Treatment of women with mild gestational diabetes mellitus decreases the risk of adverse perinatal outcomes.

AIMS: Glycemic thresholds used to diagnose gestational diabetes mellitus (GDM) are a continued subject of debate. Lower glycemic thresholds identify women with milder GDM for whom treatment benefit is unclear. We compared adverse maternal and neonatal outcomes in treated and untreated women with mild hyperglycemia. METHODS: We reviewed 11 553 patient charts from two tertiary care centers and included singleton pregnancies >32-week gestation. GDM was diagnosed using the one- or two-step 75 g oral glucose tolerance test (OGTT) depending on the center. All OGTT results were reviewed. Women with glycemic values falling between the thresholds of the two tests, referred to as intermediate hyperglycemic (IH), defined as FPG 5.1-5.2 mmol/L, 1 h PG 10.0-10.5 mmol/L, or 2 h PG 8.5-8.9 mmol/L at 75 g OGTT, were untreated at center A and treated at center B. RESULTS: There were 630 women with IH, 334 were untreated (center A) and 296 who were treated (center B). After adjusting for covariates, untreated IH women had significantly higher rates of gestational hypertension (aOR 6.02, P = 0.002), large for gestational age (LGA) (aOR 3.73, P < 0.001) and birthweights > 4000 g (aOR 3.35, P = 0.001). Our results indicate that treating 11 women with IH would prevent one LGA birth and treating 13 would prevent 1 birthweight > 4000 g. CONCLUSION: The diagnosis of GDM using the two-step OGTT fails to identify subgroups of women with mild hyperglycemia that would benefit from treatment to lower the risk for adverse maternal and neonatal outcomes. Treatment of women with mild hyperglycemia decreased the risk of LGA and birthweight >4000 g by 3-fold.

Routine third trimester ultrasound: what is the evidence?

Policies for routine third trimester obstetrical ultrasound examinations differ among countries. In Canada, a routine third trimester ultrasound scan is not offered in the low-risk pregnancy population. This practice is based mainly on results of a meta-analysis published in 2001 that concluded "routine late pregnancy ultrasound in low-risk or unselected populations does not confer benefit on mother or baby." We reviewed in detail each study included in this meta-analysis in order to re-evaluate the Canadian practice regarding routine third trimester ultrasound in the low-risk pregnant population. The meta-analysis included outdated techniques and ultrasound examinations performed in the late 1970s and early 1980s. To assess the effect of routine third trimester ultrasound on perinatal outcome, the interventions prompted by an abnormal diagnostic test result must be considered. None of the trials included in the meta-analysis evaluated the effect of routine third trimester ultrasound on perinatal outcomes in a low-risk population when ultrasound assessment was followed by an altered perinatal management plan. Our assessment of the published evidence regarding routine third trimester ultrasound puts in question the contemporary validity of the conclusion of the 2001 meta-analysis. In fact, the 2001 meta-analysis has recently been withdrawn by the authors.

Early versus late amniotomy for labour induction: a randomized controlled trial.

OBJECTIVE: To evaluate the impact of early vs. late amniotomy on delivery mode in women undergoing induction of labor. STUDY DESIGN: 143 women admitted for induction were randomized to early amniotomy (EA, concomitant with the beginning of oxytocin infusion; n = 71) or to late amniotomy (LA, four hours after the beginning of oxytocin; n = 72). Randomization was stratified by parity. The primary outcome was the rate of cesarean. Secondary outcomes were duration of labor and intrapartum fever. RESULTS: The cesarean rate was similar between groups (18% vs. 17% among nulliparous; and 3% vs. 0% among parous women, in EA and LA group, respectively). However, EA was associated with shorter oxytocin-to-delivery interval (12 vs. 15 h) and a non-significant decrease in intrapartum fever (3% vs. 25%) than LA in nulliparous women (p = 0.05). CONCLUSION: For women undergoing oxytocin induction, early amniotomy is associated with shorter labor in nulliparous women with no effect on the risk of cesarean section in both nulliparous and multiparous women.

Postpartum hyperkalemia associated with magnesium sulfate.

We report the case of a woman who first received MgSO(4) for eclampsia prophylaxis and then was treated with MgSO(4) for eclampsia. She developed hyperkalemia without severe renal failure or another explanation. We recommend close monitoring, including serial measurements of electrolytes, when MgSO(4) is administered for eclampsia prophylaxis or treatment.