Calorie restriction for treatment of gestational diabetes.

Birth weights of infants of 35 gestational diabetic mothers treated with calorie restriction alone (1200-1800 kcal) were compared with those of infants of 2337 nondiabetic women, including two control groups (A and B) matched for race, body mass index, age, and parity. All women were screened for gestational diabetes with the O'Sullivan screening method, and a 3-h oral glucose tolerance test was performed on all abnormal results. Control group A mothers had a normal screen, and control group B mothers had an abnormal screen with a normal glucose tolerance test. Pregnancy weight gain was significantly less for the gestational diabetic mothers (mean +/- SD 4.6 +/- 4.9 kg) than for the general prenatal population (9.3 +/- 5.3 kg), group A control subjects (9.7 +/- 5.3 kg), and group B control subjects (9.7 +/- 5.4 kg; P less than 0.0005). No infant of a gestational diabetic mother was below the 10th percentile for weight, and birth weights were similar to those of the control groups even though weight gain after the 28th wk of gestation was only 1.7 +/- 1.6 kg. The frequency of macrosomia (birth weight greater than or equal to 4000 g) was similar among the gestational diabetic mothers (9.3%), the general prenatal population (7.4%), and group A mothers (11.6%) but significantly higher for the group B control subjects (20.9%; chi 2 = 8.57, P less than 0.005). This study demonstrated that gestational diabetic mothers who are calorie restricted have infants with normal birth weights and a frequency of macrosomia less than that of screen-positive nondiabetic women with similar macrosomic risk factors.

The fetal maturity and mode of delivery of a woman's first baby influences the characteristics of her next labour.

There are well documented differences between the characteristics of labour in primigravidae and multigravidae. The present study was undertaken to determine whether the gestational age and mode of delivery of a woman's first baby influences the characteristics of labour in her next pregnancy. Information regarding previous obstetric history and subsequent obstetric performance was derived from a database of 75,974 consecutive singleton births. As a group, women with a history of one preterm vaginal delivery had labour characteristics similar to those women whose one previous pregnancy had resulted in a vaginal delivery at term. When this group were analysed by the gestation at which the previous birth had occurred, a gestation-dependent effect was seen. Women whose first birth had been at less than 28 weeks gestation behaved in a similar manner to primiparous women. On the other hand, the characteristics of labour in women whose first birth had occurred between 33 and 36 weeks gestation were similar to those of women who had had a previous vaginal delivery at term. Women whose first delivery had been by caesarean section behaved in a similar manner to primiparae. The typical differences between the characteristics of first and second labours are the result of a gradual change which appears to be related to the gestation at which the first birth occurred.

Risk factors for major obstetric haemorrhage.

The factors associated with major obstetric haemorrhage were analyzed using data relating to 37,497 women delivered in 1988 in National Health Service maternity units in the North West Thames Region, UK. Four hundred ninety-eight cases (1.33%) were complicated by haemorrhage of 1000 ml or more. Intrinsic factors associated with significant risk ratios (99% confidence intervals) included placental abruption 12.6 (7.61-20.9), placenta praevia 13.1 (7.47-23.0), multiple pregnancy 4.46 (3.01-6.61) and obesity 1.64 (1.24-2.17), but not high parity. Significant risk factors related to obstetric management and delivery included retained placenta 5.15 (3.36-7.87), induced labour 2.22 (1.67-2.96), episiotomy 2.06 (1.36-3.11) and birthweight 4 kg or more 1.90 (1.38 to 2.60). Among the 59 women who lost 1000 ml or more in association with a spontaneous vaginal delivery with an intact perineum, significant risk ratios (99% confidence intervals) were retained placenta 13.7 (5.92-31.8) and induced labour 2.35 (1.11-4.98). These data provide a more comprehensive assessment of risk factors for potentially life threatening haemorrhage in British obstetric practice than is possible using maternal mortality statistics. The hazards of well known factors such as multiple pregnancy, abruption, placenta praevia and caesarean delivery were confirmed but attention is drawn to the potential risk of haemorrhage associated with obesity or a large baby and to that associated with retained placenta in women classified as 'low risk'.

Mode of delivery after one caesarean section: audit of current practice in a health region.

OBJECTIVE: To audit the subsequent obstetric management of women who had had one previous baby delivered by caesarean section. DESIGN: Retrospective analysis of a regional obstetric database. SETTING: Data derived from the 17 obstetric units in North West Thames region. SUBJECTS: 1059 women who delivered a singleton fetus of at least 37 weeks' gestation with a cephalic presentation in 1988 who had a history of one previous caesarean section and no other deliveries. MAIN OUTCOME MEASURES: Mode of delivery, postnatal morbidity, and duration of hospital stay. RESULTS: 395 (37%) women were delivered by elective repeat caesarean section and 664 (63%) were allowed a trial of labour. Maternal height and birth weight of the previous infant differed significantly between those who were and those who were not allowed to labour. 471 (71%) of those allowed to labour achieved a vaginal delivery. In individual units there was no significant correlation between the proportion of patients allowed to labour and the rate of the successful trial of labour. There was a trend towards greater success rates in units that allowed a longer duration of labour (p less than 0.05) and units with greater use of oxytocin for augmentation of labour (not significant). Both elective and intrapartum caesarean section was associated with a significantly higher rate of postnatal infection than vaginal delivery (14.7% and 16.0% v 3.4%). CONCLUSIONS: In patients with a history of caesarean section there is no evidence that the likelihood of successful vaginal delivery after trial of labour is modified by the proportion of such patients allowed the option of attempted vaginal delivery. Until selection criteria of adequate prognostic value can be identified a more liberal approach to allowing women a trial of labour seems justified.

Obstetric outcome in homeless women.

OBJECTIVE: To characterise the pregnant homeless population booking and delivering at St Mary's Hospital, London, and ascertain whether their obstetric outcome was adversely affected by their homeless condition. DESIGN: Retrospective comparison of demographic characteristics of 185 homeless women booking for delivery with those of housed women booking in the same period and with the population of North West Thames region; comparison of obstetric performance of homeless women with subgroup of the housed population (group matched for age, parity, and ethnic origin). SETTING: Consultant obstetric unit, St Mary's Hospital, London. SUBJECTS: All women booking between April 1987 and March 1988 who subsequently had a registrable birth. MAIN RESULTS: 185 (8%) Of the 2308 women studied were homeless. Compared with the housed population, they had a larger proportion of young women, women of high parity, and Indo-Pakistani women and a smaller proportion of primiparas. Homeless women booked later and had had more previous obstetric problems than housed women. Pregnancy outcome (assessed by birth weight and prematurity rates) was worse than that of both women housed locally and the regional population. Antenatal attendance, complications, intrapartum performance, and perinatal outcome of homeless women did not differ from those in the control group. CONCLUSIONS: This study has been unable to show any significant differences in the outcome of pregnancy in homeless women that can be directly attributed to living in bed and breakfast accommodation, but these women have sociodemographic characteristics and obstetric risk factors that contribute to a poorer outcome in pregnancy than for the general population.

The characteristics of the second stage of labour in 25,069 singleton deliveries in the North West Thames Health Region, 1988.

OBJECTIVE: To define the contemporary characteristics of the second stage of labour in one Health Region. DESIGN: Retrospective analysis of a regional obstetric database. SETTING: Seventeen maternity units in the North West Thames Health Region. SUBJECTS: Selected from 36,727 consecutive singleton deliveries in 1988. The analysis was confined to the 25,069 women delivered of an infant of at least 37 weeks gestation with a cephalic presentation following the spontaneous onset of labour. MAIN OUTCOME MEASURES: Second stage duration, obstetric intervention and maternal and fetal morbidity. RESULTS: The duration of the second stage and the use of operative intervention were strongly negatively associated with parity and positively associated with the use of epidural analgesia. Maternal age, fetal birthweight and maternal height were also independently associated with the duration of the second stage. There were small but significant differences in the characteristics of women using epidural analgesia and those using alternative methods of pain relief. Parous women using epidural analgesia behaved in a similar manner to nulliparae without epidurals. Despite the longer second stages observed in women using epidural analgesia there appeared to be no significant increase in fetal morbidity. Within the region the epidural rate in individual units positively correlated with the overall forceps rate, the rate of caesarean section in the second stage of labour and the duration of the second stage. CONCLUSIONS: In our study the duration of the second stage in women not using epidural analgesia was similar to previous findings, but in those using epidural analgesia, the duration of the second stage was longer than has been reported previously, possibly reflecting a more conservative approach to operative intervention. Survival analysis indicates that in multiparae not using epidural analgesia the likelihood of spontaneous vaginal delivery after 1 h in the second stage was low, but in those multiparae using epidural analgesia and in all nulliparae there was no clear cut-off point for expectation of spontaneous delivery in the near future; they continue to give birth at a steady rate over several hours. While maternal and fetal conditions are satisfactory, intervention should be based on the rate of progress rather than the elapsed time since full cervical dilatation.

Neonatal and maternal morbidity in relation to the length of the second stage of labour.

OBJECTIVE: To investigate the relation between the duration of the second stage of labour and subsequent early neonatal and maternal morbidity. DESIGN: Retrospective analysis of a regional obstetric database. SETTING: 17 maternity units in the North West Thames Health Region. SUBJECTS: Selected from 36,727 consecutive singleton deliveries in 1988. The analysis was confined to the 25,069 women delivered of an infant of at least 37 weeks gestation with a cephalic presentation following the spontaneous onset of labour. MAIN OUTCOME MEASURES: The relative risk of early maternal morbidity, postpartum haemorrhage (PPH) and postpartum infection, and neonatal morbidity, as judged by low Apgar scores or admission to the special care baby unit (SCBU), in relation to anthropomorphic characteristics (parity and birthweight), interventions (epidural analgesia, episiotomy and operative delivery), signs of fetal compromise (meconium staining of the amniotic fluid or abnormal cardiotocography (CTG)), maternal morbidity in labour (pyrexia) and the duration of the second stage of labour. RESULTS: The duration of the second stage of labour had a significant independent association with the risk of both PPH and maternal infection after adjustment for other factors. However, there was a similar or greater risk of PPH in association with operative delivery or a birthweight greater than 4000 g. Both maternal pyrexia in labour and primiparity were associated with a greater risk of post partum maternal infection than was the duration of the second stage, although all these factors were statistically significant. In contrast, the duration of the second stage was not significantly associated with the risk of a low Apgar score or admission to SCBU after adjustment for other factors. CONCLUSIONS: The duration of the second stage of labour has a positive independent association with early maternal morbidity. We could show no such relation between time spent in the second stage of labour and the frequency of low Apgar scores or the rate of admission to SCBU. With current management approaches, in the absence of factors suggesting fetal compromise, second stage labours of up to 3 h duration do not seem to carry undue risk to the fetus.

A comparison of absorption rate models in the prediction of steady-state plasma concentrations during oral theophylline administration.

During therapy with oral controlled released theophylline/aminophylline, steady-state plasma drug concentrations may be predicted by fitting estimates of patient pharmacokinetic parameters to a pharmacokinetic model. The choice of model requires an assumption about the type of rate reaction of the drug absorption process (zero order or first order). In 10 subjects, plasma theophylline concentrations after a single intravenous dose of aminophylline were used to make individual estimates of drug clearance and volume of distribution. Each subject then received oral controlled release theophylline ('Theo-Dur', Fisons Pharmaceuticals plc) and steady-state pre-dose and post-dose plasma concentrations were determined. Predictions of steady-state plasma theophylline concentrations using pharmacokinetic models based on first-order (Model A) and zero order (Model 01) drug absorption were compared. Model A and Model 01 each underestimated the pre- and post-dose steady-state plasma drug concentrations. However, Model 01 was more accurate in predicting post-dose drug concentrations, whilst Model A demonstrated better precision in the prediction of pre-dose drug concentrations at steady-state (P less than 0.05).

Evaluation of computer generated neonatal discharge summaries.

Computer generated and dictated discharge summaries were compared for all 133 babies admitted for intensive and special care during a six month period. Whereas 130/133 (98%) had a computer generated summary, only 94/133 (71%) had a dictated summary. In addition, computerised summaries were completed at discharge, but there was a delay up to 26 weeks for dictated summaries. Dictated summaries had more items of basic data missing but were more readable. A main diagnosis was missing in only 5/95 (5%) of dictated and 1/130 (1%) computerised summaries. Of the computer generated summaries, 114/133 (86%) were suitable to give to parents. Satisfactory discharge summaries for babies requiring intensive or special care can be generated with an on line computer system.

Evaluating the quality of the maternity services--a discussion paper.

OBJECTIVE: A review of the use of computer collected audit data in assessing the quality of maternity services. SETTING: All maternity units managed by the North West Thames Regional Health Authority. RECOMMENDATIONS: A system of audit must supply information that is both credible and of interest to clinicians managers and consumers. The information should be adjusted for differences in populations to allow valid comparisons between units. It needs to be presented in an easily digested form. One way of implementing audit would be to establish a regional group representative of clinicians, patients and managers who would initially interpret the data and make recommendations. A local group of similar composition would be asked to comment on and respond to these with a plan for the following year. Changes would be monitored by analysis of the routinely collected data. CONCLUSIONS: Medical audit in the maternity services requires new concepts if it is to influence the quality of clinical care and the use of resources available to provide that care. The appropriate balance needs to be found between the perspectives of clinicians, patients and managers. A major challenge is the collection of valid data. This has largely been overcome by the St Mary's maternity information system. The next stage is to devise a system of audit that is epidemiologically sound and is acceptable to those who will be asked to implement the lessons that emerge. Only then will it be possible to determine whether clinical practice and the use of resources can be altered to the benefit of patients.

High prevalence of gestational diabetes in women from ethnic minority groups.

The influence of ethnic origin, body mass index, and parity on the frequency of gestational diabetes was assessed in 11,205 consecutive women attending a multiracial antenatal clinic in London, where all women were screened for gestational diabetes. Logistic regression was used to model the relationship between gestational diabetes and ethnic origin, age, body mass index (BMI), and parity. Results were presented as adjusted odds ratios, where the reference categories are White women, age < 25 years, BMI < 27, and parity < 3. Ethnic origin was the dominant influence on the prevalence of gestational diabetes. Women from ethnic groups other than White had a higher frequency of gestational diabetes than White women (2.9% vs 0.4%, p < 0.001). Compared to White women the relative risk of gestational diabetes in the other ethnic groups was: Black 3.1 (95% confidence limits 1.8-5.5), South East Asian 7.6 (4.1-14.1), Indian 11.3 (6.8-18.8), and miscellaneous 5.9 (3.5-9.9). Increasing age was an independent risk factor. The relative risk was higher in women > or = 35 years in all ethnic groups other than in South East Asian women. Obesity (BMI > or = 27) was a further independent risk factor in all ethnic groups except in the Indian and South East Asian women. Parity > or = 3 increased the relative risk of gestational diabetes in the White, Black, and South East Asian women only.(ABSTRACT TRUNCATED AT 250 WORDS)