Association of glucose metabolism and blood pressure during pregnancy with subsequent maternal blood pressure.

The goal of this study was to examine associations of measures of maternal glucose metabolism and blood pressure during pregnancy with blood pressure at follow-up in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) cohort. The HAPO Follow-Up Study included 4747 women who had a 75-g oral glucose tolerance test (OGTT) at ~28 weeks' gestation. Of these, 4572 women who did not have chronic hypertension during their pregnancy or other excluding factors, had blood pressure evaluation 10-14 years after the birth of their HAPO child. Primary outcomes were systolic blood pressure (SBP), diastolic blood pressure (DBP), and hypertension (SBP ≥ 140 and/or DBP ≥ 90 or treatment for hypertension) at follow-up. Blood pressure during pregnancy was associated with all blood pressure outcomes at follow-up independent of glucose and insulin sensitivity during pregnancy. The sum of glucose z-scores was associated with blood pressure outcomes at follow-up but associations were attenuated in models that included pregnancy blood pressure measures. Associations with SBP were significant in adjusted models, while associations with DBP and hypertension were not. Insulin sensitivity during pregnancy was associated with all blood pressure outcomes at follow-up, and although attenuated after adjustments, remained statistically significant (hypertension OR 0.79, 95%CI 0.68-0.92; SBP beta -0.91, 95% CI -1.34 to -0.49; DBP beta -0.50, 95% CI -0.81 to -0.19). In conclusion, maternal glucose values at the pregnancy OGTT were not independently associated with maternal blood pressure outcomes 10-14 years postpartum; however, insulin sensitivity during pregnancy was associated independently of blood pressure, BMI, and other covariates measured during pregnancy.

Racial and ethnic disparities in diabetes risk after gestational diabetes mellitus.

AIMS/HYPOTHESIS: To investigate racial/ethnic disparities in diabetes risk after gestational diabetes mellitus (GDM). METHODS: This is a retrospective cohort study of women enrolled in the Kaiser Permanente Southern California health plan from 1995 to 2009. GDM status was identified on the basis of plasma glucose levels during pregnancy. The incidence of diabetes after the first delivery complicated by GDM before 31 December 2009 (n = 12,998) was compared with the experience for women without GDM (n = 64,668) matched on maternal age at delivery, race/ethnicity and year of delivery (1:5 ratio). Matched Cox regression was used to compare the RRs of diabetes associated with GDM within and across racial/ethnic groups. RESULTS: Compared with the women without GDM, the HRs (95% CI) of diabetes for women after GDM were 6.5 (5.2, 8.0) in non-Hispanic white, 7.7 (6.8, 8.7) in Hispanic, 9.9 (7.5, 13.1) in black and 6.3 (5.0, 7.9) in Asian/Pacific Islanders after adjustment for parity, maternal education, comorbidity and number of outpatient visits before the index pregnancy. The HR of diabetes for black women was significantly higher than that for non-Hispanic white women (p = 0.032). Further adjustment for prepregnancy BMI reduced the diabetes risk association with GDM for each racial/ethnic group, but did not explain the risk differences across groups. CONCLUSIONS/INTERPRETATIONS: Racial/ethnic disparities exist in risk of diabetes after GDM. Black women with GDM had the highest risk of developing diabetes. This highlights the importance of developing an effective diabetes screening and prevention programme in women with GDM, particularly black women with GDM.

Managing type I diabetes in pregnancy: how near normal is necessary?

OBJECTIVE: This was a feasibility study to determine if pregnant women with type I diabetes managed with liberal target glucose values will have a decreased frequency of hypoglycemia with no differences in adverse outcomes compared with tightly controlled subjects. STUDY DESIGN: Twenty-two women who had type I diabetes were randomized in first trimester to 'rigid' and 'less rigid' groups. Participants recorded blood glucose results and symptoms of hypoglycemia on memory-based meters. RESULTS: Mean maternal glucose was significantly greater in first and second trimesters among patients in the 'less rigid' group. Both subjective and objective hypoglycemias were more frequent in the 'rigid' group. There were no differences between groups in cesarean deliveries, birth weights and neonatal glucose concentrations. CONCLUSIONS: Utilizing glucose targets higher than those conventionally recommended in pregnancies of women who have type I diabetes may decrease maternal hypoglycemia while not increasing maternal or perinatal morbidity. The findings of this study justify further investigation with a larger patient base.

Fetal macrosomia and gestational diabetes: what's the problem?

OBJECTIVE: To review the definition of, morbidity attendant upon, and interventions designed to prevent fetal macrosomia in gestational diabetes. DATA SOURCES: Both MEDLINE and manual searches of the Index Medicus from 1980-1992 for articles pertaining to fetal macrosomia were employed. Macrosomia was also cross-referenced with pregnancy in diabetes. METHODS OF STUDY SELECTION: Seventy-nine articles that provided definitions, data, and opinions relevant to this topic were selected. DATA EXTRACTION AND SYNTHESIS: There is no universally accepted definition of fetal macrosomia. Potential associated morbidities include birth trauma, neonatal hypoglycemia, and childhood and adolescent obesity. Maternal glucose intolerance, age, parity, race and ethnicity, weight, weight gain, smoking status, and fetal gender may influence birth weight. Not all of these factors have been considered in analyses of the impact of interventions designed to prevent macrosomia. CONCLUSIONS: A consensus definition of fetal macrosomia is a necessary and attainable goal. Randomized trials are necessary in which all factors that influence fetal growth and development are uniformly analyzed to develop appropriate clinical interventions.

Laminaria digitata in saline abortions.

PIP: Laminaria tents were used in addition to the technique of saline abortion in an attempt to shorten the injection-abortion interval. 142 second trimester therapeutic abortion patients, aged 13 to 40 years, agreed to participate in the study and were assigned to 1 of 4 groups. 72.2% were single, 27.8% were married, and the gestational age was from 13 to 20 weeks. Group 1 (26 primigravid patients) served as the control group (no oxytocin or laminaria tent used). Group 2 (25 primigravid patients) received an intravenous infusion of 20 units oxytocin/500 ml of 5% dextrose in water (beginning 12 hours after saline injection). Group 3 (50 primigravid patients) likewise received an infusion of 20 units oxytocin/500 ml of 5% dextrose in water (beginning 12 hours after saline injection), and in addition, a single medium, sterile laminaria tent was inserted at the time of the saline injection and removed 12 hours after insertion. Group 4 (41 multigravid patients) received treatment identical to that of Group 3. The mean interval time from injection to delivery in Group 1 was 41.26 hours. The mean injection-abortion time was 30.67 hours for Group 2, 26.84 hours for Group 3, and 22.96 hours for Group 4. The complication rate was significantly higher for both the oxytocin plus saline group (Group 2) as well as the laminaria plus saline groups (Groups 3 and 4). Group 3 experienced a 22% febrile rate, and 18% of patients required uterine curettage, while the figures for Group 4 were 12.2% and 24.4%, respectively. The laminaria tents did result in an 11% to 15% increase in complications in Groups 3 and 4, respectively, as compared with Group 2.^ieng

Oxytocin augmentation of saline abortion.

PIP: 53 patients undergoing second trimester saline abortion were given either 20 units or 100 units of oxytocin per 500 ml of 5% dextrose solution 12 hours after saline instillation. Mean abortion time (30.67 hours, 20 units; 27.66 hours, 100 units) was 11-14 hours less than a control group of 26 patients who did not receive oxytocin (41.26 hours). The smaller dose is as effective as the larger dose and should prove safer for patients undergoing saline abortion.^ieng

Screening for gestational diabetes with the one-hour 50-g glucose test.

A one-year experience of screening for gestational diabetes is reported. Patients with any of seven risk factors were screened at the time of prenatal registration. Those without risk factors, and those not found to be diabetic by 24 weeks' gestation, were tested later in pregnancy. Of 4116 patients, 77% had at least one risk factor. The prevalence of diabetes in patients with risk factors was significantly greater than among those with no risk factors (P less than .001). Of 936 patients who had no risk factors, four were found to have diabetes. Multiple logistic regression analysis suggested that family history, obesity, and age over 25 years contributed significantly to the prediction of gestational diabetes. More than 10% of gestational diabetics had screening values between 135-139 mg/dL. Among patients whose early screening values were elevated and whose initial glucose tolerance tests were normal, the odds of being classified ultimately as a gestational diabetic were 7.3 times that of patients whose initial screening tests were normal. Selective screening based on risk factors including maternal age may enhance detection of diabetes early in gestation.

The effect of drugs on uterine activity.

Uterine activity was measured for a 30-minute preinjection period and a 30-minute postinjection period for six drugs commonly used in labor. Uterine activity was quantitated by measuring the area below the uterine pressure curve with an on-line technic utilizing a voltage control oscillator. Uterine activity readings were obtained every 2.5 minutes and reported in uterine activity units (UAU). Unmedicated labor demonstrated a relatively static increase in UAU per unit of time in labor. On comparing total UAU before and after injection, only magnesium sulfate was noted to cause a decrease in total UAU. Utilizing 10-minute summations of UAU, the pre- and postinjection periods were compared to the calculated expected UAU for the 30 minutes following the preinjection period (assuming no drug had been used). For each of the other drugs, the positive slope of the calculated expected UAU shifted to a negative slope of the actual observed UAU following drug administration.

Estimating fetal weight in the management of macrosomia.

The purpose of this review is to examine the evidence that, including estimates of fetal macrosomia in patient care, will decrease adverse perinatal outcomes. A literature search for the years 1980 to 1999 was used. Shoulder dystocia and brachial plexus injuries occur more often in macrosomic than in non-macrosomic neonates. However, 26 to 58 percent of shoulder dystocias and 24 to 44 percent of brachial plexus injuries occur to babies weighing less than 4000 gm. Persistence of impairment is extremely rare. Neither historical nor clinical factors have strong positive predictive values for macrosomia. From 15 to 81 percent of the babies predicted to be macrosomic are confirmed by birth weight. Of babies determined to be macrosomic at birth, only 50 to 100 percent were successfully predicted. Shoulder dystocia and brachial plexus injuries are unpredictable events. Available evidence suggests that planned interventions based on estimates of fetal weight do not reduce the incidence of shoulder dystocia and do not decrease adverse outcomes attributable to fetal macrosomia.

Induction of labor versus conservative management of pregnant diabetic women.

Reasons for inducing labor at term in pregnancies complicated by diabetes include the avoidance of fetal demise and the prevention of excessive fetal growth and its concomitant conditions, shoulder dystocia and Cesarean delivery. Objectively evaluating the risks and benefits of labor induction is potentially confounded by the status of the cervix at the time of initiation of induction, early determination of an arrest disorder and physician bias toward Cesarean delivery for women who have diabetes. In non-diabetic women, incorporating estimates of fetal weight in deciding the route of delivery has not diminished the incidence of shoulder dystocia, and may have increased the incidence of Cesarean deliveries. Currently available evidence suggests that, while induction of labor for women who have diabetes may not carry much maternal or fetal risk, the benefit of this procedure is unclear.

Yta isoimmunization in pregnancy. A case report.

A case of isoimmunization with anti-Yta occurred. Despite transplacental passage of IgG antibody, no hemolysis of fetal cells was noted. The potential for hemolysis of cells transfused to an adult is unclear. Alternatives exist for securing compatible cells for possible maternal transfusion.

Could the fasting plasma glucose assay be used to screen for gestational diabetes?

The fasting plasma glucose assay was compared with the one-hour post-glucose test as a screening test for identification of gestational diabetes. Of 4,561 consecutive patients screened with a 50-g glucose test, 968 (21.2%) had results > or = 135 mg/dL; 141 (14.6%, or 3.1% of the total) were found to have diabetes. In the 968 patients, the area under the fasting plasma glucose receiver operating characteristic curve was greater than that under the glucose screening test curve, indicating greater discriminatory value of the former test. Of the 116 patients who had sequential glucose screening tests and fasting plasma glucose assays performed twice during pregnancy, a significant correlation was found for fasting plasma glucose values, but not for glucose screening test values. We conclude that the fasting plasma glucose assay may perform better than the one-hour post-glucose test as a screening test for gestational diabetes. Based on these data, a population-based prospective study seems justified.

Sinusoidal fetal heart rate pattern with intrapartum fetal death.

A case of sinusoidal fetal heart rate pattern with intrapartum fetal death is presented. This pattern has been observed infrequently during both the antepartum and intrapartum periods. Not all sinusoidal patterns may be ominous. A reasonable plan of management includes maternal position change, oxygen administration, scalp sampling and preparation for immediate delivery.

Pregnancy plasma glucose levels exceeding the American Diabetes Association thresholds, but below the National Diabetes Data Group thresholds for gestational diabetes mellitus, are related to the risk of neonatal macrosomia, hypoglycaemia and hyperbilirubinaemia.

AIMS/HYPOTHESIS: Gestational diabetes mellitus (GDM) is a risk factor for perinatal complications. In several countries, the criteria for the diagnosis of GDM have been in flux, the American Diabetes Association (ADA) thresholds recommended in 2000 being lower than those of the National Diabetes Data Group (NDDG) that have been in use since 1979. We sought to determine the extent to which infants of women meeting only the ADA criteria for GDM are at increased risk of neonatal complications. MATERIALS AND METHODS: In a multiethnic cohort of 45,245 women who did not meet the NDDG criteria and were not treated for GDM, we conducted nested case-control studies of three complications of GDM that occurred in their infants: macrosomia (birthweight >4,500 g, n = 494); hypoglycaemia (plasma glucose <2.2 mmo/l, n = 488); and hyperbilirubinaemia (serum bilirubin > or =342 micromol/l (20 mg/dl), n = 578). We compared prenatal glucose levels of the mothers of these infants and mothers of 884 control infants. RESULTS: Women with GDM by ADA criteria only (two or more glucose values exceeding the threshold) had an increased risk of having an infant with macrosomia (odds ratio OR = 3.40, 95% CI = 1.55-7.43), hypoglycaemia (OR = 2.61, 95% CI = 0.99-6.92) or hyperbilirubinaemia (OR = 2.22, 95% CI = 0.98-5.04). Glucose levels 1 h after the 100-g glucose challenge that exceeded the ADA threshold were particularly strongly associated with each complication. CONCLUSIONS/INTERPRETATION: These results lend support to the ADA recommendations and highlight the importance of the 1-h glucose measurement in a diagnostic test for GDM.

The utility of a single test to identify women at risk for gestational diabetes.

A number of single tests have been proposed as both screening and definitive tests of glucose intolerance during pregnancy. Despite limitations imposed by a lack of uniformity in methodology and definitions of gestational diabetes mellitus, there appears to be an independent relationship between some single-test results and clinically meaningful outcomes. Further study is needed to identify those glucose values above which women and their babies who are at risk for glycemia-related adverse outcomes may be identified.

Isoimmunization to Cromer antigen in pregnancy.

Pregnancy in a woman isoimmunized to Cromer antigen, a high-frequency antigen, is reported. Neither of her two Cromer antigen-positive infants was affected with hemolytic disease of the newborn. Autologous blood or that from a compatible Cromer antigen-negative relative may be frozen and stored for possible transfusion in a pregnant woman with anti-Cromer antigen antibodies.

Blood transfusion and Jehovah's Witnesses: medical and legal issues in obstetrics and gynecology.

Jehovah's Witnesses are members of a religious denomination whose beliefs prohibit the use of blood or blood products. Plasma volume expanders and extracorporeal hemodilution of the patient's own blood are theologically acceptable. Acute massive hemorrhage in which only blood is lifesaving may be encountered in obstetrics and gynecology. Either withholding or administering blood in such circumstances may have legal consequences for the physician and hospital. Factors to be considered include fetal viability, the presence of dependent children, and rules of informed consent. Whenever possible, the potential for transfusion should be anticipated and clearly discussed with the patient. When appropriate, the physician and hospital should move rapidly to obtain judicial resolution.

Caring for the female Jehovah's Witness: balancing medicine, ethics, and the First Amendment.

Blood transfusion has been doctrinally forbidden for Jehovah's Witnesses since 1945. Despite serious theologic consequences for its violation, this proscription may not be observed universally by members of the denomination. When a patient declines a lifesaving transfusion, a conflict is generated between the physician's autonomy-based and beneficence-based obligations to the patient. This conflict is intensified when the patient is a woman who had minor dependent children, either in utero or already born. A spectrum of opinion exists regarding the resolution of this conflict. As one of society's repositories of moral and legal values, the court is the most appropriate forum in which religious, medical, and ethical viewpoints may receive a fair and impartial hearing.

Isoimmunization in pregnancy to Gerbich antigen.

A case of hemolytic disease of the newborn due to Gerbich, a public antigen, is presented. The antibody which was IgG1 reacted in vitro with mononuclear phagocytes. Serial sonographic and amniotic fluid examinations were followed and a mildly jaundiced neonate was delivered. Further investigation may establish a relationship between severity of disease and IgG subclasses, a mononuclear phagocyte assay, and sonographic measurements. Sources of compatible blood for possible maternal, fetal, or neonatal transfusion include blood bank rare donor files, relatives, and autologous donation.