Pregnancy outcomes in women with gestational diabetes mellitus by models of care: a retrospective cohort study.

OBJECTIVE: To compare birth outcomes of women with gestational diabetes mellitus (GDM) with background obstetric population, stratified by models of care. DESIGN: Retrospective cohort study. SETTING: A tertiary referral centre in Sydney, Australia. PARTICIPANTS: All births 1 January 2018 to 30 November 2020. Births <24 weeks, multiple gestations and women with pre-existing diabetes were excluded. METHODS: Data were obtained from electronic medical records. Women were classified according to GDM status and last clinic attended prior to delivery. Model of care included attendance at dedicated GDM obstetric clinics, and routine antenatal care. MAIN OUTCOME MEASURES: Hypertensive disorders of pregnancy (HDP), pre-term birth (PTB), induction of labour (IOL), operative delivery, small for gestational age (SGA), large for gestational age, postpartum haemorrhage, obstetric anal sphincter injury (OASIS), neonatal hypoglycaemia, neonatal hypothermia, neonatal respiratory distress, neonatal intensive care unit (NICU) admission. RESULTS: The GDM rate was 16.3%, with 34.0% of women managed in dedicated GDM clinics. Women with GDM had higher rates of several adverse outcomes. Only women with GDM attending non-dedicated clinics had increased odds of HDP (adjusted OR (adj OR) 1.6, 95% CI 1.2 to 2.0), PTB (adj OR 1.7, 95% CI 1.4 to 2.0), OASIS (adj OR 1.4, 95% CI 1.0 to 2.0), similar odds of induction (adj OR 1.0, 95% CI 0.9 to 1.1) compared with non-GDM women. There were increased odds of NICU admission (adj OR 1.5, 95% CI 1.3 to 1.8) similar to women attending high-risk GDM clinics. CONCLUSIONS: Women with GDM receiving care in lower risk clinics had similar or higher rates of adverse outcomes. Pathways of care need to be similar in all women with GDM.

Comparison of adverse pregnancy outcomes based on the new IADPSG 2010 gestational diabetes criteria and maternal body mass index.

BACKGROUND: The diagnostic criteria for gestational diabetes (GDM) have been controversial following the International Association for Pregnancy Study Groups (IADPSG) 2010 recommendations to lower the diagnostic fasting blood sugar level threshold. AIM: To assess the pregnancy-related outcomes of women according to the different diagnostic criteria for GDM adjusting for body mass index categories. METHOD: A retrospective observational cohort study was conducted on 4081 pregnant women with positive 50 g glucose challenge test but without pre-gestational diabetes. Participants were grouped into four cohorts: no GDM (control group); GDM on Australasian Diabetes in Pregnancy (ADIPS) 1998 criteria only (treated); GDM on IADPSG 2010 criteria only (untreated); and GDM on both criteria (treated). The association of each cohort with pregnancy outcome measures, including birthweight centile, delivery gestation, primary caesarean section, shoulder dystocia and stillbirth, together with the effect of obesity, were examined. RESULTS: Women diagnosed with GDM according to the IADPSG 2010 (untreated) but not the ADIPS 1998 criteria (treated) had an increased risk of being large for gestational age (LGA) (odds ratio (OR) = 2.45, 95% CI: 1.46-4.12, P = 0.001) and primary caesarean section (OR = 2.03, 95% CI: 1.23-3.35, P = 0.006) compared to control women. Among the women in this untreated group and women without GDM, obese women had an increased risk of LGA (OR = 3.82, 95% CI: 2.87-5.10, P < 0.001), shoulder dystocia (OR = 1.50, 95% CI: 1.03-2.19, P = 0.04) and primary caesarean section (OR = 1.63, 95% CI: 1.26-2.10, P < 0.001), compared to those women of normal weight. These associations remained significant on multivariate analysis. CONCLUSION: Untreated women who would be diagnosed with GDM using the new criteria have an increased risk of pregnancy complications, with maternal obesity having an even greater risk.

Retrieval of an embolized amplatzer septal occluder.

Percutaneous closure of secundum atrial septal defect (ASD) by various devices has been proven to be an effective and safe treatment modality for patients with congenital heart diseases. However, we have to be aware of the potential early and late complications like device embolization and formulate plan for rescue procedures. We have reported a case of successful closure of a large secundum ASD in a 23-year-old woman by a 40 mm Amplatzer septal occluder (ASO), which embolized into the right ventricle 4 hr after the procedure. This had caused palpitation and nonsustained ventricular tachycardia. Patient safety was our most important concern and after discussion with the cardiac surgeons and the patient, we would like to make a percutaneous stepwise attempt for retrieval. We first applied an endocardial biopsy forcep to grap the disk of the ASO to fix and stabilize the dislodged device. This would prevent the device from obstructing the inflow and outflow tract and causing catastrophic consequences. Then, a 15-mm Amplatz gooseneck snare was used to catch exactly at the connecting hub of the ASO disk, and the whole apparatus could then be cautiously and safely retrieved out from her body without complications. This had saved her from an unplanned emergency open heart operation that carried significant bleeding complication.

Percutaneous transluminal coronary angioplasty in a two-month old with coronary stenosis presenting as congenital cardiomyopathy: acute results and intermediate follow-up.

Congenital or nonsurgically acquired obstructive coronary artery disease in infancy is exceedingly rare, and previous reports of catheter-based therapies in very young patients have been solely in patients having undergone arterial switch or other cardiovascular surgical procedures. We describe a previously unreported cause for ventricular dysfunction and heart failure in an infant, isolated congenital circumflex coronary artery stenosis, and successful treatment with percutaneous transluminal coronary angioplasty. Technical considerations, immediate results, and 3-year follow-up are provided.

Experience of percutaneous coronary intervention in the management of pediatric cardiac allograft vasculopathy.

In a retrospective study, we examined the procedural success rate and the short-, intermediate-, and long-term outcomes of coronary interventional procedures in children with cardiac allograft vasculopathy. Seven patients underwent 13 interventional procedures: balloon angioplasty alone (n = 3), angioplasty with stenting (n = 9), or angioplasty with brachytherapy (n = 1), with procedural success in all. Two major complications (cardiac arrest) and a single death occurred in the immediate postprocedural period. Five (83%) of the remaining 6 patients developed moderate to severe restenosis, diffuse disease, or progressive vasculopathy; 3 have been retransplanted, 1 died from progressive cardiac allograft vasculopathy, and 1 is awaiting retransplantation, 40 months after the procedure.

Coronary angioplasty on an impassable calcified stenosis using a buddy balloon technique.

We report our experience in coronary angioplasty on a calcified lesion that was not passable with balloon catheters despite an adequate preangioplasty lumen size on angiogram and intravascular ultrasonography study. The angioplasty was successfully performed with a simple and inexpensive buddy balloon technique.

Left ventricular performance in patients with severe acute respiratory syndrome: a 30-day echocardiographic follow-up study.

BACKGROUND: Severe acute respiratory syndrome (SARS) is characterized by an overaggressive immune response. Myocardial performance may be impaired in cytokine-mediated immune reactions. METHODS AND RESULTS: Forty-six patients with established clinical diagnosis of SARS were studied prospectively. Transthoracic echocardiographic examinations were done at the acute stage of infection and 30 days later. Among them, 14 patients required mechanical ventilation. The clinical course, laboratory data, SARS-CoV antibody titers, and results of reverse transcriptase-polymerase chain reaction were studied. Significantly higher left ventricular index of myocardial performance (IMP) (0.42+/-0.13 versus 0.33+/-0.09, P<0.001), longer isovolumic relaxation time (102.9+/-15.7 versus 81.6+/-14.7 ms, P<0.001), lower flow propagation velocity (69.6+/-15.7 versus 83.8+/-19.7 cm/s, P=0.011), and Doppler-derived cardiac output (4.69+/-1.01 versus 5.49+/-1.04 L/min, P<0.001) were observed during acute infection when compared with those at 30 days. No significant valvular disease or pulmonary hypertension was found. At baseline, a lower mean left ventricular ejection fraction (LVEF) (65.3+/-12.8% versus 71.4+/-5.7%, P=0.03) and a higher mean IMP (0.51+/-0.11 versus 0.40+/-0.12, P=0.017) were found in patients who required mechanical ventilation. A decrease in LVEF correlated moderately with an elevated lactate dehydrogenase level (r=-0.605, P<0.001), whereas a higher IMP correlated weakly with an increase in creatine kinase level (r=0.38, P=0.016). Histological examination of the heart in the patient with the lowest EF (30.2%) revealed no interstitial lymphocytic infiltrate or myocyte necrosis. CONCLUSIONS: Subclinical diastolic impairment without systolic involvement was observed in patients with SARS. This impairment may be reversible on clinical recovery.