Fetal overgrowth in pregnancies complicated by diabetes: validation of a predictive index in an external cohort.

PURPOSE: To assess validity of a fetal overgrowth index in an external cohort of women with diabetes in pregnancy METHODS: We performed a retrospective analysis of data derived from women with singleton gestations complicated by diabetes who delivered January 2015-June 2018. The following index variables were used to calculate risk of fetal overgrowth as defined by a customized birthweight ≥ 90th centile: age, history of fetal overgrowth in a prior pregnancy, gestational weight gain, fetal abdominal circumference measurement and fasting glucose between 24 and 30 weeks. RESULTS: In our validation cohort, 21% of 477 pregnancies were complicated by fetal overgrowth. The predictive index had a bias-corrected bootstrapped area under receiver operating characteristic curve of 0.90 (95% CI 0.86-0.93). 55% of the cohort had a low-risk index (≤ 3) which had a negative predictive value of 97% (95% CI 94-98%), while 18% had a high-risk index (≥ 8) that had a positive predictive value of 74% (95% CI 66-81%). CONCLUSION: The fetal overgrowth index incorporates five factors that are widely available in daily clinical practice prior to the period of maximum fetal growth velocity in the third trimester. Despite substantial differences between our cohort and the one studied for model development, we found the performance of the index was strong. This finding lends support for the general use of this tool that may aid counseling and allow for targeted allocation of healthcare resources among women with pregnancies complicated by diabetes.

Metoclopramide and Diphenhydramine: A Randomized Controlled Trial of a Treatment for Headache in Pregnancy when Acetaminophen Alone Is Ineffective (MAD Headache Study).

OBJECTIVE: We investigated whether metoclopramide administered with diphenhydramine (MAD) relieves headache in pregnant women when acetaminophen alone is ineffective, using codeine for comparison. STUDY DESIGN: Normotensive pregnant women in the second or third trimester were randomized to MAD intravenously (10 mg and 25 mg, respectively) or codeine orally (30 mg) for headache after 650 to 1,000 mg of acetaminophen failed to relieve their headaches. Headache severity (pain score 0-10) was noted at intervals over 24 hours. The primary outcome was reduction in pain score 6 hours after medication administration. A sample size calculation of 35 patients per group was based on estimated reduction in headache pain score by at least two points, with an α of 0.05 and a power of 80%. RESULTS: No difference was seen in the primary outcome. MAD pain scores were lower at 30 minutes (3 ± 2.8 versus 5.8 ± 2.3, p < 0.001), 1 hour (2.2 ± 2.3 vs. 4.1 ± 3; p < 0.01), and 12 hours (1.3 ± 2.5 vs. 2.7 ± 3; p < 0.05), but not at 6 hours. Time to perceived headache relief was shorter for MAD than for codeine (20.2 ± 13.4 vs. 62.4 ± 62.2 minutes; p < 0.001). More patients in the MAD group reported full headache relief within 24 hours (76.5 vs. 37.5%; p < 0.01). CONCLUSION: MAD effectively relieves headaches in pregnant women when acetaminophen fails.

Fetal overgrowth in pregnancies complicated by diabetes: development of a clinical prediction index.

PURPOSE: To develop an index to predict fetal overgrowth in pregnancies complicated by diabetes. METHODS: Data were derived from a cohort of 275 women with singleton gestations in a collaborative diabetes in pregnancy program. Regression analysis incorporated clinical factors available in the first 20-30 weeks of pregnancy that were assigned beta-coefficient-based weights, the sum of which yielded a fetal overgrowth index (composite score). RESULTS: Fifty-one (18.5%) pregnancies were complicated by fetal overgrowth. The derived index included five clinical factors: age ≤ 30, history of macrosomia, excessive gestational weight gain, enlarged fetal abdominal circumference, and fasting hyperglycemia. Area under the curve (AUC) for the index is 0.88 [95% confidence interval (CI) 0.82-0.92]. Cut-points were selected to identify "high-risk" and "low-risk" ranges (≥ 8 and ≤ 3) that have positive and negative predictive values of 84% (95% CI 70-98%) and 95% (95% CI 92-98%), respectively. The majority of women in our cohort (n = 182, 66%) had a "low-risk" index while 9% (n = 25) had a "high-risk" index. Sub-analyses of nulliparous women and women with gestational and pre-gestational diabetes revealed that the overgrowth index was equally or more predictive when applied separately to each of these groups. CONCLUSION: This fetal overgrowth index that incorporates five clinical factors provides a means of predicting fetal overgrowth and thereby serves as a tool for targeting the allocation of healthcare resources and treatment individualization.

Characteristics of Recurrent Large-for-Gestational-Age Infants in Obese Women.

Objective The objective of this study was to identify characteristics associated with recurrent large-for-gestational-age (LGA) infants in obese women and to explore the relationship between interpregnancy weight change and gestational weight gain (GWG) on risk of recurrence. Study Design We conducted a population-based historical cohort study of 1,190 obese women in Missouri who delivered LGA infants in their first pregnancy with two consecutive pregnancies resulting in singleton live births during 1998 to 2005. Adjusted odds ratios (aORs) for recurrent LGA infants were calculated with multiple logistic regression. Population-attributable risk assessed the relative importance of specific characteristics. Results A second LGA infant was delivered by 501 women (42%). Recurrence of LGA infants was associated with GWG (aOR, 1.03 [per pound]; 95% confidence interval [CI], 1.02-1.04), maternal age (aOR, 1.05 [per year]; 95% CI, 1.02-1.08), birth weight of the first LGA infant (aOR, 1.001 [per gram]; 95% CI, 1.000-1.001), being married (aOR, 1.71; 95% CI, 1.02-2.49), diabetes (aOR, 1.79; 95% CI, 1.24-2.59), and pre-pregnancy body mass index (BMI) (aOR, 1.04 [per unit BMI]; 95% CI, 1.02-1.06). Excessive GWG contributed the most to LGA infant recurrence (13%). Interpregnancy weight change was not significantly associated with LGA infant recurrence. Conclusion Lower pre-pregnancy BMI and reduced GWG may mitigate the risk of recurrent LGA infants in obese women.

Short bowel syndrome causing bleeding diathesis and profound vitamin deficiency in pregnancy.

BACKGROUND: Extensive bowel resection may lead to a state of inadequate nutrient absorption and malnutrition known as short bowel syndrome. Deficiencies in fat-soluble vitamins may occur from this condition, with sequelae such as a bleeding diathesis. Maternal vitamin deficiencies also have been associated with fetal anomalies. CASE: A young gravid patient with a history of neonatal bowel resection presented with bleeding diathesis. She subsequently was found to have profound vitamin deficiencies and delivered a newborn with multiple anomalies. CONCLUSION: Preconceptional counseling, nutritional status evaluation, and concomitant management with a gastroenterologist are essential to optimize pregnancy outcome for patients with a history of extensive bowel resection.

Treating prepartum depression to improve infant developmental outcomes: a study of diabetes in pregnancy.

Whether and how the co-occurrence of depression and diabetes in pregnancy may worsen infant development has not been reported. Pregnant women with diabetes and with (n = 34) or without (n = 34) major depressive disorder (MDD) were followed during pregnancy and 6-months postpartum. The MDD subset received randomly assigned treatment with cognitive behavior therapy (CBT) or supportive counseling (SC). Depression severity was measured with the Beck Depression Inventory (BDI); infant developmental outcomes were measured with the Bayley Scales of Infant Development (BSID) and its Behavior Rating Scale (BRS). Infants of women with MDD had lower BRS scores (p = .02). Reduction in depression scores was associated with better infant outcomes on the BSID and BRS (p values <.03). These preliminary findings suggest depression occurring in pregnant women with diabetes is associated with poorer infant development and improvement in prepartum depression is associated with improvement in measures of infant development.

Recurrent preeclampsia: the effect of weight change between pregnancies.

OBJECTIVE: To estimate whether the risk of recurrent preeclampsia is affected by interpregnancy change in body mass index (BMI). METHODS: We conducted a population-based cohort study using Missouri maternally linked birth certificates for 17,773 women whose first pregnancies were complicated by preeclampsia. The women were placed into three groups: those who decreased their BMIs, those who maintained their BMIs, and those who increased their BMIs between their first two pregnancies. The primary outcome was recurrent preeclampsia in the second pregnancy. Adjusted risk ratios and 95% confidence intervals were calculated using Poisson regression analysis. RESULTS: The overall rate of recurrent preeclampsia in women who decreased their BMIs between pregnancies was 12.8% (risk ratio 0.70, confidence interval 0.60-0.81) compared with 14.8% if BMI was maintained and 18.5% in those who increased their BMIs (risk ratio 1.29, confidence interval 1.20-1.38). Within the normal weight, overweight, and obese weight categories, women who decreased BMI between pregnancies were less likely to experience recurrent preeclampsia. Women in all weight categories who increased their BMIs between pregnancies were more likely to experience recurrent preeclampsia. CONCLUSION: Interpregnancy weight reduction decreases the risk of recurrent preeclampsia and should be encouraged in women who experience preeclampsia. LEVEL OF EVIDENCE: II.

Large-for-gestational-age infants of type 1 diabetic mothers: an effect of preprandial hyperglycemia?

OBJECTIVE: To determine how the frequency, timing and magnitude of hyperglycemia are associated with large-for-gestational-age (LGA) infants in pregnancies complicated by type 1 diabetes. METHODS: Charts from pregnant women with type 1 diabetes (n = 70) were reviewed. Indices of maternal glycemic control were determined for seven gestational periods (weeks 7-10, 11-15, 16-19, 20-24, 25-28, 29-32 and 33-38) and compared between women who delivered LGA infants and appropriate-for-gestational-age (AGA) infants. RESULTS: Of the 70 pregnancies, 57% of the infants were LGA (4.3 +/- 0.4 kg) and 43% were AGA (3.2 +/- 0.4 kg). Total maternal weight gain and rate of weight gain were significantly higher in mothers with LGA infants. The glycemic variables associated with an LGA infant were percentage of preprandial values above target for weeks 11-15, 25-28 and 29-32, and percentage of all values above target for weeks 33-38. For the entire pregnancy, the strongest predictors of an LGA infant were percentage of preprandial blood glucose values above target during weeks 29-32 and maternal weight gain. CONCLUSIONS: In pregnant women with type 1 diabetes, frequent episodes of preprandial hyperglycemia in the third trimester significantly impact the development of LGA infants.

Recurrence of preeclampsia: effects of gestational age at delivery of the first pregnancy, body mass index, paternity, and interval between births.

OBJECTIVES: The purpose of this study was to establish estimates for recurrence risk of preeclampsia based on gestational age at delivery of the first pregnancy complicated by preeclampsia and to determine whether interbirth interval, paternity, and body mass index (BMI) modify that risk in women with prior preeclampsia. STUDY DESIGN: A population-based, cohort study was conducted using data from Missouri maternally linked birth certificates. The cohort included women who had 2 singleton births between 1989 and 1997: 6157 women with preeclampsia and 97,703 women without preeclampsia at the time of their first deliveries. Data were analyzed using the Poisson regression. RESULTS: At the time of their second delivery, 14.7% women with prior preeclampsia developed recurrent preeclampsia. The risk of recurrent preeclampsia is inversely related to gestational age at the first delivery: 38.6% for 28 weeks' gestation or earlier, 29.1% for 29-32 weeks, 21.9% for 33-36 weeks, and 12.9% for 37 weeks or more. The recurrent preeclampsia risk was fairly constant if both births occurred within 7 years. Obese and overweight women had higher risks of recurrent preeclampsia (19.3% and 14.2%), compared with women with normal BMI (11.2%). The recurrence risk did not differ according to paternity status. CONCLUSION: The risk of preeclampsia recurrence increases with earlier gestational age at the first delivery complicated by preeclampsia and with increasing maternal BMI.

A lifestyle intervention of weight-gain restriction: diet and exercise in obese women with gestational diabetes mellitus.

OBJECTIVE: This study assessed whether a weight-gain restriction regimen, with or without exercise, would impact glycemic control, pregnancy outcome, and total pregnancy weight gain in obese subjects with gestational diabetes mellitus (GDM). A total of 96 subjects with GDM met the inclusion criteria and were sequentially recruited, with 39 subjects self-enrolled in the exercise and diet (ED) group, and the remaining 57 subjects self-enrolled in the diet (D) group owing to contraindications or a lack of personal preference to exercise. All patients were provided a eucaloric or hypocaloric consistent carbohydrate meal plan and instructed in the self-monitoring of blood glucose. In addition, all ED subjects were prescribed an exercise routine equivalent to a 60% symptom-limited VO2 max. Subjects were followed at weekly or biweekly office visits. Results showed maternal weight and body mass index (35.2+/-7.2 (ED) vs. 33.5+/-9.2 (D)) at study entry as well as number of weeks into the study (7.7+/-5.7 (ED) vs. 9.4+/-4.7 (D)) were similar in both the ED and D groups. Weight gain per week was significantly lower in the ED group than in the D group (0.1+/-0.4 kg vs. 0.3+/-0.4 kg; p<0.05). Subjects (either ED or D) who gained weight had a higher percentage of macrosomic infants than those subjects who lost weight or had no weight change during pregnancy. Other pregnancy and fetal outcomes such as complications, gestational age at delivery, and rate of cesarean delivery were similar in both groups. Conclusions of this study were that caloric restriction and exercise result in limited weight gain in obese subjects with GDM, less macrosomic neonates, and no adverse pregnancy outcomes. Pregnancy is an ideal time for behaviour modification, and this intervention may also help promote long-term healthy lifestyle changes.

Tertiary care improves the chance for vaginal delivery in women with preeclampsia.

OBJECTIVE: The purpose of this study was to determine whether the level of hospital care affects cesarean delivery rates for women with preeclampsia. STUDY DESIGN: We conducted a population-based cohort study using Missouri birth certificate data for 1993 through 1999. Logistic regression was used to analyze data from 13,646 nulliparous women with preeclampsia who were delivered of singleton live births. RESULTS: After adjustment was made for gestational age and birth weight, the data showed that women with preeclampsia at primary and secondary hospitals were more likely to be delivered by cesarean delivery (odds ratio, 1.37; 95% CI, 1.24,1.51; and odds ratio, 1.16; 95% CI, 1.07,1.26, respectively) than at tertiary hospitals. For women who were delivered at >or=37 weeks of gestation, cesarean delivery rates were 38.0%, 33.7%, and 30.0% for primary, secondary, and tertiary hospitals, respectively. Dysfunctional labor, cephalopelvic disproportion, and fetal distress were more commonly noted at primary and secondary hospitals (P<.001). CONCLUSION: Levels of expertise and staffing at tertiary hospitals may allow greater attempts and success with vaginal delivery among women with preeclampsia compared with primary or secondary hospitals.

Preeclampsia in the parous woman: who is at risk?

OBJECTIVE: The purpose of this study was to identify risk factors for preeclampsia in second pregnancies and to determine whether gestational age at delivery in the first pregnancy increases the risk of recurrent preeclampsia. STUDY DESIGN: We conducted a population-based, case-control study using birth certificate data from the Missouri maternally linked cohort. Data from women delivered of their first 2 singleton pregnancies between 1989 and 1997 (2332 cases with preeclampsia in the second pregnancy and 2370 control cases) were analyzed with logistic regression. RESULTS: Significant risk factors for preeclampsia in a second pregnancy include longer birth interval, previous preterm delivery, previous small-for-gestational-age newborn, renal disease, chronic hypertension, diabetes mellitus, obesity, black race, and inadequate prenatal care. Smoking and same paternity are protective. A history of preeclampsia confers the highest risk for preeclampsia in the second pregnancy; the risk is inversely proportional to gestational age at delivery of the first pregnancy: adjusted odds ratio, 15.0; 95% CI, 6.3-35.4 for 20 to 33 weeks; adjusted odds ratio, 10.2; 95% CI, 6.2-17.0 for 33 to 36 weeks; and adjusted odds ratio, 7.9; 95% CI, 6.3-10.0 for 37 to 45 weeks. CONCLUSION: The relative risk of recurrent preeclampsia increases with earlier gestational age at delivery of the first pregnancy that was complicated by preeclampsia.