Large-for-gestational age and stillbirth: is there a role for antenatal testing?

OBJECTIVE: To investigate the association between large-for-gestational-age (LGA) pregnancy and stillbirth to determine if the LGA fetus may benefit from antenatal testing with non-stress test or biophysical profile. METHODS: This was a retrospective cohort study of singleton pregnancies that were ongoing at 24 weeks' gestation and that had undergone routine second-trimester anatomy ultrasound examination, during the period 1990 to 2009. Pregnancies complicated by fetal anomaly or aneuploidy, those with missing birth weight information and those that were small-for-gestational age were excluded. Appropriate-for-gestational age (AGA) and LGA were defined as birth weight between the 10th and 90th percentiles and > 90th percentile, respectively, according to the Alexander growth standard. The incidence of stillbirth was calculated as the number of stillbirths per 10 000 ongoing pregnancies. Adjusted odds ratios (aOR) with 95% CI for stillbirth in LGA compared with AGA pregnancies were estimated using logistic regression analysis, controlling for pre-existing and gestational diabetes. The incidence and aOR for stillbirth were estimated at 4-week intervals from ≥ 24 to ≥ 40 weeks' gestation. RESULTS: Of 52 749 pregnancies ongoing at 24 weeks, 46 205 (87.6%) were AGA and 6544 (12.4%) were LGA at delivery. The incidence of stillbirth in LGA pregnancies was significantly higher than that in AGA pregnancies from 36 weeks' gestation (26/10 000 vs 7/10 000; aOR, 3.10; 95% CI, 1.68-5.70). When women with diabetes were excluded in stratified analysis, pregnancies complicated by LGA continued to be at increased risk for stillbirth ≥ 36 weeks (18/10 000 vs 7/10 000; OR, 2.63; 95% CI, 1.27-5.43). CONCLUSION: Pregnancies complicated by LGA are at significantly increased risk for stillbirth at or beyond 36 weeks, independent of maternal diabetes status, and may benefit from antenatal testing. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Early versus 6-12 week postpartum glucose tolerance testing for women with gestational diabetes.

OBJECTIVE: The objective of this study is to estimate the accuracy of early oral glucose tolerance testing (GTT), to predict impaired glucose tolerance. STUDY DESIGN: This was a prospective cohort study. Women received an early 75 g 2 h GTT between postpartum days 2-4 and again 6-12 weeks postpartum. The ability of the early GTT to accurately detect impaired glucose tolerance and diabetes was assessed by calculating sensitivity, specificity, positive predictive value (PPV) and negative predictive values (NPVs). The routine 6-12-week postpartum GTT was considered the gold standard. RESULTS: The early GTT was completed by 100% of subjects, whereas only 31 of 58 (53%) women returned to complete the 6-12-week postpartum GTT. The early GTT had modest sensitivity for impaired glucose tolerance (62.5%) and overt diabetes (50%). However, it had excellent specificity (100%), PPV (100%) and NPV (96.7%) for diabetes. The NPV for impaired glucose tolerance with the early GTT was 80%. CONCLUSION: Rates of 6-12 week postpartum GTT completion among patients with gestational diabetes is poor. Appropriate postpartum management may improve by using the early GTT as a screening test.

Prenatal visit utilization and outcomes in pregnant women with type II and gestational diabetes.

OBJECTIVE: To investigate the association between the number of prenatal visits (PNVs) and pregnancy outcomes in women with gestational diabetes (GDM) and Type 2 diabetes mellitus (DM). STUDY DESIGN: A 4-year prospective cohort study of women with GDM and DM and was conducted. Patients ⩾75th percentile for number of PNVs were compared with those ⩽25th percentile. The primary outcomes were large for gestational age (LGA) with birth weight >90% and neonatal intensive care unit (NICU) admission for >24 h. Secondary neonatal outcomes included severe LGA (>95%), shoulder dystocia, hyperbilirubinemia requiring phototherapy, neonatal hypoglycemia, low 5 min APGAR score (<7) and preterm birth (prior to 37 weeks). Secondary maternal outcomes included mean third trimester fasting blood glucose, hemoglobin A1c (Hgb A1c) in labor, preeclampsia, gestational weight gain over Institute of Medicine recommendations, mode of delivery and maternal readmission within 30 days. Logistic regression was used to adjust for maternal race, nulliparity and body mass index. RESULTS: Of the 305 women, 4 were excluded for unknown number of PNVs. Among the 301 included, the average number of visits was 12. Rates of LGA were similar between the high (28%) compared with low (18%) utilization groups (adjusted odds ratio (aOR) 1.69; 95% confidence interval (CI) 0.81-3.54). The high utilization group was 85% less likely to deliver an infant requiring NICU admission (aOR 0.15; 95% CI 0.04-0.53) and 59% less likely to have a preterm birth (aOR 0.41; 95% CI 0.21-0.80). A time-to-event analysis to account for the fact that patients who delivered earlier had fewer weeks to experience PNVs showed that the risk for NICU admission was still significantly lower in the high PNV utilization group (hazard ratio 0.15; 95% CI 0.04-0.51) after adjusting for confounders in a Cox proportional hazard model. The mean Hgb A1c at the time of delivery was significantly better in the high (6.4%) compared with low (6.9%) utilization groups (P=0.01). There were no differences in other maternal outcomes based on prenatal care utilization. CONCLUSIONS: Diabetic women with high PNV utilization have better glycemic control in the 3 months prior to delivery and are significantly less likely to deliver preterm infants or infants requiring NICU admission. There may be innovative ways to provide prenatal care for GDM and DM to optimize maternal and neonatal outcomes.

Group versus traditional prenatal care in low-risk women delivering at term: a retrospective cohort study.

OBJECTIVE: Group prenatal care (GC) models are receiving increasing attention as a means of preventing preterm birth; yet, there are limited data on whether group care improves perinatal outcomes in women who deliver at term. The purpose of this study was to evaluate our institutional experience with GC over the past decade and test the hypothesis that GC, compared with traditional individual care (TC), improves perinatal outcomes in women who deliver at term. STUDY DESIGN: We performed a retrospective cohort study of women delivering at term who participated in GC compared with TC. A group of 207 GC patients who delivered at term from 2004 to 2014 were matched in a 1:2 ratio to 414 patients with term singleton pregnancies who delivered at our institution during the same period by delivery year, maternal age, race and insurance status. The primary outcome was low birth weight (<2500 g). Secondary outcomes included early term birth (37.0 to 38 6/7 weeks), 5 min APGAR score <7, special care nursery admission, neonatal intensive care unit (NICU) admission, neonatal demise, cesarean section and number of prenatal visits. Outcomes were compared between the two groups using univariable statistics. RESULTS: Baseline characteristics were similar between the two matched groups. GC was associated with a significant reduction in low birth weight infants compared with TC (11.1% vs 19.6%; relative risk (RR) 0.57; 95% confidence interval (CI) 0.37 to 0.87). Patients in GC were significantly less likely than controls to require cesarean delivery, have low 5 min APGAR scores and need higher-level neonatal care (NICU: 1.5% vs 6.5%; RR 0.22; 95% CI 0.07 to 0.72). There were no significant differences in rates of early term birth and neonatal demise. CONCLUSIONS: Low-risk women participating in GC and delivering at term had a lower risk of low birth weight and other adverse perinatal outcomes compared with women in TC. This suggests GC is a promising alternative to individual prenatal care to improve perinatal outcomes in addition to preterm birth.

Number of prenatal visits and pregnancy outcomes in low-risk women.

OBJECTIVE: We investigated the association between number of prenatal visits (PNV) and pregnancy outcomes. STUDY DESIGN: A retrospective cohort of 12 092 consecutive, uncomplicated term births was included. Exclusion criteria included unknown or third trimester pregnancy dating, pre-existing medical conditions and common pregnancy complications. Patients with ⩽10 PNV were compared with those with >10. The primary outcome was a neonatal composite including neonatal intensive-care unit admission, low APGAR score (<7), low umbilical cord pH (<7.10) and neonatal demise. Secondary outcomes included components of the composite as well as vaginal delivery, induction and cesarean delivery. Logistic regression was used to adjust for potential confounders. RESULT: Of 7256 patients in the cohort meeting inclusion criteria, 30% (N=2163) had >10 PNV and the remaining 70% (N=5093) had ⩽10, respectively. There was no difference in the neonatal composite between the two groups. However, women with>10 PNV were more likely to undergo induction of labor and cesarean delivery. CONCLUSION: Low-risk women with ⩾10 PNV had higher rates of pregnancy interventions without improvement in neonatal outcomes.

Application of a tissue receptor assay to measurement of serum follitropin (FSH).

A rat testes tubule receptor assay, employing 125I-hFSH as the radioligand, has been applied to measurement of human serum follitropin (FSH). Highly purified hFSH LER-1575C was used as the reference preparation. Problems related to interference with uptake of radioligand by receptor, presumably due to non-hormonal serum factors, were minimized by dialysis of the serum prior to TRA. Results obtained by TRA were compared with those obtained by radioimmunoassay (RIA). The mean index of discrimination (TRA/RIA) for a series of 11 postmenopausal sera (PM) was 5.4 and the mean index of precision was 0.063. Sensitivity of the TRA was 9 ng hFSH/ml. Postmenopausal serum averaged 81 ng/ml, PM on estrogen therapy averaged less than 9 ng/ml, Turners Syndrome was 40 ng/ml. No FSH was detected in hypophysectomized serum, in normal male serum or in blood bank serum. PM levels by TRA were similar to those obtained by others with RIA after multiplying by the conversion factor of 5.4.