Treating hyperglycemia in early pregnancy: a randomized controlled trial.

BACKGROUND: Treating women with gestational diabetes mellitus in the third trimester improves perinatal outcomes. It is unknown whether treating women with mild glucose intolerance earlier in pregnancy would be beneficial in the reduction of maternal and neonatal morbidities. OBJECTIVE: In women with hyperglycemia (hemoglobin A1c ≥5.7% and/or fasting glucose ≥92 mg/dL) in early pregnancy, we sought to determine whether immediate treatment improved maternal and neonatal outcomes. STUDY DESIGN: This unblinded randomized controlled trial enrolled women with hyperglycemia at ≤15+0 weeks gestation between 2013 and 2015. Participants were assigned randomly to early pregnancy or third-trimester treatment of hyperglycemia that included nutrition counseling, glucose monitoring, and medications as needed. Participants underwent a blinded 2-hour glucose tolerance test at 24-28 weeks gestation. Exclusion criteria were pregestational diabetes mellitus and multiple gestations. The primary outcome was the proportion of infants with neonatal umbilical cord C-peptide >1.77 nmoL (90th percentile). Secondary outcomes were neonatal fat mass, infant World Health Organization weight-for-length percentile at birth, maternal gestational weight gain, and diagnosis of gestational diabetes mellitus on glucose tolerance test. Mann-Whitney-Wilcoxon test and Fisher's exact test were used, as appropriate. RESULTS: A total of 202 women were assigned randomly; 45 women dropped out before delivery, which left cases 157 for analysis (82 with early pregnancy and 75 with third-trimester treatment). The trial was terminated early because of low enrollment. Baseline characteristics were similar between groups. There was no difference in C-peptide >90th percentile between groups (1 [1.5%] vs 4 [6.7%]; P=.19) in the early pregnancy and third-trimester groups, respectively). There was also no difference in fat mass (0.37±0.16 vs 0.36±0.17 kg; P=.91), weight-for-length percentile at birth (25% vs 25%; P=.46), or macrosomia (1.5 vs 5.0%; P=.84). Maternal gestational weight gain was 22.6±12.9 lb and 23.9±11.2 lb in the early pregnancy and third-trimester groups, respectively (P=.88). Gestational diabetes mellitus was diagnosed in 19.0% of the cohort and did not differ between groups (14.2% vs 25.8%; P=.17). CONCLUSION: In this population of women with hyperglycemia, treatment in early pregnancy did not appear to improve maternal or neonatal outcomes significantly. Given comparable results in both groups, caution should be used in the initiation of an intensive diabetes mellitus treatment protocol for women with the diagnosis of hyperglycemia in early gestation.

Anti-coagulation complications in pregnancies with severe pulmonary arterial hypertension.

BACKGROUND: Epoprostenol, a potent vasodilator, is the treatment of choice for severe pulmonary arterial hypertension (PAH) in pregnancy. However, its inhibition of platelet aggregation increases the risk of coagulation complications with conjunctive use of anti-coagulants for thromboprophylaxis. CASES: Case 1 demonstrates a pregnancy complicated by thrombocytopenia. Case 2 describes a pregnancy with newly diagnosed PAH at 35 weeks who delivered by repeat cesarean delivery complicated by a wound hematoma. Case 3 describes a patient who delivered at 32 weeks. She required extracorporeal membrane oxygenation and a heart-lung transplant. Her care was further complicated by severe thrombocytopenia with postpartum hemorrhage refractory to usual conservative measures. CONCLUSIONS: This case series describes three patients with severe PAH in pregnancy and the range of different complications that arose from anticoagulation in the setting of epoprostenol.

Maternal obesity and sex-specific differences in placental pathology.

OBJECTIVE: Adverse effects of obesity have been linked to inflammation in various tissues, but studies on placental inflammation and obesity have demonstrated conflicting findings. We sought to investigate the influence of pregravid obesity and fetal sex on placental histopathology while controlling for diabetes and hypertension. METHODS: Placental histopathology focusing on inflammatory markers of a cohort of normal weight (BMI = 20-24.9) and obese (BMI ≥ 30) patients was characterized. Demographic, obstetric and neonatal variables were assessed. RESULTS: 192 normal and 231 obese women were included. Placental characteristics associated with obesity and fetal sex independent of diabetes and hypertension were placental disc weight >90(th) percentile, decreased placental efficiency, chronic villitis (CV), fetal thrombosis, and normoblastemia. Additionally, female fetuses of obese mothers had higher rates of CV and fetal thrombosis. Increasing BMI increased the risk of normoblastemia and CV. The final grade and extent of CV was significantly associated with obesity and BMI, but not fetal gender. Finally, CV was less common in large-for-gestation placentas. CONCLUSIONS: Maternal obesity results in placental overgrowth and fetal hypoxia as manifested by normoblastemia; it is also associated with an increased incidence of CV and fetal thrombosis, both more prevalent in female placentas. We have shown for the first time that the effect of maternal obesity on placental inflammation is independent of diabetes and hypertension, but significantly affected by fetal sex. Our data also point to the intriguing possibility that CV serves to normalize placental size, and potentially fetal growth, in the setting of maternal obesity.

Changes in Postpartum Insulin Requirements for Patients with Well-Controlled Type 1 Diabetes.

Objective To compare postpartum with preconception insulin doses in well-controlled (HbA1c ≤ 7.4%) type 1 diabetes mellitus (T1DM) and to characterize differences in postpartum insulin dosing based on infant feeding. Study Design The primary outcome in this retrospective cohort was the change in total daily insulin (TDI) from preconception to postpartum. Insulin administration (continuous subcutaneous insulin infusion [CSII] vs. multiple daily injections [MDI]), HbA1c, body mass index (BMI), and infant feeding were abstracted. Results We identified 44 women with T1DM and HbA1c ≤ 7.4%. Preconception mean BMI was 24.6 ± 3.6 kg/m(2) and median (interquartile range [IQR]) HbA1c was 6.4 (6.0-6.9)%. Of these, 73% used CSII and 27% used MDI. Additionally, 80% of patients reported exclusive breastfeeding, 7% were exclusively formula feeding, and 13% used both breast milk and formula. Median (IQR) preconception TDI was 0.64 (0.49-0.69) U/kg/day, and postpartum: 0.39 (0.30-0.50) U/kg/day. Postpartum TDI was 34% lower than preconception TDI (p = 0.02). There was no difference in the postpartum TDI in patients who were breast versus formula feeding or when comparing CSII with MDI. Conclusion There was a significant decrease in the TDI required postpartum when compared with preconception. Dosages do not seem to be impacted by administration route or breastfeeding. These findings warrant consideration when dosing postpartum insulin in patients with T1DM.

Continuous Subcutaneous Insulin Infusion versus Multiple Daily Injections of Insulin for the Management of Type 1 Diabetes Mellitus in Pregnancy: Association with Neonatal Chemical Hypoglycemia.

OBJECTIVE: We hypothesized that patients with type 1 diabetes mellitus (T1DM) who were managed during their pregnancy with a continuous subcutaneous insulin infusion (CSII) would have a lower incidence of neonatal hypoglycemia (NH) than patients managed with multiple daily injections (MDI) of insulin. STUDY DESIGN: This was a retrospective cohort of 95 women with T1DM who delivered singleton, term neonates between 2007 and 2014. The primary outcome was incidence of NH (capillary plasma glucose ≤ 45 mg/dL) in the first 24 hours after birth. RESULTS: The incidence of NH was 66.0% (62/95). The NH rate was significantly higher in women managed with CSII versus MDI (62 vs. 38%, p = 0.024). Neonates with NH had a higher birth weight (3,867 ± 658 vs. 3,414 ± 619 g, p = 0.002). When analyzing intrapartum glucose management, mothers of neonates with NH had significantly less time managed on an insulin infusion (median interquartile range 7 [3.5-30.5] vs. 17.5 [2.0-17.5] hours, p = 0.014). In multivariable analysis, only maternal body mass index (BMI) (p = 0.035) and time on an insulin infusion (p = 0.043) were significantly associated with NH. CONCLUSION: In our population of patients with T1DM, CSII was more prevalent in the NH group; however, when controlling for other factors, intrapartum glucose management and early maternal BMI were the only variables associated with NH.

First trimester gestational diabetes screening - Change in incidence and pharmacotherapy need.

AIMS: Adopting recommendations of the International Association of Diabetes in Pregnancy Study Groups (IADPSG) and the California Diabetes and Pregnancy Program, our institution implemented early gestational diabetes (GDM) screening. Our objective was to compare GDM diagnosis rates using the standard two-step approach versus early screening, and secondarily to compare pharmacotherapy needs and perinatal outcomes. METHODS: This retrospective study included singleton pregnancies diagnosed between 7/2010 and 6/2012. Two cohorts were compared; those diagnosed via two-step screening versus early screening diagnosis: HbA1c≥5.7% (39 mmol/mol) or fasting plasma glucose (FPG)≥92 mg/dL at ≤24 weeks gestation, or an abnormal 2-h oral glucose tolerance test (GTT) between 24 and 28 weeks. We calculated the rate of diagnosis, analyzed the need for pharmacotherapy, and reviewed neonatal outcomes. RESULTS: A total of 2652 patients were screened. GDM was diagnosed in 5.3% with two-step screening and 9.4% with early screening. Of those diagnosed via early screening with HbA1c, FPG, or both HbA1c and FPG, 49.2%, 66.7%, and 78.9% respectively required pharmacotherapy. In contrast, of those diagnosed with a 2-h GTT, 30.6% required pharmacotherapy (p<0.001). When controlling for confounders in a multivariable regression, BMI is most predictive of medication requirements (aOR 1.13, 95% CI 1.08-1.18, p<0.001). There were no differences in mean birth weight (3240±619 g vs. 3179±573 g, p=0.51) and macrosomia rates (7% vs. 2.5%, p=0.12). CONCLUSION: Implementing early screening nearly doubled the incidence of GDM. Patients with early screening had a greater need for pharmacotherapy, but BMI was the best predictor of this outcome. There was no significant difference in neonatal outcomes.

First-trimester maternal serum C-reactive protein as a predictor of third-trimester impaired glucose tolerance.

OBJECTIVE: We evaluated whether first-trimester high-sensitivity C-reactive protein (hsCRP), a suggested marker of pregnancy-associated hyperglycemia, predicts third-trimester impaired glucose tolerance (IGT) in a secondary analysis of a prospective cohort of nondiabetic singletons enrolled at <26 weeks gestation. STUDY DESIGN: We measured the association between hsCRP collected at <14 weeks among women classified as IGT (gestational diabetes screening results, 135 to <200 mg/dL) and those among normoglycemic women. Multivariable modeling estimated the association between log hsCRP and IGT, adjusted for maternal body mass index (BMI). RESULTS: Among 300 women, 13% (39 of 300) had IGT. The hsCRP was positively associated with glucose (P = .005). Compared with normoglycemic women, women with IGT had higher log hsCRP (0.87 ± 0.66 vs 0.67 ± 0.60, P = .04), but the association was not significant in adjusted models (adjusted odds ratio 1.20, 95% confidence interval 0.65-2.21). The hsCRP did not predict third-trimester IGT in this analysis when BMI is considered. CONCLUSION: Early identification of women at risk of IGT remains a priority, but the contribution of maternal BMI appears greater than hsCRP.

Abnormal uterine artery Doppler velocimetry predicts adverse outcomes in patients with abnormal analytes.

OBJECTIVES: Our aim was to determine if uterine artery (UtA) Doppler studies would risk-stratify women with abnormal serum analytes on prenatal genetic screening into those at baseline and increased risk for preeclampsia and small-for-gestational age (SGA). STUDY DESIGN: This retrospective cohort study examined outcomes of patients with ⩾one abnormal analyte (PAPP-A<0.3, hCG>3.0, AFP>2.5, inhibin>2.0, or unconjugated estriol<0.3MoM). At approximately 24weeks, we assessed UtA pulsatility index (PI). MAIN OUTCOME MEASURES: Preeclampsia, preterm preeclampsia, SGA (birthweight (BW) <10%) and intrauterine growth restriction (IUGR) (BW<3%). RESULTS: We identified 132 patients with ⩾one abnormal analyte, UtA Doppler screening, and delivery outcomes. Twenty-four (18%) had an elevated UtA PI (PI>1.6); preeclampsia occurred in 16 (12%) and 26 (20%) delivered a SGA neonate. Abnormal UtA Doppler PI increased the likelihood of a composite outcome of preeclampsia or SGA from 27% to 71% (LR 6.48 (2.93, 14.30)); a negative UtA Doppler PI reduced the likelihood to 18% (LR 0.57 (0.42, 0.78)). Abnormal UtA Doppler PI increased the likelihood of a more severe composite outcome of preterm preeclampsia or IUGR from 11% to 39% (LR 5.49 (3.03, 9.97)); a negative UtA Doppler study reduced the likelihood to 4% (LR 0.35 (0.16, 0.80)). CONCLUSIONS: In patients with abnormal serum analytes, abnormal UtA Doppler PI is significantly associated with preeclampsia or SGA and improves the prediction of these adverse outcomes by 9-15-fold. Providers can incorporate UtA Doppler PI into an abbreviated surveillance regimen; they can be reassured that a normal study markedly decreases the risk of a severe early adverse outcome.

Insulin pump dosing across gestation in women with well-controlled type 1 diabetes mellitus.

OBJECTIVE: We hypothesized that bolus and basal insulin doses in women with type 1 diabetes mellitus who use insulin pumps would increase 2-fold to maintain hemoglobin A1c <6.5% across gestation. STUDY DESIGN: This was a retrospective study of 9 women with type 1 diabetes mellitus with preconceptional hemoglobin A1c ≤ 7.4% using insulin pumps. The primary outcome was absolute and percentage change of basal and bolus insulin from preconception to delivery. RESULTS: Total daily dose of insulin increased from 33.3 ± 7.8 U/d before conception to 93.5 ± 27.9 U/d at delivery. Basal rates rose modestly (50% increase, from 16.2 ± 6.5 U/d to 24.0 ± 9 U/d); bolus insulin doses quadrupled from 17.1 ± 6.1 U/d to 69.5 ± 29.6 U/d (P = .0001). Bolus insulin increased from approximately 50% of total daily dose of insulin before conception to 75% of total daily dose of insulin at 36 weeks' gestation. CONCLUSION: In well-controlled type 1 diabetes mellitus, insulin requirements increased 3-fold from before conception to 36 weeks' gestation. Most of this requirement was attributed to an increase in bolus rates that are required for control with meals.

A look at uterine wound healing through a histopathological study of uterine scars.

BACKGROUND: Few histopathologic studies of uterine wound healing have been published compared with similar healing in other tissues. Our objective was to examine the histopathology resulting from iatrogenic trauma to the myometrium to acquire a better understanding of possible aberrations in uterine wound healing. METHODS: We studied paired injured myometrium and uninvolved myometrium from 7 hysterectomy specimens. All subjects had either abnormal bleeding or chronic pain following an iatrogenic injury to the myometrium. The time between the initial injury and hysterectomy ranged from 2 months to 13 years. Tissue was evaluated with hematoxylin and eosin (H&E) followed by Masson Trichrome staining for collagen, Weigert-Van Gieson elastic staining, and/or Kreyberg staining for fibrin and glycosaminoglycans or MIB-1 (Ki-67) immunhistochemistry for cell proliferation. RESULTS: Histopathologic examination of the 7 paired tissues revealed evidence of altered healing including myofiber disarray, elastosis, tissue edema, and inflammation. Small fibroids, myometrial hyperplasia, a keloid-like region of scar and adenomyosis were also observed. CONCLUSIONS: Myofiber disarray and elastosis may be markers of aberrancy in wound healing after iatrogenic uterine trauma. Altered myometrial scarring in these cases may have contributed to the clinical outcome necessitating hysterectomies. Myometrial hyperplasia in the region of the scars might also contribute to the clinical presentation as well. Small fibroids found within scars and evidence of a keloid-like structure may also represent alterations in uterine wound healing.

Maternal valvular heart disease in pregnancy.

UNLABELLED: Valvular heart disease is common in pregnancy. Maternal physiology changes significantly during gestation with substantial increases in cardiac output and blood volume; this can cause unmasking or worsening of cardiac disease. Acquired valvular lesions most frequently arise from rheumatic fever, especially in patients who have emigrated from developing nations. Congenital lesions are also encountered. The most common conditions seen, mitral stenosis and regurgitation and aortic stenosis and regurgitation, each require a specific evaluation and management and are associated with their own set of possible complications. Patients with prosthetic valves require anticoagulation, and maternal and fetal risks and benefits must be carefully weighed. Patients with heart disease should be meticulously managed preconceptionally up to the postpartum period by maternal-fetal medicine specialists, obstetricians, cardiologists, and anesthesiologists using a multi-disciplinary approach to their cardiac conditions. TARGET AUDIENCE: Obstetricians & Gynecologists and Family Physicians. LEARNING OBJECTIVES: After the completing the CME activity, physicians should be better able to examine the epidemiology of valvular heart disease in pregnancy, categorize key physiologic parameters that change in the cardiovascular system during pregnancy, classify the pathophysiology of valvular lesions, and evaluate the general principles of maternal and fetal management for cardiac disease.

The influence of prior obstetrical history on current 17-hydroxyprogesterone caproate use.

OBJECTIVE: To determine if gestational age of prior preterm delivery influences a woman's receipt of 17-hydroxyprogesterone caproate (17-OHP-C). METHODS: Retrospective cohort of women eligible for 17-OHP-C at Duke Obstetrics Clinic were identified by medical record review. Sociodemographic and clinical characteristics were abstracted. Results. Of 104 eligible subjects, 82 (78.8%) were offered 17-OHP-C. Of these, thirty-four (41.5%) declined. The median gestational age of the most recent preterm delivery was significantly lower among subjects who accepted 17-OHP-C as compared to those who declined (28.7 vs. 34.0 weeks, P = .02) and in subjects offered 17-OHP-C compared to those not offered 17-OHP-C (30.2 vs. 36.0 weeks, P = .03). Subjects not offered 17-OHP-C were more likely to have had an interval term delivery (31.8% vs. 9.7%, P = .009) CONCLUSION: Women with earlier preterm deliveries were more likely to be offered and accept 17-OHP-C. Prior obstetric history may influence both providers' and patients' willingness to discuss and/or accept 17-OHP-C.