact of change in pre-pregnancy body mass index on development of Gestational Diabetes Mellitus: An Australian population-based cohort.

BACKGROUND: International studies examining maternal overweight and obesity have found GDM risk increases with increasing weight gain between pregnancies. AIM: The study aimed to estimate the association between pre-pregnancy maternal body mass index (BMI), change in BMI between pregnancies and Gestational Diabetes Mellitus (GDM) amongst women with consecutive births in an Australian cohort. METHODS: We used a population cohort of women who had at least two consecutive singleton births between 2010 and 2017 in one NSW health district to investigate the risk of GDM in the pregnancy after the index pregnancy, BMI change between pregnancies and the impact of BMI change on risk of GDM. FINDINGS: Of 10,074 women 1987 (16.7%) had no GDM in the index pregnancy but GDM in the subsequent one while 823 (8.2%) had GDM in both pregnancies. No change in BMI between pregnancies occurred in 47% of women, while 12% had a decrease and 41% an increase. After adjusting for socio-demographic characteristics and selected maternal and perinatal confounders, a reduction in BMI between births in women without GDM in the index pregnancy was associated with a 36% lower risk in GDM (aRR: 0.64; 95% CI: 0.49-0.85), while an increase in BMI was associated with increased risk of GDM with the greatest risk amongst those who gained 4+ kg/m² (aRR 2.27; 95%CI: 1.88-2.75). CONCLUSION: Interpregnancy weight change is an important modifiable risk factor for the risk of GDM in a subsequent pregnancy. Clinical guidelines and health messages about interpregnancy weight change are important for all women.

Simplified and standardized intrapartum management can yield high rates of successful VBAC in spontaneous labor.

OBJECTIVE: To examine the outcomes of vaginal birth after cesarean (VBAC) in women, in spontaneous labor, delivering after 37 weeks' gestation at an institution where trial of labor after a previous cesarean delivery (TOLAC) is encouraged and management of labor is standardized. METHODS: This retrospective cohort study included 3071 women with one previous cesarean only and no vaginal delivery who underwent a trial of labor from 2001 to 2011. Women were managed using the standardized "active management of labor" intrapartum protocol. Outcomes and characteristics of women who delivered vaginally were compared with those who required cesarean delivery. RESULTS: In spontaneous labor in their second pregnancy, those who attempted TOLAC had a 72.5% (1611/2222) rate of successful VBAC. Women who had a successful VBAC had smaller babies (3584 ± 452 g versus 3799 ± 489 g; p < 0.0001) at earlier gestations than those who had a repeat intrapartum cesarean delivery. They also required less intrapartum intervention, such as oxytocin augmentation (14.5% [234/1611] versus 41% [251/611]; p < 0.0001) and epidural anesthesia (64.8% [1044/1611] versus 82.8% [506/611]; p < 0.0001). The rate of uterine rupture was 0.54% (12/2222), while the rate of peri-partum hysterectomy was 0.18% (4/2222). CONCLUSION: This study shows that serious complications associated with TOLAC are rare providing intrapartum care and decision-making is made simple for the benefit of staff and patients alike. This is achieved through a standardized labor management protocol.

Vaginal birth after caesarean section prediction models: a UK comparative observational study.

OBJECTIVE: Primarily, to assess the performance of three statistical models in predicting successful vaginal birth in patients attempting a trial of labour after one previous lower segment caesarean section (TOLAC). The statistically most reliable models were subsequently subjected to validation testing in a local antenatal population. STUDY DESIGN: A retrospective observational study was performed with study data collected from the Northern Ireland Maternity Service Database (NIMATs). The study population included all women that underwent a TOLAC (n=385) from 2010 to 2012 in a regional UK obstetric unit. Data was collected from the Northern Ireland Maternity Service Database (NIMATs). Area under the curve (AUC) and correlation analysis was performed. RESULTS: Of the three prediction models evaluated, AUC calculations for the Smith et al., Grobman et al. and Troyer and Parisi Models were 0.74, 0.72 and 0.65, respectively. Using the Smith et al. model, 52% of women had a low risk of caesarean section (CS) (predicted VBAC >72%) and 20% had a high risk of CS (predicted VBAC <60%), of whom 20% and 63% had delivery by CS. The fit between observed and predicted outcome in this study cohort using the Smith et al. and Grobman et al. models were greatest (Chi-square test, p=0.228 and 0.904), validating both within the population. CONCLUSION: The Smith et al. and Grobman et al. models could potentially be utilized within the UK to provide women with an informed choice when deciding on mode of delivery after a previous CS.

Influence of alprazolam on opioid analgesia and side effects during steady-state morphine infusions.

The primary purpose of this study was to examine whether alprazolam pretreatment can increase the analgesic potency of morphine without increasing opioid side-effect intensities. We employed computer-controlled, variable-rate morphine infusions based on each subject's pharmacokinetic profile for morphine derived from a tailoring bolus dose of the drug administered 1 or 2 weeks before the infusion test sessions. On each of 2 test days, we used dental electrical stimulation to determine stimulus intensity that produced consistent reports of strong (but tolerable) pain; this intensity was used for the rest of that session. Then, we measured baseline (no drug) pain intensity reports, pain-related evoked potentials recorded from vertex, and other parameters typically affected by opioids (subjective side effects). We administered alprazolam (1 mg) or placebo (lactose) orally to the subject and then repeated the test battery 30 min later. One hour after the alprazolam or placebo dose, we initiated the tailored morphine infusion to reach target plasma morphine concentration plateaus of 16, 32 and 64 ng/ml (45-min duration each) on both test days. The test battery used during baseline was then repeated at each target concentration plateau. The order of alprazolam versus placebo pretreatments was counterbalanced across subjects and known only to the investigator operating the infusion system. Results suggest that alprazolam at the dose studied did not alter analgesic potency of morphine. However, alprazolam did clearly decrease the intensity of nausea reported by subjects during and after termination of the morphine infusions. Of special interest, alprazolam alone (30 min after oral dosing) decreased evoked potential amplitude consistently without affecting pain intensity reports.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescents use patient-controlled analgesia effectively for relief from prolonged oropharyngeal mucositis pain.

We compared patient-controlled analgesia (PCA) and continuous infusion (CI) morphine delivery in a randomized controlled trial in adolescents during oropharyngeal mucositis pain after bone marrow transplantation. Results from 20 patients who completed 7 or more days on study (10 PCA, 10 CI) were evaluated. The group means for age, weight and height were comparable. Daily measures were morphine intake, self-report of pain intensity and side effect scores. Over 10 study days, the mean cumulative morphine dose to subjects in each group was 4.94 mg/kg (PCA) vs. 12.17 mg/kg (CI); the difference is significant (P less than 0.01). No significant differences were found between the groups for patient ratings of pain intensity or side effect scores despite the large difference in mean morphine intake, but the PCA group tended to report less intense sedation and less difficulty concentrating. Adolescents can use PCA effectively and safely for 1-3 weeks. Morphine intake of adolescent patients using PCA morphine intake is significantly lower than that of similar patients receiving staff-controlled CI.

Patient-controlled analgesic infusions: alfentanil versus morphine.

Previously, we found that cancer patients using a pharmacokinetically based patient-controlled intravenous infusion system (PKPCA) to regulate their own morphine infusion rates achieved more relief from oral mucositis pain than similar patients using morphine by bolus-dose PCA. In this study, we employed the PKPCA system to compare efficacy and side-effect intensities of 2 mu-selective opioid analgesics, alfentanil and morphine, in bone marrow transplant (BMT) patients self-administering the drugs to relieve pain from oral mucositis. Patients using morphine by PKPCA obtained more pain relief than patients regulating their own alfentanil infusions during the first 4 days of continuous opioid infusion therapy. Side-effect intensities did not differ between the 2 study groups. In contrast to patients using morphine for 4-14 days, those receiving alfentanil by PKPCA required unexpectedly high plasma concentrations of the drug to obtain equivalent pain relief. Our results indicate that either the relative potencies of these 2 mu-selective opioids differ from previous estimates or analgesic tolerance developed to alfentanil but not to morphine. We conclude that alfentanil has similar efficacy in control of prolonged pain in BMT patients, but the utility of alfentanil in long-term pain management may be limited by relatively rapid tolerance onset.

The role of HPV testing in patients with possible high-grade cervical cytology.

AIM: To assess the role of human papillomavirus (HPV) testing for high-risk types in an Australian population with the equivalent cytological result of atypical squamous cells of undetermined significance - possible high-grade (ASC-H). METHODS: A retrospective review was conducted of all patients referred with a 'possible high-grade squamous abnormality' Pap-smear result who underwent HPV testing for 13 high-risk types, colposcopy and directed biopsy, and any subsequent treatment. RESULTS: The study included 100 patients. Overall, 79% of patients had a positive test for high-risk HPV DNA types. Histopathology was available for 98 patients and demonstrated that 47% of patients had confirmed high-grade dysplasia. HPV testing had a high sensitivity (98%), but low specificity (40%) for the detection of high grade dysplasia, and a negative predictive value of 95%. CONCLUSIONS: The results of this study suggest that among patients with the equivalent of ASC-H cytology, a negative HPV DNA test for high-risk types is a good predictor of the absence of high-grade dysplasia. HPV testing in this patient population therefore has the potential to reduce the number women referred for colposcopy.