Estimating the risk of gestational diabetes mellitus: a clinical prediction model based on patient characteristics and medical history.

OBJECTIVE: To develop a clinical prediction rule that can help the clinician to identify women at high and low risk for gestational diabetes mellitus (GDM) early in pregnancy in order to improve the efficiency of GDM screening. DESIGN: We used data from a prospective cohort study to develop the clinical prediction rule. SETTING: The original cohort study was conducted in a university hospital in the Netherlands. POPULATION: Nine hundred and ninety-five consecutive pregnant women underwent screening for GDM. METHODS: Using multiple logistic regression analysis, we constructed a model to estimate the probability of development of GDM from the medical history and patient characteristics. Receiver operating characteristics analysis and calibration were used to assess the accuracy of the model. MAIN OUTCOME MEASURE: The development of a clinical prediction rule for GDM. We also evaluated the potential of the prediction rule to improve the efficiency of GDM screening. RESULTS: The probability of the development of GDM could be predicted from the ethnicity, family history, history of GDM and body mass index. The model had an area under the receiver operating characteristic curve of 0.77 (95% CI 0.69-0.85) and calibration was good (Hosmer and Lemeshow test statistic, P = 0.25). If an oral glucose tolerance test was performed in all women with a predicted probability of 2% or more, 43% of all women would be tested and 75% of the women with GDM would be identified. CONCLUSIONS: The use of a clinical prediction model is an accurate method to identify women at increased risk for GDM, and could be used to select women for additional testing for GDM.

External validation of a clinical scoring system for the risk of gestational diabetes mellitus.

AIM: A prediction rule for gestational diabetes mellitus (GDM) could be helpful in early detection and increased efficiency of screening. A prediction rule by means of a clinical scoring system is available, but has never been validated externally. The aim of this study was to validate the scoring system. METHODS: We used data from a prospective cohort study. Women were assigned a score based on age, BMI and ethnicity. Performance of the scoring system was evaluated in terms of discrimination and calibration (agreement between clinical score and observed probability of GDM). We compared the efficiency of a screening strategy derived from the scoring system with conventional screening. RESULTS: We studied 1266 women. Forty-seven women had GDM (3.7%). The scoring system discriminated moderately (area under the curve=0.64 (95% CI 0.56-0.72)). Calibration was limited (chi(2)=8.89, p=0.06). The screening strategy derived from the scoring system reduced the number of women needed to be screened with 25% for a comparable detection rate to universal screening. CONCLUSION: Despite moderate discriminative capacity and calibration of the scoring system, the screening strategy based on the scoring system appears clinically useful. There is need for better prediction models for GDM.

[Tamoxifen: does a wider range of indications require more careful monitoring?]. / Tamoxifen; ruimere indicaties, uitgebreidere controle?

Two patients, premenopausal women aged 48 years and 37 years, who were treated with tamoxifen following a mammary carcinoma operation, experienced abdominal complaints, hot flushes, vaginal discharge, an irregular menstrual cycle and/or concern about the increased risk of ovarian carcinoma. Transvaginal ultrasonography of the ovaries and laboratory tests indicated ovarian overstimulation. Both patients temporarily stopped using tamoxifen; in one of the patients both ovaries were ablated. The range of indications for treatment with tamoxifen has in recent years been extended to premenopausal patient groups and the length of treatment has been increased from two to five years. We recommend more extensive checks when prescribing tamoxifen to premenopausal patients in view of the possible adverse effects of ovarian stimulation associated with this treatment.

[Pregnancy in women with diabetes mellitus type I: maternal and perinatal complications, in spite of good blood glucose control]. / Zwangerschap bij vrouwen met diabetes mellitus type I: nog steeds maternale en perinatale complicaties, ondanks goede bloedglucoseregulatie.

OBJECTIVE: To examine the maternal and neonatal outcome of pregnancies of women with type I diabetes mellitus. DESIGN: Retrospective. METHODS: The medical records of pregnancies (> or = 16 weeks) in women with type I diabetes mellitus between 1986/'97 were studied in University Medical Center Utrecht, Academic Hospital Groningen and Isala Clinics, location 'De Weezenlanden', Zwolle, the Netherlands. RESULTS: During the study period, 172 women had 220 pregnancies: 212 single and 8 twin pregnancies. The mean age was 29.1 years (SD: 4.1), the mean duration of standing of the diabetes was 12 years (range: 1-32) and the mean concentration of glycosylated haemoglobin (HbA1c) was 6.3% at 10 weeks of pregnancy. The incidence of children with congenital malformations was 4 times higher (n = 19; 9.0%) than that in the Dutch population (2%). Macrosomia occurred in 92 children (43.4%) and perinatal mortality in 7 (3.3%). Maternal hypertensive complications occurred in 39 single pregnancies (18.4%), which is 2-3 times more often than in the Dutch population. CONCLUSION: In type I diabetic women maternal complications, perinatal morbidity and mortality are increased, despite near optimal glycaemic control.

[Link between indication for cesarean section and need for resuscitation of the neonate]. / Samenhang tussen indicatie voor sectio caesarea en noodzaak van reanimatie van de neonatus.

OBJECTIVE: To study the relationship between the indication for caesarean section (CS) and the need for resuscitation of the infant. DESIGN: Prospective cohort study. METHODS: During one year the following information was collected for each CS in a secondary teaching hospital (Isala klinieken/Weezenlanden Hospital), Zwolle, the Netherlands: indication for the CS, Apgar scores after 1 and 5 min and measures taken by the attending paediatrician at birth. These measures were divided into two groups: resuscitation (bag and mask ventilation or endotracheal intubation and ventilation) or no resuscitation (stimulation, supplemental oxygen, or no action at all). RESULTS: During the study year 202 CS were carried out. In the 50 CS carried out because of a narrow pelvis or a previous CS and in the 61 CS carried out for non-progressive labour there was little need for resuscitation of the newborn (4 and 3.3%, respectively), similar to resuscitation requirements after vaginal birth. The need for resuscitation of the newborn was significantly greater in the other indication groups, namely in 6/37 (16%) of cases of foetal malposition, in 3/10 (30%) of placental dysfunction, and in 11/44 (25%) of foetal distress. One infant had to be intubated directly after birth. The 1-minute Apgar score was lower in infants born after CS under general anaesthesia than under spinal anaesthesia (p = 0.002), regardless of the indication for the CS. CONCLUSION: Based on the indication for a CS, a paediatrician or physician experienced in neonatal resuscitation is required for a high-risk CS (foetal malposition, placental dysfunction, foetal distress, and general anaesthesia).

Beta-glucuronidase deficiency as cause of recurrent hydrops fetalis: the first early prenatal diagnosis by chorionic villus sampling.

We describe a patient with recurrent non-immune hydrops fetalis diagnosed as mucopolysaccharidosis type VII. This rare autosomal recessive disorder is caused by a beta-glucuronidase deficiency. Chorionic villus sampling was performed in the 11th week of the subsequent pregnancy and beta-glucuronidase deficiency in chorionic villi indicated that the fetus was affected. After termination in the 12th week, signs of early hydrops fetalis were observed.

Pelvic kidney: a rare cause of obstetrical obstruction.

This case report presents a patient with a pelvic kidney. The child was delivered by caesarean section because of obstruction of the birthcanal. A relation with amyoplasia congenita in the newborn is presumed. The literature of the pelvic kidney and its implications in pregnancy is reviewed.

[Gallstones in the lesser pelvis following laparoscopic cholecystectomy]. / Galstenen in het kleine bekken na laparoscopische cholecystectomie.

A woman aged 45 years who had undergone laparoscopic cholecystectomy a little over one year previously complained of progressive dysmenorrhoea, dyspareunia and disorder of the cycle; she also had palpable nodules in the recto-uterine pouch. At vaginal hysterectomy, 15 gallstones were found in the recto-uterine and vesicouterine pouches. Problems of radiological diagnosis in cases of gallstones in the true pelvis after laparoscopic cholecystectomy have been reported before.

The pin-hole cervical os; a small fertility problem.

24 women with a so-called pin-hole cervical os during the pre-ovulatory phase of the menstrual cycle were detected in a group of 850 infertile couples. This cervical condition is rarely seen and is often combined with extreme oligomucorrhea and poor cervical mucus qualities. Sperm quality was so poor in four couples that they were excluded. Nine women were likely to have been exposed to diethylstilbestrol (DES) in utero. The pregnancy rate in this group was poor, only two pregnancies by coitus and none by intra-uterine AIH. In the other eleven women there was a strong correlation between a good result of the post-coital test (PCT) and the chance to achieve pregnancy. Four of the eight women with a good result of the PCT became pregnant by coitus. The three women with a poor result of the PCT became pregnant by intra-uterine AIH. It is possible that the fertility prognosis of a woman with a pin-hole cervical os during the pre-ovulatory phase of the menstrual cycle is unfavourably influenced by DES exposure in utero. A pin-hole cervical os in the pre-ovulatory phase of the menstrual cycle, without DES exposure, has probably no influence on fertility.