Early Pregnancy Screening for Women at High-Risk of GDM Results in Reduced Neonatal Morbidity and Similar Maternal Outcomes to Routine Screening.

The Australasian Diabetes in Pregnancy Society recommends screening high-risk women for gestational diabetes mellitus (GDM) before 24 weeks gestation, under the assumption that an earlier diagnosis and opportunity to achieve normoglycemia will minimize adverse outcomes. However, little evidence exists for this recommendation. The study objective was to compare the pregnancy outcomes of high-risk women diagnosed with GDM before 24 weeks gestation and routinely diagnosed women after 24 weeks gestation. A retrospective audit was conducted of all pregnancies diagnosed with GDM using International Association of Diabetes and Pregnancy Study Groups criteria over 12 months at a tertiary Australian hospital. Adverse perinatal outcomes were compared between "Early GDM" diagnosed before 24 weeks (n = 133) and "Late GDM" diagnosed from 24 weeks (n = 636). Early GDM had a significantly lower newborn composite outcome frequency (hypoglycemia, birth trauma, NICU/SCN admission, stillbirth, neonatal death, respiratory distress, and phototherapy) compared to Late GDM (20.3% vs. 30.0%, p = 0.02). Primary cesarean, hypertensive disorders, postpartum hemorrhage, birthweight >90th percentile, macrosomia, and preterm birth frequencies were not significantly different between groups. Therefore, high-risk women diagnosed with GDM in early pregnancy were not more likely to have an adverse outcome compared to routinely diagnosed women. As they are a high-risk group, this may indicate a possible benefit to the early diagnosis of GDM.

Antenatal models of care for women with gestational diabetes mellitus: Vignettes from an international meeting.

BACKGROUND: Gestational diabetes (GDM) is one of the commonest pregnancy complications and is placing an increasing burden on diabetes and obstetric resources. AIMS: To describe different antenatal models of care that have developed to address the increasing proportion of pregnancies complicated by GDM. MATERIALS AND METHODS: Narrative review with thematic analysis from 15 volunteer antenatal diabetes in pregnancy services from Australia and New Zealand identified through a national diabetes organisation. Main outcomes were approaches to patient education, medical nutrition therapy (MNT), ongoing management and escalation of therapy for women with GDM. RESULTS: All clinics provided at least one group education and one MNT session within 1-2 weeks of GDM diagnosis. Women from culturally and linguistically diverse communities usually required 1:1 education. Ongoing management of women with GDM was through either all women being seen in the GDM clinic, a step-up approach (ongoing management by the primary antenatal team with diabetes team referral if self-blood glucose monitoring (SBGM) or insulin therapy dosage criteria are reached) or step-down approach (ongoing management by the diabetes team with step-down to the primary antenatal team if SBGM criteria are reached). Telehealth was used to reduce the burden of clinic attendance, particularly in rural areas. CONCLUSIONS: Increasing numbers, earlier diagnoses, the need to provide care to women in rural, remote areas, and cultural/language differences, have generated a range of different antenatal models of care, allowed better workload accommodation and probably reduced costs. Randomised controlled trials of different models of care, with associated health economic analyses, are urgently needed.

Pregnancy outcomes among women with type 1 diabetes mellitus using continuous subcutaneous insulin infusion versus multiple daily injections: A retrospective cohort study.

BACKGROUND: Insulin delivery options for pregnant women with type 1 diabetes mellitus are either continuous subcutaneous insulin infusion or multiple daily injections. The aim of this paper is to compare pregnancy outcomes in women with type 1 diabetes mellitus using continuous subcutaneous insulin infusion or multiple daily injections in pregnancy. METHODS: Retrospective single-centre cohort study of 298 pregnancies booked between 2006 and 2016. Descriptive analysis was performed for HbA1c values. Logistic regression models were created to compare selected maternal and neonatal outcomes. RESULTS: Continuous subcutaneous insulin infusion was associated with increased risk of large-for-gestational age (aOR 2.00, 95% CI 1.20-3.34) and preterm neonates (aOR 1.80, 95% CI 1.04-3.03). Continuous subcutaneous insulin infusion had no association with increased risk of adverse pregnancy outcomes. No difference in HbA1c values existed between groups. CONCLUSION: Using continuous subcutaneous insulin infusion for type 1 diabetes mellitus through pregnancy is associated with increased risk of large-for-gestational age and preterm neonates, without increased risk of associated adverse maternal or neonatal outcomes.

Optic nerve sonography and ophthalmic artery Doppler velocimetry in healthy pregnant women: an Australian cohort study.

PURPOSE: Maternal ocular sonography offers a window into cerebrovascular and intracranial pressure changes in pregnancy. This study aimed to determine the Doppler velocimetric variables of the ophthalmic artery, and the mean diameter of the optic nerve sheath (ONSD), in an Australian cohort of healthy pregnant women. METHODS: A prospective observational cohort study of healthy women with uncomplicated singleton pregnancies in the third trimester was undertaken in a tertiary maternity service. A single prenatal ultrasonographic examination was performed on all participants, with a postnatal examination performed on a subgroup with uncomplicated deliveries. RESULTS: Fifty women were examined at a mean gestation of 35 weeks. The mean ± SD Doppler variables in the ophthalmic artery were peak systolic velocity (PSV) 41.89 ± 13.13 cm/s, second peak velocity 20.63 ± 8.97 cm/s, end diastolic velocity 9.29 ± 5.13 cm/s, pulsatility index 1.97 ± 0.53, resistive index 0.78 ± 0.07, peak ratio (second peak velocity/PSV) 0.49 ± 0.12, while the mean ONSD was 4.34 ± 0.4 mm. None of these variables had a demonstrable relationship with gestation or mean arterial pressure (MAP), nor did the sheath diameter have a relationship with any of the Doppler variables. CONCLUSIONS: The ocular sonographic variables observed in this population are similar to those reported in other cohorts. No clear relationship could be identified in this cohort between ophthalmic artery Doppler variables and the ONSD, and between each of these variables and gestation or MAP.

Implications of the introduction of new criteria for the diagnosis of gestational diabetes: a health outcome and cost of care analysis.

OBJECTIVE: To identify effects on health outcomes from implementing new criteria diagnosing gestational diabetes mellitus(GDM) and to analyse costs-of-care associated with this change. DESIGN: Quasi-experimental study comparing data from the calendar year before (2014) and after (2016) the change. SETTING: Single, tertiary-level, university-affiliated, maternity hospital. PARTICIPANTS: All women giving birth in the hospital, excluding those with pre-existing diabetes or multiple pregnancy. MAIN OUTCOME MEASURES: Primary outcomes were caesarean section, birth weight >90th percentile for gestation, hypertensive disorder of pregnancy and preterm birth less than 37 weeks. A number of secondary outcomes reported to be associated with GDM were also analysed.Care packages were derived for those without GDM, diet-controlled GDM and GDM requiring insulin. The institutional Business Reporting Unit data for average occasions of service, pharmacy schedule for the costs of consumables and medications, and Medicare Benefits Schedule ultrasound services were used for costing each package. All costs were estimated in figures from the end of 2016 negating the need to adjust for Consumer Price Index increases. RESULTS: There was an increase in annual incidence of GDM of 74% without overall improvements in primary health outcomes. This incurred a net cost increase of AUD$560 093. Babies of women with GDM had lower rates of neonatal hypoglycaemia and special care nursery admissions after the change, suggesting a milder spectrum of disease. CONCLUSION: New criteria for the diagnosis of GDM have increased the incidence of GDM and the overall cost of GDM care. Without obvious changes in short-term outcomes, validation over other systems of diagnosis may require longer term studies in cohorts using universal screening and treatment under these criteria.

Does Gestational Diabetes Cause Additional Risk in Twin Pregnancy?

It has been suggested that the risk of adverse perinatal outcomes in twin pregnancies is exacerbated by concomitant gestational diabetes mellitus (GDM). This study aimed to assess the risk incurred by twin pregnancy and by a diagnosis of GDM, separately, on the development of poor perinatal outcomes. A retrospective cohort study was conducted on all pregnant women at a tertiary center between 2016 and 2017. The impact of GDM and twin pregnancies on perinatal outcomes - birth weight above the 90th centile for gestational age, cesarean delivery, clinical neonatal hypoglycemia, and premature delivery (before 37 weeks' gestation) - was assessed using univariate and multivariate analyses. Overall, 13,527 women were eligible for the study; 11,915 were uncomplicated singleton pregnancies; 1379 of these had GDM; 194 were twin pregnancies, and 39 of these had GDM. Univariate analyses showed that twin pregnancies were associated with a higher risk of all perinatal outcomes except macrosomia. In the multivariate analyses, twin pregnancy was a much higher predictor of cesarean delivery (OR 8.40, 95% CI [6.25, 11.49], p < .0001) and preterm birth (OR 58.82, 95% CI [31.25, 125], p < .0001) compared to GDM but GDM was a higher predictor of neonatal hypoglycemia (OR 4.87, 95% CI [3.74, 6.29], p < .0001). Twin pregnancy is more strongly associated with all adverse perinatal outcomes except macrosomia. GDM does not increase risk of adverse perinatal outcomes except for neonatal hypoglycemia.

Pregnancy risk factors associated with birthweight of infants born to Australian Aboriginal women in an urban setting - a retrospective cohort study.

BACKGROUND: A key focus of the Closing the Gap campaign is to reduce low birthweight in Aboriginal babies. Limited research exists on factors affecting Aboriginal birthweight in urban areas. METHODS: Retrospective cohort analysis of 38,382 births (38,167 non-Aboriginal, 215 Aboriginal) at the Royal Women's Hospital in Melbourne from January 2010 to December 2015. Aboriginal status was defined by mothers who identified themselves and their baby as Aboriginal or Torres Strait Islander. The aim was to examine the association of maternal health risk behaviours and obstetric complications with birthweight of infants born to Australian Aboriginal women birthing in an urban setting. RESULTS: Aboriginal babies had a lower mean birthweight than non-Aboriginal babies (mean difference -290 g; 95% confidence interval [CI] -413, - 166 g), but when accounting for gestational age and sex there was little difference (mean difference 5 g; 95% CI -53, 6 g). Aboriginal babies were significantly more likely to be delivered preterm < 37 weeks (23.3% vs 7.9%, odds ratio [OR] 3.58; 95% CI 2.58, 4.95) and be of low birthweight < 2500 g (22.3% vs 6.7%, OR 4.03; 95% CI 2.90, 5.60) or very low birthweight < 1500 g (9.8% vs 1.8%, OR 5.81; 95% CI 3.67, 9.16). Aboriginal mothers were significantly more likely to be teenage mothers (9.8% vs 1.6%, OR 5.72; 95% CI 3.54, 9.24), smoke cigarettes throughout the pregnancy (53.8% vs 5.6%, OR 17.2; 95% CI 12.8, 23.0), and use drugs (26.5% vs 2.4%, OR 14.3; 95% CI 10.4, 19.6) during pregnancy, all of which were associated with lower birthweight. Aboriginal mothers were also more likely to have a mental health diagnosis (49.5% vs 18.8%, OR 3.77; 95% CI 2.86, 4.97), be overweight (59.9% vs 42.6%, OR 1.88; 95% CI 1.39, 2.56) and have diabetes (15.3% vs 7.3%, OR 2.31; 95% CI 1.59, 3.35) which were all associated with higher birthweight. CONCLUSIONS: Aboriginal babies born in metropolitan Melbourne are more likely to be of low birthweight compared with non-Aboriginal babies, which in turn was related to higher rates of prematurity and not to being small for gestational age.

Should the spot albumin-to-creatinine ratio replace the spot protein-to-creatinine ratio as the primary screening tool for proteinuria in pregnancy?

OBJECTIVES: To determine the correlation between the spot albumin-to-creatinine (ACR) ratio and protein-to-creatinine ratio (PCR) in pregnancy and if either test is predictive of adverse pregnancy outcome. STUDY DESIGN: Prospective consecutive cohort study in a single tertiary centre examining 181 patients undergoing proteinuria screening after 20weeks of pregnancy. A spot PCR and ACR was performed on the first void of the day. Comparison was with linear and logistic regression and ROC curve. Optimal values for the ACR were obtained and compared to a PCR value of 30mg/mmol with respect to adverse pregnancy outcomes. MAIN OUTCOME MEASURES: Birth weight <10th centile, preterm birth <32 and <37weeks, placental abruption, caesarean section, induction of labour, fetal death in utero or neonatal death, Apgar score <5 at 1min and/or 5min, pulmonary oedema, sustained blood pressure >170/110mmHg, magnesium infusion or labetalol infusion during labour. RESULTS: 254 tests were performed. The ACR and PCR were highly correlated (r=0.95, p<0.001) and the area under ROC curve was 0.98. An ACR of 13.4mg/mmol corresponded to a PCR of 30mg/mmol. Neither was more predictive of adverse pregnancy outcome nor was the level of proteinuria. CONCLUSIONS: The ACR is not inferior to nor does it perform better than the PCR in screening for proteinuria in pregnancy. Clinicians should use the test with which they are more familiar and may wish to assess local laboratory costs and methods in their selection.

Congenital Malformations Associated With a Single Umbilical Artery in Twin Pregnancies.

A single umbilical artery (SUA) was identified in 1.5% of twin pregnancies. The presence of a SUA in a twin pregnancy was associated with a 50% incidence of fetal anomalies, many of them complex and severe. The embryology and pathophysiological mechanisms associated with a SUA are reviewed. Aneuploidy is relatively common and should be considered, particularly in the presence of associated anomalies. Fetal growth restriction is frequent and preterm delivery is common.

Prognostic significance of steroid receptor positivity and adjuvant progestogen use in endometrial stromal sarcoma.

BACKGROUND: The prognostic significance of oestrogen and progesterone receptors (ER/PR) in endometrial stromal sarcoma (ESS) has conflicting reports in the literature, and the routine use of adjuvant progestogen is of uncertain efficacy. AIMS: To examine the prognostic significance of ER/PR positivity and of primary adjuvant progestogen use with outcome in ESS. MATERIALS AND METHODS: All women with a diagnosis of ESS in our tertiary institution and associated private practices over the last 23 years were included. Primary variables were ER/PR positivity and adjuvant progestogen use. Other variables included high-grade disease and extrauterine disease. The primary outcome was survival, and the secondary outcome was recurrence-free survival (both overall and at 5 years). Survival was calculated using the Kaplan-Meier method. Univariate analyses were performed with t-test for means and chi-squared test for proportions, and multivariate analysis was used to control for age. RESULTS: 35 women were included. ER/PR positivity was associated with a survival benefit (OR death 0.22, P = 0.02), but primary adjuvant progestogen was not. High-grade disease (OR 13, P = 0.02) and extrauterine disease (OR 8.7, P = 0.04) were associated with decreased survival. No variable significantly affected recurrence-free survival. Eight of ten cases of recurrence treated with progestogen have survived more than 3 years. CONCLUSIONS: ER/PR positivity appears to be useful for prognosis, but routine administration of primary adjuvant progestogen is not supported. There may be a role for progestogen in ER/PR positive tumours with recurrence or incomplete surgical clearance, but further research is required.

Pregnancy prognosis associated with an isolated single umbilical artery in twin pregnancy.

To determine the prognosis of an isolated single umbilical artery (SUA) in a twin pregnancy, we selected twin pregnancies with a second trimester ultrasound diagnosing a SUA in at least one fetus at our tertiary hospital. This was confirmed by placental histopathology or by expert review of ultrasound images. Cases were identified by searching the hospital ultrasound database over a period of 7.5 years. Higher order multiples or coexistent aneuploidy or major anomalies were excluded. Each case of an isolated SUA was assigned three consecutive twin pregnancy controls paired for chorionicity and maternal age. Primary outcomes were preterm birth <34 weeks, small for gestational age (SGA) or perinatal death. Other outcomes included antenatal growth restriction, mode of delivery, and admission to neonatal intensive care or special care nursery. Nine pregnancies (18 fetuses) were identified for analysis as cases. Isolated SUA was associated with preterm birth <34 weeks (odds ratio = 12.2; 95% CI = 2.0-75.2; p = .005) but not for SGA. There was also no difference in SGA between the affected twin and its normal co-twin. Perinatal death was increased but after controlling for gestational age and clustering this finding was no longer significant. We conclude that isolated SUA in twins adds a degree of risk to an already high-risk pregnancy but does not increase the need for surveillance for growth restriction.

Laparoscopic transabdominal cervical cerclage: a 6-year experience.

BACKGROUND: Cervical cerclage has been used as a treatment for cervical insufficiency for over 60 years. Transabdominal cerclage is indicated for cervical insufficiency not amenable to a transvaginal procedure, or following previous failed vaginal cerclage. A laparoscopic approach to abdominal cerclage offers the potential to reduce the morbidity associated with laparotomy. AIMS: To evaluate the obstetric outcome and surgical morbidity of laparoscopic transabdominal cerclage. METHODS: An observational study of consecutive women undergoing laparoscopic transabdominal cerclage from 2007 to 2013 by a single surgeon (AA). Eligible women had a diagnosis of cervical insufficiency based on previous obstetric history and/or a short or absent cervix. The primary outcome was neonatal survival. Secondary outcomes were delivery of an infant at ≥34 weeks gestation. Surgical morbidity and complications were also evaluated. RESULTS: Sixty-four women underwent laparoscopic transabdominal cerclage during the study period. Three women underwent cerclage insertion during pregnancy; the remaining 61 were not pregnant at the time of surgery. Thirty-five pregnancies have been documented to date. Of those, 24 were evaluated for the study. The remaining cases were either early miscarriages, ectopic pregnancies or are still pregnant. The perinatal survival rate was 95.8% with a mean gestational age at delivery of 35.8 weeks. Eighty-three per cent of women delivered at ≥34 weeks gestation. There was one adverse intra-operative event (1.6%), with no postoperative sequelae. CONCLUSION: Laparoscopic transabdominal cerclage is a safe and effective procedure resulting in favourable obstetric outcomes in women with a poor obstetric history. Success rates compare favourably to the laparotomy approach.

Long-term outcomes after progestogen treatment for early endometrial cancer.

BACKGROUND: For select women with early endometrial cancer, particularly nulliparous women, nonsurgical options may be considered. There is increasing experience using progestogens, but little is known about the long-term outcomes and safety of such treatment. AIMS: To present the cancer and pregnancy outcomes of women with greater than five years follow-up after progestogen treatment for early endometrial cancer. METHODS: Ten women who underwent greater than six months of continuous progestogen therapy for early endometrial cancer were included in the study. All were managed by a gynaecological oncologist at a major tertiary centre in Melbourne, Australia. The histology of each subsequent curette was recorded, as was the timing and histology of hysterectomy (if relevant), and the results of any subsequent pregnancies. RESULTS: All ten women showed histological regression of cancer with no cases of recurrence on follow-up curette. Four of ten women have undergone hysterectomy with one case of occult disease persistence in a woman noncompliant with therapy. The mean follow-up time was 89 months (range 62-142 months), there were no deaths and no woman was lost to follow-up. All four women attempting pregnancy were successful. There were eight pregnancies and five live births. CONCLUSIONS: This form of treatment appears to be successful and safe in the long term with good pregnancy outcomes. However, it is not standard and should be supervised in a specialised gynaecological oncology unit.

The accuracy of spot urinary protein-to-creatinine ratio in confirming proteinuria in pre-eclampsia.

BACKGROUND: The gold standard for diagnosis of proteinuria in pre-eclampsia is traditionally a 24-h urine collection. Current Australian guidelines advocate use of the spot urine protein-to-creatinine ratio (PCR); however, there is controversy in the international literature about its accuracy and little recent Australian data exists. AIM: To clarify the accuracy of the spot urine PCR in a cohort of Australian women with pre-eclampsia. METHODS: Women with pre-eclampsia over a 52-month period from a single obstetric unit were included in the study. Spot urine PCR, 24-h urine collection, gestation at delivery, severe hypertension in labour and magnesium sulphate requirement were recorded. Primary analysis of predictive values was performed on women who had had both a spot urine PCR and a 24-h collection. Continuous data were assessed using least squares analysis with Pearson correlation coefficient, Bland-Altman plot and receiver operator characteristics curve. RESULTS: Two hundred and seventeen women had pre-eclampsia, and 121 of these underwent both tests. The two tests were highly correlated (r = 0.98, P < 0.0001). The urine PCR had a positive predictive value of 94% and a sensitivity of 95% for predicting proteinuria. There were no significant increases in the diagnosis of severe hypertension in labour nor the need for magnesium sulphate infusion in labour in those women in whom the 24-h collection was omitted. CONCLUSIONS: The urine PCR is highly accurate in predicting significant proteinuria in women with pre-eclampsia using the recommended cut-off of 30 mg/mmol. Our findings support current guidelines suggesting the use of a 24-h urine collection is now rarely required.

Predictive value of magnetic resonance imaging in assessing myometrial invasion in endometrial cancer: is radiological staging sufficient for planning conservative treatment?

OBJECTIVES: There has been an increasing interest in accurately assessing tumors preoperatively to plan appropriate surgery or, in some low-risk patients, conservative treatment. We wish to determine the accuracy of magnetic resonance imaging (MRI) in predicting myometrial invasion in endometrial cancer and whether it is a safe and suitable tool for planning conservative treatment. MATERIALS AND METHODS: We compared MRI scans and final histopathologic diagnoses of 111 patients with endometrioid adenocarcinoma over a 6-year period at a major tertiary centre. Data were analyzed collectively and according to histological differentiation and types of MRI scans (1.5 vs 3 T). Outcomes were presence versus absence of myometrial invasion and recently revised International Federation of Gynecology and Obstetrics stage IA (up to 50% myometrial invasion) versus deep invasion. RESULTS: Magnetic resonance imaging had a high negative predictive value for the presence of deep invasion (87% overall and 95% for grade 1 disease). However, although the positive predictive value for the presence of any myometrial invasion was high, negative predictive values were poor (35% for all grades and 46% for grade 1). There was no difference between 1.5- and 3-T scanning. CONCLUSIONS: Magnetic resonance imaging is a suitable screening tool for the presence of stage IA disease under the newly revised International Federation of Gynecology and Obstetrics staging system. The significance of this finding will depend on whether clinicians are willing to treat all grade 1 stage IA disease (under the revised system) as low risk and to deem selected patients in this group suitable for more conservative treatment.