Long-term follow-up of infants of mothers with type 1 diabetes: evidence for hereditary and nonhereditary transmission of diabetes and precursors.

OBJECTIVE: To estimate the impact of type 1 diabetes during pregnancy on transgenerational genetically caused and/or fuel-mediated amplification of types 1 and 2 diabetes and to estimate the impact of elevated amniotic fluid insulin levels. RESEARCH DESIGN AND METHODS: A total of 75 white offspring of type 1 diabetic mothers and 49 control subjects of similar age and pubertal stage were examined at 5-15 years of age. All offspring had an oral glucose tolerance test. Glucose, insulin, and C-peptide were measured at 0, 30, 60, and 120 min after loading. Lipids and autoimmune antibodies were measured in fasting plasma. RESULTS: Of the 75 offspring, 4 (5.3%) had overt diabetes, and 16 of 71 (22.5%) had autoimmune antibodies. Offspring of diabetic mothers had significantly higher BMI; symmetry indexes; cholesterol, glucose, insulin, and C-peptide levels; and insulin resistance than control subjects. With the exception of cholesterol, these values were significantly elevated in offspring who had elevated amniotic fluid insulin levels (>8 microU/ml, >48 pmol/l) during pregnancy compared with normoinsulinemic offspring and control subjects. CONCLUSIONS: Offspring of type 1 diabetic mothers have an increased risk for diabetes later in life. The relative risk for type 1 and type 2 diabetes is 71.6 and 3.2, respectively. Type 2 diabetes-associated risk factors, such as high BMI; elevated glucose, insulin, and C-peptide levels; and insulin resistance, are related to the fetal metabolic experience in utero, as reflected by amniotic fluid insulin concentration.

Low fetal oxygen saturation at birth and acidosis.

OBJECTIVE: To measure umbilical cord blood oxygen saturation, to calculate preductal oxygen saturation at birth, and to assess its predictive value for acidosis. METHODS: Umbilical cord blood samples of 1537 live-born singleton neonates were analyzed. Oxygen saturation was measured by spectrophotometry; pH and base excess were measured by a pH and blood gas analyzer. Preductal oxygen saturation was calculated with an empirical equation. Acidosis was defined as 2 standard deviations (SDs) below the mean of umbilical artery (UA) pH or base excess (7.09 and -10.50 mmol/L, respectively). The predictive value for acidosis of UA and umbilical vein (UV) oxygen saturation and calculated preductal oxygen saturation was determined with receiver operating characteristic curves. RESULTS: The mean values (+/-SD) of UV, UA, and calculated preductal oxygen saturation were 52 +/- 18%, 26 +/- 17%, and 31 +/- 16%, respectively. Forty-seven neonates had UA pH less than 7.09 and 60 had UA base excess less than -10.50 mmol/L. The UV, UA, and calculated preductal oxygen saturation showed considerably weaker relations to UA base excess (multiple r(2) =.056,.003, and.017, respectively; P <.001) than to UA pH (multiple r(2) =.112,.126, and.148, respectively; P <. 001). Receiver operating characteristic areas under the curve were higher when predicting low pH compared with low base excess (for UV, UA, and calculated preductal oxygen saturation: 0.716 versus 0.699, 0.747 versus 0.586, and 0.765 versus 0.628, respectively). The difference was significant for UA oxygen saturation (P <.05). All tests showed high sensitivity and negative predictive values, but low specificity and positive predictive values. CONCLUSION: Low fetal oxygen saturation measured at birth seemed to be associated with low fetal pH and base excess values, but its predictive value for acidosis in an unselected population was limited, particularly if acidosis was metabolic.

Stage IV ovarian cancer: prognostic factors and survival beyond 5 years.

BACKGROUND: Ovarian cancer continues to be the leading cause of death due to gynecologic malignancies and most patients still present with advanced disease. In the present study we evaluated long-term survival and prognostic factors in patients with stage IV ovarian cancer. PATIENTS AND METHODS: The charts of 62 consecutive women with FIGO stage IV epithelial ovarian cancer were reviewed. RESULTS: Chemotherapy was the only factor associated with longer survival. Three patients (5%) survived for longer than 5 years. One died of disease at 6.3 years and two are alive without evidence of disease at 12.4 and 14.9 years, respectively. CONCLUSION: Survival seemed to correlate with the possibility of administering chemotherapy. Patients with verified stage IV ovarian cancer, in whom due to the initial tumor load, operative extent and concomitant illness, the possibility of postoperative chemotherapy administration seems questionable, might be considered for primary chemotherapy followed by surgery.

Long-term survival of a patient with fallopian tube cancer presenting with a supraclavicular mass.

BACKGROUND: Five-year survival of patients with stage IV cancer of the fallopian tube is poor. Furthermore, patients with gynecological cancers presenting with a supraclavicular mass generally have an unfavorable prognosis. CASE REPORT: We describe a 70-year-old patient who presented with a left supraclavicular mass. The mass was removed and histology showed metastatic papillary adenocarcinoma strongly suggestive of papillary serous carcinoma. Abdominal hysterectomy and salpingo-oophorectomy showed a primary carcinoma of the fallopian tube. Postoperatively the patient received six cycles of carboplatin-based chemotherapy and is alive and well with no evidence of disease 5 years and 10 months after the primary diagnosis. CONCLUSION: Surgery and adjuvant carboplatin-based chemotherapy seem justified even in older patients with fallopian tube cancer and distant metastasis at the time of diagnosis.

Preoperative thrombocytosis is an independent prognostic factor in stage III and IV endometrial cancer.

BACKGROUND: To identify prognostic factors in stage III and IV endometrial cancer with special attention to pretreatment platelet count. MATERIALS AND METHODS: 59 patients with FIGO stage III or IV disease operated on between 1983 and 1993 were analyzed. Patients with preoperative thrombocytosis were compared with those without thrombocytosis. Prognostic factors were analyzed with a Cox proportional hazard model. RESULTS: With the exception of age, there were no significant differences between patients with or without thrombocytosis. At multivariate analysis, five-year disease-free survival was influenced significantly by FIGO stage (stage III vs stage IV; p = 0.009), thrombocytosis (p = 0.02) and cervical involvement (p = 0.024). Similarly, overall five-year survival was significantly influenced by stage (p < 0.001), cervical involvement (p = 0.005) and thrombocytosis (p = 0.01). Age, histology, grade, myometrial invasion, lymph-vascular space involvement or spread to adnexae were not significantly associated with survival. CONCLUSION: Thrombocytosis is an independent prognostic factor in stage III and IV endometrial cancer.

Spontaneous vaginal delivery in the birth-chair versus in the conventional dorsal position: a matched controlled comparison.

AIM: The aim of the study was to assess the effect of a birth-chair on obstetric outcome. PATIENTS AND METHODS: We reviewed the hospital records of 220 consecutive pregnant women who gave birth on a birth-chair at our institution. The control group consisted of 440 pregnant women who preceded and followed the index cases and who had spontaneous vaginal deliveries in the conventional dorsal supine position. The controls were matched for parity and for the attending mid-wife. RESULTS: Patients who delivered in the birth-chair had significantly lower rates of episiotomy and manual separation of the placenta. The umbilical blood cord pH was significantly higher in neonates of the birth-chair group. The duration of labour, rate of perineal and vaginal injury, Apgar scores and rate of admission to a neonatal intermediate care unit were not influenced by the mode of delivery. CONCLUSION: Our data support previous studies that a birth-chair delivery may be a safe alternative to conventional delivery in the supine position.

[Wound rupture after Misgav-Ladach cesarean section: a case report]. / Platzbauch nach Misgav-Ladach-Sektio Ein Fallbericht.

INTRODUCTION: We describe a patient with wound rupture and burst abdomen after cesarean section with the Misgav-Ladach technique. CASE REPORT: A 33-year-old woman underwent primary cesarean section at 36 + 5 weeks gestation for a fetal indication. The procedure was done according to the Misgav-Ladach technique, i.e. the uterus was closed with a one-layer continuous locking stitch and the visceral and parietal peritoneal layers were left open. The rectus sheath was stitched with a continuous nonlocking stitch, the skin was closed with a continuous intracutaneous suture. On the seventh postoperative day, omentum was seen extruding from the skin incision. Reexploration showed that the suture of the rectus sheath had ruptured. The further postoperative course was uneventful. CONCLUSION: Although no general recommendations can be deduced from a single case, further reports on any complications of this technique will show whether it is as safe as believed until now.

Do primiparas aged 40 years or older carry an increased obstetric risk?

BACKGROUND: It is unclear whether older primiparas are at increased risk for complications of pregnancy other than an increased cesarean section rate. The aim of this study was to compare the rate of complications of pregnancy and delivery of primiparas aged 40 years or older with those of primiparas aged 20 to 30 years. METHODS: We reviewed the maternal and neonatal hospital records of 59 consecutive primiparas aged 40 years or older who delivered at our institution between 1986 and 1995. A total of 118 primiparas aged 20 to 30 years who preceded and followed the cases served as controls. RESULTS: The mean duration of gestation was significantly shorter in primiparas > or = 40 years of age. Induction of labor was more common and the cesarean delivery rate was higher (47 vs 12%) in older primiparas. The mean birth weight was significantly lower in the offspring of the cases. The perinatal mortality rate was 5% in the primiparas over 40 years and 0% in the control group; fetal malformations were found in 5% (vs 1%) of the children of older primiparas. CONCLUSIONS: In our series, older primiparas were at increased risk for prematurity, preeclampsia, and perinatal mortality. The high rate of cesarean section in older primiparas is due mainly to a higher incidence of obstetric complications. These data suggest that the prenatal care of older primiparas in the third trimester should concentrate on the early detection of premature contractions and signs of preeclampsia.

Effect of fetal hyperinsulinism on oral glucose tolerance test results in patients with gestational diabetes mellitus.

OBJECTIVE: This study was undertaken to evaluate the impact of the fetoplacental glucose steal phenomenon on the results of oral glucose tolerance testing in pregnancies complicated by gestational diabetes mellitus with fetal hyperinsulinism. STUDY DESIGN: This was an analysis of the cases of 34 patients with two consecutive abnormal oral glucose tolerance test results and amniotic fluid insulin measurement before institution of insulin therapy. Patients were divided into groups on the basis of normal versus elevated amniotic fluid insulin concentrations. RESULTS: Oral glucose tolerance tests were done at a mean (+/-SD) of 24.9 +/- 5.7 and 30.7 +/- 3.2 weeks' gestation, and amniotic fluid insulin measurements were done at 31.1 +/- 3.2 weeks' gestation. In 13 women with gestational diabetes mellitus with normal amniotic fluid insulin concentration, maternal postload blood glucose levels at 1 hour increased by 12 mg/dL (168 vs 180 mg/dL; 9.3 vs 10.0 mmol/L; P = .0006) during the course of 6 weeks. In contrast, in 21 women with gestational diabetes mellitus with elevated amniotic fluid insulin levels (>7 microU/mL; >42 pmol/L), 1-hour postload blood glucose levels decreased by 22 mg/dL (201 vs 179 mg/dL; 11.2 vs 9.9 mmol/L; P = .002) during the same period. The higher the amniotic fluid insulin level, the larger the decrease (R = 0.504; P =.02). Although low amniotic fluid insulin levels were correlated significantly with 1-hour glucose levels of the first and second oral glucose tolerance tests, high insulin levels were no longer correlated with the second oral glucose tolerance test. CONCLUSION: Exaggerated fetal glucose siphoning may provide misleading oral glucose tolerance test results in pregnancies complicated by fetal hyperinsulinism by blunting maternal postload glucose peaks. Consequently, oral glucose tolerance test results in a pregnancy complicated by gestational diabetes mellitus with a fetus that already has hyperinsulinemia may erroneously be considered normal.

Pretreatment hemoglobin, platelet count, and prognosis in endometrial carcinoma.

We analyzed whether a low pretreatment hemoglobin level is a prognostic factor in endometrial cancer and whether it is associated with thrombocytosis. Two hundred and twelve patients with endometrial cancer treated with surgery were reviewed. Data were analyzed with Pearson's chi-squared test, Fisher's exact test in contingency tables, the Mann-Whitney U-test, the Student's t-test, and Kaplan-Meier estimates. Multivariate analysis was performed with the log-rank test and the Cox proportional hazard model. Thirty-nine patients (18%) had a pretreatment hemoglobin value of < 12.0 g/dL. These 39 patients had significantly higher rates of nonendometrioid histology, high-grade tumors, myometrial invasion of > 50%, adnexal involvement, lymph-vascular space involvement, and advanced FIGO stage than patients with hemoglobin > or = 12.0 g/dL. The rate of thrombocytosis was significantly higher in patients with a low hemoglobin level (36% vs. 8%, P < 0.01). The overall 5-year survival rate of patients with low pretreatment hemoglobin was 59% compared with 89% for those with hemoglobin > or = 12 g/dL (P < 0.01). In the multivariate analysis age, thrombocytosis, nonendometrioid histology, high-grade histology, and advanced FIGO stage were significantly associated with a poor prognosis whereas adnexal involvement, lymph-vascular space involvement, low hemoglobin and myometrial invasion were not. These data indicate that low pretreatment hemoglobin is a prognostic factor in patients with endometrial cancer and that it is associated with thrombocytosis. Low hemoglobin was strongly associated with other unfavorable prognostic factors so that it was significant in the univariate but not the multivariate analysis.

Inguinal lymph node metastasis as the only manifestation of lymphatic spread in ovarian cancer: A case report.

OBJECTIVE: Inguinal metastasis is a rare manifestation of ovarian cancer. Autopsy studies have reported inguinal metastasis in 0-3% of patients with advanced disease. CASE REPORT: We describe a 43-year-old patient with ovarian cancer limited to the adnexa who had an isolated metastasis in an enlarged inguinal lymph node. The patient underwent total abdominal hysterectomy, omentectomy, pelvic and paraaortic lymphadenectomy, and excision of the enlarged inguinal lymph node. All 78 pelvic and 40 paraaortic lymph nodes were negative. CONCLUSION: This case demonstrates that early isolated distant lymph node metastasis, although rare, can occur in patients with ovarian cancer and may be a presenting symptom.

Course of maternal serum magnesium levels in low-risk gestations and in preterm labor and delivery.

OBJECTIVES: To describe the course of total and ionized magnesium and total calcium levels in maternal serum during low-risk pregnancies and to compare women who developed preterm labor and delivery with those who delivered at term. METHODS: 209 women with low-risk pregnancies were enrolled in a prospective trial before the 18th week of gestation. No woman received oral magnesium supplementation. The ionized and total magnesium and total calcium levels in maternal serum were measured every 4-6 weeks. The data were grouped into 3 gestational periods (/=28 weeks of gestation) for overall comparison and analyzed with the general linear model for repeated measurements and ANOVA. p values of < 0.05 were considered statistically significant. RESULTS: 145 gestations were available for analysis. 27 women were hospitalized for preterm labor and in 16 of these preterm delivery occurred. Ionized and total magnesium and calcium levels were significantly lower after the 18th week of gestation than before. The cation levels in women with preterm labor and delivery did not differ from those with term delivery. CONCLUSION: Ionized and total magnesium and calcium levels decrease with increasing gestational age. Preterm labor and delivery do not seem to be related to changes in serum cation levels.

Cord blood oxygen saturation in vigorous infants at birth: what is normal?

OBJECTIVE: To define the normal ranges of umbilical cord blood oxygen saturation (SaO2) and acid-base status at birth and to evaluate the effect of gestational age on cord blood values in vigorous newborn infants following spontaneous vaginal birth from a vertex position. DESIGN: Prospective study. SETTING: Department of Obstetrics and Gynaecology, University of Graz, Austria. SAMPLE: Cord blood samples from 1281 vigorous newborn infants. METHODS: Cord blood sampling was performed following on newborn infants following spontaneous vaginal birth in a vertex position. SaO2 was measured directly by a spectrophotometer and pH, base excess, pCO2 and pO2 by a pH/blood-gas analyser. Infants with a 5-minute Apgar score > or = 7 were considered vigorous. Subgroups were classified according to the gestational age: preterm, term and post-term (< 37, 37-42 and > 42 weeks, respectively). RESULTS: The median umbilical artery SaO2 was 24.3% and the 2.5th centile was as low as 2.7%. The median umbilical artery values were pH = 7.25, base excess = -4.3 mmol/L and pO2 = 16 mmHg. The 2.5th centiles were 7.08, -11.1 mmol/L and 5 mmHg, respectively. The median umbilical artery pCO2 was 50 mmHg and the 97.5th centile was 75 mmHg. The mean umbilical artery and vein SaO2 values were not significantly influenced by gestational age. The umbilical artery SaO2 and base excess values were strongly skewed. The mean umbilical artery pH values in preterm infants were higher than in other subgroups. The mean umbilical artery and vein base excess values were lower in post-term newborn infants than in other subgroups. CONCLUSIONS: The physiological range of oxygen saturation in umbilical cord of vigorous newborn infants at birth is wide and skewed. In contrast to pH and base excess, umbilical cord blood oxygen saturation is not influenced significantly by gestational age at birth.