Correlation of Meconium-Stained Amniotic Fluid and Adverse Pregnancy Outcomes between 37 to 39 and 40 to 42 Weeks of Gestational Age.

OBJECTIVE: We aimed at assessing the association between meconium-stained amniotic fluid (MSAF) and adverse maternal and neonatal outcomes in early-term versus late-term pregnancies. STUDY DESIGN: Early-term pregnancies (37-39 weeks of gestation) presented with MSAF were compared with late-term (40-42 weeks of gestation) pregnancies with MSAF. The groups were compared with respect to background characteristics, maternal outcomes, and neonatal outcomes. The composite neonatal outcome was the primary outcome of the study, and secondary outcomes included maternal and neonatal outcomes. RESULTS: The early-term group comprised 239 women, compared with 362 women in the late-term group. The primary outcome did not differ between groups. We found a higher prevalence of gestational diabetes (8.37 vs. 3%, p < 0.05), a shorter second stage of labor (45.61 ± 54.67 vs. 65.82 ± 62.99 minutes, p < 0.05), and a longer hospital stay (2.84 ± 2.21 vs. 2.53 ± 1.26 days, p < 0.05) in the early-term group. Other maternal and neonatal characteristics and outcomes were not significantly different between the two groups. CONCLUSION: In term pregnancies complicated by MSAF, adverse neonatal and maternal delivery outcomes are equivalent, regardless of gestational age, and therefore, any term pregnancy complicated by MSAF should be considered high risk and managed appropriately. KEY POINTS: · In term pregnancies complicated by MSAF, adverse neonatal and maternal delivery outcomes are equivalent, regardless of gestational age.. · Any term pregnancy complicated by MSAF should be considered high risk and managed appropriately.. · Deliveries presented with MSAF are typically considered to be high risk and require close fetal surveillance by a certified team with resuscitation skills.. · Our study may help to reduce the need for a close fetal surveillance and delivery interventions if MSAF is not identified as a risk factor for adverse outcomes in late-term pregnancies..

Pregnancy outcome after cesarean section following a failed vacuum attempt.

OBJECTIVE: To compare the pregnancy outcome of women who underwent cesarean section in the second stage of labor, with or without a vacuum extraction attempt. METHODS: A retrospective cohort study of women who underwent a cesarean section during the second stage of labor in a single tertiary university-affiliated medical center (2012-2019). Pregnancy outcome was compared for women who underwent cesarean section following a failed vacuum extraction to women who had cesarean section during the second stage of labor with no vacuum extraction attempt. Neonatal outcomes included umbilical artery pH less than 7.1, Apgar at 5 min < 7, hypoxemic ischemic encephalopathy and NICU admission. Maternal outcomes included duration of hospitalization, need for blood transfusion and need for re-surgery in 45 days. RESULTS: Overall, 88,375 women delivered during the study period. Of them, 120 women had a cesarean section following a failed vacuum (study group). Another 551 women underwent a cesarean section in the second stage of labor without a VE attempt (control group). The groups were similar with regard to obstetrical and demographic characteristics. The rates of umbilical artery pH < 7.1 (17.50% vs 6.53%, p < .001), NICU admission (13.33% vs 2.90%, p < .001), hypoxemic ischemic encephalopathy (5.83% vs 0.18%, p < .001) and epicranial sub-aponeurotic hemorrhage (16.67% vs 2.18%, p < .001) were significantly higher in the study group. No significant differences were found in maternal outcomes. In a sub-analysis including only labor with reassuring fetal heart tracing, failed vacuum attempt was associated with higher rate of NICU admission and epicranial hemorrhage (16.67% vs 3.13%, p = .009, 27.78% vs. 3.41, p = .001, respectively). CONCLUSION: Failed vacuum attempt is associated with a significant increased neonatal morbidity, but not increased maternal morbidity.

Low glucose at 3-hour 100 gram oral glucose tolerance test: implications for glucose control.

OBJECTIVE: To assess the clinical significance of a low 180-minute glucose value in a 100 g oral glucose tolerance test (OGTT) and a single high abnormal value. METHODS: A retrospective cohort study. The study group included women with 180-minute plasma glucose levels of ≤60 mg/dL and one abnormal value in the OGTT. The control group was comprised of women with one abnormal value in the OGTT and normal 180-minute glucose value. The primary outcome was glycemic control, defined as fasting blood glucose measurements > 90 mg/dL or post-prandial glucose values >140 mg/dL or 120 mg/dL (one-hour and two-hour post-prandial, respectively) in >30% of the measurements. Secondary outcomes were the rate of insulin treatment and the perinatal outcome consisting of birthweight, large-for-gestational-age, and polyhydramnios. RESULTS: Three hundred and one women were included, 143 in the study group and 158 in the control group. Pre-pregnancy BMI, first trimester fasting glucose levels, previous GDM, and familial diabetes were similar for both groups. Suboptimal glycemic control was more prevalent among the women in the study group (14% vs. 5.1%, respectively, p= .01). The need for insulin treatment was similar in both groups. CONCLUSIONS: Women with one abnormal value and a 180-minute hypoglycemia in the OGTT are at increased risk for suboptimal glycemic control.

Efficacy of a second external cephalic version (ECV) after a successful first external cephalic version with subsequent spontaneous reinversion to breech presentation: a retrospective cohort study.

OBJECTIVE: Determining the efficacy of performance of a second external cephalic version (ECV) following successful first ECV with subsequent spontaneous reinversion to breech presentation in reducing the rate of cesarean delivery (CD). METHODS: Data were reviewed on healthy women with fetuses in breech presentation who underwent a first ECV after 36 weeks. Routine ultrasound study was performed at 39-week gestation, and a repeat ECV procedure was performed if the fetus had reverted to non-cephalic presentation. Obstetrical outcome measures were compared between women who underwent one successful ECV between 36- and 41-week gestation in which the fetus remained in cephalic presentation until labor and those who underwent a successful first ECV after which the fetus returned to breech and a second ECV was performed. The primary outcome was the rate of secondary CD during vaginal delivery in cephalic presentation; rate of successful second ECV was the secondary outcome. RESULTS: Overall 250 women underwent one ECV attempt of which 169 (67%) were successful. Of them 28 reverted to breech presentation, all women underwent two attempts of which 21 (76%) were successful. A second successful ECV attempt was associated with a 33% incidence of a CD vs. 2.8% after one successful ECV in which the fetus remained in cephalic presentation. CONCLUSION: A second ECV after a successful first ECV with subsequent spontaneous reversion to breech presentation can be expected to be successful in 76% of cases but lead to CD in 33% of cases. Our findings can be used to support patient counseling and decision-making before second ECV attempt.

Fetal gender and umbilical cord characteristics at birth.

OBJECTIVE: To determine fetal gender on umbilical cord parameters. METHODS: Umbilical cords were prospectively collected from uncomplicated, singleton, term pregnancies, which ended either by elective cesarean section or spontaneous vaginal delivery. Data regarding obstetrical history and pregnancy outcome were collected. Various cord parameters were examined including, length, number of coils, umbilical cord index (UCI), which demonstrate the ratio between number of coils and cord length, site of placental insertion, direction of coiling and the presence of true knots. RESULTS: Overall, 154 umbilical cords were collected, of them 84 from male and 70 from female newborns. No differences were found regarding obstetrical history parameters or pregnancy outcome between the groups. The umbilical coiling index was significantly higher in female compared to male newborns (0.183 coils/cm versus 0.157 coils/cm, p=.006) due to higher number of cord coils (12.25 ± 5.31 vs. 10.17 ± 3.96, p=.007), with no difference in cord length (66.48 vs. 64.61 cm, p=.372). These differences remained statistically significant even after correction for gravidity, parity and gestational age using multiple linear regression analysis. CONCLUSION: Female newborns having higher umbilical cord index, compared to male as a result of more coils, with no length dissimilarity.

The effects of a postmiscarriage menstrual period prior to reconceiving.

BACKGROUND: The optimal interpregnancy interval after a single pregnancy loss is controversial. It is common obstetrical practice to recommend that women who have had a miscarriage in the first trimester of pregnancy should wait for 1 or more menstrual cycles before attempting to conceive again. OBJECTIVE: This study aimed to assess whether conception before the first menstrual period after a spontaneous pregnancy loss is associated with a risk of repeat miscarriage or adverse perinatal outcomes. STUDY DESIGN: This retrospective cohort study included 107 women who had a spontaneous miscarriage in the first trimester of pregnancy followed by a subsequent pregnancy with an interpregnancy interval of <12 weeks. All miscarriages had ended in either spontaneous expulsion of the products of conception or medical or surgical evacuation of the uterus. The perinatal outcome measures of 57 women who conceived after the first menstrual period following a spontaneous miscarriage were compared with perinatal outcome measures of 50 women who conceived before the first menstrual period following a spontaneous miscarriage. The primary outcome was rate of pregnancy loss, and the secondary outcomes were gestational age at delivery and birthweight. RESULTS: The rate of recurrent miscarriage was 10.4% for women who conceived before the first menstrual period following a spontaneous miscarriage and 15.8% for those who conceived after (P=.604). There were no differences in the gestational age at delivery (38.9 vs 38.7 weeks; P=.66) or the birthweight (3347±173 vs 3412±156 g; P=.5) between the 2 groups. Other outcomes, such as mode of delivery and 5-minute Apgar score, were also similar for both groups. A multiple logistic regression analysis confirmed that conception before the first menstrual period following a spontaneous miscarriage was not associated with a higher incidence of subsequent miscarriage (odds ratio, 1.74; P=.46) or any other untoward outcome. CONCLUSION: Conception shortly after a spontaneous miscarriage without waiting for at least the first postmiscarriage menstrual period is not associated with adverse maternal or neonatal outcomes compared with those of women with similar interpregnancy intervals who conceived after their next menstrual period.

Comparison of pregnancy outcome between immigrant women in couples with same ethnicity to mixed ethnicity couples.

Aim: To compare the pregnancy outcome of immigrant women who became pregnant to the same ethnicity partner versus a partner from a different ethnicity.Methods: A retrospective cohort study on all singleton pregnancies of immigrant women who delivered between the years 2011-2015 in a single tertiary University Affiliated Hospital. Demographic and obstetrical data were collected. Same ethnicity couples and mixed couples were compared using the Pearson chi-square test for dichotomous variables, and Student's T-test for normally distributed continuous variables.Results: Overall, 443 immigrant women delivered during the study period, of them, 294 (66.37%) had the same ethnicity spouse and 149 (33.63%) were part of a mixed couple. Women of same ethnicity couples were significantly younger (32.7 versus 35.05 years, p < .0001) and more likely to be nulliparous (48 versus 32%, p = .001), compared to women of mixed couples. The rate of episiotomy was significantly higher among women with the same ethnicity spouse in comparison to women of mixed couples (37.22 versus 23.85%, p = .01). There was no significant difference in all other obstetrical or perinatal outcomes tested.Conclusions: Maternal component is the main factor for perinatal outcomes among immigrant mothers.

Paleolithic diet during pregnancy-A potential beneficial effect on metabolic indices and birth weight.

BACKGROUND: Paleolithic diet has recently gained popularity due to its presumed health benefits. The favorable metabolic effects of this diet were assessed in non-pregnant population but its impact during pregnancy remains to be evaluated. STUDY DESIGN: A retrospective cohort study comparing two groups. Group A comprised of women with singleton low-risk pregnancy adherent to paleolithic diet throughout gestation (n = 37). Group B comprised low risk pregnant women on a regular diet (n = 39). Women were excluded if they had low adherence to diet, started paleolithic diet during pregnancy, and had pre-gestational diabetes mellitus or other types of metabolic syndrome such as pre gestational hyperlipidemia, hypertension or BMI > 35. Blood indices such as Glucose challenge test scores, hemoglobin, ferritin, and TSH levels were compared. Other pregnancy factors such as maternal weight gain, rest days during gestation and pregnancy complications such as IUGR, GDM or preeclampsia were compared. Lastly, obstetrical outcomes such as mode of delivery and complications such as high-grade tears, as well as neonatal factors such as birth weight and pH were compared between the two groups. RESULTS: General maternal characteristics such as age, BMI and parity were comparable between the two groups. Women who maintained a paleolithic diet had a significant decrease in glucose challenge test scores (95.8 mg/dL vs. 123.1 mg/dL, p < 0.01) and increase in hemoglobin levels (12.1 g/dL vs. 11.05 g/dL p < 0.01) and Ferritin (32.1 vs 21.3 mg/mL, p = 0.03) compared to women maintaining regular diet. Maternal pregnancy weight gain was also slightly decreased in group A (9.3Kg vs. 10.8 kg, p = 0.03). Birthweights were lower in group A (3098 g Vs.3275 g, p = 0.046) with no difference in adverse neonatal outcomes. We found no differences in other pregnancy complications or labor outcomes such as mode of delivery, shoulder dystocia or high grade perineal tears. CONCLUSION: Paleolithic diet maintained during pregnancy may have a beneficial effect on the glucose tolerance. It also may increase iron stores and hemoglobin levels. Neonates of women maintaining paleolithic diet are slightly lighter but appropriate for gestational age with no difference in neonatal outcomes.

Prediction of Success in External Cephalic Version for Breech Presentation at Term.

OBJECTIVE: To design a clinically based predictive model for the likelihood of successful external cephalic version (ECV). METHODS: This single-center retrospective study was conducted from February 2016 to July 2018 and included all candidates for ECV between 36 and 41 weeks of gestation. Variables with a potential effect on ECV success were collected. These variables include: body mass index, amniotic fluid index, gestational age, parity, location of placenta, fetal trunk posture, time in breech presentation before the procedure and the ultrasonographically measured size of the amniotic fluid preceding the fetal presenting part (fore-bag). Variables' association with ECV success was evaluated using a multivariate logistic regression and a decision tree predicting ECV outcome was developed using 75% of the patients and validated on the remaining 25%. RESULTS: Overall, 250 pregnant women were identified and opted for a trial of ECV by a single operator, with a success rate of 64.8%. Body mass index, size of fore-bag, and parity were independent determinants of the version success, whereas other variables had no statistically significant effect on the success rate. Our decision tree model divided the cohort into five subgroups according to various combinations of the three variables. When evaluated on the internal validation set, the C-Index of the tree was 0.933 (0.863-1) and the prediction accuracy was 91.9% (86.5%-97.3%). CONCLUSION: A prediction model composed of three easily measurable variables enables accurate prediction of successful ECV at term. Fore-bag was identified as the most important discriminator. Our model holds in internal validation and it can be used to support patient counseling and decision making for ECV but should be externally validated.

Success rates of early versus late initiation of external cephalic version.

OBJECTIVE: To determine optimum timing of external cephalic version (ECV). METHODS: A retrospective cohort study was conducted at a tertiary hospital in Israel between February 1, 2016, and July 1, 2017. Healthy primiparous women with breech presentation were offered either early ECV (35-36 weeks; n=54) or late ECV (37-38 weeks; n=106). Group assignment was according to the patient's preference and physician availability. The primary outcome was the rate of cephalic presentation at delivery. Secondary outcomes included rate of cesarean delivery, presentation of fetus after the first and last ECVs, and serious fetal complications. RESULTS: The incidence of undergoing more than two ECV attempts was 18.5% in the early ECV group and 5.6% in the late ECV group (P=0.039). The incidence of cephalic presentation after the first ECV was 72.2% in the early ECV group versus 66.0% in the late ECV group (P=0.048). By contrast, no statistically significant between-group differences were found for presentation at delivery or rate of cesarean delivery. The other outcomes were also similar. CONCLUSION: Early initiation of ECV among primiparous women increased the chance of immediate cephalic presentation; however, it had no effect on presentation at delivery or cesarean delivery rate.

Redefining normal hemoglobin and anemia in singleton and twin pregnancies.

OBJECTIVE: To assess the benefit of a hemoglobin cutoff of 105 g/L as a trigger for anemia evaluation during the second trimester of pregnancy. METHODS: The present cross-sectional study, conducted at a health center in Israel between January 1, 2010, and December 31, 2015, included pregnant women with hemoglobin values below 105 g/L who were assessed for anemia. Anemia workup included complete blood count, serum ferritin and vitamin B12 measurements, and hemoglobin electrophoresis. The primary outcome was the incidence of nondilutional anemia, defined by a positive workup, across predefined hemoglobin thresholds. Receiver operating characteristic curves were created to identify the best hemoglobin threshold for predicting anemia, mandating further evaluation. RESULTS: In total, 651 women with singleton and 300 women with twin pregnancies were evaluated for nondilutional anemia. Of these, 340 (52.2%) and 127 (42.3%) women, respectively, had positive workup results. The most common cause was iron deficiency. The hemoglobin values that best predicted positive workup results were 100 g/L in singleton pregnancies and 97 g/L in twin pregnancies. CONCLUSION: Anemia evaluation could be unnecessary in pregnant women with a hemoglobin value of 100-105 g/L. Consideration should be given to redefining anemia in singleton and twin pregnancies.

Iron Supplementation in Twin Pregnancy - The Benefit of Doubling the Iron Dose in Iron Deficient Pregnant Women: A Randomized Controlled Trial.

OBJECTIVE: To assess the efficacy of doubling the daily dose of iron supplement in iron-deficient women with twin pregnancies. STUDY DESIGN: Using a prospective randomized controlled trial, iron-deficient women with twin gestations were randomized to receive a single or a double dose of daily iron from 16 weeks of gestation until 6 weeks postpartum. The primary outcome was hemoglobin at 32 weeks. Secondary outcomes included ferritin at 32 weeks, hemoglobin during pregnancy and postpartum, birth weights, preterm birth rate, gastrointestinal side effects, intravenous iron administration, and compliance with treatment. RESULTS: Eighty-five and 87 women were randomized to receive one capsule (group A) or two capsules (group B) of 34 mg of ferrous sulfate, respectively. Mean hemoglobin (9.6 g/dL and 9.7 g/dL) and ferritin (8.6 ng/ml and 8.5 ng/ml) were similar in both groups A and B, respectively, at allocation. Hemoglobin in group B was significantly higher from 32 weeks onward, until 6 weeks postpartum. There were no significant differences in any of the secondary outcomes examined. CONCLUSIONS: In twin pregnancies complicated by iron deficiency anemia, doubling the dose of iron increases hemoglobin and ferritin without worsening gastrointestinal side effects.

The importance of declining insulin requirements during pregnancy in patients with pre-gestational gestational diabetes mellitus.

OBJECTIVE: In patients with pre-gestational and gestational diabetes mellitus (GDM), insulin requirements often increase during the third trimester of pregnancy in order to maintain proper glycemic control. However, a fraction of patients demonstrate a significant decrease in insulin requirements in late gestation. We aimed to evaluate the clinical significance of decreasing insulin requirements in patients with pre-gestational diabetes and GDM with respect to fetal wellbeing and pregnancy outcome. STUDY DESIGN: We performed a retrospective cohort study in a single referral center for gestational diabetes between 1/2010 and 12/2014. Healthy pregnant women with pre-gestational diabetes and GDMA2 and a decrease of at least 30% in insulin requirements over a period of two weeks during the third trimester (group A) were compared to women with stable or increasing insulin requirements (group B). The primary outcome was a composite of situations associated with feto-placental dysfunction (fetal growth restriction, oligohydramnios and cesarean section due to category 2-3 monitor). Secondary outcomes were maternal oral glucose tolerance test (OGTT) results 6 weeks postpartum, neonatal intensive care unit (NICU) admission rates, Apgar scores ≤7 at 5min, arterial blood pH≤7.1, macrosomia, neonatal hypoglycemia and a composite adverse neonatal outcomes (defined as one or more of the following: respiratory morbidity, cerebral morbidity, phototherapy, need for blood transfusion, necrotizing enterocolitis or death). RESULTS: Group A consisted of 101 women and group B - of 203 women. There were no differences between the groups in demographic characteristics or diagnostic characteristics of diabetes. The frequency of conditions related to feto-placental dysfunction did not differ between the groups (7.9% vs. 8.4%, p=0.61). Secondary outcome measures also did not differ between the groups, regardless of insulin requirements. CONCLUSION: Decreasing insulin requirements during the third trimester are not associated with adverse perinatal outcome related to placental dysfunction.

Preterm meconium-stained amniotic fluid is an ominous sign for the development of chorioamnionitis and for in utero cord compression.

PURPOSE: Meconium-stained amniotic fluid (MSAF) is rarely observed in preterm pregnancies, and its clinical significance is undetermined. We evaluated the correlation between MSAF and obstetrical and perinatal complications prior to 34 weeks' gestation. MATERIALS AND METHODS: Pregnancies complicated with MSAF between 24 and 34 weeks of gestation were compared with same gestational age-matched controls. The variables measured were: obstetrical complications: clinical chorioamnionitis, Intrahepatic Cohlestasis of Pregnancy - ICP, Intra Uterine Growth Restriction - IUGR, preeclampsia, gestational diabetes; nonobstetrical complications; and perinatal complications: cord around neck/body, Apgar <7 at 5 min, cord pH, Neonatal Intensive Care Unit - NICU admission, complications during NICU hospitalization, and composite outcome. RESULTS: Higher incidence of clinical chorioamnionitis (15% versus 4.3%; p = 0.041) and higher incidence of cord around the neck/body were found in the MSAF group in comparison with the clear AF group (27.4% versus 18.4%; p = 0.04). No significant differences between the study's groups were found in nonobstetrical complications or other perinatal complications investigated in our study. CONCLUSION: MSAF in preterm pregnancy is an ominous sign for the occurrence of chorioamnionitis and for in utero cord compression. Therefore, MSAF in preterm pregnancies should be considered as a non-reassuring sign.

Distribution of Third-Stage Length and Risk Factors for Its Prolongation.

Introduction The aim of our study was to demonstrate the distribution of an uncomplicated third stage and to determine the optimal time for manual intervention. Risk factors for a prolonged third stage were studied. Materials and Methods Computerized data of all vaginal deliveries at our L&D unit from 2010 to 2014 were obtained. Cases of complete and spontaneous placental separation were extracted for further analysis. Cases necessitating manual removal of the placenta due to immediate postpartum hemorrhage (PPH) were also excluded. Patient demographics, obstetrical history, course of delivery, and delivery outcome were assessed, and risk factors for a prolonged third stage were analyzed. Results There were 31,226 vaginal deliveries during the study period. Of these, 25,160 deliveries met inclusion criteria. The median third-stage length was 12 minutes. Within 30 minutes 97% of the placentas separated spontaneously. Independent risk factors for a third stage > 30 minutes included older maternal age, primiparity, history of abortions, twin gestation, and intrapartum fever. Conclusion The average time for third stage is < 15 minutes with 97% occurring by 30 minutes and 100% by 60 minutes. In the absence of PPH, it is clinically prudent to perform manual removal after 30 minutes.

How Long Is Safe? Setting the Cutoff for Uncomplicated Third Stage Length: A Retrospective Case-Control Study.

OBJECTIVE: The aim of our study was to determine the optimal time for manual placental removal in an uncomplicated third stage while taking into consideration the risk for blood transfusion. Risk factors for postpartum blood transfusions were studied. METHODS: Computerized data of all vaginal deliveries at our labor and delivery unit from 2010 to 2014 were obtained. Cases of complete and spontaneous placental separation up to 60 minutes into the third stage of labor were extracted for analysis. Patient demographics, obstetrical history, delivery course, and outcome were assessed as well as blood product requirements during the postpartum period. Receiver-operating curves (ROC) for prediction of blood transfusion during the third stage were calculated and risk factors were assessed. RESULTS: 31,226 vaginal deliveries occurred during the study period and 28,586 deliveries culminated with complete and spontaneous placental separation, 25,160 of which met inclusion criteria. Independent risk factors for blood transfusions were primiparity, longer second and third stage length, labor induction, and maternal intrapartum fever. ROC curves showed that the optimal cutoff for the prediction of blood transfusions was 17 minutes into the third stage of labor. Waiting more than 30 minutes for placental separation increases the risk for blood transfusion more than threefold. CONCLUSIONS: A third stage longer than 17 minutes is associated with an increased risk for blood transfusion postpartum. After more than 30 minutes, the risk for blood transfusions increases more than threefold.

Can we predict the need for pharmacological treatment according to demographic and clinical characteristics in gestational diabetes?

OBJECTIVE: To determine the ability to predict the need for pharmacological treatment in gestational diabetes mellitus (GDM). METHOD: A retrospective cohort study. Data were collected from medical records of 1324 GDM patients including demographic data, family history of diabetes, obstetrical history, laboratory results, treatment modality and level of glycemic control. Patients who were identified as pre-gestational diabetes were excluded. RESULTS: Overall, 143 (10.8%) GDM patients required pharmacological therapy. Of women who had GDM in their previous pregnancy; only 11.65% achieved desired glycemic control solely by diet treatment. Moreover, 62.5% of patients requiring pharmacological therapy in their previous pregnancy achieved desired level of glycemic control only by diet. Of patients who achieved desired level of glycemic control on diet until the second antenatal visit, 95% continued to maintain desired level glycemic control throughout pregnancy. Pre-pregnancy BMI >30, fasting plasma glucose >95 mg/dL and maternal age above 30 were associated with increase need for pharmacological treatment. One abnormal value in the OGTT and GCT result >2 mg/dL did not predict the need for pharmacological therapy. Primigravida and family history of GDM were not found to be predictors for treatment modality. CONCLUSION: Using clinical and demographical data can predict the need for pharmacological treatment for GDM.

Questioning the role of pituitary oxytocin in parturition: spontaneous onset of labor in women with panhypopituitarism--a case series.

OBJECTIVE: Oxytocin, a nanopeptide secreted by the posterior pituitary gland, has well-established uterotonic activity. Its role in initiating the vigorous and regular contractions of the first stage of labor is still controversial. We report four cases of panhypopituitarism who had spontaneous onset of labor, undermining the role of maternal oxytocin in the first phase of labor. STUDY DESIGN: Four women with no residual pituitary function conceived through ovulation induction and were treated throughout pregnancy with thyroid replacement therapy, desmopressin and glucocorticoids. In all cases pituitary function was undetectable in repeated blood tests. We report their course of pregnancy and delivery. RESULTS: All four pregnancies progressed to term with hormonal replacement therapy. All cases went into spontaneous labor. Two women delivered vaginally unassisted by pharmacological intervention and two delivered by cesarean sections during active labor due to obstetrical indications. Three suffered postpartum hemorrhage. Lactation did not ensue in all four cases. CONCLUSIONS: Endogenous pituitary oxytocin is probably not obligatory for initiation of labor in the first phase of parturition.

Guidelines for the Management of a Pregnant Trauma Patient.

OBJECTIVE: Physical trauma affects 1 in 12 pregnant women and has a major impact on maternal mortality and morbidity and on pregnancy outcome. A multidisciplinary approach is warranted to optimize outcome for both the mother and her fetus. The aim of this document is to provide the obstetric care provider with an evidence-based systematic approach to the pregnant trauma patient. OUTCOMES: Significant health and economic outcomes considered in comparing alternative practices. EVIDENCE: Published literature was retrieved through searches of Medline, CINAHL, and The Cochrane Library from October 2007 to September 2013 using appropriate controlled vocabulary (e.g., pregnancy, Cesarean section, hypotension, domestic violence, shock) and key words (e.g., trauma, perimortem Cesarean, Kleihauer-Betke, supine hypotension, electrical shock). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English between January 1968 and September 2013. Searches were updated on a regular basis and incorporated in the guideline to February 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS: This guideline is expected to facilitate optimal and uniform care for pregnancies complicated by trauma. Summary Statement Specific traumatic injuries At this time, there is insufficient evidence to support the practice of disabling air bags for pregnant women. (III) Recommendations Primary survey 1. Every female of reproductive age with significant injuries should be considered pregnant until proven otherwise by a definitive pregnancy test or ultrasound scan. (III-C) 2. A nasogastric tube should be inserted in a semiconscious or unconscious injured pregnant woman to prevent aspiration of acidic gastric content. (III-C) 3. Oxygen supplementation should be given to maintain maternal oxygen saturation > 95% to ensure adequate fetal oxygenation. (II-1B) 4. If needed, a thoracostomy tube should be inserted in an injured pregnant woman 1 or 2 intercostal spaces higher than usual. (III-C) 5. Two large bore (14 to 16 gauge) intravenous lines should be placed in a seriously injured pregnant woman. (III-C) 6. Because of their adverse effect on uteroplacental perfusion, vasopressors in pregnant women should be used only for intractable hypotension that is unresponsive to fluid resuscitation. (II-3B) 7. After mid-pregnancy, the gravid uterus should be moved off the inferior vena cava to increase venous return and cardiac output in the acutely injured pregnant woman. This may be achieved by manual displacement of the uterus or left lateral tilt. Care should be taken to secure the spinal cord when using left lateral tilt. (II-1B) 8. To avoid rhesus D (Rh) alloimmunization in Rh-negative mothers, O-negative blood should be transfused when needed until cross-matched blood becomes available. (I-A) 9. The abdominal portion of military anti-shock trousers should not be inflated on a pregnant woman because this may reduce placental perfusion. (II-3B) Transfer to health care facility 10. Transfer or transport to a maternity facility (triage of a labour and delivery unit) is advocated when injuries are neither life- nor limb-threatening and the fetus is viable (≥ 23 weeks), and to the emergency room when the fetus is under 23 weeks' gestational age or considered to be non-viable. When the injury is major, the patient should be transferred or transported to the trauma unit or emergency room, regardless of gestational age. (III-B) 11. When the severity of injury is undetermined or when the gestational age is uncertain, the patient should be evaluated in the trauma unit or emergency room to rule out major injuries. (III-C) Evaluation of a pregnant trauma patient in the emergency room 12. In cases of major trauma, the assessment, stabilization, and care of the pregnant women is the first priority; then, if the fetus is viable (≥ 23 weeks), fetal heart rate auscultation and fetal monitoring can be initiated and an obstetrical consultation obtained as soon as feasible. (II-3B) 13. In pregnant women with a viable fetus (≥ 23 weeks) and suspected uterine contractions, placental abruption, or traumatic uterine rupture, urgent obstetrical consultation is recommended. (II-3B) 14. In cases of vaginal bleeding at or after 23 weeks, speculum or digital vaginal examination should be deferred until placenta previa is excluded by a prior or current ultrasound scan. (III-C) Adjunctive tests for maternal assessment 15. Radiographic studies indicated for maternal evaluation including abdominal computed tomography should not be deferred or delayed due to concerns regarding fetal exposure to radiation. (II-2B) 16. Use of gadolinium-based contrast agents can be considered when maternal benefit outweighs potential fetal risks. (III-C) 17. In addition to the routine blood tests, a pregnant trauma patient should have a coagulation panel including fibrinogen. (III-C) 18. Focused abdominal sonography for trauma should be considered for detection of intraperitoneal bleeding in pregnant trauma patients. (II-3B) 19. Abdominal computed tomography may be considered as an alternative to diagnostic peritoneal lavage or open lavage when intra-abdominal bleeding is suspected. (III-C) Fetal assessment 20. All pregnant trauma patients with a viable pregnancy (≥ 23 weeks) should undergo electronic fetal monitoring for at least 4 hours. (II-3B) 21. Pregnant trauma patients (≥ 23 weeks) with adverse factors including uterine tenderness, significant abdominal pain, vaginal bleeding, sustained contractions (> 1/10 min), rupture of the membranes, atypical or abnormal fetal heart rate pattern, high risk mechanism of injury, or serum fibrinogen < 200 mg/dL should be admitted for observation for 24 hours. (III-B) 22. Anti-D immunoglobulin should be given to all rhesus D-negative pregnant trauma patients. (III-B) 23. In Rh-negative pregnant trauma patients, quantification of maternal-fetal hemorrhage by tests such as Kleihauer-Betke should be done to determine the need for additional doses of anti-D immunoglobulin. (III-B) 24. An urgent obstetrical ultrasound scan should be undertaken when the gestational age is undetermined and need for delivery is anticipated. (III-C) 25. All pregnant trauma patients with a viable pregnancy who are admitted for fetal monitoring for greater than 4 hours should have an obstetrical ultrasound prior to discharge from hospital. (III-C) 26. Fetal well-being should be carefully documented in cases involving violence, especially for legal purposes. (III-C) Obstetrical complications of trauma 27. Management of suspected placental abruption should not be delayed pending confirmation by ultrasonography as ultrasound is not a sensitive tool for its diagnosis. (II-3D) Specific traumatic injuries 28. Tetanus vaccination is safe in pregnancy and should be given when indicated. (II-3B) 29. Every woman who sustains trauma should be questioned specifically about domestic or intimate partner violence. (II-3B) 30. During prenatal visits, the caregiver should emphasize the importance of wearing seatbelts properly at all times. (II-2B) Perimortem Caesarean section 31. A Caesarean section should be performed for viable pregnancies (≥ 23 weeks) no later than 4 minutes (when possible) following maternal cardiac arrest to aid with maternal resuscitation and fetal salvage. (III-B).

Objectif : Une femme enceinte sur 12 en vient à subir des traumatismes physiques et ceux-ci exercent des effets importants sur la mortalité et la morbidité maternelles, ainsi que sur l'issue de la grossesse. La mise en œuvre d'une approche multidisciplinaire s'avère justifiée pour assurer l'optimisation des issues, et ce, tant pour la mère que pour son fœtus. Le présent document a pour but d'offrir, aux fournisseurs de soins obstétricaux, une approche systématique factuelle qu'ils pourront utiliser pour assurer la prise en charge des patientes enceintes ayant subi un traumatisme. Issues : Issues sanitaires et économiques considérables, par comparaison avec les pratiques de rechange. Résultats : La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans Medline, CINAHL et The Cochrane Library entre octobre 2007 et septembre 2013 au moyen d'un vocabulaire contrôlé (« pregnancy ¼, « Cesarean section ¼, « hypotension ¼, « domestic violence ¼, « shock ¼) et de mots clés (« trauma ¼, « perimortem Cesarean ¼, « Kleihauer-Betke ¼, « supine hypotension ¼, « electrical shock ¼) appropriés. Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs publiés en anglais entre janvier 1968 et septembre 2013. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en février 2014. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. Valeurs : La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau). Avantages, désavantages et coûts : Nous nous attendons à ce que la présente directive clinique facilite l'offre de soins optimaux et uniformes dans les cas de grossesse compliquée par un traumatisme. Déclaration sommaireLésions traumatiques particulières Pour l'instant, nous ne disposons pas de données probantes suffisantes pour soutenir la désactivation des coussins gonflables dans le cas des femmes enceintes. (III) RecommandationsExamen primaire 1. La présence d'une grossesse devrait être présumée chez toutes les femmes en âge de procréer ayant subi des blessures considérables, jusqu'à ce que le contraire ait été prouvé au moyen d'une échographie ou d'un test de grossesse définitif. (III-C) 2. Chez les femmes enceintes blessées inconscientes ou à demi conscientes, une sonde nasogastrique devrait être insérée afin de prévenir l'aspiration de contenu gastrique acide. (III-C) 3. Une oxygénothérapie devrait être mise en œuvre pour garantir le maintien d'une saturation maternelle en oxygène > 95 %, de façon à assurer une oxygénation fœtale adéquate. (II-1B) 4. Chez les femmes enceintes blessées, l'insertion d'une sonde de thoracostomie (à un endroit se situant à un ou deux espaces intercostaux de plus que d'habitude) pourrait être envisagée, au besoin. (III-C) 5. Chez les femmes enceintes gravement blessées, deux lignes intraveineuses de gros calibre (14-16) devraient être mises en place. (III-C) 6. En raison des effets indésirables qu'ils exercent sur la perfusion utéroplacentaire chez les femmes enceintes, les vasopresseurs ne devraient être utilisés qu'en présence d'une hypotension réfractaire qui ne réagit pas à la réanimation liquidienne. (II-3B) 7. Chez les femmes enceintes gravement blessées qui ont passé le cap de la mi-grossesse, l'utérus gravide devrait être repositionné de façon à ce qu'il ne comprime plus la veine cave inférieure, et ce, dans le but d'accroître le retour veineux et le débit cardiaque. Ce repositionnement peut être obtenu en déplaçant l'utérus manuellement ou en plaçant la patiente en position latérale gauche (en s'assurant alors d'immobiliser la moelle épinière de la patiente au préalable). (II-1B) 8. Pour prévenir l'allo-immunisation rhésus D chez les femmes Rh négatives, du sang O négatif devrait être transfusé, au besoin, jusqu'à ce que du sang provenant d'un donneur compatible soit obtenu. (I-A) 9. La partie abdominale du pantalon pneumatique hypotenseur ne devrait pas être gonflée en présence d'une grossesse, car cela pourrait atténuer la perfusion placentaire. (II-3B) Transfert vers un établissement de santé 10. Le transfert vers un service de maternité (service de triage d'une unité de travail et d'accouchement) est recommandé lorsque la patiente en question ne présente pas de blessures potentiellement mortelles ou pouvant mener à la perte d'un membre et lorsque le fœtus est viable (≥ 23 semaines); le transfert vers une salle des urgences est recommandé lorsque le fœtus n'a pas encore atteint l'âge gestationnel de 23 semaines ou lorsqu'il n'est pas considéré comme étant viable. En présence d'un traumatisme majeur, la patiente devrait être transférée ou transportée vers une unité de traumatologie ou une salle des urgences, sans égard à l'âge gestationnel. (III-B) 11. Lorsque la gravité du traumatisme est indéterminée ou lorsque l'âge gestationnel est incertain, la patiente devrait faire l'objet d'une évaluation menée dans une unité de traumatologie ou une salle des urgences en vue d'écarter la présence de blessures majeures. (III-C) Évaluation, au sein d'une salle des urgences, d'une patiente enceinte ayant subi un traumatisme 12. En présence d'un traumatisme majeur, la priorité doit être accordée à l'évaluation, à la stabilisation et à la prise en charge de la femme enceinte; par la suite, lorsque le fœtus est viable (≥ 23 semaines), l'auscultation de la fréquence cardiaque fœtale et un monitorage fœtal peuvent être mis en œuvre. De plus, une consultation en obstétrique devrait être obtenue dès que possible. (II-3B) 13. La tenue d'une consultation d'urgence en obstétrique est recommandée en ce qui concerne les femmes enceintes dont le fœtus est viable (≥ 23 semaines) et chez qui l'on soupçonne la présence de contractions utérines, d'un décollement placentaire ou d'une rupture utérine traumatique. (II-3B) 14. En présence de saignements vaginaux à 23 semaines ou par la suite, la tenue d'un examen vaginal au moyen d'un spéculum ou des doigts devrait être reportée jusqu'à ce que la présence d'un placenta praevia ait été écartée par échographie (préalable ou actuelle). (III-C) Tests d'appoint dans le cadre de l'évaluation maternelle 15. Les études de radiographie nécessaires aux fins de l'évaluation maternelle (dont la tomodensitométrie abdominale) ne devraient pas être retardées ni reportées en raison de préoccupations à l'égard de l'exposition du fœtus à des rayonnements. (II-2B) 16. L'utilisation de produits de contraste à base de gadolinium peut être envisagée lorsque les avantages maternels l'emportent sur les risques fœtaux potentiels. (III-C) 17. En plus des tests sanguins qui sont régulièrement menés dans le cadre de l'évaluation des patientes enceintes ayant subi un traumatisme, un profil de coagulation (comprenant la mesure du taux de fibrinogène) devrait être obtenu. (III-C) 18. Chez les patientes enceintes ayant subi un traumatisme, la tenue d'une échographie abdominale ciblée pour l'identification de traumatismes devrait être envisagée aux fins de la détection des saignements intrapéritonéaux. (II-3B) 19. Lorsque la présence de saignements intra-abdominaux est soupçonnée, la tomodensitométrie abdominale pourrait constituer une solution de rechange au lavage péritonéal diagnostique ou au lavage ouvert. (III-C) Évaluation fœtale 20. Toutes les patientes enceintes ayant subi un traumatisme qui présentent une grossesse viable (≥ 23 semaines) devraient faire l'objet d'un monitorage fœtal électronique pendant au moins 4 heures. (II-3B) 21. Les patientes enceintes ayant subi un traumatisme (≥ 23 semaines) qui présentent des facteurs indésirables (dont la sensibilité utérine, des douleurs abdominales considérables, des saignements vaginaux, des contractions soutenues [> 1/10 min], la rupture des membranes, un profil de fréquence cardiaque fœtale atypique ou anormal, un mécanisme de blessure à risque élevé ou un taux sérique de fibrinogène < 200 mg/dl) devraient être hospitalisées pour une période d'observation de 24 heures. (III-B) 22. De l'immunoglobuline anti-D devrait être administrée à toutes les patientes enceintes Rh négatives ayant subi un traumatisme. (III-B) 23. Chez les patientes enceintes Rh négatives ayant subi un traumatisme, l'hémorragie fœtomaternelle devrait être quantifiée au moyen de mesures telles que le test de Kleihauer-Betke, et ce, dans le but de déterminer la nécessité de procéder à l'administration de doses additionnelles d'immunoglobuline anti-D. (III-B) 24. Une échographie obstétricale devrait être menée d'urgence lorsque l'âge gestationnel est indéterminé et que la nécessité de procéder à l'accouchement est anticipée. (III-C) 25. Toutes les patientes enceintes ayant subi un traumatisme qui présentent une grossesse viable et qui sont hospitalisées aux fins de la tenue d'un monitorage fœtal pendant plus de 4 heures devraient faire l'objet d'une échographie obstétricale avant d'obtenir leur congé de l'hôpital. (III-C) 26. Il est important de disposer, particulièrement à des fins juridiques, d'une documentation rigoureuse du bien-être fœtal dans les cas mettant en cause de la violence. (III-C) Complications obstétricales du traumatisme 27. La prise en charge de la présence soupçonnée d'un décollement placentaire ne devrait pas être différée jusqu'à l'obtention d'une confirmation par échographie; l'échographie ne dispose pas de la sensibilité requise pour l'établissement d'undiagnostic de décollement placentaire. (II-3D) Lésions traumatiques particulières 28. La vaccination antitétanique est sûre pendant la grossesse et devrait être administrée, au besoin. (II-3B) 29. Toutes les femmes qui subissent un traumatisme devraient faire l'objet de questions visant particulièrement la violence familiale ou conjugale. (II-3B) 30. Dans le cadre des consultations prénatales, le fournisseur de soins devrait souligner l'importance du port de la ceinture de sécurité de façon adéquate, en tout temps. (II-2B) Césarienne péri-mortem 31. En présence d'une grossesse viable (≥ 23 semaines), la tenue d'une césarienne est recommandée au plus tard 4 minutes (dans la mesure du possible) à la suite de l'arrêt cardiaque chez la mère, et ce, en vue de faciliter la réanimation maternelle et le sauvetage du fœtus. (III-B).