The Toronto Tri-Hospital Gestational Diabetes Project. A preliminary review.

In this study, we assessed maternal-fetal outcomes in untreated patients with increasing carbohydrate intolerance not meeting the current criteria for the diagnosis of gestational diabetes mellitus (GDM), examined the relationship between birth weight and mode of delivery among women with untreated borderline GDM, treated overt GDM, and normoglycemia, and established more efficient screening strategies for detection of GDM. This was a prospective analytic cohort study in which nondiabetic women aged > or = 24 years were eligible for enrollment. A 50-g glucose challenge test (GCT) and a 100-g oral glucose tolerance test (OGTT) were administered at 26 and 28 weeks gestational age, respectively. Risk factors for unfavorable maternal-fetal outcomes were recorded. Time since the last meal prior to the screening test was recorded, as well. Caregivers and patients were blinded to glucose values except when test results met the National Diabetes Data Group criteria for GDM. Maternal and fetal outcomes, including the mode of the delivery, were recorded in the postpartum period. Of 4,274 patients screened, 3,836 (90%) continued to the diagnostic oral glucose tolerance test. GDM was seen in 145 women. Increasing carbohydrate intolerance in women without overt gestational diabetes was associated with a significantly increased incidence of cesarean section, preeclampsia, macrosomia, and need for phototherapy, as well as an increased length of maternal and neonatal hospital stay. Multivariate analysis showed that increasing carbohydrate intolerance remained an independent predictor for various unfavorable outcomes, but the strength of the associations was diminished. Compared with normoglycemic control subjects, the untreated borderline GDM group had increased rates of macrosomia (28.7 vs. 13.7%, P < 0.001) and cesarean delivery (29.6 vs. 20.2%, P = 0.03). Usual care of known GDM patients normalized birth weights, but the cesarean delivery rate was about 33%, whether macrosomia was present or absent. An increased risk of cesarean delivery among treated patients compared with normoglycemic control subjects persisted after adjustment for multiple maternal risk factors. As for the screening tests, time since the last meal had a marked effect on mean plasma glucose. Receiver operating characteristic curve analysis allowed the selection of the most efficient cut points for the GCT based on the time since the last meal. These cut points were 8.2, 7.9, and 8.3 mmol/l (1 mmol/l = 18.015 mg/dl) for elapsed postprandial time of < 2, 2-3, and > 3 h, respectively. With this change from the current threshold of 7.8 mmol/l, the number of patients with a positive screening test dropped from 18.5 to 13.7%. There was an increase in positive predictive value from 14.4 to 18.7%. The overall rate of patient misclassification fell from 18.0 to 13.1%. In conclusion, increasing maternal carbohydrate intolerance in pregnant women without GDM is associated with a graded increase in adverse maternal and fetal outcomes. Infant macrosomia is an important factor in high cesarean delivery rates for women with untreated borderline GDM. Although detection and treatment of GDM normalizes birth weights, rates of cesarean delivery remain inexplicably high. Recognition of GDM may lead to a lower threshold for surgical delivery. The efficiency of screening for GDM can be enhanced by adjusting the current GCT threshold of 7.8 mmol/l to new values related to time since the last meal before screening. Further analyses are underway to elucidate whether maternal risk factors can be used to achieve additional efficiency gains in screening.

Impact of increasing carbohydrate intolerance on maternal-fetal outcomes in 3637 women without gestational diabetes. The Toronto Tri-Hospital Gestational Diabetes Project.

OBJECTIVE: Our purpose was to assess maternal-fetal outcomes in patients with increasing carbohydrate intolerance not meeting the current criteria for the diagnosis of gestational diabetes. STUDY DESIGN: We conducted a prospective analytic cohort study in which nondiabetic women aged > or = 24 years, receiving prenatal care in three Toronto teaching hospitals, were eligible for enrollment. A glucose challenge test and an oral glucose tolerance test were administered at 26 and 28 weeks' gestation, respectively; risk factors for unfavorable maternal-fetal outcomes were recorded. Caregivers and patients were blinded to glucose values except when test results met the current criteria for gestational diabetes. RESULTS: Of 4274 patients screened, 3836 (90%) continued to the diagnostic oral glucose tolerance test. The study cohort was formed by the 3637 (95%) patients without gestational diabetes, carrying singleton fetuses. Increasing carbohydrate intolerance in women without overt gestational diabetes was associated with a significantly increased incidence of cesarean sections, preeclampsia, macrosomia, and need for phototherapy, as well as an increased length of maternal and neonatal hospital stay. Multivariate analysis showed that increasing carbohydrate intolerance is an independent predictor for various unfavorable outcomes. CONCLUSION: Increasing maternal carbohydrate intolerance in pregnant women without gestational diabetes is associated with a graded increase in adverse maternal-fetal outcomes.

Impact of time since last meal on the gestational glucose challenge test. The Toronto Tri-Hospital Gestational Diabetes Project.

OBJECTIVE: The purpose of the study was to evaluate the impact of time since the last meal on the glucose challenge test and to find cut points that are most likely to predict the outcome of the oral glucose tolerance test in patients screened for gestational diabetes. STUDY DESIGN: This prospective analytic cohort study was carried out at the University of Toronto Perinatal Complex. A 50 gm glucose load was given at 26 weeks' gestation and the time since previous meal ingestion was recorded. At 28 weeks' gestation a 100 gm oral glucose tolerance test was administered. A total of 4274 eligible patients were screened. RESULTS: Time since the last meal had a marked effect on mean plasma glucose. Receiver-operator characteristic curve analysis with National Diabetes Data Group criteria to interpret the oral glucose tolerance allowed the selection of the most efficient cut points for the glucose challenge test on the basis of time since the last meal. These cut points were 8.2, 7.9, and 8.3 mmol/L for elapsed postprandial times of < 2, 2 to 3, and > 3 hours, respectively. With this change from the current threshold of 7.8 mmol/L the number of patients with a positive screening test dropped from 18.5% to 13.7%. There was an increase in positive predictive value from 14.4% to 18.7%. The rate of patient misclassification fell from 18.0% to 13.1%. CONCLUSION: We suggest that screening strategies for detection of gestational diabetes be reconsidered, to account for the impact of variable postprandial status on the test results.

Association of fetal heart block and massive placental infarction due to maternal autoantibodies.

Two different effects of maternal autoantibodies presented in a third-trimester pregnancy. The first was complete fetal heart block, demonstrated ultrasonographically, which correlated with the presence of anti-Ro and anti-La antibodies in the maternal serum. The second effect was decidual vasculopathy and thrombosis, a morphologic finding in the placenta that caused massive placental infarction and intrauterine death. The placental pathology correlated with the presence of anticardiolipin antibodies in the maternal serum at the time of stillbirth.

Psychological adaptation to pregnancy in childless women more than 35 years of age.

Forty-five pregnant childless women with a mean age of 36.6 years (+/- 1.7) were compared with 42 nulliparous pregnant women with a mean age of 26.7 years (+/- 2.8). Initial interviews determined the basic demographic data, the reasons for delaying pregnancy, attitudes to pregnancy, and plans concerning careers. Psychological tests were given to measure anxiety, depression, anger, marital intimacy, sense of autonomy, and role expectations. These psychological tests were applied to all patients at 12 to 16 weeks' gestation and again at 28 to 32 weeks' gestation. The demographic information from the two groups was remarkably similar. Although their ages differed by 10 years, their career goals, their family incomes, reasons for delaying pregnancy, and reasons for now getting pregnant revealed minimal differences. The Maffer Feminine Identity Scale revealed that the younger women held more traditional attitudes toward a woman's roles than the older group. The Sociotrophy-Autonomy Scale indicated that the older women were more independent than the younger pregnant patients. The Symptom Checklist indicated that the older group were less troubled by pregnancy than the control group, and although their level of distress increased as the pregnancy progressed, they remained better adjusted as they entered the last trimester of their pregnancies.

The influence of prolonged pregnancy on infant development at one and two years of age: a prospective controlled study.

Isolated reports of developmental disturbances following prolonged pregnancy led us to compare, prospectively, at 1 and 2 years of age, infants born after normal term gestations with those born after prolonged pregnancies (exceeding 294 days). The infants were subgrouped according to their physical condition at birth, that is, normal or dysmature (mild or advanced dysmaturity). Infant assessments included: (1) height and weight, (2) hospitalizations, and (3) mental development by the Griffiths Mental Development Scales. Follow-up testing was obtained on 130 term control infants and 89 infants of prolonged pregnancies at 1 year of age and 111 term control infants and 76 infants of prolonged pregnancies at 2 years of age. At 1 and 2 years the general intelligence quotient, physical milestones, and intercurrent illnesses for normal infants and those of prolonged pregnancies were not significantly different.

Prolonged pregnancy: surveillance of the fetus and the neonate and the course of labor and delivery.

The perinatal events in 184 term control pregnancies and 129 prolonged pregnancies were prospectively compared. Fetal surveillance consisted of weekly biophysical profile testing. Thirty-two infants were dysmature, and 10 of these had advanced dysmaturity. The incidence of advanced dysmaturity rose quickly after 44 weeks. This group was at greater risk for fetal distress, lower Apgar scores, and emergency cesarean section. The combination of oligohydramnios, a suboptimal nonstress test, and a low profile score was highly predictive of a neonate with advanced dysmaturity. In the control pregnancies, the rate of induction of labor was 13.81% compared with 39.84% in the prolonged pregnancies. The induced labor group had a 51.32% cesarean section rate. Our approach to prolonged pregnancy consists of elective induction of labor when the cervix is favorable and biweekly profile testing when it is not; however, the high incidence of advanced dysmaturity after 44 weeks warrants delivery.

Home or hospital births?

Advocates of home birth cite psychological and medical benefits in their demand for a different approach to birthing procedures. Opponents emphasize the risks of this approach and point to improved outcomes through medical progress available only in hospitals, as well as to recent, less positive European attitudes toward home births. A review of the literature shows that present data are limited and do not conclusively support either opinion. It is essential that the medical profession become actively involved in an objective analysis of the merits and deficiencies of home and hospital birth settings. This participation should ensure that new approaches to birth will maintain the highest possible standards in maternal, fetal, and neonatal welfare.

Rhythmic fetal movements.

In recent years, studies have confirmed that rhythmic movement of the fetal torso occurs. These movements have been investigated with respect to a large number of factors, but no conclusive evidence of their significance has been documented. Much effort has been directed at developing better methods of measuring these movements. In this paper, examples of preliminary clinical results utilizing an advanced real-time B-scan phase-locked tracking scheme are presented. These traces represent a significant advancement in our ability to record rhythmic fetal torso movements and should enable us to enhance our knowledge of the physiology and clinical significance of this phenomenon.

Coping with obstetric hemorrhage.

Intrapartum hemorrhage can be life threatening at worst; at best it is an obstetrical emergency. This article outlines the main causes-uterine atony, lacerations, retained placental fragment, abruptio placentae and placenta previa-together with the steps to take in managing these acute conditions.