What is the "cost" of reducing adverse pregnancy outcomes in patients with gestational diabetes mellitus - risk factors for perinatal complications in a retrospective cohort of pregnant women with GDM.

BACKGROUND: Gestational diabetes mellitus (GDM) is a frequent pregnancy complication, affecting the maternal and neonatal health. The new diagnostic strategy for GDM, proposed by the International Association of Diabetes and Pregnancy Study Groups in 2010 and World Health Organization in 2013, raised hope to reduce perinatal complications. The purpose of the study was to compare risk factors influencing maternal and foetal outcomes in a group of pregnant women diagnosed with GDM, and in a group of pregnant women without GDM, regardless of the adopted diagnostic criteria. Also, the aim of the study was to evaluate the impact of risk factors on perinatal results and the "cost" of reducing adverse pregnancy outcomes in patients with GDM. METHODS: It was a retrospective study based on the analysis of births given after 37 weeks of pregnancy at the 2nd Department of Obstetrics and Gynaecology, Warsaw Medical University during the years 2013 to 2015. All pregnant women had a 75 g OGTT between the 24th and 28th weeks of pregnancy. The study compared risk factors for perinatal complications in 285 GDM patients and in 202 randomly selected women without GDM. The impact of selected risk factors on perinatal outcomes was analysed. RESULTS: Both the diagnosis of GDM and maternal BMI prior to pregnancy, significantly modified the risk of excessive and insufficient weight gain during pregnancy. The parameters significantly influencing the risk of the composite adverse maternal outcome were the maternal abdominal circumference [OR: 1.08 (1.04; 1.11)] and multiparity, which reduced the risk by almost half [OR: 0.47 (0.30; 0.75)]. The maternal abdominal circumference before the delivery was a strong factor correlating with the occurrence of perinatal complications in both the mother and the foetus in the entire cohort. A circumference over 100 cm increased the risk of at least one maternal complication (increased blood loss, soft tissue injury, pre-eclampsia) by almost 40% (OR 1.38, p < 0.001). CONCLUSIONS: No differences were found in maternal and foetal outcomes in GDM and non-GDM women except gestational weight gain below Institute of Medicine recommendations. The only "cost" of reducing adverse pregnancy outcomes in GDM patients seems to be lowering gestational weight gain, the future impact of which on GDM pregnant population should be assessed. The maternal abdominal circumference measured before delivery not the severity of carbohydrate intolerance, remained the main predictor for significant perinatal complications.

Mirror Syndrome with Severe Postpartum Presentation following Stillbirth and Shoulder Dystocia.

Background: Mirror syndrome (MS) is a pregnancy-related condition characterized by fetal, placental and maternal edema. Methods: We report a case of MS with severe postpartum presentation following stillbirth, shoulder dystocia, McRoberts maneuver, anterior shoulder disimpaction and manual posterior shoulder delivery together with serum soluble fms-like tyrosine kinase 1 (sFlt-1)/placental growth factor (PlGF) ratio results. Results: A 33-year-old patient G3P0A2 at 34 weeks gestation was referred with fetal Ebstein anomaly and fetal hydrops. At 36 weeks of gestation, examination revealed fetal demise with placental hydrops. Delivery of a stillborn child was complicated by shoulder dystocia. Twelve hours postpartum patient developed massive edema and acute kidney injury. Five days postpartum serum creatinine level (CrL) peaked and the sFlt-1/PlGF ratio was elevated. Twelve days after delivery CrL normalized and edema resolved. Conclusions: Shoulder dystocia may increase the severity of postpartum MS. The sFlt-1/PlGF ratio may be useful for MS management.

Influence of Glycemic Control on Coagulation and Lipid Metabolism in Pregnancies Complicated by Pregestational and Gestational Diabetes Mellitus.

Hypercoagulability and altered lipid metabolism, which are observed in normal pregnancy, can be enhanced in diabetes mellitus. The aim of the study was to evaluate the influence of glycemic control on coagulation and lipid metabolism in women with pregestational (PGDM) and gestational (GDM) diabetes treated with insulin. There were 50 patients with PGDM and 101 patients with GDM enrolled into the study. Serum lipid and coagulation parameters were assessed at 18-22, 25-28, and 31-34 weeks of pregnancy and were compared within the diabetic groups with reference to the effectiveness of glycemia control. We found that poor glycemic control was associated with shortened activated partial thromboplastin time (APTT) and increased activity of antithrombin III (ATIII) in both diabetic groups and with a higher plasminogen activator inhibitor (PAI-1) content level in the GDM group. Poorly controlled PGDM was associated with higher levels of total cholesterol and high-density cholesterol (HDL) in the second trimester and triglycerides in the third trimester. In patients with poorly controlled GDM, a higher concentration of HDL was observed in third trimester, whereas a higher triglyceride level was found in both second and third trimesters. Positive correlations between total cholesterol and APTT and between triglyceride and APTT and ATIII were found in the poorly controlled PGDM group. We conclude that poor glycemic control of diabetic pregnancy impacts both lipid metabolism and the blood coagulation system.

Gestational diabetes mellitus (GDM) - do the number of fulfilled diagnostic criteria predict the perinatal outcome?

OBJECTIVES: The aim of the study was to check whether the number of fulfilled diagnostic criteria of gestational diabetes mellitus (GDM) had any association with patients' characteristics and pregnancy outcomes. MATERIAL AND METHODS: A total of 756 women with single pregnancies and GDM who gave birth at the 2nd Department of Obstetrics and Gynecology of the Medical University of Warsaw between 01.2013-12.2016 were included in a retrospective analysis. Patients were divided into 2 groups: A - 499 patients diagnosed with GDM on the basis of one diagnostic criterion, B - 257 patients diagnosed with GDM on the basis of more than one diagnostic criterion. RESULTS: Patients from group A had lower pre-pregnancy BMI than those from group B (median 24.9 kg/m2 vs. 26.5 kg/m2, p=0.0003). Women from group A were less frequently treated with insulin than women from group B (19.1% vs. 32.7%; p=0.00002). Group A had lower median OGTT levels than group B (85.9 mg/dL vs. 94.1 mg/dL, p=0,0001; 160.2 mg/dL vs. 197.6 mg/dL, p=0.0001; 144.8 mg/dL vs. 167.0 mg/dL,p=0.0001; respectively). Moreover, in group B the average week of labor was earlier than in group A (mean 38,1 and 38,5 weeks of gestation, p=0,0006). CONCLUSIONS: Patients who fulfilled more than one diagnostic criterion for GDM may have worse pregnancy outcome. We think that a number of fulfilled diagnostic criteria for GDM may be an important risk factor for insulin therapy during pregnancy and earlier gestational age at delivery.

New criteria for gestational diabetes mellitus - do they impact the outcome?

OBJECTIVE: The aim of the study was to compare the perinatal outcome of pregnancies in mothers who were diagnosed with gestational diabetes mellitus (GDM) with previous versus current Polish Gynecological Society (PTG) criteria. METHODS: 475 patients were divided into three groups. In group A, the patients only met the previous PTG criteria for a GDM diagnosis, i.e., those with a blood glucose level of 140-152 mg/dl 2 hours after administration, a fasting glucose level <92 mg/dl, and a blood glucose level <180 mg/dl 1 hour after administration. Group B included patients complying with both the previous and current PTG criteria for a GDM diagnosis. Group C included patients who only met the current PTG criteria for a GDM diagnosis, i.e., those with a fasting blood glucose level of 92-99 mg/dl, a blood glucose level <180 mg/dl 1 hour and <140 mg/dl 2 hours after administration, respectively. RESULTS: Women from group C were characterized by the highest fasting glycaemia in the first trimester of pregnancy (93.0 mg/dL vs. 88.0 mg/dL vs. 83.5 mg/dL, p=0.012) and during the OGTT (p=0.001). Gestational diabetes was diagnosed significantly earlier in patients from group C (23 vs. 26 vs. 26 weeks, p=0.005). The patients from group A significantly less frequently required insulin therapy for proper glycemic control (p=0.035). Women from group A were characterized by lower pre-pregnancy BMI (p=0.001). CONCLUSIONS: Current PTG criteria for diagnosing GDM according to the IADPSG allow for identification of women who often require insulin therapy to achieve proper glycemic control.

Evaluation of the amoxicillin concentrations in amniotic fluid, placenta, umbilical cord blood and maternal serum two hours after oral administration.

OBJECTIVES: Amoxicillin is a broad-spectrum beta-lactam antibiotic. Due to its low toxicity, it is commonly used in obstetrics. The objective of this study was to assess amoxicillin concentrations in amniotic fluid, umbilical blood, placenta and maternal serum two hours following oral administration among pregnant women at term and to assess obstetric and non-obstetric factors that might affect amoxicillin's penetration of these tissues. MATERIALS AND METHODS: A total of 30 full-term pregnant women who qualified for elective Caesarean delivery were included in the study. Amoxicillin at a dose of 500 mg was administered prior to surgery. Amoxicillin levels were determined by diffusion microbial assay. RESULTS: The maternal serum, placental, umbilical blood and amniotic fluid levels of amoxicillin two hours after oral administration were 2.18±1.30 µg/g, 1.00±0.71 µg/g, 1.00±0.73 µg/g, and 0.67±0.59 µg/g, respectively (Table 2). Maternal serum levels of amoxicillin were significantly higher compared to other tissues (p<0.05). CONCLUSION: If the target tissues for the use of antibiotic drugs in pregnant patients are the fetus and/or the placenta, the drug should be administered in a higher-than-standard dose than that used to treat infections in non-pregnant patients. Considering that there is a maximum absorbable dose following oral administration, intravenous administration should be considered to prevent failure of antibiotic treatment. A higher dose of amoxicillin should be considered in obese mothers.

Emergency peripartum hysterectomy - a challenge or an obstetrical defeat?

OBJECTIVES: Peripartum hysterectomy remains an obstetric nightmare. Most obstetricians consider it a defeat. The aim of our study was to assess the prevalence, indications, procedures and complications of emergency peripartum hysterectomy (EPH) in the 2nd Department of Obstetrics & Gynecology, Medical University of Warsaw during a 7 year period (2007-2013). METHODS: A retrospective evaluation of 21,144 deliveries was performed. We analyzed all cases of EPH, including the maternal characteristics, obstetrical history, course of pregnancy and delivery, type of surgery and complications. RESULTS: Nineteen peripartum hysterectomies were performed between January 1, 2007 and October 30, 2013 (0.9/1000), including 16 EPH (0.76/1000). The rate of EPH was between 0.66 and 1.0 per 1000 deliveries. The majority of the patients were multiparous (79.0%), and EPH was performed after at least one cesarean section (75.0%). Fifteen women had a singleton pregnancy and one woman had a triplet pregnancy. The mean gestational age was 34.2 weeks. The delivery mode was cesarean section in 93.8% of the cases. The most common reason for peripartum hemorrhage and the indication for EPH was abnormal placentation (75.0%). All patients underwent a total hysterectomy, including 43.8% during the same operation and 50.0% during a reoperation. There was no maternal death. The serious maternal complication rates were relatively low in our study and included one case of cardiac arrest that required cardiopulmonary resuscitation and one case of sepsis with pulmonary embolism. CONCLUSIONS: EPH is typically performed as a result of massive hemorrhage associated with abnormal placentation, and it should be treated as a challenging, life-saving procedure.

Evaluation of the amoxicillin concentrations in amniotic fluid, placenta, umbilical cord blood and maternal serum two hours after intravenous administration.

OBJECTIVES: The aims of this study were to evaluate amoxicillin concentrations in amniotic fluid, placenta, umbilical cord blood and maternal blood two hours after intravenous administration to assess obstetric and non-obstetric factors that could have influences on the penetration of the antibiotic into the examined tissues and to analyze the sensitivity to amoxicillin of the most common pathogens isolated from the genital tract. METHODS: A total of 35 full-term pregnant women who qualified for elective Caesarean delivery were included in the study. Amoxicillin at a dose of 1000 mg was administered prior to surgery. Amoxicillin levels were determined by diffusion microbial assay. RESULTS: The drug concentration was highest in umbilical cord blood compared with amniotic fluid, maternal blood and placenta (4.20±1.06 µg/g versus 3.96±0.79 µg/g, 3.22±0.64 µg/g and 2.81±0.64 µg/g, respectively). Obstetric and non-obstetric factors had no influence on the amoxicillin concentration. The most common bacteria isolated from the genital tracts of pregnant women (Streptococcus agalactiae, Enterococcus faecalis, Escherichia coli) were sensitive to amoxicillin. The MIC for the sensitive strain of Streptococcus agalactiae was seen in the majority of tissues of all of the patients; however, the MICs for E. faecalis and E. coli were not observed in any compartment. CONCLUSIONS: Amoxicillin proved to have good penetration into the fetal tissues and placenta after intravenous administration. The most common bacteria isolated from the genital tracts of pregnant women were sensitive to amoxicillin. Pregnancy complications were not found to have an influence on the amoxicillin concentrations in the examined tissues.

Shoulder dystocia in diabetic and non-diabetic pregnancies.

OBJECTIVES: Shoulder dystocia remains an obstetric emergency. Maternal diabetes is considered to be one of the major risk factors for shoulder dystocia. The aim of this study was to analyze antepartum and peripartum risk factors and complications of shoulder dystocia in diabetic and non-diabetic women. DESIGN: We performed a retrospective analysis of 48 shoulder dystocia cases out of 28,485 vaginal deliveries of singleton, live-born infants over a 13 year period: 13 cases were diagnosed in diabetic women and 35 cases in non-diabetic women. SETTING: The study was conducted in the 2nd Department of Obstetrics and Gynecology, Medical University of Warsaw, Poland, from January 2000 to December 2012. RESULTS: Compared to non-diabetic women, diabetic patients had significantly higher pre-pregnancy body weight (83.4±23.8 kg vs. 62.5±10.9 kg, p=0.002), higher pre-pregnancy BMI (30.2±6.8 kg/m2 vs. 22.9±4.3 kg/m2, p=0.0003), and lower gestational weight gain (11.4±6.2 kg vs. 16.0±4.7 kg, p=0.01). Diabetic women with shoulder dystocia were more likely to deliver before completion of the 38th week of gestation (30.8% vs. 5.7%, p=0.02) and had a higher incidence of 1st and 2nd stage perineal tears compared with the non-diabetic group (23.1% vs. 0%, p=0.02). There were two cases of symphysis pubis dehiscence in non-diabetic women. Children of diabetic mothers had a significantly higher birth weight (4,425.4±561.6 g vs. 4,006.9±452.8 g, p=0.03). Children of diabetic mothers with dystocia were at significantly higher risk of peripartum injuries (92.3% vs. 45.7%). A significant difference was observed in the percentage of brachial plexus palsy (61.5% vs. 17.1%). Children of diabetic women experiencing shoulder dystocia were more frequently affected by Erb's brachial plexus palsy and respiratory disturbances. These children had an increased likelihood of birth weights above the 90th percentile (not necessarily reaching 4,000 g) compared to children born to non-diabetic mothers. CONCLUSIONS: Shoulder dystocia in women with diabetes mellitus during pregnancy was associated with earlier gestational age of labor, and these women were more frequently overweight. The newborns of diabetic mothers after shoulder dystocia appeared to be at an increased risk for perinatal morbidity compared to the newborns of non-diabetic mothers experiencing this complication.

Double diabetes as an effect modifier for adverse perinatal outcome in pregnant women with type 1 diabetes mellitus - a retrospective multicenter cohort study.

Introduction: Double diabetes (DDiab) is defined as T1DM coexisting with insulin resistance (IR), metabolic syndrome (MetS), and/or obesity. Little evidence is available regarding how frequent DDiab is among T1DM pregnancies and whether it affects the perinatal outcome in this population. Aims of the study: To explore the prevalence of DDiab in early pregnancy in the cohort of pregnant women with T1DM and to examine the association between an early-pregnancy DDiab status and fetomaternal complications characteristic for T1DM in pregnancy. Material and methods: A retrospective data analysis of the multicenter cohort of N=495 pregnant women in singleton pregnancy complicated with T1DM followed from early pregnancy until delivery in three tertiary referral centers. DDiab status was defined as T1DM plus pre-pregnancy obesity defined as BMI≥30 kg/m2 measured at the first antenatal visit (DDiabOb), or T1DM plus pre-pregnancy IR defined as eGDR (estimated Glucose Disposal Rate) below the 25th centile for the cohort measured at the first antenatal visit (DDiabIR). Proportions of the adverse pregnancy outcomes were compared between DDiabOb and Non-DDiabOb and between DDiabIR and Non-DDiabIR patients. Characteristics of the study group: (data presented as mean(SD) or percentage): age: 30.0(5.1) years; age when T1DM diagnosed: 17.5(8.5) years; T1DM duration: 12.0(7,9) years; microvascular complications (White classes R,F,RF): 11.9%, pre-pregnancy counselling: 26.6%, baseline gestational age: 10.5(4.3) weeks, pre-pregnancy BMI: 23.7(4.3) kg/m2; chronic hypertension: 9.1%, gestational hypertension (PIH) 10.7%, preeclampsia (PET): 3.2%; nulliparity 53.8%, smoking in pregnancy: 4.8%, eGWG: 22.4%, DDiabOB: 10.1%; DdiabIR: 25.2%; LGA: 44.0%, and NICU admission: 20.8%. Results: (data from the univariate analysis given as OR(95%CI)): both DDiabOB and DDiabIR status increased the risk for eGWG [23.15 (10.82; 55.59); 3.03 (1.80; 5.08), respectively]. DDiabIR status increased the risk for PET [4.79 (1.68;14.6)], preterm delivery [1.84 (1.13; 3.21)], congenital malformation [2.15 (1.07;4.25)], and NICU hospitalization [2.2 (1.20;4.01)]. Both DDiabOB and DDiabIR accurately ruled out PET (NPV 97.3%/98.3%, accuracy: 88.3%/75.6%, respectively), congenital malformation (NPV 85.6%/88.4%, accuracy: 78.9/69.8, respectively), and perinatal mortality (NPV 98.7%/99.2%, accuracy: 88.8%/74.5%, respectively). Conclusions: Double diabetes became a frequent complication in T1DM pregnant population. Double diabetes diagnosed in early pregnancy allows for further stratification of the T1DM pregnant population for additional maternal risk.

Risk factors of abnormal carbohydrate metabolism after pregnancy complicated by gestational diabetes mellitus.

OBJECTIVE: In gestational diabetes mellitus (GDM) abnormal glucose metabolism normalizes soon after delivery. However, the history of GDM predisposes to carbohydrate intolerance in the future. The aim of the study was to explore risk factors and to evaluate risk of glucose intolerance and diabetes mellitus in women with a history of GDM. METHODS: 155 patients entered this case-control study. Participants fulfilled the inclusion criteria: a history of GDM, perinatal care in the study center. Medical and family history and laboratory findings were analyzed. Oral glucose tolerance test (OGTT) was performed. RESULTS: 18.1% of patients presented impaired fasting glucose during the study, 20% presented impaired glucose tolerance and 23.2% presented diabetes mellitus. Gestational age at diagnosis of GDM, the results of OGTT during pregnancy, serum HbA1c concentration at 2nd and 3rd trimester, serum fructosamine concentration, symptoms of diabetic fetopathy in the neonate, the need for insulin therapy after delivery, maternal age at diagnosis of GDM and maternal body mass index before pregnancy were the significant risk factors of impaired glucose tolerance or diabetes in the future. CONCLUSION: GDM increases the risk of diabetes mellitus. Several risk factors of impaired carbohydrate metabolism can be distinguished in patients with a history of GDM.

[Recommendations of Polish Gynecological Society concerning perinatal care in obese pregnant women]. / Standardy Polskiego Towarzystwa Ginekologicznego "Opieka poloznicza nad ciezarna otyla".

Maternal obesity (defined as prepregnancy maternal BMI> or = 30 kg/m2) is a risk factor strongly associated with serious perinatal complications and its prevalence has increased rapidly in a general population during the last decades. Therefore, following international approach to regulate perinatal care in this population, Group of Experts of Polish Gynecological Society developed these new guidelines concerning perinatal care in obese pregnant women, including women after bariatric surgery. The recommendations cover detailed information on specific needs and risks associated with obesity in women of reproductive age, pregnancy planning, antenatal care, screening, prophylaxis and treatment for other pregnancy complications characteristic for maternal obesity fetal surveillance, intrapartum care and post-partum follow-up. Pregnancy planning in these patients should involve dietary recommendations aiming at well balanced diet and daily caloric uptake below 2000 kcal and modest but regular physical activity with sessions every two days starting from 15 min and increased gradually to 40 min. Laboratory work-up should include tests recommended in general population plus fasting glycemia and oral glucose tolerance if necessary thyroid function, lipidprofile, blood pressure and ECG. Patients after bariatric surgery should allow at least one year before they conceive and have their diet fortified with iron, folic acid, calcium and vit. B12. Antenatal care should include monitoring body weight gain with a target increase in body weight less than 7 kg, thromboprophylaxis, strict monitoring of blood pressure and diagnostic for gestational diabetes in early pregnancy. Fetal ultrasonic scans should be arranged following protocols recommended by US section of Polish Gynaecological Society with additional scan assessing fetal growth performed within 7 days before delivery and aiming at assessing a risk for shoulder dystocia in a patient. Intrapartum care should be delivered in referral centers where fetal and maternal intrapartum complications can be addressed, preferably equipped with a proper medical equipment necessary to deal safely with extremely heavy individuals. Medical staff taking intrapartum care for obese parturient should be also aware of reduced reliability of methods used for intrapartum fetal surveillance, increased risk for intrapartum fetal death, maternal injuries, postpartum haemorrhage, shoulder dystocia, thrombophlebitis and infection. Pediatrician should be also available due to increased neonatal morbidity mainly due to meconium aspiration syndrome, hypoglycemia, and respiratory distress syndrome. In puerperium, medical staff should be prepared to deal with breastfeeding disturbances and increased maternal mortality.

Results of expectant management in singleton and twin pregnancies complicated by preterm premature rupture of membranes.

OBJECTIVES: This study aimed to examine whether expectant management in twin pregnancies with preterm premature rupture of membranes (pPROM) is as safe as in singleton pregnancies. MATERIAL AND METHODS: It was a retrospective cohort study comparing pregnancy course and outcome in singleton (n = 299) and twin pregnancies (n = 49) complicated by preterm premature rupture of membranes. Analysed factors included maternal diseases, gestational age at premature rupture of membranes (PROM), management during hospitalization, latency periods between PROM and delivery, gestational age at delivery, neonatal management and outcome. RESULTS: The difference in the proportion of patients with latency up to 72 hours, latency between 72 hours and seven days, and latency exceeding seven days were insignificant. The percentage of patients who received intravenous tocolysis and antenatal corticosteroids were similar; however, patients in twin pregnancies more often received incomplete steroids dose (p = 0.01). The occurrence of the positive non-stress test result and signs of intrauterine infection were similar between the groups. No statistically significant differences in the prevalence of neonatal complications except transient tachypnoea of the newborn were identified (24% in the singleton vs 13% in the twin group, p = 0.03). CONCLUSIONS: Expectant management of pPROM in singleton and twin pregnancies results in similar perinatal and neonatal outcome. Consequently, in case of no evident contraindications, expectant management of twin pregnancies seems to be equally as safe as in singleton pregnancies. Patients in twin pregnancies may be at higher risk of delivery before administration of full antenatal corticosteroids dose, therefore require immediate management initiation and transfer to a tertiary referral centre.

Gestational weight gain and glycemic control in GDM patients with positive genital culture.

OBJECTIVE: Gestational diabetes mellitus (GDM) is related to many complications of pregnancy. The aim of the study was the assessment of cervical colonization in GDM patients and its correlation with inappropriate glycaemic control and gestational weight gain (GWG). MATERIALS AND METHODS: The study included 483 women with GDM in a singleton pregnancy who delivered at term. Cervical smears samples were collected >35th week of gestation and cultured for aerobic and aerobic bacteria, and fungi. The patients were divided into two groups on the basis of cervical culture test results: women with negative and positive cervical culture results. Gestational weight gain was estimated in both groups as inadequate, adequate or excessive based on pre-gestational body mass index (BMI) according to the Institute of Medicine (IOM) guidelines. GWG and need of insulin therapy were used as an indicator of complying with dietary recommendations. RESULTS: Patients with positive cervical culture results more frequently had pre-pregnancy BMI >35kg/m2 (4.9% vs 9.5%, p = 0.0508) than patients who had negative cervical culture results. One third (32.1%) of patients had one, and 9.3% had at least two microorganisms in their genital tracts. The most frequent bacteria species isolated was Streptococcus agalactiae (20.1%). Fungi were present in 14.1% of the cervical cultures. Patients with GDM with inadequate GWG more often had genital tract's colonization with Enterococcus spp. (6.83% vs. 1.19% vs. 1.83%, in group with inadequate GWG vs. adequate GWG vs. excessive GWG respectively p = 0.007). CONCLUSION: Insulin therapy in GDM patients was not correlated with the presence of microorganisms in genital tracts. Inadequate GWG in GDM may be linked to genital tract colonization with Enteroccocus spp. Genital colonization during pregnancy among patients with GDM is more often among patients' with pre-pregnancy BMI >35 kg/m2.

Risk factors for unsuccessful vaginal birth after caesarean at full dilatation.

OBJECTIVES: The purpose of this study was to determine the risk factors for caesarean sections in the second stage of labour after a previous caesarean section among women who underwent trial of labour (TOL). MATERIAL AND METHODS: From a total of 639 women who experienced one caesarean section, 456 women were qualified for TOL. From this group, 105 women were subjected to a caesarean section in the first stage of labour and another 351 women reached the second stage of labour. From the latter group, 309 women delivered naturally and 42 were subjected to a caesarean section. RESULTS: Risk factors for the necessity of performing a caesarean section in the second stage of labour after a previous caesarean section was the weight gain during pregnancy (OR = 1.07), the height of fundus uteri (OR = 1.25) before delivery, and the estimated foetal weight (OR = 1.01), a past delivery of a child with a birth weight exceeding 4.000 g (OR = 2.14), the presence of pre-gestational diabetes (OR = 15.4) and gestational diabetes (OR = 2.22), necessity of applying a delivery induction (OR = 2.52), stimulation of uterine activity during delivery (OR = 2.43) and application of epidural analgesia (OR = 4.04). A factor reducing the risk of a caesarean section in the second stage was a vaginal delivery in a woman's history (OR = 0.21). CONCLUSIONS: Women should be encouraged to deliver naturally after a previous caesarean section, especially when their history includes a vaginal delivery and if there is no need for labour induction.

Comparison of maternal characteristics, pregnancy course, and neonatal outcome in preterm births with and without prelabor rupture of membranes.

OBJECTIVES: The aim of this study was to evaluate pregnancy outcome of patients with prelabor rupture of membranes receiving expectant management and giving birth prematurely in comparison to preterm births of patients with intact membranes. MATERIAL AND METHODS: It was a retrospective cohort study comparing maternal and neonatal outcome in two groups of preterm births. The first group included 299 consecutive singleton preterm births complicated by prelabor rupture of membranes. The second group consisted of 349 consecutive singleton preterm births without prelabor rupture of membranes. RESULTS: Patients without pPROM underwent Caesarean sections more often than women from the pPROM group (65.3% vs 45.2%; p < 0.001). No statistically significant differences regarding the gestational age during delivery were identified. Lower birth weight was detected in the group with no history of pPROM (p < 0.001). No differences regarding early-onset sepsis were identified and higher percentage of late-onset infections was observed in infants with no history of pPROM (8.9% vs 4.7%; p = 0.04). Pulmonary hypertension was more common in the infants from the pPROM group (4% vs 1.4%; p = 0.049). Neonatal respiratory distress syndrome and respiratory failure were more prevalent in cases of no pPROM history - 20% vs 12.7% (p = 0.02) and 40% vs 25.8% (p < 0.001), respectively. CONCLUSIONS: Development of multiple complications in preterm neonates may be more associated with the management, gestational age at birth, and birth weight than with the occurrence of preterm prelabor rupture of membranes.

[Course of pregnancy and delivery in patients with pregestational diabetes mellitus]. / Przebieg ciazy i porodu u pacjentek z cukrzyca przedciazowa.

INTRODUCTION: Pregnancy in a woman with pregestational diabetes mellitus (PGDM) is associated with increased risk of complications in both the mother and the fetus. A close surveillance is strongly recommended in these pregnancies. OBJECTIVES: The aim of the study was to assess perinatal outcome in pregnancies complicated by PGDM. STUDY DESIGN: The study covered 127 pregnancies with PGDM. Apart from perinatal outcome the patient's age, past obstetric history, the duration of perinatal diabetic care and the course of pregnancy were taken into consideration. Diabetes mellitus was classified according to White. RESULTS: 37.8% of patients were diagnosed PGDM B class, 38.6%--C class, 15.7%--D class, 1.6%--F class and 6.3%--RF class. Less than half of women (45.5%) remained under medical care since the first trimester. The arterial hypertension was the most common complication of pregnancy and occurred in over 18% of studied pregnancies. The incidence of preterm delivery was 41.7%. Cesarean section was performed in 55.9% of patients. 16.6% of the neonates had a birth weight below 2500 g. 4 neonates were stillborn (2.4%) and the next 3 ones (2.4%) died within the first month following the delivery. Congenital heart defects were found in 8.7% of offsprings. CONCLUSIONS: Despite the progress in perinatal care pregestational diabetes mellitus is still associated with increased risk of maternal and fetal mortality and morbidity.

Renal function and lipid metabolism in pregnant renal transplant recipients.

OBJECTIVE: To estimate renal function and lipid metabolism in pregnant renal transplant recipients. STUDY DESIGN: The study covered 64 women during the third trimester of pregnancy including 33 renal transplant recipients (the study group) and 31 healthy women (the control group). Serum concentrations of uric acid, urea, creatinine, electrolytes, total protein, albumin, acid-base balance and blood cell count were examined to assess renal function. Moreover, the levels of the following lipid metabolism parameters were estimated: (1) total lipids (TL), (2) total LDL fraction (TLDL), (3) total cholesterol (TCh), (4) free cholesterol (fCh), (5) free/total cholesterol (fCh/TCh) ratio, (6) phospholipids (PhL), (7) total cholesterol/phospholipids (fCh/PhL) ratio, (8) triglycerides (TG), (9) HDL-cholesterol (HDL-Ch), (10) LDL-cholesterol (LDL-Ch) and (11) LDL-Ch/HDL-Ch ratio. 'The effect of immunosuppressants (cyclosporine, prednisone and azathioprine) on serum lipid levels was estimated in the study group. The mean maternal age, gestational age and BMI did not differ in both groups. RESULTS: Pregnant renal transplant recipients presented mild renal insufficiency during the third trimester resulting in the increase in serum level of uric acid (P<0.001), urea (P<0.001), creatinine (P<0.001), and Cl- (P<0.001). Proteinuria (1.19+/-1.9 g/24 h) leading to hypoproteinemia (P<0.001) and hypoalbuminemia (P<0.05) confirmed renal function impairment in the study group. Additionally, the diagnosis of renal insufficiency was supported by mild acidosis reflected by a drop in pH (P<0.001). standard HCO3- (P<0.001) and base excess (P<0.001). The women with renal grafts presented vital lipid metabolism disturbances illustrated by the elevated levels of: (1) TL by 72% (P<0.001), (2) TLDL by 21% (P<0.001), (3) TCh by 16% (P<0.001), (4) fCh by 34% (P<0.001), (5) fCh/TCh ratio by 21% (P<0.001), (6) PhL by 28% (P<0.001), (7) TG by 53% (P<0.001), (8) LDL-Ch by 13% (P<0.05) and (9) LDL-Ch/HDL-Ch ratio by 23% (P<0.001). No difference in HDL-Ch level between the two groups was found. Hyperlipidemia in pregnant kidney recipients was associated with immunosuppressive treatment and depended on cyclosporine treatment regimen. Treatment with azathioprine and prednisone was associated with elevated serum levels of examined lipids. CONCLUSION: Serum lipid abnormalities are significantly influenced by the administered dosages of immunosuppressants.