Ultrasound markers for prediction of complex gastroschisis and adverse outcome: longitudinal prospective nationwide cohort study.

OBJECTIVES: To identify antenatal ultrasound markers that can differentiate between simple and complex gastroschisis and assess their predictive value. METHODS: This was a prospective nationwide study of pregnancies with isolated fetal gastroschisis that underwent serial longitudinal ultrasound examination at regular specified intervals between 20 and 37 weeks' gestation. The primary outcome was simple or complex (i.e. involving bowel atresia, volvulus, perforation or necrosis) gastroschisis at birth. Fetal biometry (abdominal circumference and estimated fetal weight), the occurrence of polyhydramnios, intra- and extra-abdominal bowel diameters and the pulsatility index (PI) of the superior mesenteric artery (SMA) were assessed. Linear mixed modeling was used to compare the individual trajectories of cases with simple and those with complex gastroschisis, and logistic regression analysis was used to estimate the strength of association between the ultrasound parameters and outcome. RESULTS: Of 104 pregnancies with isolated fetal gastroschisis included, four ended in intrauterine death. Eighty-one (81%) liveborn infants with simple and 19 (19%) with complex gastroschisis were included in the analysis. We found no relationship between fetal biometric variables and complex gastroschisis. The SMA-PI was significantly lower in fetuses with gastroschisis than in healthy controls, but did not differentiate between simple and complex gastroschisis. Both intra- and extra-abdominal bowel diameters were larger in cases with complex, compared to those with simple, gastroschisis (P < 0.001 and P < 0.005, respectively). The presence of intra-abdominal bowel diameter ≥ 97.7th percentile on at least three occasions, not necessarily on successive examinations, was associated with an increased risk of the fetus having complex gastroschisis (relative risk, 1.56 (95% CI, 1.02-2.10); P = 0.006; positive predictive value, 50.0%; negative predictive value, 81.4%). CONCLUSIONS: This large prospective longitudinal study found that intra-abdominal bowel dilatation when present repeatedly during fetal development can differentiate between simple and complex gastroschisis; however, the positive predictive value is low, and therefore the clinical usefulness of this marker is limited. © 2019 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasonographic prediction of birth weight discordance in twin pregnancies.

OBJECTIVE: This study aimed to assess the accuracy of the ultrasonographic prediction of intertwin birth weight discordance based on crown-rump length, estimated fetal weight (EFW) and abdominal circumference. METHOD: We retrospectively studied variables of prenatal surveillance of 281 twin pregnancies at the University Medical Centre Utrecht, between 2008 and 2011. RESULTS: Fifteen per cent of twins had a birth weight discordance of ≥20%. One twin more commonly had intrauterine growth restriction in the birth weight discordance group compared with the concordantly grown group (69% vs 20%, respectively). Sonographically, EFW discrepancy and increased abdominal circumference ratio were significantly correlated with birth weight discordance. The negative predictive values were high (92% and 87%, respectively). The best prediction of weight discordance was given by EFW discordance at the last ultrasound before delivery. CONCLUSION: Intertwin birth weight discordance is best predicted by an intertwin EFW discordance at the last ultrasound. If discordance is not suspected by ultrasound, the vast majority had no birth weight discordance. In case of birth weight discordance, the presence of at least one growth-restricted twin is very likely. However, because around 20% of concordantly grown twin pairs comprise at least one intrauterine growth restriction infant, one cannot rely on weight discordance alone.

Does 17-α-hydroxyprogesterone caproate affect fetal biometry and birth weight in twin pregnancy?

OBJECTIVE: Increasingly, maternal administration of 17-α-hydroxyprogesterone caproate (17-OHPC) is utilized to prevent preterm birth, but the fetal safety of 17-OHPC is still a matter of concern. This study aimed to assess whether exposure to 17-OHPC during the second and third trimesters of pregnancy affects fetal biometry in twin gestations. METHODS: This study included a subset of women with a twin pregnancy who had been previously included in a randomized clinical trial comparing the effectiveness of 17-OHPC and placebo on neonatal outcomes and preterm birth rates in multiple pregnancy. In the present study, the individual growth patterns of femur length, head circumference and abdominal circumference were compared between fetuses of women who had been randomized to receive weekly injections of either 17-OHPC (n = 52) or placebo (n = 58) at between 16-20 and 36 weeks' gestation. RESULTS: The three biometric variables assessed developed similarly in fetuses in both the group exposed to 17-OHPC and the placebo group during the second half of pregnancy. Birth weight adjusted for parity and fetal sex was also comparable between groups. CONCLUSION: The use of 17-OHPC has no adverse effects on fetal biometry and birth weight in twins.

Evaluation of antenatal umbilical coiling index at 16-21 weeks of gestation as a predictor of trisomy 21 and other chromosomal defects.

OBJECTIVES: To determine whether there is an association between sonographically assessed hyper- or hypocoiling of the umbilical cord and the presence of trisomy 21, to provide reference values for the antenatal umbilical coiling index (aUCI) at a gestational age of 16-21 weeks and to determine whether these measurements are reliable and reproducible. METHODS: This was a prospective study of 737 pregnancies in which the aUCI was measured between 16 and 21 weeks of gestation by ultrasound at the time of amniocentesis. The aUCI was calculated as the reciprocal value of the mean length of one complete coil in centimeters. We created reference curves and studied the relationship with trisomy 21 and other chromosomal defects. In 30 pregnancies we studied the intra- and interobserver variation in measurements using Bland-Altman plots with associated 95% limits of agreement and intraclass correlation coefficients. RESULTS: aUCI was found to be non-linearly related to gestational age at 16-21 weeks and reference curves were created for the mean aUCI and the 2.3(rd) , 10(th) , 90(th) and 97.7(th) percentiles. There was no significant difference in aUCI values between the reference group (n = 714) and cases with trisomy 21 (n = 16) or other aneuploidies (n = 7) (one-way ANOVA, P = 0.716). There was good intra- and interobserver agreement in aUCI measurements. CONCLUSIONS: The aUCI can be measured reliably and varies according to gestational age at 16-21 weeks. The aUCI was not significantly associated with trisomy 21 or other chromosomal defects.

Three-dimensional ultrasound and maternal bonding, a third trimester study and a review.

OBJECTIVE: To compare the effect of third trimester three-dimensional and four-dimensional (3D/4D) versus two-dimensional (2D) ultrasound (US) of the fetal face on maternal bonding. Studies quantifying the psychological effect of 3D/4D US on mothers, pregnant of a fetus with no detectable abnormalities, were reviewed. METHODS: One hundred sixty Caucasian women attended a third trimester 3D/4D or 2D US examination. Women filled out the Maternal Antenatal Attachment Scale (MAAS) 1 to 2 weeks before (MAAS1) and 1 to 2 weeks after (MAAS2) the US examination. Visibility, recognition and attractiveness were assessed. RESULTS: Within both US groups, the MAAS2 scores were significantly higher than the MAAS1 scores (p < 0.0001). No differences in MAAS scores between the US groups emerged. Visibility and recognition were significantly positively related with the increase in MAAS scores (p = 0.003 and p = 0.042) in the 3D/4D group. Of 13 psychological studies, eight studies evaluated bonding and found no difference between 3D/4D and 2D US. The effect of 3D/4D US on satisfaction or perception showed conflicting results, and on anxiety/stress, reduction was the same as after 2D US. CONCLUSIONS: Bonding increases after either a 3D/4D or 2D US. The effect of 3D/4D US on bonding is stronger at better degrees of visibility and recognition.

Quality of ultrasound biometry obtained by local health workers in a refugee camp on the Thai-Burmese border.

OBJECTIVE: In a refugee camp on the Thai-Burmese border, accurate dating of pregnancy relies on ultrasound measurements obtained by locally trained health workers. The aim of this study was to substantiate the accuracy of fetal biometry measurements performed by locally trained health workers by comparing derived reference equations with those published for Asian and European hospitals. METHODS: This prospective observational study included 1090 women who had a dating crown-rump length (CRL) scan and one study-appointed ultrasound biometry scan between 16 and 40 weeks of gestation. The average of two measurements of each of biparietal diameter, head circumference, abdominal circumference and femur length was used in a polynomial regression model for the mean and SD against gestational age (GA). The biometry equations obtained were compared with published equations of professional sonographers from Asian and European hospitals by evaluation of the SD and Z-scores of differences between models. RESULTS: Reference equations of biometric parameters were found to fit cubic polynomial models. The observed SD values, for any given GA, of fetal biometric measurements obtained by locally trained health workers were lower than those previously reported by centers with professional sonographers. For nearly the entire GA range considered, the mean values of the Asian and European equations for all four biometric measurements were within the 90% expected range (mean ± 1.645 SD) of our equations. CONCLUSION: Locally trained health workers in a refugee camp on the Thai-Burmese border can obtain measurements that are associated with low SD values and within the normal limits of published Asian and European equations. The fact that the SD values were lower than in other studies may be explained by the use of the average of two measurements, CRL dating or motivation of the locally trained sonographers.

High-density SNP association study and copy number variation analysis of the AUTS1 and AUTS5 loci implicate the IMMP2L-DOCK4 gene region in autism susceptibility.

Autism spectrum disorders are a group of highly heritable neurodevelopmental disorders with a complex genetic etiology. The International Molecular Genetic Study of Autism Consortium previously identified linkage loci on chromosomes 7 and 2, termed AUTS1 and AUTS5, respectively. In this study, we performed a high-density association analysis in AUTS1 and AUTS5, testing more than 3000 single nucleotide polymorphisms (SNPs) in all known genes in each region, as well as SNPs in non-genic highly conserved sequences. SNP genotype data were also used to investigate copy number variation within these regions. The study sample consisted of 127 and 126 families, showing linkage to the AUTS1 and AUTS5 regions, respectively, and 188 gender-matched controls. Further investigation of the strongest association results was conducted in an independent European family sample containing 390 affected individuals. Association and copy number variant analysis highlighted several genes that warrant further investigation, including IMMP2L and DOCK4 on chromosome 7. Evidence for the involvement of DOCK4 in autism susceptibility was supported by independent replication of association at rs2217262 and the finding of a deletion segregating in a sib-pair family.

Fetal growth trajectories in Type-1 diabetic pregnancy.

OBJECTIVE: To describe the individual intrauterine growth patterns of fetuses of insulin-dependent (Type-1) diabetic women and to examine determinants of overgrowth (macrosomia) and its timing. METHODS: This retrospective longitudinal study examined the developmental trajectories of fetal abdominal circumference (AC) and biparietal diameter in 76 Type-1 diabetic women with singleton pregnancies. Latent class analysis was used to identify subgroups of patients with a shared fetal AC growth trajectory. Subsequently, maternal factors, including glycemic control as assessed by glycosylated hemoglobin (HbA1c), were examined to see whether they had any effect on fetal growth. RESULTS: Four subgroups with different AC growth patterns were identified. Differences in birth weight between the distinct subgroups were related to the shape of the AC growth velocity curve over gestation. Acceleration of AC growth commencing before or after 25 weeks' gestation was associated with the birth of a heavy or large-for-dates baby in 94 and 56% of cases, respectively. Poor glycemic control (HbA1c > 7.0%) during the periconception period or before 12 weeks' gestation was a modest predictor of midtrimester growth in AC. Other diabetes-related factors, fetal sex, parity, or maternal weight/obesity were unrelated to the fetal growth pattern. CONCLUSION: The findings suggest that an individual fetus's growth trajectory is set early in gestation and that the contemporaneous degree of maternal glycemia plays a role in determining birth weight.

Predictors of outcome at 2 years of age after early intrauterine growth restriction.

OBJECTIVE: To examine the relative importance of antenatal and perinatal variables on short- and long-term outcome of preterm growth restricted fetuses with umbilical artery (UA) Doppler abnormalities. METHODS: This was a cohort study of 180 neonates with birth weight < 10(th) percentile, gestational age at delivery < 34 weeks and abnormal Doppler ultrasound examination of the UA. Various antenatal and perinatal variables were studied in relation to short- and long-term outcome. RESULTS: Neonatal and overall mortality (up to 2 years of age) were predicted by low gestational age at delivery. Neonatal mortality was additionally predicted by absent or reversed UA end-diastolic flow, while the presence of severe neonatal complications and placental villitis were additional predictors of both infant (between 28 days and 1 year of postnatal life) and overall mortality. Placental villitis was found to be the only predictor of necrotizing enterocolitis. Low gestational age at delivery, male sex, abnormal cardiotocography, absent or reversed UA end-diastolic flow and the HELLP syndrome predicted respiratory distress syndrome. Abnormal neurodevelopmental outcome at 2 years was predicted by low birth weight (< 2.3(rd) percentile), fetal acidosis (UA pH < 7.00), and placental villitis. CONCLUSION: Less advanced gestation at delivery remains an important predictor of short-term outcome in growth-restricted fetuses. In addition, the presence of placental villitis may aid neonatologists in the early identification of infants at increased risk of necrotizing enterocolitis, death and abnormal neurodevelopment at 2 years of age. Abnormal neurodevelopment was related to low weight and acidosis at birth, indicating that the severity of malnutrition and fetal acidosis affect long-term outcome.

Fetal electrocardiography: feasibility of long-term fetal heart rate recordings.

The feasibility and accuracy of long-term transabdominal fetal electrocardiogram (fECG) recordings throughout pregnancy were studied using a portable fECG monitor. Fifteen-hour recordings of fetal heart rate (FHR) were performed in 150 pregnant women at 20-40 weeks of gestation and 1-hour recordings were performed in 22 women in labour and compared with simultaneous scalp electrode recordings. When >or=60% of fECG signals was present, the recording was defined as good. Eighty-two percent (123/150) of antenatal recordings were of good quality. This percentage increased to 90.7 (136/150 recordings) when only the night part (11 p.m.-7 a.m.) was considered. Transabdominal measurement of FHR and its variability correlated well with scalp electrode recordings (r=0.99, P<0.01; r=0.79, P<0.01, respectively). We demonstrated the feasibility and accuracy of long-term transabdominal fECG monitoring.

Antenatal corticosteroid therapy: short-term effects on fetal behaviour and haemodynamics.

Antenatal corticosteroid therapy to enhance fetal lung maturity in threatened preterm delivery has a number of non-pulmonary side-effects, both beneficial and undesirable. This review focuses on the short-term (transient) effects of betamethasone and dexamethasone on aspects of fetal circulation and behaviour which are used clinically as markers of fetal well-being. We summarise the effects observed, discuss the proposed underlying mechanisms, and emphasise the consequences for clinical decision-making. Recommendations are given to optimise medical care and to minimise the risk of unwarranted iatrogenic preterm delivery.

Role of prenatal ultrasound in predicting survival and mental and motor functioning in children with spina bifida.

OBJECTIVE: To determine which prenatal ultrasound findings can predict survival and mental and motor functioning in children with spina bifida. METHODS: Prenatal ultrasound examinations of all liveborn children who were prenatally diagnosed with spina bifida between 1997 and 2002 at the University Medical Centre, Utrecht (n = 41) were retrospectively reviewed for lesion level, head circumference, ventriculomegaly, scoliosis and talipes. These measures were correlated with postnatal anatomical (as assessed by magnetic resonance imaging (MRI)) and functional lesion levels, survival and motor and mental outcome at 5 years of age. The capacity of prenatal ultrasonography to determine lesion level was also assessed in all fetuses diagnosed with spina bifida from 2006-2007 (n = 18). RESULTS: Nineteen infants died before the age of 5 years. Multivariate regression analysis showed that higher lesion level and head circumference > or = the 90th percentile on prenatal ultrasound examination were independent predictors of demise (P < 0.05 and P = 0.01, respectively). None of the ultrasound features was a predictor of motor or mental functioning. Ultrasound predicted anatomical lesion level within one level of the postnatal findings in 50% of the first cohort and 89% of the second cohort (P < 0.01). The level of the anatomical lesion as assessed by postnatal MRI differed from the functional lesion by as many as six vertebral levels. CONCLUSIONS: Lesion level and head circumference on prenatal ultrasound are predictive of survival in children with spina bifida. No predictors were found for mental or motor function at the age of 5 years.

Prenatal stress in pigs: experimental approaches and field observations.

Prenatal stress can affect the offspring's behaviour, physiology, and immune parameters. This paper summarises and discusses experimental and field studies on prenatal maternal stress in pigs. Often, elevated maternal corticosteroid concentrations during gestation are used to model prenatal stress. We used prolonged oral administration of cortisol (hydrocortisone acetate, HCA) to pregnant sows, which resulted in elevated maternal plasma and salivary cortisol concentrations. This treatment induced elevated fetal basal and adrenocorticotropic hormone (ACTH)-induced plasma cortisol concentrations, as demonstrated by a pilot study. Postnatally, it reduced birth weight of the piglets, and resulted in more live born piglets and higher preweaning mortality. In addition, it reduced the female offspring's salivary cortisol response to ACTH, and it enhanced the piglets' novelty-induced locomotion and vocalisations, and the piglets were more aggressive in a social test. Some of these effects depended on the period of gestation during which maternal cortisol concentrations were elevated, and on the sex of the offspring. These results demonstrate that piglet physiology and behaviour can indeed be affected when the mother has elevated cortisol concentrations during gestation. Regular mixing of pregnant sows with unfamiliar sows during the last third of gestation did not affect maternal salivary cortisol concentrations. Also, it did not affect the piglets' performance, behaviour, adrenocortical response to ACTH, or wound healing. Regular mixing of pregnant sows during the last third of gestation did not affect the piglets' characteristics as studied in these experiments. However, performance and behaviour of piglets were highly influenced by the social rank of their mother during gestation. Our studies have demonstrated that piglets can be affected by elevated maternal cortisol concentrations during fetal development and by social rank of the pregnant sow during gestation.

Improved SNAPPE-II and CRIB II scores over a 15-year period.

OBJECTIVE: During the last decades mortality and morbidity of preterm infants have declined in the Western world. We hypothesized that the decrease in mortality in preterm infants was associated with a decrease in illness severity scores (SNAPPE-II and CRIB II scores). STUDY DESIGN: Subjects were inborn infants born between January 1997 and December 1999 (period 1) and between January 2006 and December 2011 (period 2) with a gestational age of 26+0 through 28+6 weeks and without congenital malformations (n=394). SNAPPE-II, CRIB II scores, mortality, severe morbidity and survival without morbidity were recorded. Outcomes between the two periods were analyzed using multivariable analysis. RESULTS: SNAPPE-II, but not CRIB II, scores were significantly lower for all GAs in period 2 compared with period 1. The risk of mortality for identical SNAPPE-II scores and CRIB II scores did not differ between the two periods. The risk of morbidity for identical SNAPPE-II scores and CRIB II scores was significantly lower in period 2 versus period 1. Hence, the chance of survival without morbidity for identical SNAPPE-II scores and CRIB II scores increased significantly in period 2 versus period 1. CONCLUSIONS: SNAPPE-II, but not CRIB II, scores decreased over 15 years. The risk of mortality for identical SNAPPE-II and CRIB II scores did not change, but the risk of morbidity decreased and the chance of survival without morbidity increased for identical SNAPPE-II and CRIB II scores. These findings suggest substantial improvements in both obstetrical and neonatal care.

Effects of morphine and naloxone on fetal heart rate and movement in the pig.

To test the hypothesis that an increasing opioid tonus is involved in decreases in fetal heart rate (FHR) and movement (FM) during late gestation, we studied the effects of intravenous bolus injections of morphine (1 mg) and naloxone (1 mg) on FHR and FM in the fetal pig. Twenty-one fetuses (1 per sow) were catheterized at 90-104 days of gestation (median 100 days). Recordings of FHR (electrocardiograph or Doppler-derived signals) and FM (ultrasonography) were made from 15 min before to 45 min after treatment. Morphine administration significantly decreased FHR, but it increased FHR variation and forelimb movements (LM). LM were clustered, and this stereotyped behavior has never before been observed in any mammalian fetus. Naloxone administration increased gross body movements and FHR without significant changes in FHR variation. It is concluded that FHR and motility are under opioidergic control in the pig fetus. Both morphine and naloxone induce hypermotility, suggesting that naloxone does not act as a pure opioid antagonist in the fetal pig.

Morbidity and mortality of reconstructive surgery of noninfected false aneurysms detected long after aortic prosthetic reconstruction.

OBJECTIVE: To determine the morbidity and mortality of surgical treatment of false (anastomotic) aneurysms, we analyzed the results of 158 consecutive surgical procedures for repair of false aneurysms that were detected as a result of a surveillance program after aortic reconstruction with a prosthesis. DESIGN: Retrospective analysis of patient data from a vascular registry that included information on the long-term follow-up of our patients. SETTING: A university hospital (tertiary referral center) in the Netherlands that has been performing vascular reconstructive surgery since 1958. PATIENTS: We performed 158 surgical procedures on 135 patients with 220 noninfected false aneurysms. Using a yearly surveillance program, the false aneurysms were detected at a mean interval of 8 years after the initial reconstruction. Most patients (60%) were asymptomatic. The operation was performed as an emergency in 25 instances (16%). RESULTS: The mortality rate of patients receiving nonsurgical treatment was very high (61%) owing to documented rupture (11 of 18 patients). The intraoperative death rate was 7.6% per procedure. This was higher for emergency (24%) than for elective procedures (4.5%). CONCLUSIONS: Conservative follow-up carries a very high mortality rate, as does emergency surgery for a false aneurysm. However, the intraoperative mortality rate of elective reconstruction of a false aneurysm can be in the same range as that of elective primary aortic reconstruction. Therefore, we advocate a surveillance program, including yearly ultrasound studies, after prosthetic aortic reconstruction for the timely detection and elective repair of all false aneurysms.

Genetic analysis of IQ, processing speed and stimulus-response incongruency effects.

Psychometric IQ (WAIS-III), onset and peak latency of the lateralized readiness potential (LRP), decision time, and accuracy were assessed during an Eriksen Flanker task in a young (149 families) and in an older (122 families) cohort of twins and their siblings. Stimulus-response incongruency effects were found on all measures of processing speed and accuracy. The effects on the percentages of wrong button presses and too slow (>1,000 ms) responses were larger in the older than in the younger age cohort. Significant heritability was found for processing speed (33-48%), accuracy (41%), and stimulus-response incongruency effects (3-32%). Verbal and performance IQ correlated significantly with stimulus-response incongruency effects on accuracy (-0.22 to -0.39), and this correlation was completely mediated by an underlying set of common genes. It is concluded that measures of the ability to perform well under conditions of stimulus-response incongruency are viable endophenotypes of cognitive ability.

Salivary cortisol levels and anxiety are not increased in women destined to develop preeclampsia.

OBJECTIVE: To compare salivary cortisol levels and maternal anxiety (general and pregnancy-specific) in the early and late second trimester of pregnancy between women who developed preeclampsia (PE) and women who remained normotensive. DESIGN: Nested case-referent study. In a prospectively studied cohort of 250 pregnant women, nine women developed PE in late pregnancy. These nine patients were matched and compared with nine controls. Diurnal cortisol levels were obtained by collecting saliva samples at 17-18 and 27-28 weeks gestation. Salivary cortisol levels were determined by radioimmunoassay. Maternal anxiety was determined by Spielberger's State-Trait Anxiety Inventory (STAI) and a pregnancy-specific stress questionnaire. RESULTS: For both patients and controls, a similar pattern of salivary cortisol excretion was observed. Salivary cortisol levels and anxiety scores (general and pregnancy-specific) did not differ significantly between patients and controls. CONCLUSIONS: Our findings do not lend support to a role for maternal anxiety or second trimester increases in circulating stress hormones in the pathogenesis of PE.

Effects of maternal alcohol intake on fractal properties in human fetal breathing dynamics.

Fractal methods have been found to be useful in characterizing biomedical signals. The use of fractal estimation requires the estimation of parameter H, which is directly related to the fractal dimension D. Here, we propose a new approach which is a combination of the wavelet transform and fractal estimators to characterize the human fetal breathing signals before and after the intake of two glasses of wine by a mother. This study was performed on 26 fetuses. The variances of the wavelet coefficients were estimated at each scale. The slope of the representation on a logarithmic plot from the scales 5 to 1 was found to be increased after alcohol intake. Our results suggested that fetal breathing rates have a rough structure before the alcohol intake and a smooth structure after alcohol intake.

Whole rat embryo culture in serum of insulin-dependent (type-1) diabetic women.

Pregnancies in women with type-1 diabetes are associated with an increased risk of developmental disorders. Despite extensive research, the toxicological mechanisms and pathogenesis of these disorders are far from explained. The whole rat embryo culture system was used to study the pathogenesis of malformations induced by culture in sera from diabetic women. In undiluted control sera, rat embryos with 4-8 initial somites developed well. During 26 hr of culture, on average 13 somites were formed per embryo, corresponding to the normal in vivo development. Only 3 out of 59 embryos had a significantly lower morphological score than did controls after culture. In the diabetic group no increased incidence of malformations was found, and development tended to be better than in control sera. Embryos cultured in sera derived from conventionally treated patients had a higher morphological score after culture than did embryos cultured in sera derived from women treated with an insulin pump. The sera of diabetic patients contained on average a fivefold higher insulin concentration than did control sera. However, addition of 300 mU/litre insulin to sera that contained on average 30 mU/litre did not improve the development of cultured embryos. The absence of malformations after culture in sera of diabetic women may relate to the fact that their blood glucose control was on average reasonably good.