Immediate delivery or expectant management in gestational diabetes at term: the GINEXMAL randomised controlled trial.

OBJECTIVE: To evaluate maternal and perinatal outcomes after induction of labour versus expectant management in pregnant women with gestational diabetes at term. DESIGN: Multicentre open-label randomised controlled trial. SETTING: Eight teaching hospitals in Italy, Slovenia, and Israel. SAMPLE: Singleton pregnancy, diagnosed with gestational diabetes by the International Association of Diabetes and Pregnancy Study Groups criteria (IADPSGC), between 38+0 and 39+0 weeks of gestation, without other maternal or fetal conditions. METHODS: Patients were randomly assigned to induction of labour or expectant management and intensive follow-up. Data were analysed by 'intention to treat'. MAIN OUTCOME MEASURES: The primary outcome was incidence of caesarean section. Secondary outcomes were maternal and perinatal mortality and morbidity. RESULTS: A total of 425 women were randomised to the study groups. The incidence of caesarean section was 12.6% in the induction group versus 11.7% in the expectant group. No difference was found between the two groups (relative risk, RR 1.06; 95% confidence interval, 95% CI 0.64-1.77; P = 0.81). The incidence of non-spontaneous delivery, either by caesarean section or by operative vaginal delivery, was 21.0 and 22.3%, respectively (RR 0.94; 95% CI 0.66-1.36; P = 0.76). Neither maternal nor fetal deaths occurred. The few cases of shoulder dystocia were solved without any significant birth trauma. CONCLUSIONS: In women with gestational diabetes, without other maternal or fetal conditions, no difference was detected in birth outcomes regardless of the approach used (i.e. active versus expectant management). Although the study was underpowered, the magnitude of the between-group difference was very small and without clinical relevance. TWEETABLE ABSTRACT: Immediate delivery or expectant management in gestational diabetes at term?

Dilution effects on combined magnetic and electric dipole interactions: A study of ferromagnetic cobalt nanoparticles with tuneable interactions.

Improved understanding of complex interactions between nanoparticles will facilitate the control over the ensuing self-assembled structures. In this work, we consider the dynamic changes occurring upon dilution in the self-assembly of a system of ferromagnetic cobalt nanoparticles that combine magnetic, electric, and steric interactions. The systems examined here vary in the strength of the magnetic dipole interactions and the amount of point charges per particle. Scattering techniques are employed for the characterization of the self-assembly aggregates, and zeta-potential measurements are employed for the estimation of surface charges. Our experiments show that for particles with relatively small initial number of surface electric dipoles, an increase in particle concentration results in an increase in diffusion coefficients; whereas for particles with relatively high number of surface dipoles, no effect is observed upon concentration changes. We attribute these changes to a shift in the adsorption/desorption equilibrium of the tri-n-octylphosphine oxide (TOPO) molecules on the particle surface. We put forward an explanation, based on the combination of two theoretical models. One predicts that the growing concentration of electric dipoles, stemming from the addition of tri-n-octylphosphine oxide (TOPO) as co-surfactant during particle synthesis, on the surface of the particles results in the overall repulsive interaction. Secondly, using density functional theory, we explain that the observed behaviour of the diffusion coefficient can be treated as a result of the concentration dependent nanoparticle self-assembly: additional repulsion leads to the reduction in self-assembled aggregate size despite the shorter average interparticle distances, and as such provides the growth of the diffusion coefficient.

Technology and pregnancy.

The World Health Organisation projects that the number of diabetes-related deaths will double between the years 2005 and 2030. An important method for reducing the number of new cases of diabetes is by screening for and controlling glucose in women with gestational diabetes, the form of diabetes that afflicts up to 10% of the pregnant population. Uncontrolled gestational diabetes mellitus results in an increased risk of complications due to maternal hyperglycaemia and the resultant fetal hyperinsulinaemia. These complications include macrosomia and an increased risk of metabolic disorders including diabetes later in the child's life. Advances in the treatment of gestational diabetes have shown promising results in minimising fetal complications; they have also helped to slow the vicious cycle of women who contract gestational diabetes mellitus producing children with a high risk of developing diabetes later in life. A comprehensive literature review with an emphasis on technology has resulted in the following collection of papers relating to pregnancy and diabetes. Last year there were several technological advances in glucose monitoring. This year the applications of telemedicine in the treatment of gestational diabetes and the use of ultrasound for early detection of the disease have been at the forefront. The authors aimed to include articles that were not only relevant to the field of diabetes technology in pregnancy, but that also improved treatment and advanced understanding. The study design and results were also carefully examined in considering the articles. The selected articles contain findings that provide new techniques for diagnosing gestational diabetes mellitus as well as provide additional treatment methods for those affected by the disease.

Technology and pregnancy.

In the USA, depending upon the diagnosis criteria used, 135,000-200,000 women annually develop gestational diabetes mellitus, adding to the number of pregnant women already suffering from either type 1 or type 2 diabetes. Maternal hyperglycaemia and the resultant fetal hyperinsulinaemia are central to the pathophysiology of diabetic complications of pregnancy. These complications include congenital malformations and an increase in neonatal intensive care unit admission and birth trauma. In addition, there is an increased rate of accelerated fetal growth, neonatal metabolic complications and risk for stillbirth. Importantly, during the last century there were two breakthroughs in diabetes management and monitoring that changed the course of treatment: the discovery of insulin and the progress in the understanding of glucose monitoring. As technology has evolved, both glucose monitoring and insulin administration can now be achieved in a continuous fashion. In this review of the literature we focus on the utility of new technologies in the management and monitoring of diabetes in pregnancy.

The associations between early pregnancy lipid profiles and pregnancy outcomes.

OBJECTIVE: To evaluate the association between early pregnancy lipid profiles and pregnancy outcomes. STUDY DESIGN: Retrospective 6 months analysis of 5218 singleton pregnant women. Each participant's demographic and medical data were collected by questionnaires and medical records. Total cholesterol (TC), triglycerides (TG), high-density lipid cholesterol (HDL-C) and low-density lipid cholesterol (LDL-C) levels were divided into quartiles, and the women were categorized as having low (<25th percentile), referent (25 to <75th percentile) or high (>75th percentile) TC, TG, HDL-C and LDL-C values. Differences between groups were tested using t-test and Pearson's χ2-test. Binary logistic regression and multivariate analysis was conducted to evaluate the associations between lipid values and the risk of pregnancy outcomes. RESULTS: (1) Women who subsequently developed adverse pregnancy outcomes had higher levels of TC, TG, LDL-C and lower levels of HDL-C during early pregnancy (<14 gestational weeks). (2) A trend toward an increasing incidence of adverse pregnancy outcomes was noted with increasing levels of TC, TG and LDL-C, and decreasing level of HDL-C. (3) The more numbers of TC, TG and LDL-C above 75th percentile and HDL-C inferior to 25th percentile women had, the higher their risk of developing adverse pregnancy outcomes. (4) Low TG level was a protective factor for gestational diabetes mellitus (GDM) (<1.44 mmol l-1, odds ratio (OR)=0.706, 95% confidence interval (CI), 0.586 to 0.852) and large for gestational age infants (LGA) (<1.44 mmol l-1, OR=0.769, 95% CI, 0.631 to 0.936), and low LDL-C (<1.89 mmol l-1) level was protective factor for preterm birth. High TG (>1.40 mmol l-1, OR=1.327, 95% CI, 1.130 to 1.558), TC (>4.29 mmol l-1, OR=1.250, 95% CI, 1.062 to 1.471), and LDL-C (>2.62 mmol l-1, OR=1.25, 95% CI, 1.069 to 1.480) levels and a low HDL-C (<1.89 mmol l-1, OR=1.190, 95% CI, 1.007 to 1.405) level were associated with increased risk of GDM. A high TG (>1.40 mmol l-1, OR=1.550, 95% CI, 1.025 to 2.343) level was related to high risk of pre-eclampsia (PE), while a high LDL-C (>2.62 mmol l-1, OR=1.400, 95% CI, 1.100 to 1.781) level was risk factor for macrosomia. (5) After adjusting for confounders, early pregnancy TC was an independent risk factor for GDM (ajusted odds ratio [aOR]=1.184, 95% CI, 1.085 to 1.291), TG level was independently associated with the prevalence of GDM (aOR=1.253, 95% CI, 1.141 to 1.375) and PE (aOR=1.245, 95% CI, 1.023 to 1.516), and LDL-C level was significantly associated with risk of GDM (aOR=1.162, 95% CI, 1.052 to 1.283) and preterm birth (aOR=1.264, 95% CI, 1.065, 1.501). CONCLUSIONS: Early pregnancy high levels of TC, TG, LDL-C and low level of HDL-C may be predictive biomarkers for adverse pregnancy outcomes, while early pregnancy low TC, TG, LDL-C levels and high HDL-C levels could have some protective roles.

Relationship of maternal birth weight on maternal and neonatal outcomes: a multicenter study in Beijing.

OBJECTIVE: Birth weight is an important indicator for childhood and adulthood diseases. Published studies lack information on the relative contribution of women's own birth weight to the course of her pregnancy, not only for maternal but especially to neonatal outcome. The aim of the study was to evaluate the relationship of maternal birth weight on maternal and perinatal complications during pregnancy. STUDY DESIGN: Medical and obstetrical data were collected from 5479 women at 15 hospitals in Beijing, by a systemic cluster sampling survey conducted from 20 June 2013 to 30 November 2013. These women were categorized into five groups, according to their own birth weight: low birth weight (⩽2500 g, n=275), sub-optimal birth weight (2500 to 2999 g, n=1079), optimal birth weight (3000 to 3499 g, n=2590; 3500 to 3999 g, n=1085) and high birth weight (⩾4000 g, n=450). The occurrence of maternal and neonatal complications was recorded and compared among the groups. Statistical analysis was performed by SPSS 20.0 and values of P<0.05 were considered to be statistically significant. RESULTS: Low maternal birth weight was associated with higher rates of gestational diabetes mellitus (χ2=21.268, P=0.006) and hypertensive disorders (χ2=10.844, P=0.028). The latter association was strongest in women with a pre-pregnancy body mass index above 25 kg m-2. Low maternal birth weight was also associated with an apparently higher incidence of preterm labor (χ2=18.27, P=0.001) and hypertriglyceridemia (χ2=2.739, P=0.027) in pregnancy. An association between women with low birth weight and a significantly higher rate of small for gestational age infants (χ2=93.507, P<0.001) and low birth weight (χ2=36.256, P<0.001) was detected. High maternal birth weight was associated with an increased risk of pre-pregnancy overweight and obesity (P<0.001), as well as for large for gestational age infants (χ2=93.507, P<0.001) and macrosomia (χ2=72.594, P<0.001). CONCLUSIONS: In our study, high or low maternal birth weight was strongly associated with maternal and perinatal adverse pregnancy outcomes. This suggests that by controlling the birth weight of female infants among the normal range, adverse outcomes may be decreased in the future and for the following generations.

Gestational diabetes mellitus. A survey of perinatal complications in the 1980s.

Neonatal morbidity was assessed in the offspring of 878 mothers with gestational diabetes mellitus (GDM), 132 mothers with pre-GDM, and 380 control subjects. Compared with the control group, the GDM group had a higher incidence of complications, including macrosomia, hypoglycemia, hyperbilirubinemia, hypocalcemia, polycythemia, and major congenital anomalies (P less than 0.05). Although our GDM patients were stringently managed with diet or diet plus insulin, as indicated, and maintained almost euglycemic values, these neonatal complications could not be eliminated. Our data may be consistent with observations published during the last decade that even subtle degrees of maternal hyperglycemia can have a detrimental effect on perinatal outcome. Most neonatal complications readily respond to therapy if diagnosed and treated early and promptly. Macrosomia can have a detrimental effect on delivery (trauma) and later long-term implications during childhood. Tight metabolic control with diet and, when indicated, insulin treatment may be advantageous in reducing fetal birth weight. Criteria of how tight the metabolic control should be remain to be accurately defined.

The pharmacologic approach to the prevention of preeclampsia: from antiplatelet, antithrombosis and antioxidant therapy to anticonvulsants.

Preeclampsia has been suggested to be a two-stage disorder of an alteration in placental perfusion (stage 1) leading to generalized vascular endothelial damage (stage 2). Because the mechanism linking the two stages remains unclear, effective primary prevention is still impossible. However, advances made in our understanding of the pathophysiology of preeclampsia have paved the way for secondary and tertiary prevention approaches. Platelets are known to be activated in early pregnancy. They also play a pivotal role in the process of inflammation, as demonstrated by the finding that CD40 ligand is shed from activated platelets to directly initiate inflammation of the vessel wall. According to the Cochrane Library Update summarizing data from over 30,000 women, secondary prevention with antiplatelet drugs is associated with a 19% decrease in the risk of preeclampsia. Additional randomized controlled trials are needed to establish the association between preeclampsia and thrombophilia. The effect of the antithrombotic agent heparin on pregnancy outcome in preeclampsia and its potential preventive action in high-risk patients need to be elucidated. One of the several hypotheses of the pathogenesis of preeclampsia focuses on the oxidative stress caused by the imbalance in prooxidant and antioxidant forces. Preliminary findings on vitamin E and vitamin C supplementation in preeclamptic women are encouraging, and suggest a rationale for larger clinical trials. Although there is currently no explanation for the positive effect of magnesium sulfate on eclamptic seizures, studies have provided enough evidence to encourage its worldwide use as the primary anticonvulsant of choice in the tertiary prevention of maternal and perinatal death in severe preeclampsia/eclampsia. In conclusion, secondary and tertiary prevention of preeclampsia is possible when targeted at reducing maternal and neonatal morbidity and mortality.

Antepartum management protocol. Timing and mode of delivery in gestational diabetes.

We sought to determine whether strict glycemic control during diabetic pregnancy combined with elective early induction of labor reduces the rate of cesarean delivery and fetal birth trauma. We used a population-based longitudinal design covering three periods corresponding to changes in the management protocol for diabetic pregnancy at our center: 1) 1980-1989: no set level of maternal glycemia, elective cesarean section when estimated fetal weight was 4,500 g or more, and no elective early induction; 2) 1990-1992: desired mean maternal glycemia < or = 5.8 mmol/l, elective cesarean section when estimated fetal weight was 4,000 g or more, and elective early induction at 40 weeks for large-for-gestational-age fetuses; 3) 1993-1995: desired mean maternal glycemia < or = 5.3 mmol/l, elective cesarean section when estimated fetal weight was 4,000 g or more, and elective early induction at 38 weeks for large-for-gestational-age fetuses. Outcome of diabetic pregnancies was compared for the three periods, relative to that of the normal population. There was a gradual, constant, and significant decline in the incidence of macrosomia (17.9, 14.9, and 8.8%, respectively; P < 0.05) and large-for-gestational-age fetuses (23.6, 21.0, and 11.7%; P < 0.05) coupled with a gradual, nonsignificant decrease in cesarean deliveries (20.6, 18.4, and 16.2%) and in cases of shoulder dystocia (1.5, 1.2, and 0.6%), to rates close to those of the normal population. Our data show that maintaining strict control of maternal diabetes and adhering to an active management protocol for early elective delivery based on the estimated fetal weight have a significant effect on reducing the rate of macrosomia, thereby affecting the incidence of both traumatic births and cesarean deliveries.

Intrapartum GBS screening and antibiotic prophylaxis: a European consensus conference.

Group B streptococcus (GBS) remains worldwide a leading cause of severe neonatal disease. Since the end of the 1990s, various strategies for prevention of the early onset neonatal disease have been implemented and have evolved. When a universal antenatal GBS screening-based strategy is used to identify women who are given an intrapartum antimicrobial prophylaxis, a substantial reduction of incidence up to 80% has been reported in the USA as in other countries including European countries. However recommendations are still a matter of debate due to challenges and controversies on how best to identify candidates for prophylaxis and to drawbacks of intrapartum administration of antibiotics. In Europe, some countries recommend either antenatal GBS screening or risk-based strategies, or any combination, and others do not have national or any other kind of guidelines for prevention of GBS perinatal disease. Furthermore, accurate population-based data of incidence of GBS neonatal disease are not available in some countries and hamper good effectiveness evaluation of prevention strategies. To facilitate a consensus towards European guidelines for the management of pregnant women in labor and during pregnancy for the prevention of GBS perinatal disease, a conference was organized in 2013 with a group of experts in neonatology, gynecology-obstetrics and clinical microbiology coming from European representative countries. The group reviewed available data, identified areas where results were suboptimal, where revised procedures and new technologies could improve current practices for prevention of perinatal GBS disease. The key decision issued after the conference is to recommend intrapartum antimicrobial prophylaxis based on a universal intrapartum GBS screening strategy using a rapid real time testing.

Regulation of platelet aggregation and adenosine triphosphate release in vitro by 17beta-estradiol and medroxyprogesterone acetate in postmenopausal women.

Clinical studies have suggested that hormone replacement therapy (HRT) may reduce the risk of coronary heart disease in postmenopausal women. Although progestins are commonly added to HRT preparations for uteroprotection, the perceived beneficial cardiovascular effects of HRT are thought to be mediated predominantly by the estrogen component. Platelets play a critical role in the pathogenesis of atherosclerosis and cardiovascular disease and, hence, it is possible that the cardiovascular effects of estrogens are mediated, at least in part, through inhibition of illicit platelet activation. The aim of this study was to examine the effects of sex steroids on adenosine diphosphate (ADP)-induced platelet aggregation and adenosine triphosphate (ATP) release in vitro in postmenopausal women. In addition, the effects of antiestrogens 14-hydroxy tamoxifen (4-OHT) and ICI 182780] and antiprogestins (RU 486 and ZK 98299) were also investigated. Preincubation of platelet-rich plasma (PRP) with antiestrogens or antiprogestins did not alter subsequent platelet aggregation or ATP release in response to ADP. However, preincubation with 17beta-estradiol (E2) significantly inhibited ADP-mediated platelet aggregation by a mean (+/-SEM) of 37%+/-6% (p = 0.02) and ATP release by 82%+/-6% (p = 0.03), an effect that was reversed by the addition of ICI 182780 or 4-OHT but not RU 486 and ZK 98299. Although the progestin medroxyprogesterone acetate (MPA) also significantly inhibited platelet aggregation (by 28%+/-5%, p = 0.02) and ATP release (by 63%+/-9%, p = 0.02), this inhibition was not reversed by the addition of antiprogestins or antiestrogens. These data show that sex steroids can modulate platelet function in vitro. Furthermore, as platelets are devoid of nuclear components, these findings indicate that estrogens may regulate platelet function through binding to a non-nuclear receptor with ligand-binding properties similar or identical to the wild-type receptor. By contrast, MPA appears to exert its effect through a mechanism that does not involve binding to the "classical" progesterone receptor.

The regulation of platelet aggregation in vitro by interleukin-1beta and tumor necrosis factor-alpha: changes in pregnancy and in pre-eclampsia.

Platelet activation occurs in early pregnancy in women at risk of developing pre-eclampsia. Cytokines have been implicated in the pathogenesis of pre-eclampsia, so we determined the effects of interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha (TNF-alpha) on the in vitro aggregation of human platelets. IL-1beta increased aggregation of platelets from non-pregnant and pre-eclamptic women, and inhibited the aggregation of platelets from normal pregnant women. This latter effect was linked to a diminished P-selectin expression on ADP-stimulated whole blood platelets in normal pregnant women (p = 0.011). Platelet aggregation in response to ADP was found to be inhibited after preincubation with TNF-alpha in non-pregnant (38%, p = 0.01) and in normal pregnant women (54%, p = 0.001) and not affected in pre-eclamptic women. The inhibitory effects of TNF-alpha were mediated through the P75 receptor for TNF-alpha.

Aggregation of white cells and C-reactive protein: relation between these two indices in acute phase reaction.

The association between aggregates of leucocytes in blood drawn from patients with various inflammatory conditions and the serum concentration of C-reactive protein (CRP) was examined: serum concentration of CRP might contribute to the development of cellular aggregations. A total of 213 patients with various inflammatory or necrotic conditions were examined (including 31 women with normal pregnancy and 59 controls). A significant correlation between the degree of leucocyte aggregation and CRP concentration was noted in patients with bacterial infections and in a group of patients with various inflammatory conditions. In contrast, there was no correlation between the extent of leucocyte aggregation and CRP concentrations in patients with viral infections, malignancies, or pregnancy. The presence or absence of aggregated leucocytes can help in differentiating between the respective bacterial or viral infections. The serum concentrations of CRP were increased in both types of infection, although when a quantitative CRP assay was used, considerably higher concentrations were detected in bacterial diseases.

Improving pregnancy outcome in twin gestations with one malformed fetus by postponing selective feticide in the third trimester.

OBJECTIVE: To examine the course of pregnancy and fetal outcome in patients with twin gestations in which one abnormal fetus underwent selective feticide in the third trimester of pregnancy. DESIGN: A study of 23 consecutive late selective feticide procedures. SETTING: Department of Obstetrics and Gynecology, Rabin Medical Center, Israel. PATIENT(S): Twenty-three patients with twin pregnancies with one malformed fetus. INTERVENTION(S): Selective feticide with intracardiac injection of KCl was performed at 28-33 weeks of gestation after the diagnosis of fetal genetic (56.5%) or structural (43.5%) malformations made in the second trimester (18-24 weeks). All procedures were performed at the patient's request and on approval of a committee for fetal termination late in pregnancy. Betamethasone treatment was initiated to enhance lung maturity 3 weeks before selective feticide. All patients were placed on complete bed rest until 35 weeks' gestation. MAIN OUTCOME MEASURE(S): Early and late complications related to the procedure; outcome of pregnancy and fetal survival. RESULT(S): All 23 twin pregnancies had an uneventful course after selective feticide performed at 28-33 weeks. All birth weights were > 2,000 g (mean +/- SD, 2,628 +/- 646 g), indicating an excellent chance of survival. CONCLUSION(S): Our results suggest that late selective feticide in twin gestations is safe and efficient and results in a favorable outcome for the surviving fetus. This procedure should be performed at 28-30 weeks after treatment for enhancement of lung maturity.

Effect of thrombophylaxis on uterine and fetal circulation in pregnant women with a history of pregnancy complications.

PURPOSE: The aim of this study was to investigate the effect of thromboprophylactic therapy on fetal and maternal Doppler flow parameters in pregnant women with severe complications in previous pregnancies and evidence of acquired or congenital thrombophilia in the current pregnancy. METHODS: Sixty-five patients with a history of recurrent abortions, intrauterine fetal death, intrauterine growth restriction (IUGR), and severe early-onset preeclampsia were tested for the presence of acquired or congenital thrombophilia. Those with positive findings were prescribed low-dose aspirin plus low-molecular-weight heparin (LMWH) (enoxaparin); the remainder received low-dose aspirin only. A Doppler flow study was performed before and after treatment and in the third trimester of pregnancy. RESULTS: Of the 65 pregnancies, four ended in spontaneous abortion and were excluded from the analysis. Of the 61 women with completed pregnancies, 37 (61%) had evidence of acquired or congenital thrombophilia: 22 (36%) protein S deficiency; 1 (2%) protein C deficiency; 2 (3%) activated protein C resistance (APC-R); 2 (3%) IgG for antiphospholipid antibodies; 1 (2%) circulating anticoagulant; and 9 (15%) a combined defect. This group showed a significant decrease in mean uterine artery pulsatility index (PI) before and after treatment (1.32+/-0.36 vs. 1.04+/-0.23, P=.006), whereas the remaining 24 patients treated with low-dose aspirin only had nonsignificant changes. Pearson's correlation test yielded no correlations of the pregnancy outcome parameters with Doppler flow values in the umbilical or uterine arteries. CONCLUSIONS: Thromboprophylactic therapy transiently improves maternal circulation parameters in patients with thrombophilia at risk of fetal loss and other severe complications of pregnancy, but not in correlation with their pregnancy outcome. Therefore, Doppler examination of maternofetal circulation in the second trimester is not predictive of pregnancy outcome.

Increased D-dimer levels in twin gestation.

In normal pregnancy, the hemostatic balance is displaced toward hypercoagulability. The elevation in plasma levels of coagulation factors VII, VIII, and X and fibrinogen and the increased concentrations of plasminogen activator inhibitors [1,2] may predispose individuals to thromboembolism, especially near term [1,3]. Because human multifetal gestation requires still greater physiological alterations, the imbalance in hemostasis is further exaggerated. It has been suggested that the changes in the coagulation system near term may even mimic low-grade disseminated intravascular coagulopathy [4]. However, for the majority of women with multifetal gestation, the coagulopathy observed in the laboratory is not clinically apparent [5]. Despite the large body of research on the physiological adaptation to pregnancy, relatively little is known of the biological adaptation in general and the hemostatic changes in particular associated with multiple gestation.

White coat hypertension and pregnancy outcome.

The presence and outcome effect of white coat hypertension in pregnancy was determined with 24-h ambulatory blood pressure (BP) monitoring. Sixty women presenting with high clinic BP (>/=140/90 mm Hg) in the second trimester were included. Patients were divided into two groups based on daytime ambulatory BP findings: <135/85 mm Hg, white coat hypertension (n = 37); >/=135/85 mm Hg, 'true' hypertension (n = 23). Complicated pregnancy outcome was defined as the presence of pre-eclampsia and/or intrauterine growth restriction. Groups were compared for pregnancy outcome and for background and delivery factors. The predictive value of ambulatory BP measurements for pregnancy outcome was determined. Pregnancy outcome was better in the white coat hypertension group than in the true hypertension group: pre-eclampsia-3 (8.1%) vs 13 (56.5%) (P = 0.0046); intrauterine growth restriction-5 (13.5%) vs 10 (43.4%) (P = 0. 0139); and preterm delivery-11 (29.7%) vs 15 (65.2%) (P = 0.015). Night-time ambulatory BP measurements were the best predictor of complicated pregnancy, followed by daytime and 24-h measurements. We conclude that second trimester ambulatory BP monitoring can be used to differentiate patients who have white coat hypertension, which is associated with a better pregnancy outcome than true hypertension.

Microalbuminuria as an early marker of severity in hypertensive pregnant women.

The value of microalbuminuria in predicting hypertensive complications in pregnant patients at high risk was tested in a prospective trial. A total of 276 patients were studied (142 in the study group vs 134 controls). Albumin was measured in 8-h overnight urine collection throughout pregnancy using radioimmunoassay technique. The pregnant women, in both the study and control groups demonstrated a statistically significant increase in albumin excretion rate in the second and third trimester compared with the first. Using logistic and linear regression models, the presence of microalbuminuria in the early third trimester was proven to be predictive of severe disease (odds ratio 2.1, confidence interval (CI) 1.26-3.53) and birth weight (R2 = 0.7, P < 0.05) in the study group. Intrauterine growth retardation and neonatal outcome were less predictable. With the introduction of radioimmunoassays, we believe severe disease can be predicted by detecting microalbuminuria in the early third trimester of pregnancy in high risk patients.