What degree of maternal metabolic control in women with type 1 diabetes is associated with normal body size and proportions in full-term infants?

OBJECTIVE: To assess what degree of maternal metabolic control in women with type 1 diabetes is associated with normal fetal growth and results in normal neonatal body proportions in a group of full-term infants. RESEARCH DESIGN AND METHODS: We investigated the anthropometric characteristics of 98 full-term singleton infants born to 98 Caucasian women with type 1 diabetes enrolled within 12 weeks of gestation. The type 1 diabetic mother-infant pairs were divided into three groups on the basis of the daily glucose levels reached during the second and third trimesters of pregnancy (group 1: 37 mother-infant pairs with an average daily glucose level during the second and third trimesters of < or =95 mg/dl; group 2: 37 mother-infant pairs with an average daily glucose level during the second trimester of >95 mg/dl and during the third trimester of < or =95 mg/dl; group 3: 24 mother-infant pairs with an average daily glucose level during the second and third trimesters of >95 mg/dl; control group: 1,415 Caucasian mother-infant pairs with full-term singleton pregnancies and normal glucose challenge test screened for gestational diabetes. RESULTS: Infants of diabetic mothers in group 1 were similar to those of the control group in birth weight and in other anthropometric parameters. In contrast, offspring of diabetic mothers of groups 2 and 3 showed an increased incidence of large-for-gestational-age infants, significantly greater means of ponderal index and thoracic circumferences, and significantly smaller cranial/thoracic circumference ratios with respect to the control group. CONCLUSIONS: The results of our study suggest that, in diabetic pregnancies, only overall daily glucose values < or =95 mg/dl throughout the second and third trimesters can avoid alterations in fetal growth.

[Hematocrit and hemoglobin, parameters of hematic viscosity, in pregnancy-induced hypertension]. / L'ematocrito e l'emoglobina, parametri di viscosità ematica, in corso di ipertensione gravidanza-indotta.

During pregnancy because of physiologic hemodiluition and changes in various plasma protein levels, plasma viscosity is decreased compared to the non pregnant condition. Specifically the whole blood viscosity profile throughout pregnancy follows that of the hematocrit. However some pathological condition like pregnancy induced hypertension and intrauterine growth retardation are characterized by an increase of plasma viscosity. In order to evaluate the effect of plasma viscosity on placental perfusion, in 41 patients affected by pregnancy induced hypertension and with no iron deficiency we compared maternal hemoglobin and hematocrit to the birth weight. High maternal hemoglobin and hematocrit levels were associated to an increased frequency of low weight for date newborns (less than or equal to 10th centile), although the relationship with the hemoglobin levels is stronger (p less than or equal to 0.02) than the one with the hematocrit (p less than or equal to 0.05). In contrast, high weight for date newborns (greater than or equal to 90th centile) were not related to maternal hemoglobin and hematocrit parameters. We found that maternal hemoglobin and hematocrit, indicators of plasma viscosity, are useful in predicting low birth weight, but not high birth weight. We speculate that hypoxia due to the modification of microcirculation is a very important factor in determining the low birth weight; in contrast the oxygen is not the only factor involved in determining the high birth weight.

[Intensive care of insulin dependent diabetic pregnant women. Perinatal outcome in relation to gestational age at the initial visit]. / Controllo intensivo della gestante affetta da diabete mellito insulino-dipendente. Outcome perinatale in rapporto all'epoca di i osservazione.

BACKGROUND AND AIM: To correlate the perinatal outcome of insulin-dependent diabetic (IDDM) pregnant women with the quality of metabolic control defined as gestational age at initial visit, extent and duration. MATERIALS AND METHODS: A total of 64 pregnant women classified from White's class B to class R were included in the study: 55 pregnant women joined the study before the 9th week (early control group), 9 after the 26th week (late control group). On the basis of perinatal outcome, the 55 pregnant women in the early control group were then subdivided into a further two groups: 34 patients with optimal outcome and 21 with non-optimal outcome. RESULTS: In the early control group of pregnant women, overall mean daily glycemia was significantly lower in the group with optimal outcome compared to that with non-optimal outcome during the 1st and 2nd trimester, but not in the 3rd. Compared to the early control group, during the 3rd trimester patients in the late control group showed significantly higher levels of: overall mean daily glycemia, glycosylated hemoglobin and fructosamine. In the early control group maternal morbidity (p < 0.05), neonatal morbidity (p < 0.03) and perinatal mortality (p < 0.05) were significantly lower than in the late control group. CONCLUSIONS: The achievement of optimal glycometabolic control in the 2nd trimester appears to be a prerequisite for improving maternal-fetal outcome in the early control group compared to that in the late control group in which the attainment of good glycemic control during the 3rd trimester does not seem to be efficacious in reducing overall morbidity and mortality.

[Acute fetofetal transfusion in dichorionic twins: a clinical case report]. / Transfusione feto-fetale acuta in gemelli bicoriali: descrizione di un caso clinico.

Fetofetal transfusion is due to the twin to twin blood shunt caused by vascular anastomoses. It has been suggested that two types of FFT exist: a chronic form existing during pregnancy, and an acute form occurring only during parturition. Cross-circulation may be demonstrated in monochorionic as well as dichorionic placentas. However, such communications were found in 85-100% of monochorionic placentas, compared with one of 68 dichorionic fused placentas. Authors describe one case of acute feto-fetal transfusion in dichorionic twins.

[Epidemiologic data on breast feeding in Florence and the province. Survey carried out in 1364 children born between 1985 and 1987]. / Dati epidemiologici sull'allattamento al seno in Firenze e provincia. Indagine condotta su 1364 bambini nati tra il 1985 ed il 1987.

We have studied the breast-feeding frequency in Florentine Area. We investigate a group of 1364 children born between January 1985 and June 1987. We collected following data: 1) Kind of feeding at birth. 2) Duration of breast-feeding related with birth-weight, kind of delivery, mother's age, mother's working activity. 3) Growth in relation to feeding practices from birth to 3rd month. The percentage of infants breast-feed in the hospital was 81.6%, 50.5% at the end of third month, 21.9% at the end of sixth month. We have found that children weighing more than 3000 g at birth had an higher frequency of breast-feeding at birth and last longer than children weighing less than 3000 g (p less than 0.01). Maternal age had a clear effect on both the incidence and the duration of breast-feeding. Mother aged 30 years or more begin to breast-feed in lower percentage but they continue breast-feeding for a longer time. One of the factors that has a negative influence on breast-feeding at birth is caesarean section since it precludes early mother-infant contact and early initiation of breast-feeding. Mother's resume working has a negative influence on breast-feeding duration. With regard to growth in first three months of life related with different kind of feeding we have found no differences between breast-feeding and artificial-fed infants.

Acardiac twins. Two case reports.

The acardius syndrome is a rare complication of monozygotic twin pregnancies, occurring in 35,000 births. Development results from arterio-arterial and veno-venous anatomoses leading to predominance of one of the twins. The acardiac twin is grossly abnormal and the outcome is invariably fatal. The normal twin provides circulation for itself as well as the acardiac and the perinatal mortality is about 50-70%, as the result of congestive heart failure. Conservative therapy may be important for congestive cardiac failure in the normal twin. Surgical therapy is direct to maintain the pump fetus by interrupting the vascular communication between the twins. We present two cases of acardiac twin prenatally diagnosed by ultrasound and successfully managed by conservative therapy.

Congenital malformations and maternal occupation: a registry based case-control study.

OBJECTIVES: To investigate the relations between congenital malformations and maternal occupation during pregnancy with a registry based case-control study. METHODS: Analysis was performed on data derived from the Florence Eurocat registry surveillance programme. The study included cases with isolated conditions, including chromosomal anomalies (n = 1351), cases with multiple anomalies registered during the 1980-91 period (n = 440), and babies with no congenital malformations recognised at birth who were born from 1982 to 1989 and selected as controls (n = 3223). 11 categories were defined, 10 including cases with isolated malformations and one for cases with multiple congenital anomalies. Four categories of maternal occupation were selected for the study. Odds ratio (OR) values were adjusted for maternal origin, maternal and paternal education, number of previous live births, illness during pregnancy, and maternal age when the group of chromosomal anomalies was analysed. RESULTS: A notable and significant association between oral clefts and mothers involved in leather and shoe manufacturing was found (adjusted OR 3.9; 99% confidence interval (99% CI) 1.5 to 9.8) and the risk consistently increased when considering cases with isolated cleft palate separately (OR 5.4; 95% CI 1.8 to 13.4). Moreover, a significant risk was identified for the association between multiple anomalies and textile dye workers (adjusted OR 1.9; 99% CI 1.0 to 3.8). CONCLUSIONS: This study indicates a notable, significant relation between maternal occupation as a pelt or leather worker and orofacial clefts in offspring. This finding is in agreement with the suggested inheritance models. The dilution effect due to studying large and heterogeneous groups of workers and occupations limits the value of the study; but it provides a good example of the use of a large database to search for teratogenic risk with the aid of malformation registries.

[Relationship between the platelet aggregation of the newborn and mother (author's transl)]. / Rapporti tra l'aggregazione piastrinica del neonato e della madre.

The platelets function of newborn aroused great interest in these last years. On this line, AA. made the stretching test according to Breddin K. and Burck K. H., and. Breddin's Aggregation test on blood coming from 30 couples mother-newborn, drawn immediately after the birth. 22 newborns (73.3%) showed a stretching less than 65%, as well as 21 mothers (70%). The average stretching of mothers resulted 59.5% (+/- 2.26), whereas the average of newborns resulted 55.03% (+/- 2.71). Student's T, calculated on these values, did not result statistically meaningfull. Data-difference of Aggregation test according to Breddin and Burck, pertinent the couples mother-newborn gave on contrary satisfactory statistical information (p less than 0.0001). The explanatory characteristics of stretching test did not allow further issues, whereas Aggregation test results allow to come to the conclusion that newborn's platelets show a less capacity, as to mother's platelets, to aggregata under a mechanical standardized stimulation.

[Urinary tract ultrasonography in newborns with late oligohydramnios]. / Indagine ecografica dell'apparato urinario in neonati con oligoidramnios tardivo.

BACKGROUND AND AIM: The aim of this study was to evaluate the value of neonatal renal ultrasonography in the diagnosis of urinary tract malformation pathologies in newborns from pregnancies complicated by late oligohydramnios. METHODS: During the period January 1994-October 1997, 119 newborns from pregnancies complicated by oligohydramnios occurring in the third trimester of pregnancy underwent ultrasonography of the urinary tract at our Centre. All newborns had previously undergone prenatal ultrasonography. RESULTS: Ultrasonography revealed calicopyelic dilatation < 10 mm in 7 newborns (5.8%), 5 of whom had already been reported at the prenatal ultrasonography. One new-born (0.8%) also showed the presence of an ectopic kidney that had not been diagnosed at the prenatal scan. By the next follow-up all the calico-pyelic dilatations had become normal. CONCLUSIONS: Neonatal ultrasonography did not show any alterations to the urinary tract that might be responsible for the reduction of amniotic liquid. We therefore feel that is useful to perform neonatal ultrasonography in those situations in which the onset of oligohydramnios occurred in the second trimester of pregnancy and in cases in which no scan was performed during the prenatal period.

Effects of indomethacin and ibuprofen on mesenteric and renal blood flow in preterm infants with patent ductus arteriosus.

OBJECTIVE: To evaluate the effect of intravenous ibuprofen and indomethacin for treatment of patent ductus arteriosus (PDA) on mesenteric and renal blood flow velocity in preterm infants. STUDY DESIGN: Seventeen mechanically ventilated preterm infants (<33 weeks' gestation) with PDA received either 0.2 mg/kg indomethacin (n = 8) or 10 mg/kg ibuprofen (n = 9), infused over 15 minutes. Mesenteric and renal blood flow velocity were measured by using Doppler ultrasonography. RESULTS: Indomethacin caused a significant reduction in mesenteric and renal blood flow velocity 30 minutes after drug administration; mesenteric and renal blood flow velocity did not return to the pretreatment values by 120 minutes. Ibuprofen did not alter blood flow 30 minutes after treatment, and blood flow increased 120 minutes after treatment. Mesenteric and renal blood flow velocity changes were significantly different between the 2 treatment groups. CONCLUSIONS: Compared with indomethacin, ibuprofen did not significantly reduce mesenteric and renal blood flow velocity.

[Influence of the early mother-infant contact in the delivery room on short or long term breast feeding]. / Influenza del contatto precoce madre-figlio in sala parto sull'allattamento al seno a breve e lungo termine.

Two groups of mothers and their children were followed up in order to assess the influence of early mother-child contact on breast-feeding; a first control was carried out at discharge from the nursery and a follow-up 6 months later. All the mothers were in good health and pregnancy was physiological with uncomplicated eutocic delivery; none of the babies presented pathologies during the period of their stay in the nursery and in the subsequent 6 months. Group A comprised 126 mothers who had had contact with their babies in the delivery room for at least one hour; group B comprised 109 mothers whose first contact with their baby was only 3-6 hours after birth. Significant differences between the 2 groups were observed as early as the first control which took place at discharge from the nursery: 69.1% of the babies in group A against 51.3% in group B had taken mother's milk exclusively (p < 0.01). Equally significant differences emerged from the subsequent control at 6 months: 70 babies out of 116 (60.4%) were breast fed exclusively or partially, against 42 out of 101 (42.4%) in group B (p < 0.01). Furthermore, important data emerged from the duration of breast-feeding, whether this was exclusive or otherwise, in the first 6 months of life: group A differed significantly from group B (p < 0.002). Our figures suggest a positive influence of early mother-child contact on breast-feeding and on its duration. Notwithstanding the fact that there is no unanimous confirmation in the literature, it is considered that such behaviour will bring benefits to both mother and child.

Met-enkephalin-like immunoreactivity (MELI) and enkephalinase activity (EKA) in cord blood and newborns in the first hours of life.

Recently, the presence and the concomitant release with catecholamines of metenkephalin and other pro-enkephalin A deriving peptides have been demonstrated in the adrenal medulla of various mammals and man. As high amounts of catecholamines are released in the newborn at delivery, probably following the stress of parturition, a similar release of met-enkephalin and other pro-enkephalin A deriving peptides from the newborn chromaffin tissue may be hypothesized. In the present study we investigate the occurrence of met-enkephalin-like immunoreactivity and enkephalinase (quite a specific enkephalin degrading enzyme) in cord and newborn plasma at different hours after birth. Our results show the presence of high met-enkephalin-like immunoreactivity levels in cord and newborn plasma with respect to normal adult values. On the contrary, cord blood enkephalinase activity was lower than in adult subjects and further decreased during the first hours of life. A positive correlation was found between the two parameters. These data seem to indicate a release of met-enkephalin-like peptides from the newborns' sympathoadrenal tissue following the stress of delivery and in the first hours of life.

Anthropometric characteristics of full-term infants: effects of varying degrees of "normal" glucose metabolism.

Aim of this study was to examine the maternal-neonatal outcome and the neonatal anthropometric characteristics of a full-term mother-infant pairs group with a positive oral glucose challenge test (GCT) without gestational diabetes mellitus (GDM). Our study involved 1615 white women with singleton pregnancies who underwent universal screening for GDM in two periods of pregnancy. This population was divided into three groups according to GCT results: 1) 172 patients with abnormal GCT in both periods; 2) 391 patient with normal GCT in the early period and abnormal GCT in the late period; 3) 1052 patients with normal GCT in both periods (control group). The incidence of LGA (large for gestational age) infants was higher in Group (40.7%) and Group 2 (22.0%) respect to control group (8.3%) (p < 0.00001 and p < 0.0001 respectively) and was significantly different in the two groups (p < 0.0008). Comparison among the three groups of LGA infants showed the following results: male and female newborns of Group I were heavier than those of Group 2 and of the control group, while males and females of the control group had significantly greater length and cranial circumference means. A significant decrease in ponderal index, choracic circumference, weight/length ratio means could be seen as well as a significative increase in cranial/thoracic circumference ratio means from Group I to the control group. These data confirm the involvement of fetal development in terms of weight and anthropometric characteristics in the presence of alterations in maternal glucose metabolism which are not currently classified as gestational diabetes.

[An epidemiological study of congenital heart disease. I. Incidence of cardiovascular malformations in 11,584 live-born babies in the District of Florence (Italy) (author's transl)]. / Epidemiologia delle cardiopatie congenite. I. Incidenza della malformazioni cardiovascolari in 11.584 nati vivi nella Provincia di Firenze.

11,584 consecutive live-born babies in the Ostetric Clinic of Florence in the years 1975 and 1976 were examined for the presence of congenital heart disease. Diagnosis was made by necropsy, cardiac catheterization and operation in 20% of cases and by clinical observations in 80%. The 74% of babies who were diagnosed as affected by congenital heart disease at birth were eventually controlled. The incidence of congenital heart disease was 7.1% in 10,789 live-born of weight over 2500 g while it was 37% in 795 under such weight. Global incidence was 9.2%. The first essentials in epidemiological study of congenital heart malformations is to define the method which is used for diagnosis since this is the primary factor responsible for wide variations in incidence. It is suggested that the institution of a Regional Register of malformations would allow more accurate estimate of overall incidence of congenital cardiopathies.

[Epidemiology of the cardiovascular malformations. II. Follow-up of 337 newborn in 1975-1980 at the Maternity of Florence (author's transl)]. / Epidemiologia delle malformazioni cardiovascolari. II) Follow-up di 337 nati nel periodo 1975-80 alla Maternità di Firenze.

337 newborn, in whom a cardiovascular malformation was diagnosed at birth by criteria previously reported, were followed for variable period of time from January 1975 to December 1980. They came from a population of 32,561 live births which occurred at the Maternity of Florence in the same period. The diagnosis was confirmed by angiography, surgical procedure or autopsy in the 15 per cent of the whole group. Fifty-nine babies (18 per cent) with one exception died within the first year of age. Signs and symptoms referable to the cardiovascular malformation at birth disappeared during the follow-up period in 33.8 per cent of cases. Total incidence lowered from 10.3 per thousand at birth to 6.8 at the end of the follow-up. The percentage of normalized babies correspond to the frequency with which ventricular septal defects close spontaneously in the first period of age and accounts for the disappearance of this malformation from the first place of relative incidence of cardiac malformations in adults.

[The epidemiology of cardiovascular malformations. III. The prevalence and follow-up of 46,895 live births at the Careggi Maternity Hospital, Florence, in 1975-1984]. / Epidemiologia delle malformazioni cardiovascolari. III. Prevalenza e decorso in 46.895 nati vivi alla Maternità di Careggi, Firenze, nel periodo 1975-1984.

BACKGROUND: To evaluate the prevalence of congenital heart disease in a homogeneous population we examined 46,895 liveborns in the period from January 1975 to December 1984 in the Careggi Maternity Hospital in Florence. METHODS: The diagnosis of congenital heart disease was made in 579 newborns within five days from birth. All newborns were examined clinically by two neonatologists and referred to the pediatric cardiologist in case of cardiac abnormalities. An ECG was recorded in each of them, chest x-ray in 87% and echo in those who were born after 1980. The children were followed up until December 1989. Mean follow-up period was 6 years. RESULTS: The annual incidence ranged from 9.5% to 15.7% (average 12.3%). Chromosomic anomalies and extra-cardiac malformations occurred in 102 children (17.6%), respectively in 50 (8.6%) and 52 (9.0%) cases. Ventricular septal defect (VSD) and the patent ductus arteriosus (PDA), isolated or associated, were the most frequently recognized congenital heart diseases. 52 children (9.0%) were lost at follow-up. The initial diagnosis was changed in 11/579 cases. In 187 children (32.3%) there was a spontaneous disappearance of clinical and/or instrumental findings that had suggested the presence of congenital heart disease at birth: in 144 the diagnosis was VSD, and in 43 PDA. The prevalence of VSD was 4.7 per thousand in the period 1975-80 and 8.6 in the period 1981-84. 131 children (22.6%) died, 127 (96.9%) of them in the first year of life. 52 children were operated on and pulmonary valvuloplasty was performed in 5. CONCLUSIONS: The prevalence of congenital heart disease does not change during a long observation period, while the number of VSDs increases. VSD and PDA spontaneously close in a high percentage of cases. The study suggests the usefulness of an intensive care unit for newborns with severe congenital heart disease, especially for those in the first year of life.

Omphalocele and gastroschisis: a collaborative study of five Italian congenital malformation registries.

During 1984-1989, 116 cases of omphalocele and 42 cases of gastroschisis were detected among 736,760 consecutive births in the area covered by five Italian congenital malformation registries. The prevalence rate was 1.6 per 10,000 for omphalocele and 0.6 per 10,000 for gastroschisis. Three additional cases were detected among spontaneous abortions, giving a total of 117 cases of omphalocele and 44 of gastroschisis. No variations in prevalence rates were observed among registries. A cluster of omphalocele was found in 1989 in Firenze. All cases were sporadic except for one infant with two sibs with Beckwith-Wiedemann syndrome. A predominance of male infants was observed for both defects. This study confirms the very young maternal age for isolated gastroschisis as compared to that for omphalocele and controls. Birth weight and the percentage of small-for-date is different among isolated gastroschisis, omphalocele and controls. Associated anomalies occurred in 45 cases of omphalocele and 11 cases of gastroschisis. Our data confirm the association of omphalocele with trisomies 13 and 18. Twelve cases of omphalocele and gastroschisis with associated limb defects were classified as limb body wall complex. The possible differences in etiopathology between omphalocele and gastroschisis, both isolated and associated, are discussed.

Glycosilated fetal hemoglobin in neonates of diabetic mothers.

In diabetic patients, the correlation between glycosilated adult hemoglobin (HbA1c) levels and average glucose concentration over the preceding weeks is well known. We have, therefore, sought the possibility to identify newborns at risk measuring cord blood levels of fetal glycosilated hemoglobin (HbF1) in neonates of diabetic mothers. HbF1 was tested by the isoelectrofocusing method. Mean values of HbF1 have been proven to be higher in in infants born to diabetic mothers as compared to normal newborns. The highest levels were encountered in those babies whose mothers had shown a poor glycemic control during the last few weeks of pregnancy.