Bishop score and transvaginal ultrasound for preinduction cervical assessment: a randomized clinical trial.

OBJECTIVE: To compare transvaginal ultrasound with the Bishop score in assessment of cervical ripening for choice of induction agent. METHODS: Eighty women were randomized to have preinduction cervical assessment for choice of induction agent based on either Bishop score or transvaginal ultrasound. The primary outcome measure was the percentage of women who were administered prostaglandin as a preinduction agent. The criteria for considering the cervix as unripe and thus for using prostaglandin were either a Bishop score < 6 or a cervical length > 30 mm with cervical wedging of < 30% of the total cervical length. Secondary outcome measures included interval to active phase, interval to delivery and rate of Cesarean section. RESULTS: While 85% of women received prostaglandin in the Bishop score group, only 50% of them did in the transvaginal ultrasound group (P = 0.001). The interval to active phase, interval to delivery and rate of Cesarean section were similar in both groups. CONCLUSIONS: With the suggested cut-off values of a Bishop score < 6 or a cervical length > 30 mm and wedging < 30%, the use of transvaginal ultrasound instead of Bishop score for preinduction cervical assessment to choose induction agent significantly reduces the need for intracervical prostaglandin treatment without adversely affecting the success of induction.

Maternal anxiety and fetal behavior at 15 weeks' gestation.

OBJECTIVE: To analyze the relationship between maternal anxiety and fetal behavior at 15 weeks' gestation. METHODS: Twenty women in two groups were studied: 10 women underwent amniocentesis and 10 controls did not. Maternal anxiety was evaluated using the State Trait Anxiety Inventory questionnaire. Maternal plasma catecholamines (noradrenaline, adrenaline, dopamine) and maternal serum adrenocorticotropic hormone, cortisol, glucose, insulin, triiodothyronine, thyroxine and thyroid-stimulating hormone were measured. Catecholamines were also measured in the amniotic fluid of women undergoing amniocentesis. Compiled actograms of 40-min observations were done using ultrasonography. RESULTS: Maternal state-anxiety was significantly increased in the amniocentesis group. Except for fetal hiccups (r = 0.49, P = 0.03) there was no significant correlation between maternal anxiety and any of the other studied fetal movements. Maternal glucose was significantly correlated with hiccups (r = -0.59, P = 0.01), isolated leg movements (r = -0.52, P = 0.03), startles (r = -0.47, P = 0.04) and the total of the studied movements (r = -0.47, P = 0.04). Amniotic fluid catecholamines were significantly correlated with hand-face contact (r = 0.71, P = 0.02 for adrenaline), startles (r = 0.75, P = 0.01 for noradrenaline and r = 0.64, P = 0.04 for dopamine) and general movements (r = 0.89, P = 0.001 for noradrenaline). CONCLUSIONS: This study does not support a relationship between maternal anxiety and fetal behavior in early pregnancy. Maternal glucose and plasma catecholamines could be related to fetal movements at 15 weeks' gestation.

Postpartum metabolism and autoantibody markers in women with gestational diabetes mellitus diagnosed in early pregnancy.

OBJECTIVE: Our purpose was to study postpartum metabolism and autoantibody markers of type 1 diabetes mellitus in women with gestational diabetes mellitus diagnosed in early pregnancy. STUDY DESIGN: Thirty women with gestational diabetes diagnosed in early pregnancy were compared with 72 women who had gestational diabetes diagnosed in late pregnancy. Glucose tolerance, parameters of carbohydrate and lipid metabolism, and antibodies to glutamic acid decarboxylase and to islet cells were measured. RESULTS: The percentages of overt diabetes and abnormal glucose tolerance were significantly higher in the early-pregnancy group (26.7% vs 1.4%; P =.0002; and 40% vs 5.56%; P <.0001; respectively). Only 1 woman had positive test results for antibodies to the islet cells. The rate of positive test results for antibodies to glutamic acid decarboxylase was similar in both groups (13.7% vs 9.3%). CONCLUSIONS: Women with early gestational diabetes have an increased risk of postpartum diabetes mellitus, whereas those with late-onset gestational diabetes have a minimal risk. In women predisposed to type 1 diabetes, gestational diabetes develops either early or late in pregnancy.

Lymphocyte subpopulations after normal pregnancy and spontaneous abortion in primigravidas.

OBJECTIVE: To evaluate lymphocyte subpopulations after a first pregnancy in women who had normal pregnancies and in those whose pregnancies terminated in spontaneous abortion. STUDY DESIGN: Sixty healthy, nonpregnant women in three groups were studied: 20 with a prior abortion, 20 with a prior normal pregnancy and 20 nulligravid. Peripheral blood lymphocytes were studied using monoclonal antibodies and flow cytometry. Women were followed for one year, and if they became pregnant again, pregnancy complications were recorded. RESULTS: The percentage of B lymphocytes was significantly decreased in the postpartum group (6% +/- 2.22) in comparison to nulligravid women (8.7% +/- 3.37) (P = .005). The percentage of CD4 lymphocytes was significantly higher in the postabortion group (44.7% +/- 7.81) in relation to the control group (39.85% +/- 6.01) (P = .03). A significantly higher CD4/CD8 ratio was found in the postabortion group in relation to the control group (1.65 vs. 1.24) (P = .01). Women with pregnancy complications in their next pregnancy had a lower absolute value for total lymphocytes (P = .02), T lymphocytes (P = .04), absolute CD8 lymphocytes (P = .01) and percentage of CD8 lymphocytes (P = .02) and a higher percentage of CD4 lymphocytes (P = .03) and higher CD4/CD8 ratio (P = .02) than women who had not experienced any pregnancy complications. CONCLUSION: The percentage of B lymphocytes was lower in normal primipara in comparison to women who had never been pregnant. Women with previous spontaneous abortions had an immunologic profile expected in a rejection phenomenon; that result was more marked if they went on to experience complications in their next pregnancies.

Oral misoprostol and intracervical dinoprostone for cervical ripening and labor induction: a randomized comparison.

OBJECTIVE: To compare efficacy, safety, and tolerance of oral misoprostol with intracervical dinoprostone for cervical ripening and labor induction. METHODS: Two hundred women were randomized to receive single doses of oral misoprostol 200 microg or 0.5 mg of dinoprostone intracervically every 6 hours for a maximum four doses. RESULTS: The intervals from administration of the drug to active phase of labor (11.1 hours [7-24] versus 15.8 hours [7.5-29.62], P =. 01), to delivery (14.0 hours [8.42-27.61] versus 20.2 hours [16.7-32. 8], P =.01), and to rupture of membranes (10.0 hours [4.95-24.7] versus 15.6 hours [8.2-29.2], P =.003) were significantly shorter in the misoprostol group. All those variables were not distributed normally, so results are presented as median and interquartile range. The rates of women who needed oxytocin (68% versus 52%, P =.03) and cesarean for failed induction (9% versus 1%, P =.01) were higher in the dinoprostone group. CONCLUSION: A single dose of 200 microg oral misoprostol was more effective for cervical ripening and labor induction than 0.5 mg of dinoprostone intracervically every 6 hours, with a maximum of four doses.

Insulin-sensitivity index and carbohydrate and lipid metabolism in gestational diabetes.

OBJECTIVE: To study insulin action in normal and gestational diabetic pregnant women by using an insulin tolerance test. STUDY DESIGN: Twenty-four women diagnosed as having gestational diabetes were compared to 22 nondiabetic, matched controls. The insulin-tolerance test (ITT) consisted of an intravenous bolus of 0.1 IU/kg of regular insulin with glucose sampling at -5, 0, 3, 5, 7, 10 and 15 minutes. The insulin sensitivity index (ISI) was assessed by using a delta G/G0 ratio (G0 = initial glycemia level, delta G = variation between G0 and glycemia level obtained at 15 minutes by calculation of the regression plot). RESULTS: Two women had glucose levels < 50 mg/dL at 15 minutes, without clinical symptoms. Women with gestational diabetes had a significantly lower level than those with normal glucose tolerance. The rate of abnormal insulin resistance (ISI) (< 10th percentile in the control group) was significantly higher in the insulin-treated subgroup (8/11, 72.7%, vs. 2/12, 16.6%). ISI correlated negatively with glycemia (r = -.38, P = .01) and glycosylated hemoglobin (r = -.50, P = .001) and correlated positively with low density lipoprotein-c (r = -.40, P = .01) and apolipoprotein B (r = -.42, P = .01). In the gestational diabetes group, ISI was correlated negatively with gestational age (r = -.50, P = .01) and triglycerides (r = -.50, P = .01). CONCLUSION: ITT seems to be a safe and rapid method of measuring in vivo insulin action in pregnant women. Women with gestational diabetes had higher insulin resistance, especially those who needed insulin therapy. Lipid profile in gestational diabetes was related to the level of insulin resistance.

Gestational diabetes mellitus diagnosed during early pregnancy.

OBJECTIVE: This study was undertaken to compare pregnancy complications, obstetric outcomes, and perinatal outcomes between women with early-onset and late-onset gestational diabetes mellitus. STUDY DESIGN: Fifty-gram oral glucose challenge screening was conducted among 3986 pregnant women at the time of their first antenatal visit. Women without abnormal results underwent another test at 24 to 28 weeks' gestation. Patients with gestational diabetes mellitus in early pregnancy were compared with those who had a normal glucose tolerance at the time of this first test but in whom diabetes subsequently developed. RESULTS: Women with early-onset gestational diabetes mellitus (n = 65) were likely to be hypertensive (18.46% vs 5.88%; P =.006) and had higher glycemic values and need for insulin therapy (33.85% vs 7.06%, P =.0000) than those in whom diabetes developed later (n = 170). All the cases of neonatal hypoglycemia (n = 4) and all perinatal deaths (n = 3) were within this group (P =.005 and P =.01, respectively). CONCLUSIONS: Women with an early diagnosis of gestational diabetes represent a high-risk subgroup.