Diagnosis of gestational diabetes in early pregnancy.

OBJECTIVE: To determine whether glucose intolerance can be identified early in gestation in a high-risk population so that early intervention can be planned to prevent associated morbidity. RESEARCH DESIGN AND METHODS: After appropriate dietary preparation, patients with a high risk for gestational diabetes underwent a 50-g oral glucose screening test during fasting. Patients were tested on enrollment and every 10 wk until delivery. Those with a 1-h plasma glucose value of greater than or equal to 7.5 mM underwent a 100-g oral glucose tolerance test. Gestational diabetes was based on either a markedly abnormal 50-g screening test or abnormal 100-g oral glucose tolerance test. RESULTS: Ten of 15 (66%) patients who developed gestational diabetes were diagnosed during the first half of the pregnancy. Six were diagnosed in the first trimester. If the definition of an abnormal 1-h plasma glucose value was lowered from 7.5 to 7.2 mM, an additional 2 patients could have been identified in the first trimester with an improvement in sensitivity from 70 to 91% with only a slight drop in specificity (from 91 to 88%). Diagnosis of gestational diabetes was not enhanced by measuring plasma insulin concentrations or insulin-glucose molar ratios. CONCLUSIONS: The diagnosis of gestational diabetes in a high-risk population can be made in the first half of pregnancy. Early diagnosis should permit evaluation of intervention strategies, which may result in improved perinatal outcome.

Glucose-alanine relationship in diabetes in human pregnancy.

We have previously reported a decrease in gluconeogenesis from alanine in normal pregnant women at term gestation as compared with nonpregnant women. In the present study, the effect of diabetes on alanine metabolism was examined in five gestationally diabetic (GDM) women and seven women with type I (insulin-dependent) diabetes (IDDM) during the third trimester of pregnancy. The hemoglobin A1c (HbA1c) concentrations in all subjects were within normal range, indicating good metabolic control. After an overnight fast, each subject was infused simultaneously with L-[2,3, 13C2]alanine and D-[6,6,2H2]glucose tracers as prime constant rate infusion. Plasma alanine and glucose isotopic enrichments were measured by gas chromatography-mass spectrometry. Alanine and glucose turnover rates were quantified by tracer dilution. In five subjects, the contribution of alanine carbon to CO2 was quantified by respiratory calorimetry and by measurement of 13C enrichment of expired CO2. Data from 15 previously reported normal pregnant subjects were used for comparison. The rate of alanine turnover was similar in the GDM and IDDM subjects and was not different from the normal subjects (GDM, 4.6 +/- 1.9; IDDM, 5.4 +/- 2.5; normals, 4.4 +/- 0.8 mumol/kg.min, mean +/- SD). The rate of glucose turnover was significantly reduced (P less than .05) in IDDM as compared with GDM and normal subjects (IDDM, 8.1 +/- 0.8; GDM, 11.5 +/- 3.5; normals, 12.2 +/- 2.2 mumol/kg.min). The contribution of alanine C to glucose C and expired CO2 was similar in the three groups. These data demonstrate that rigorous metabolic control results in normal glucose and alanine metabolism in diabetic pregnancy during fasting.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic studies and fetal assessment in advanced extrauterine pregnancy.

Advanced extrauterine pregnancy occurs rarely and may present diagnostic difficulty. Failure to induce uterine contractions during oxytocin infusion is a well-established diagnostic technic. The present case suggests that additional newer technics for fetal assessment, including sonography, unstressed monitoring of the fetal heart rate, uterine contractions, fetal movements, and serial urinary estriol determinations may also be useful in diagnosing and managing such complex cas-s.

Treatment of postpartum uterine atony with prostaglandin E2 vaginal suppositories.

When severe postpartum hemorrhage secondary to uterine atony is unresponsive to medical management, including oxytocic drugs and/or ergonovine and its derivatives, surgical intervention becomes necessary. This case of postpartum uterine atony, with several features suggesting persistent myometrial dysfunction which did not respond to usual medical measures, responded to treatment with intravaginal prostaglandin E2 (PGE2) suppositories. Prostaglandin E2 vaginal suppositories may be useful in the treatment of persistent postpartum uterine atony.

Rigorous management of insulin-dependent diabetes mellitus during pregnancy.

The effect of rigorous management of insulin-dependent diabetes mellitus (IDDM) during pregnancy on the perinatal outcome was assessed by comparing 78 prepartum gravid patients with IDDM managed prospectively with 78 matched controls. The diabetic women were treated with insulin by either infusion pump or split-dose therapy, with the goal of normalization of the fasting blood sugars and hemoglobin Hb A1c values. Differences in the perinatal outcome were evaluated by either chi-square or analysis of variance. Of the women with IDDM, 14% where White class B, 43% class C, 26% class D, 17% classes R and F. The mean Hb A1c value in the first half of pregnancy was 8.49% +/- 2.30%, and 7.34% +/- 1.79% in the second half. Women with IDDM had higher rates of premature delivery (31% vs. 10%, P = 0.003), pre-eclampsia (15% vs. 5%, P = 0.035), and cesarean section (55% vs. 27%, P = 0.002). Complications of infants born to diabetic mothers included large size for gestational age (41% vs. 16%, P = 0.0002), hypoglycemia (14% vs. 1%, P = 0.0025), hyperbilirubinemia (46% vs. 23%, P = 0.0002), and respiratory distress (12% vs. 1%, P = 0.008). The Apgar scores and mortality were similar. Congenital malformations occurred in 7.7% of infants of diabetic mothers and 1.3% of controls (P = 0.05). The maternal Hb A1c level did not correlate with the infant size for gestation. Although the improved medical management of IDDM has decreased neonatal mortality, significant perinatal complications persist.

Regular and irregular human fetal respiratory movement.

Fetal respiratory movements (FRM) were studied using abdominal strain gauges (tocodynamometers). The patterns of the FRM were evaluated during both active and quiet fetal time periods, which were determined by the fetal heart rate (FHR) and fetal body movement (FM). The FRM were classified into Regular and Irregular patterns based on neonatal respiratory criteria for sleep-state studies in the term infant. Evaluation of the breath-to-breath intervals (BBI) showed statistically significant respiratory differences during active and quiet fetal time periods. Irregular fetal respiratory movement patterns were noted during fetal active periods. It would appear that the correlation of regular fetal respiratory movement with fetal quiet periods in the term fetus adds additional evidence that a quiet sleep state may exist in the term fetus.

Management of third-trimester diabetic pregnancies with the use of continuous subcutaneous insulin infusion therapy: a pilot study.

Six women with juvenile-onset diabetes were managed as outpatients during the third trimester of pregnancy with continuous subcutaneous insulin infusion therapy. Twenty-four-hour metabolic profiles for plasma glucose, beta-hydroxybutyrate, and triglycerides were monitored prior to, 1 week, 5 weeks, and 10 weeks after initiation of continuous subcutaneous insulin infusion therapy and compared with the metabolic profiles of 10 normal (nondiabetic) pregnant women. Near-normal metabolic profiles were achieved in these patients after 5 weeks of therapy in this pilot study. Patient motivation, compliance, and understanding of their illness were crucial in achieving the therapeutic goals of normoglycemia.

Human fetal respiratory arrhythmia.

The association of human fetal respiration with the fetal heart rate was studied in 13 pregnant patients between Weeks 34 and 41 of pregnancy. Fetal respiration was recorded with the use of a tocodynamometer. Fetal heart rate was recorded with the use of ultrasound and abdominal fetal electrocardiogram monitoring devices. The results documented the presence of human fetal respiratory arrhythmia. An increase in fetal heart rate was seen during fetal "inspiration" followed by a decrease during "expiration." The possible mechanisms of the respiratory arrhythmia are discussed.

A comparison between maternal, tocodynamometric, and real-time ultrasonographic assessments of fetal movement.

Fetal movements were simultaneously studied with maternal perception, tocodynamometry, and real-time ultrasonography. A comparison between these three modalities demonstrated good agreement. The percentage of agreement improved with increasing duration of fetal movements. For fetal movements lasting longer than 3 seconds, the agreement between ultrasonography and tocodynamometry was 95.6%. These findings suggest that tocodynamometry is a sensitive method for studying fetal movements.

Neonatal resuscitation in community hospitals. A regional-based, team-oriented training program coordinated by the tertiary center.

Neonatal resuscitation in community hospitals is problematic because of the lack of on-site personnel with adequate training and experience. Even when efforts are made to transport high-risk mothers to tertiary care centers, the most complex resuscitations must occasionally be performed in all obstetric services. This dilemma can result in increased neonatal morbidity and mortality, and is reflected in the obstetric malpractice crisis. We present an approach to the problem in which a tertiary center actively intervenes to assist regional community hospitals to develop and implement resuscitation team capabilities. Key aspects of the system are training and implementation of hospital shift "Code Pink" teams composed of nonphysician professionals, a regional neonatal resuscitation protocol used by all participants, "mock code" resuscitation drills to maintain skills, and extensive quality assurance both at the local hospital and regional levels.

Classification of human fetal movement.

A study of fetal activity was undertaken as the first step in a series of physiologic fetal movement studies. A simple, safe, noninvasive, clinically applicable method for studying fetal movement with a tocodynamometer is described. Four basic types of fetal movement have been seen and defined in terms of their durations, recorded patterns, and descriptive terminologies for identifying each movement.

Fetal movements associated with fetal heart rate accelerations and decelerations.

In normal pregnant women, the relationship between the FHR and fetal movements (FM) was evaluated during 1,541 consecutive observed FM of at least 1 second's duration. Two observed FHR changes were: (1) accelerations and (2) accelerations followed by decelerations. An acceleration in FHR was observed in association with 91.2 per cent of all FM of 1 to 3 seconds' duration and with 99.8 per cent of FM of longer than 3 seconds' duration. FM were associated with an acceleration followed by a deceleration 66.7 per cent of the time. FM lasting longer than 1 second and associated with neither accelerations nor decelerations were seen 1.8 per cent of the time.

Clinical estimation of gestational age: rules for avoiding preterm delivery.

Reliable knowledge of the duration of pregnancy prior to birth is often of crucial importance in making obstetric care decisions. Laboratory methods for estimating fetal maturity have received considerable attention, but the usefulness of historical information has only rarely been addressed. In order to examine the value of clinical estimators of fetal gestational age (GA) in 690 pregnancies, the correlations of menstrual history (LMP), first unamplified audible fetal heart tones (FFH), and quickening (Q), with GA, based on the modified Dubowitz examination at birth, were examined. Evaluation of each of the data sets used alone reveals that in order to be 90% certain that an infant will be mature at delivery (greater than or equal to 38 weeks), a reliable LMP must have been noted for 42 weeks prior to birth, the FFH heard for 21 weeks, and Q felt for 25 weeks. These findings suggest that carefully obtained historical and physical examination information remains a cornerstone of appropriate obstetric care.

Human fetal respiratory movements: a technique for noninvasive monitoring with the use of a tocodynamometer.

A tocodynamometer applied to the maternal abdomen is used for monitoring human fetal respiratory movements (FRM). This provides a recording of fetal chest wall movements from which observations and measurements relating to fetal respiratory physiology may be made. The FRM must be differentiated from materanal vascular and respiratory movements, as well as fetal movements and cardiac pulsations. The technique lends itself to extended periods of observation, since it does not transmit energy to the fetus as in other techniques. The simplicity of the technique, combined with the use of monitoring devices already available in most hospitals, warrants further observation of this method of respiratory movement monitoring in the developing fetus.

Antenatal investigation of human fetal systolic time intervals.

A noninvasive method for measuring the antenatal human fetal systolic time intervals with the use of the transabdominal fetal electrocardiogram and Doppler cardiogram is described. Unique interactive computer routines were developed for rapid and accurate determination of the pre-ejection period (PEP), ventricular ejection time (VET), PEP/VET ratio, and fetal heart rate (FHR). Thirty normal patients were monitored between 20 and 40 weeks of gestation. A regression analysis of the fetal systolic time intervals and FHR against gestational age was done. PEP and PEP/VET ratio were significantly correlated to the gestational age, while VET and FHR were not.