Changing patterns in medication prescription for gestational diabetes during a time of guideline change in the USA: a cross-sectional study.

OBJECTIVE: To define patterns of prescription and factors associated with choice of pharmacotherapy for gestational diabetes mellitus (GDM), namely metformin, glyburide and insulin, during a period of evolving professional guidelines. DESING: Cross-sectional study. SETTING: US commercial insurance beneficiaries from Market-Scan (late 2015 to 2018). STUDY DESIGN: We included women with GDM, singleton gestations, 15-51 years of age on pharmacotherapy. The exposure was pharmacy claims for metformin, glyburide and insulin. MAIN OUTCOMES: Pharmacotherapy for GDM with either oral agent, metformin or glyburide, compared with insulin as the reference, and secondarily, consequent treatment modification (addition and/or change) to metformin, glyburide or insulin. RESULTS: Among 37 762 women with GDM, we analysed data from 10 407 (28%) with pharmacotherapy, 21% with metformin (n = 2147), 48% with glyburide (n = 4984) and 31% with insulin (n = 3276). From late 2015 to 2018, metformin use increased from 17 to 29%, as did insulin use from 26 to 44%, whereas glyburide use decreased from 58 to 27%. By 2018, insulin was the most common pharmacotherapy for GDM; metformin was more likely to be prescribed by 9% compared with late 2015/16, but glyburide was less likely by 45%. Treatment modification occurred in 20% of women prescribed metformin compared with 2% with insulin and 8% with glyburide. CONCLUSIONS: Insulin followed by metformin has replaced glyburide as the most common pharmacotherapy for GDM among a privately insured US population during a time of evolving professional guidelines. Further evaluation of the relative effectiveness and safety of metformin compared with insulin is needed. TWEETABLE ABSTRACT: Insulin followed by metformin has replaced glyburide as the most common pharmacotherapy for gestational diabetes mellitus in the USA.

Prediction of large-for-gestational-age infant by fetal growth charts and hemoglobin A1c level in pregnancy complicated by pregestational diabetes.

OBJECTIVES: To compare the ability of three fetal growth charts (Fetal Medicine Foundation (FMF), Hadlock and National Institutes of Child Health and Human Development (NICHD) race/ethnicity-specific) to predict large-for-gestational age (LGA) at birth in pregnant individuals with pregestational diabetes, and to determine whether inclusion of hemoglobin A1c (HbA1c) level improves the predictive performance of the growth charts. METHODS: This was a retrospective analysis of individuals with Type-1 or Type-2 diabetes with a singleton pregnancy that resulted in a non-anomalous live birth. Fetal biometry was performed between 28 + 0 and 36 + 6 weeks of gestation. The primary exposure was suspected LGA, defined as estimated fetal weight ≥ 90th percentile using the Hadlock (Formula C), FMF and NICHD growth charts. The primary outcome was LGA at birth, defined as birth weight ≥ 90th percentile, using 2017 USA natality reference data. The performance of the three growth charts to predict LGA at birth, alone and in combination with HbA1c as a continuous measure, was assessed using the area under the receiver-operating-characteristics curve (AUC), sensitivity, specificity, positive predictive value and negative predictive value. RESULTS: Of 358 assessed pregnant individuals with pregestational diabetes (34% with Type 1 and 66% with Type 2), 147 (41%) had a LGA infant at birth. Suspected LGA was identified in 123 (34.4%) by the Hadlock, 152 (42.5%) by the FMF and 152 (42.5%) by the NICHD growth chart. The FMF growth chart had the highest sensitivity (77% vs 69% (NICHD) vs 63% (Hadlock)) and the Hadlock growth chart had the highest specificity (86% vs 76% (NICHD) and 82% (FMF)) for predicting LGA at birth. The FMF growth chart had a significantly higher AUC (0.79 (95% CI, 0.74-0.84)) for LGA at birth compared with the NICHD (AUC, 0.72 (95% CI, 0.68-0.77); P < 0.001) and Hadlock (AUC, 0.75 (95% CI, 0.70-0.79); P < 0.01) growth charts. Prediction of LGA improved for all three growth charts with the inclusion of HbA1c measurement in comparison to each growth chart alone (P < 0.001 for all); the FMF growth chart remained more predictive of LGA at birth (AUC, 0.85 (95% CI, 0.81-0.90)) compared with the NICHD (AUC, 0.79 (95% CI, 0.73-0.84)) and Hadlock (AUC, 0.81 (95% CI, 0.76-0.86)) growth charts. CONCLUSIONS: The FMF fetal growth chart had the best predictive performance for LGA at birth in comparison with the Hadlock and NICHD race/ethnicity-specific growth charts in pregnant individuals with pregestational diabetes. Inclusion of HbA1c improved further the prediction of LGA for all three charts. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

An evaluation of fetal heart rate characteristics associated with neonatal encephalopathy: a case-control study.

OBJECTIVE: We sought to identify fetal heart rate (FHR) characteristics that are associated with neonatal encephalopathy (NE). DESIGN: Retrospective case-control study. SETTING: A single medical centre in Shanghai, China, 2006-2015. SAMPLE: Women delivering a singleton, non-anomalous infant at ≥36 weeks' gestation diagnosed with NE (cases, n = 109) were compared with a group of women with unaffected infants (controls, n = 233). METHODS: Two physicians blinded to the outcome independently reviewed FHR tracings during the last 30 minutes of tracing prior to delivery. FHR characteristics were compared in the two groups and multivariable logistic regression was used to adjust for confounding. MAIN OUTCOME MEASURES: Adjusted odds ratio (aOR) and 95% confidence interval (CI) for the presence of specific FHR categories and characteristics. RESULTS: Category II FHR tracings were observed in 89% of women prior to delivery and were not independently associated with NE. Notably, a category III FHR was observed in 17.4% of women in the NE group compared with 0.9% of women in the control group (aOR 44.99, 95% CI 7.23-279.97). Bradycardia, minimal/absent variability, late decelerations and prolonged decelerations were independently associated with NE, whereas accelerations were protective. Similar findings were found when the cases were limited to NE with arterial cord pH <7.1 and in a subgroup analysis of women with category II tracings. CONCLUSIONS: Category III tracings, while infrequent, are not uncommon prior to delivery among fetuses who develop NE. In contrast, most FHR tracings are category II prior to delivery; however, individual FHR characteristics within this category are associated with NE. FUNDING: This research was supported by the Interdisciplinary Programme of Shanghai Jiao Tong University. TWEETABLE ABSTRACT: Category III tracings are not uncommon prior to delivery among fetuses who develop neonatal encephalopathy.

Lowering the high rate of caesarean delivery in China: an experience from Shanghai.

OBJECTIVE: To examine the trends of caesarean delivery (CD) after an intervention to lower the high rate of CD at a Chinese maternity hospital. DESIGN: Retrospective cohort study. SETTING: A large tertiary obstetric centre in Shanghai, China, from 2007 to 2014. SAMPLE: 81 459 nulliparous women who delivered a term singleton infant. METHODS: Logistic regression was used to calculate the odds of CD while adjusting for confounders. MAIN OUTCOME MEASURE: Rate of CD before and after the intervention. RESULTS: The rate of CD decreased from 51.5% in 2008 to 36.1% in 2014, mostly due to a reduction in non-indicated antepartum CD from 27.9% in 2010 to 11.9% in 2014. After adjustment, a period effect remained with delivery between 2011 and 2014 associated with a 31% reduction in the odds of CD compared with delivery between 2007 and 2010 [odds ratio (OR): 0.69, 95% CI: 0.66-0.71)] and a 33% reduction in the odds of antepartum CD (OR: 0.67, 95% CI: 0.64-0.69). The frequencies of perinatal mortality (0.5 versus 0.4/1000), hypoxic ischaemic encephalopathy (0.9 versus 1.2/1000), meconium aspiration syndrome (0.5/1000), birth trauma (0.6/1000), respiratory distress syndrome (0.5% versus 0.4%) and necrotising enterocolitis (0.9 versus 0.6/1000) were similar. The frequency of neonatal infection increased slightly (0.6% versus 0.8%), although this could be explained by other factors. CONCLUSIONS: A marked reduction in CD has occurred at an urban tertiary care centre as a result of efforts to reduce the high rate of caesarean delivery. No notable differences in neonatal outcomes were observed. TWEETABLE ABSTRACT: High rates of caesarean delivery can be lowered without increases in neonatal morbidity and mortality.

Breastfeeding following bariatric surgery among obese women with and without diabetes mellitus.

BACKGROUND: Information on exclusive breastfeeding (BF) and BF initiation following bariatric surgery (BS) among obese women with diabetes mellitus (DM) and without DM (non-DM) is limited. METHODS: Retrospective cohort study. Obesity was defined by BMI (kg/m2) as grade 1 (30-34.9), grade 2 (35-39.9) or grade 3 (≥40). The 65 women in the DM group (40 women with gestational, 19 with Type 2 and 6 with Type 1) was similar to 84 with non-DM in BS type: Roux-en-Y (51 vs 55%), sleeve gastrectomy (32 vs 35%), laparoscopic gastric banding (17 vs 7%) and gastro-duodenal anastomosis (0 vs 4%). RESULTS: Women with DM were older (35 vs 33y), of advanced age (54 vs 27%), with higher prevalence of grade 3 obesity (66 vs 46%), chronic hypertension (31 vs 10%), delivery of late-preterm infants (23 vs 10%) and neonatal hypoglycemia (25 vs 12%). Although infant feeding intention was similar: BF (66 vs 79%), partial BF (9 vs 7%) or formula (25 vs 14%), at discharge women with DM had lower exclusive BF (29 vs 41%) and BF initiation rates (68 vs 76%) than those with non-DM. Women with grade 3 obesity (52% were DM) differed from those with grades 1-2 (34% were DM) in exclusive BF (27 vs 52%), and BF initiation rates (66 vs 86%). CONCLUSION: After BS, women with DM, especially those with grade 3 obesity, had higher rates of chronic hypertension and preeclampsia and lower rates of exclusive BF and BF initiation than those who had DM but had less severe obesity.

Breastfeeding initiation among women with chronic hypertension superimposed on pregestational diabetes mellitus.

OBJECTIVE: To compare breastfeeding (BF) initiation among 317 women with chronic hypertension (CHTN) and 106 women with CHTN superimposed on pregestational diabetes (CHTN-DM) who intended exclusive or partial BF. METHODS: Retrospective cohort study of women who delivered at≥34 weeks of gestation. At discharge, exclusive BF was defined by direct BF or BF complemented with expressed breast milk (EBM) while partial BF was defined by formula supplementation. RESULTS: CHTN and CHTN-DM groups were similar in prior BF experience (42 vs 52%), intention to BF exclusively (89 vs 79%) and intention to partially BF (11 vs 21%). Women in the CHTN group were younger (31 vs 33y), more likely primiparous (44 vs 27%), and delivered vaginally (59 vs 36%) at term (85 vs 75%). Women in the CHTN-DM group had higher repeat cesarean rates (32 vs 18%), preterm birth (25 vs 15%), neonatal hypoglycemia (42 vs 14%) and NICU admission (38 vs 16%). At discharge, exclusive BF rates among CHTN was higher (48 vs 19%), while rates of partial BF (34 vs 44%) and FF (18 vs 37%) were lower than in the CHTN-DM group. BF initiation (exclusive plus partial BF) occurred in 82%of CHTN and in 63% of CHTN-DM. CONCLUSION: Although intention to BF was similar, BF initiation rates were higher for the CHTN compared to the CHTN-DM group. Exclusive BF was low in the CHTN and even lower in the CHTN-DM group signaling the need for targeted interventions if BF initiation rates are to be improved.

Breastfeeding initiation among women with preeclampsia with and without severe features.

BACKGROUND: Timely delivery and magnesium sulfate (MgSO4) are mainstay in the treatment of preeclampsia with severe features (PWSF). Premature delivery, severity of illness and mother-infant separation may increase the risk for breastfeeding (BF) initiation failure. OBJECTIVE: To compare BF initiation among women with late-onset PWSF treated with MgSO4 to women with late-onset preeclampsia without severe features (WOSF) who did not receive MgSO4. METHODS: Retrospective study of 158 women with PWSF and 104 with WOSF who delivered at ≥34 weeks. Intention to BF, formula feed (FF) or partially BF was declared prenatally. At discharge, exclusive BF included direct BF or direct BF with expressed breast milk (EBM). RESULTS: PWSF and WOSF groups were similar in age, race, and obstetric history. PWSF and WSOF differed in primiparity (65 & 51%), late preterm births (73 vs 15%), admission to NICU (44 &17%) and mother (5 & 4d) and infant (6 & 3d) hospital stay. Both groups were similar in intention to BF (80 & 84%), to FF (16 & 13%) and to partially BF (5 & 5%). At discharge, exclusive BF (37 & 39%), partial BF (33 & 31%) and FF (30 & 30%) were similar. Exclusive BF in the PWSF group was 43% direct BF, 28% direct BF and EBM and 29% EBM alone whereas in the WOSF group exclusive BF was 93% direct BF and 7% direct BF and EBM. CONCLUSION: BF initiation rates for women with PWSF and WOSF were similar. EBM alone or with direct BF enabled infants in the PWSF group to exclusively BF at discharge.

In-hospital formula supplementation and breastfeeding initiation in infants born to women with pregestational diabetes mellitus.

OBJECTIVE: To ascertain the rate of in-hospital supplementation as it relates to early breastfeeding (BF) and early formula feeding (FF) and its effects on BF (exclusive and partial) at the time of discharge for infants born to women with pregestational diabetes mellitus (PGDM). METHODS: Retrospective cohort investigation of 282 women with PGDM who intended to BF and their asymptomatic infants admitted to the newborn nursery for blood glucose monitoring and routine care. Early feeding was defined by the initial feeding if given within four hours of birth. RESULTS: Of the 282 mother-infant dyads, for 134 (48%) early feeding was BF and for 148 (52%) early feeding was FF. Times from birth to BF and FF (median 1 hr, 0.3-6) were similar, while the time to first BF for those who FF and supplemented was longer (median 6 hr., 1-24). Ninety-seven infants (72%) who first BF also supplemented. Of these, 22 (23%) BF exclusively, 67 (69%) BF partially and 8 (8%) FF at discharge. One hundred seventeen (79%) who first FF also supplemented. Of these, 21 (18%) BF exclusively, 76 (65%) BF partially and 20 (17%) FF at discharge. CONCLUSION: Regardless of the type of first feeding, the majority of infants born to women with PGDM require supplementation. Even when medically indicated, in-hospital supplementation is an obstacle, albeit not absolute, to exclusive BF at discharge. Parents should be reminded that occasional supplementation should not deter resumption and continuation of BF.

Early feeding, hypoglycemia and breastfeeding initiation in infants born to women with pregestational diabetes mellitus.

OBJECTIVE: To examine the effects of early breastfeeding (eBF) or early formula feeding (eFF) on hypoglycemia and on BF initiation in infants born to women with pregestational diabetes mellitus (PGDM) who intended to BF. METHODS: Retrospective cohort investigation of 554 women with PGDM and their infants (IDMs) who delivered during 2008-2016. The first feeding (BF or FF) was considered early if given within 4 hours from birth. RESULTS: 282 (51%) IDMs were admitted to the Well Baby Nursery. Of the 134 IDMs whose early feeding was BF, hypoglycemia affected 30% which was corrected with oral feedings in 78% of the cases. At discharge, 49% BF exclusively while 45% BF partially. Of the 148 IDMs whose early feeding was FF, hypoglycemia affected 40% which was corrected with oral feedings in 69% of the cases. At discharge, 14% BF exclusively while 48% BF partially. There were 272 (49%) IDMs admitted to the NICU. Their early feeding was BF (14%) and FF (86%). Hypoglycemia developed in 50% and 43% of these groups, respectively. Benefits of early feedings on hypoglycemia were masked by the routine use of IV dextrose infusions. At discharge, early BF led to exclusive BF in 45% and partial BF in 50% of the cases. Early FF led to exclusive BF in 17% and partial BF in 42% of the cases. CONCLUSIONS: Early and continued feeding (BF preferably or FF if BF is not feasible) should be the first line of treatment for hypoglycemia. Early BF is paramount for BF initiation. Early FF is an obstacle, albeit not absolute, to BF initiation, thus it should not deter continued efforts to start or resume BF.

Decreasing NICU admissions of asymptomatic infants of women with pregestational diabetes mellitus improves breastfeeding initiation rates.

BACKGROUND: Asymptomatic infants born to women with pregestational diabetes mellitus (PGDM) are usually admitted to the well baby nursery (WBN) while those who are symptomatic or in need of specialized care are admitted to the neonatal intensive care unit (NICU). OBJECTIVE: To determine if changes in the NICU admission rate of asymptomatic infants born to women with PGDM during two different epochs affected breastfeeding (BF) initiation rates. DESIGN/METHODS: Retrospective cohort investigation of 386 women with PGDM and their infants who delivered in 2008-11 (epoch 1) and 457 who delivered in 2013-16 (epoch 2) at a single institution. RESULTS: NICU admissions: Comparison between epoch 1 and epoch 2 showed a decrease in the number of admissions from 243 (63%) to 175 (38%) *(chi square *p < 0.05). Respiratory distress (39 and 43%) and prematurity (28 and 23%) as admission diagnoses remained unchanged. Admissions for prevention of hypoglycemia declined (32% to 21%)*. At discharge from the NICU, exclusive BF (12 to 19%)* and any BF increased (41 to 55%)* while formula feeding (FF) decreased (59 to 45%)*. Admission to the NICU remained a strong predictor of BF initiation failure (a OR 0.6, 95% , CI 0.4-0.9, p 0.005).WBN admissions: Comparison between epoch 1 and epoch 2 showed an increase in the number of admissions from 143 (37%) to 282 (62%)*. The incidence of hypoglycemia (31% and 38%) and its correction with oral feedings (76% and 71%) remained unchanged. At discharge from the WBN, exclusive BF (15 to 27%)* and any BF (52 to 62%)* increased while FF decreased (48 to 38%)*. CONCLUSIONS: A decrease in the number of NICU admissions of asymptomatic infants born to women with PGDM is associated with improvements in BF initiation rates.

Failure to initiate breastfeeding among high risk obstetrical patients who intended to breastfeed.

BACKGROUND: In the US, at the time of discharge from the hospital, 79% of women had initiated breastfeeding. Intention to breastfeed is a strong predictor of breastfeeding initiation; however, we reported initiation failure in 45% of women with pregestational diabetes who intended to breastfeed. Information regarding intention and initiation among women with other high risk obstetrical conditions (HROB) remains scarce. OBJECTIVE: To ascertain demographic and clinical factors associated with breastfeeding initiation failure among women with HROB conditions who intended to breastfeed. METHODS: The study population is comprised of 89 women with diabetes (DM), 57 who were receiving treatment for substance abuse (SA), 51 women diagnosed with miscellaneous (MISC) conditions and 32 with history of preterm labor/delivery (PTL/D). Intention to exclusively breastfeed or in combination with formula (breastfed/FF) was ascertained prenatally. Breastfeeding was considered initiated if at discharge ≥50% of their infant feedings were maternal milk. Statistics include chi-square, Wilcoxon's and logistic regression (p < 0.05). RESULTS: Of all women, 59% initiated any breastfeeding. Intention to breastfeed/FF, lack of mother-infant contact during the first hour following birth and limited lactation consultation were predictive of initiation failure. The odds of initiation failure were 2.3 times higher among women who wished to breastfeed/FF as compared to those who wished to exclusively breastfeed. Women from the SA group had lower rates of initiation failure than the other three HROB groups. CONCLUSION: Intention to breastfeed among women with diverse HROB conditions is similar to that of the general population; however, initiation rates are disappointingly low. Intention to exclusively breastfeed results in fewer initiation failures. Prenatal intention to combine breast and formula feeding characterize women who may benefit from specific educational programs.

Antepartum fetal surveillance in gestational diabetes mellitus.

Pregnancy in patients with gestational diabetes mellitus (GDM) is associated with increased perinatal morbidity. Whether the perinatal mortality rate, particularly the fetal death rate, is greater in these patients remains controversial. The present study was undertaken to review the role of antepartum fetal monitoring in 69 patients with GDM controlled by diet only (class A) and 28 women requiring insulin therapy (class AB). Hypertension complicated 21.6% of these pregnancies. Antepartum fetal surveillance included outpatient nonstress testing, urinary estriol assays, maternal assessment of fetal activity, and clinical estimation of fetal weight. All insulin-requiring patients as well as fourteen class A patients with identifiable risk factors underwent testing. No perinatal deaths occurred. Only six patients required intervention for suspected fetal jeopardy and four of these women had hypertension. Macrosomia was correctly identified in only 6 of 16 infants weighing 4000 g or more. This study suggests that, in GDM, an outpatient program of fetal testing, using primarily the nonstress test and maternal assessment of fetal activity, can be employed in patients requiring insulin as well as class A patients with identifiable risk factors. This protocol resulted in a low rate of unnecessary intervention and good perinatal outcome. The risks for abnormal antepartum testing results appear increased in GDM with hypertension and prolonged pregnancy.

Sonographic measurement of fetal humeral soft tissue thickness in pregnancy complicated by GDM.

Sonographic measurement of fetal humeral soft tissue thickness (STT) was performed in 93 women with gestational diabetes mellitus during the third trimester. STT measurements revealed accelerated growth in large for gestational age infants at 31 wk gestation. This new measurement proved to be the most accurate predictor of excessive fetal size compared with other standard ultrasound parameters (sensitivity 82%, specificity 95%, positive predictive value 90%). Asymmetrical growth was more evident in infants with large STT measurements in utero. Humeral STT measurement may distinguish large fetuses with truncal obesity from those that are symmetrically large, thereby allowing prediction of risk for birth trauma before delivery.

Neonatal outcomes of macrosomic infants of diabetic and non-diabetic mothers.

OBJECTIVE: To compare neonatal outcomes (including breastfeeding (BF) initiation) of 170 macrosomic IDM with that of 739 macrosomic nIDM. DESIGN/METHODS: Retrospective cohort investigation of all macrosomic infants born consecutively over a four-year period (2008-2011). Macrosomic (birth weight ≥4000 g) IDM included 100 infants whose mothers had gestational diabetes and 70 whose mothers had pregestational diabetes. RESULTS: IDM were more likely to be delivered by cesarean to obese women while nIDM were more likely to be delivered vaginally to younger women with a higher level of education. Ethnic distribution (60% white, 20% black, 10% Hispanic and 10% Asian or African) was similar in each group. Forty-nine percent of IDM and 7% of nIDM required NICU admission. Respiratory disorders (mainly TTNB) affected 21% of IDM and 3% of nIDM while hypoglycemia was observed in 36% of IDM and 15% of nIDM. Of the 35 IDM delivered vaginally, 10 were complicated by shoulder dystocia without injury. Conversely, 70 of the 458 nIDM delivered vaginally experienced shoulder dystocia that resulted in 6 limb fractures and 3 brachial plexus injuries. On arrival to labor and delivery, 75% of all women intended to BF; however, at the time of discharge, 65% of women with diabetes and 92% of those without diabetes who intended to BF had initiated BF. CONCLUSIONS: Both macrosomic IDM and macrosomic nIDM are at risk for significant morbidities. Macrosomic IDM carry a higher risk for NICU admissions, leading to maternal-infant separation, and lower BF initiation rates.

Management of infants of diabetic mothers.

OBJECTIVE: To describe the clinical outcome of infants born to mothers with gestational diabetes mellitus (GDM) and preexisting insulin-dependent diabetes mellitus (IDDM). SETTING: A tertiary care regional perinatal center with a specialized diabetes-in-pregnancy program. DESIGN: Case series. RESULTS: Five hundred thirty infants were born to 332 women with GDM and 177 women with IDDM. Thirty-six percent of these 530 newborns were large for gestational age, 62% were appropriate for gestational age, and only 2% were small for gestational age. Seventy-six (14%) of all infants were born before 34 weeks' gestation, 115 (22%) between 34 and 37 weeks of gestation, and 339 (64%) at term. Two hundred thirty-three infants (47%) were admitted to the neonatal intensive care unit due to respiratory distress syndrome (RDS), prematurity, hypoglycemia, or congenital malformation. Hypoglycemia (more common among infants of maternal diabetic classes C through D-R) was documented in 137 (27%) of all newborns. One hundred eighty-two infants (34%) had RDS of varying severity. Polycythemia (5% of infants), hyperbilirubinemia (25%), and hypocalcemia (4%) were other morbidities present. Two hundred forty-four infants were admitted for routine care and enteral feedings. Forty-three of these newborns required subsequent transfer to the neonatal intensive care unit for treatment of hypoglycemia (16 cases), RDS (19 cases), or both (8 cases). Routine care failures were more common among infants whose mothers had advanced diabetes, but less frequent among breast-fed infants. CONCLUSIONS: With modern management, fewer morbidities can be expected in infants of diabetic mothers. Those infants born to women with IDDM remain at risk for hypoglycemia, which can be treated in one half of the cases by enteral feedings alone. The majority of cases of RDS are mild and require short admissions to special care nurseries. Optimal care of infants of diabetic mothers is based on prevention, early recognition, and treatment of common conditions. Severe congenital malformations, significant prematurity, RDS, recurrent hypoglycemic episodes, and asymptomatic infants of women with advanced IDDM should be admitted to special care nurseries. Breast-feeding among women with GDM and IDDM should be encouraged.

Accuracy and modifying factors for ultrasonographic determination of fetal weight at term.

OBJECTIVE: To determine the accuracy of various sonographic formulas for estimating fetal weight at labor. METHODS: We evaluated prospectively four published equations by Hadlock et al, Shepard et al, Rose and McCallum, and Sabbagha et al, as well as clinical examination for accuracy in determining fetal weight during labor. Two hundred twenty-three patients at 35-42 weeks' gestation underwent sonographic examination. Amniotic fluid index (AFI), placental location, maternal weight, and fetal station were recorded for each study. RESULTS: The Hadlock and Shepard equations both had a lower percentage of error than the Sabbagha formula (6.1%/204 g and 6.2%/200 g respectively, versus 7.8%/271 g; P < .007). For all four equations, 70-79% of the fetal weight predictions were within 10% of actual birth weight. Sensitivities for detecting birth weights greater than 3800 g varied greatly (11-76%), whereas specificities for detecting birth weights less than 3800 g exceeded 88%. For most equations, AFI, placental location, and maternal weight did not affect predictive accuracy. The error in weight estimation varied between 6.3-8.1% in patients with oligohydramnios. Biparietal diameter (BPD) could not be measured in approximately two-thirds of the patients studied. CONCLUSION: Using any of the four standard equations or clinical examination, accurate estimation of fetal weight can be achieved for patients in labor, even in the presence of ruptured membranes. Since the Hadlock equation does not rely on BPD measurements, it appears to be both the most accurate and clinically useful method for predicting fetal weight for patients in labor at term.

Management of diabetes mellitus and pregnancy: a survey of obstetricians and maternal-fetal specialists.

To ascertain current practice trends among obstetricians and maternal-fetal subspecialists regarding the care of pregnancies complicated by diabetes mellitus, a questionnaire was sent to all members of the Society of Perinatal Obstetricians (SPO) and a randomly selected group of American College of Obstetricians and Gynecologists (ACOG) Fellows. A total of 273 of 356 SPO members (77%) and 198 of 504 ACOG Fellows (39%) responded. When divided according to years post-residency (ACOGa, less than 15 years; ACOGb, 15 years or more), significant differences in practice patterns were observed for ACOG Fellows. The SPO responses were similar among these subgroups. Despite current ACOG recommendations, most clinicians practice universal screening for gestational diabetes. Significant discrepancies appear to exist between ACOGb versus ACOGa and SPO with regard to methods of glucose surveillance and the threshold for initiating insulin therapy in gestational diabetes. Intensive fetal surveillance, elective delivery, and high cesarean rates are common in pregnancies complicated by insulin-dependent diabetes mellitus, which is most often managed by a perinatologist or by an obstetrician in consultation with an internist. Few insulin-dependent patients seek preconceptional care.

Duration of incarceration and perinatal outcome.

The number of incarcerated women is increasing, thus pregnancy in prison is no longer uncommon. We reviewed the perinatal outcome of 53 women with short-term incarceration (fewer than 90 days) and of 53 women who experienced long-term incarceration (more than 120 days). Poor prenatal care, history of drug abuse, hepatitis, and poor nutrition were more common among the short-incarceration group. Of infants born to short-incarceration women, 32 (60%) were normal, four (7%) stillborn, eight (15%) premature, six (11%) small for gestational age, and four (7%) septic. Women in the long-incarceration group delivered 48 normal infants (91%), whereas two were offspring of diabetic mothers and three were premature. Birth weight for infants born to smokers in the short-incarceration group was significantly lower than that of infants born to smokers in the long-incarceration group. Women who suffer short incarcerations experience high perinatal mortality and morbidity. In contrast, those incarcerated longer appear to benefit from better prenatal care, improved nutrition, and a structured environment, and thus a more favorable perinatal outcome.