Universal vs. risk factor-based screening for gestational diabetes mellitus: detection rates, gestation at diagnosis and outcome.

AIMS: Gestational diabetes mellitus (GDM) is associated with adverse maternal and fetal outcome. Screening for GDM is therefore recommended but the best screening method remains controversial. This prospective, randomized study compared a risk factor-based screening programme with a universally based one. METHODS: Subjects were randomized at booking to one of two groups: the risk factor group had a 3-h 100-g oral glucose tolerance test (OGTT) at 32 weeks if any risk factor for GDM was present; the universal group had a 50-g glucose challenge test performed and if their plasma glucose at 1 h was > or = 7.8 mmol/l, a formal 3-h 100-g OGTT was then performed. RESULTS: Universal screening detected a prevalence of GDM of 2.7%, significantly more than the 1.45% detected in the risk factor screened group (P<0.03). Universal screening facilitated earlier diagnosis than risk factor screening - mean gestation 30 +/- 2.6 weeks vs. 33 +/- 3.7 weeks (P<0.05). A higher rate of spontaneous vaginal delivery at term, and lower rates of macrosomia, Caesarean section, prematurity, pre-eclampsia and admission to neonatal intensive care unit were observed in the universally screened, early diagnosis group. CONCLUSIONS: Universal screening for GDM is superior to risk factor based screening-detecting more cases, facilitating early diagnosis and is associated with improved pregnancy outcome.

Outcome of diabetic pregnancy with spontaneous labour after 38 weeks.

One hundred and forty-eight patients with well controlled insulin dependent diabetes that were allowed to labour spontaneously from 1981 to 1994 were reviewed. There were 2 perinatal deaths, giving a perinatal mortality rate of 13.5/1000. One hundred and twenty-four patients (84 per cent) had a normal vaginal delivery, 13 (9 per cent) forceps delivery and 11 (7 per cent) caesarean section. Twenty-one infants (14 per cent) required admission to a Special Care Baby Unit. One third of infants weighed 4 Kg or more, however there was only 1 case of shoulder dystocia. We compared these results with those of the general hospital population of 1987. The 2 main differences are; 1) the Caesarean section rate in labour was higher for this diabetic group than for the general hospital population, 7 per cent versus 3.4 per cent, 2) the birth weight was heavier, 33 per cent of infants of the diabetic group weighed 4 Kg or more versus 18 per cent of the general hospital population. The other parameters were comparable. We conclude that conservative management of pregnancy in well controlled diabetic women is advantageous, resulting in a high vaginal delivery rate without an increase in shoulder dystocia, and a low perinatal morbidity and mortality rate.

Urinary tract fistulas following gynaecological surgery.

Urinary tract fistulas are a relatively uncommon but important complication of gynaecological surgery. Between 1980 and 1995 we identified 17 patients who developed a urinary tract fistula after gynaecological surgery. Seven of the patients had surgery performed for neoplastic disease but none of these patients received adjuvant radiotherapy before the formation of the fistula. There were 12 vesicovaginal fistulas and five ureteric fistulas. Four of the vesicovaginal fistulas were repaired by the vaginal approach and five vesicovaginal fistulas were repaired by the abdominal route. Three vesicovaginal fistulas were treated by catheterisation alone. Two of the 17 patients took medicolegal action. Early recognition and repair of urinary tract fistulas is recommended. Repair of vesicovaginal fistulas by the vaginal approach is advised. The litigious nature of this distressing condition is lessened when early primary closure is successful.

Factors associated with rapid labour in nulliparae.

The objective of this study was to assess the factors which may influence rapid labour in nulliparae. This is a cohort study of 991 consecutive nulliparae who were admitted in spontaneous labour with a singleton pregnancy and cephalic presentation. The setting was the National Maternity Hospital, Dublin where active management of labour is applied to all nulliparae fitting the above criteria. Rapid labour of 2 hours or less occurred in 82 patients (8.3%). Dilatation of 2 cm of the cervix on admission in labour, gestation of less than 37 weeks, and diminishing birthweight, were more common in rapid labours compared with other labours. Women in rapid labour were not surprisingly less likely to require oxytocin augmentation, or to need operative vaginal delivery or Caesarean section, receive epidural anaesthesia, or attend antenatal classes, compared with other women in labour. Rapid labour was not influenced by the finding that the membranes were already ruptured before admission, the time spent at home with contractions, or social background. Women with rapid labour were more likely to arrive in hospital within 4 hours compared with other women in labour. Rapid labour depends on the efficiency of uterine action which is reflected by the dilatation of the cervix on admission.

Prolonged labor in nulliparas: lessons from the active management of labor.

OBJECTIVE: To define factors causing prolonged labor in nulliparous women undergoing active management of labor. METHODS: We included all nulliparas delivered during 1990-1994 with spontaneous onset of labor lasting more than 12 hours, singleton gestation, cephalic presentation, and labor at greater than 37 weeks. Each patient was matched with the next nulliparous woman who delivered with a labor lasting less than 12 hours and who fulfilled the same inclusion criteria. Subjects were managed according to the previously described active management of labor protocol from The National Maternity Hospital, Dublin. RESULTS: In the 5-year period, 9018 nulliparas met inclusion criteria, with 147 (1.6%) having prolonged labor. Prolonged labor was due to inefficient uterine action in 65%, persistent occipitoposterior position in 24%, and cephalopelvic disproportion in 11% of cases. Univariate analysis showed statistically significant (P < .05) differences in maternal body mass index, cervical dilation on admission, oxytocin use, epidural use, placement of epidural at less than 2 cm of dilation, and birth weight between these study groups. On multivariate conditional logistic regression analysis, the following were significant independent predictors for having a prolonged labor (odds ratios with 95% confidence intervals presented): 3.1 (1.3-7.3) for cervical dilation less than 2 cm on admission, 42.7 (7.5-242.0) for early epidural placement, 5.1 (1.9-13.7) for epidural placement at greater than or equal to 2 cm, and 10.2 (3.6-29.4) for birth weight greater than 4000 g. CONCLUSION: Less-advanced cervical dilation on admission and epidural use, especially when placed early, are strongly associated with prolonged labor.

Wernicke's encephalopathy presenting in the puerperium.

A case of Wernicke's encephalopathy presenting in the puerperium is described. The clinical diagnosis was supported by dramatic reversal of the symptoms and signs following the administration of intravenous thiamine. A similar case report not identified on review of the literature.

Shoulder dystocia--is it predictable?

An unmatched comparative study is described to determine if routine clinical indicators are useful predictors for shoulder dystocia. Parity, maternal weight gain during pregnancy, and a history of a previous large baby and increased operative vaginal delivery rate were more often associated with shoulder dystocia. No other significant associations were found. However, shoulder dystocia can not be predicted accurately antepartum using routinely available clinical factors.

Hyponatraemia and non-electrolyte solutions in labouring primigravida.

We performed a prospective randomised study on one hundred primigravid women who required oxytocin to augment labour, comparing dextrose infusion with normal saline. After delivery, the 45 patients whose oxytocin was infused in dextrose had significantly lower serum sodium levels in both mother and baby compared to the 48 patients who had their oxytocin administered in normal saline. This was particularly evident in those cases where epidural analgesia was employed.

Nulliparous caesarean section in the home of active management of labour.

The world-wide incidence of Caesarean section continues to rise with dystocia recognized as the major indication. Active management of labour has been proposed as an alternative treatment to Caesarean section for dystocia. At the National Maternity Hospital, Dublin, a recent increase in the Caesarean section rate has been observed. This retrospective review reveals this to be due to other indications.

A review of triplet pregnancy.

Nineteen sets of triplets were delivered in the National Maternity Hospital between January 1st 1980 and December 31st 1990 inclusive. Thirteen triplet pregnancies resulted from spontaneous ovulation and six from ovulation induction therapy for infertility. Management was conservative. Bed rest and home monitoring were not advised routinely and cervical cerclage and tocolytic agents were not used. Ten of the patients were delivered by caesarean section. The prematurity rate was 79% and five sets of triplets were delivered before 32 weeks gestation. The perinatal mortality rate was 35/1000. This reflects a general improvement in the obstetric and neonatal care of triplet pregnancy over the past decade.

The timing of delivery in diabetic pregnancy: a 10-year review.

The approach of term in the pregnancy of a diabetic woman is a time of anxiety for patient and physician alike. The impact of a conservative approach to the timing of delivery is outlined in this review of the clinical course and outcome of 276 pregnancies of diabetic women, delivered at the National Maternity Hospital, Dublin between 1981 and 1990. The mean gestation at delivery was 39 weeks, 229 patients (83%) delivered at or beyond 38 weeks and 112 patients (41%) delivered at or beyond 40 weeks. The overall induction of labour rate was 27% and the elective Caesarean section rate was 19%. Sixty seven percent of patients achieved a normal delivery, the forceps rate was 5%, and 28% of patients were delivered by Caesarean section. There were 16 perinatal deaths in the series, with 7 due to lethal malformations. There were 5 deaths of normally formed infants occurring at or beyond 38 weeks' gestation. All of these 5 deaths had been preceded by clinically apparent polyhydramnios or macrosomia and recognized poor control. This study stresses the value of strict diabetic control in the management of diabetic pregnancy and highlights the significance of polyhydramnios and macrosomia as indicators of risk approaching term in diabetic pregnancy.

DES clinic--the first six months.

In October 1990 a DES (Diethylstilbestrol) clinic was established at the National Maternity Hospital, Dublin. We describe the results of the first six months of the clinic. During this time, 172 inquiries were received; 95 women were seen at the clinic, 16 were deemed to be DES--exposed and eight were classified as possibly DES exposed. Classical cervicovaginal signs of DES exposure were noted in 15 women, a further eight women showed cervical epithelial abnormalities at colposcopy, the history of in utero DES exposure was confirmed in eight cases. No cases of cervical intraepithelial neoplasia or vaginal clear-cell adenocarcinoma were detected. Pregnancy related problems possibly attributable to DES exposure were documented in six women.

En bloc radical vulvectomy and lymphadenectomy with modifications of separate groin incisions.

A new modification of radical vulvectomy and lymphadenectomy through separate groin incisions involves dissection of the intervening skin bridge and allows an en bloc dissection. The results in 26 women treated with this technique are compared with those of seven treated with separate incisions without an en bloc dissection. All 33 women had squamous carcinoma of the vulva and were treated between 1985-1989. The incidence of advanced disease was high, with nodal metastases present in 52% of cases. Dissection of the tissue beneath the skin bridge did not alter the morbidity of the procedure in terms of the incidence of wound infection, number of units of blood transfused, or duration of hospitalization. The only case of an isolated recurrence in the skin bridge occurred in a woman who did not have an en bloc dissection, although there was no significant difference in the overall local recurrence rate between the groups. Further evaluation with larger numbers is required, but we suggest that an en bloc dissection using separate incisions may reduce the risk of isolated recurrence in the skin bridge, particularly in patients with advanced disease.

Outcome of the second labour in patients whose first labour was prolonged: the Dublin experience.

This observational study examined the outcome of the second delivery in patients whose first labour was prolonged. The onset of labour was defined as that time when the diagnosis of labour was made on admission to the delivery unit. The first labour was defined as prolonged when delivery occurred more than 12 h later. The study was confined to those patients (n = 66) who had a prolonged first labour with a single, live fetus and cephalic presentation during 1984-1987 and who had a subsequent labour. Sixty-one of the 66 patients (92%) delivered vaginally, and 5 were delivered by emergency caesarean section. Forty-six (70%) delivered within 6 h of admission. Although all 66 had received oxytocin in their first labour, only 8 (12%) required oxytocin in their second labour. Fourteen (82.4%) of the 17 patients with a previous caesarean section had a vaginal delivery. These results indicate that compared to the first labour the duration of the second labour and the oxytocin requirements in the second labour were significantly reduced. These findings are reassuring for patients who have had a long difficult first labour.

Fetal acidosis in labour: a prospective study on the effect of parity.

The effect of parity on intrapartum fetal scalp pH was investigated in 6466 patients in labour with a live fetus who were delivered in 1987. 350 (5.4%) required fetal scalp blood sampling for pH (FBS), 236 primigravidae (10.4%) and 114 multigravidae (2.7%) (P less than 0.001). Fetal acidosis (pH less than 7.20) was detected in 35 patients, 27 primigravidae (11.4%) and 8 multigravidae (7.0%) (P less than 0.001). The incidence of intrapartum acidosis in the 2275 primigravidae and the 4191 multigravidae was 1.2 and 0.2% respectively (P less than 0.001). The two deaths from birth asphyxia and three cases of neonatal seizures occurred in primigravidae. In primigravidae requiring FBS, fetal acidosis was not associated with the use of oxytocin or with increased duration of labour. Neonatal seizures were more common overall in primigravidae than in multigravidae and more common in patients requiring FBS than in those not requiring FBS (P less than 0.05). The higher incidence of FBS, fetal scalp acidosis and neonatal seizures in primigravidae has important implications for intrapartum fetal monitoring.