Search

Normal labor and delivery are dependent on the presence of regular and effective contractions of the uterine myometrium. The mechanisms responsible for the initiation and maintenance of adequate and synchronized uterine activity that are necessary for labor and delivery result from a complex interplay of hormonal, mechanical, and electrical factors that have not yet been fully elucidated. Monitoring uterine activity during term labor and in suspected preterm labor is an important component of obstetrical care because cases of inadequate and excessive uterine activity can be associated with substantial maternal and neonatal morbidity and mortality. Inadequate labor progress is a common challenge encountered in intrapartum care, with labor dystocia being the most common indication for cesarean deliveries performed during labor. Hereafter, an accurate assessment of uterine activity during labor can assist in the management of protracted labor by diagnosing inadequate uterine activity and facilitating the titration of uterotonic medications before a trial of labor is prematurely terminated. Conversely, the ability to diagnose unwanted or excessive uterine activity is also critical in cases of threatened preterm labor, tachysystole, or patients undergoing a trial of labor after cesarean delivery. Knowledge of uterine activity in these cases may guide the use of tocolytic medications or raise suspicion of uterine rupture. Current diagnostic capabilities are less than optimal, hindering the medical management of term and preterm labor. Currently, different methods exist for evaluating uterine activity during labor, including manual palpation, external tocodynamometry, intrauterine pressure monitoring, and electrical uterine myometrial activity tracing. Legacy uterine monitoring techniques have advantages and limitations. External tocodynamometry is the most widespread tool in clinical use owing to its noninvasive nature and its ability to time contractions against the fetal heart rate monitor. However, it does not provide information regarding the strength of uterine contractions and is limited by signal loss with maternal movements. Conversely, the intrauterine pressure catheter quantifies the strength of uterine contractions; however, its use is limited by its invasiveness, risk for complications, and limited additive value in all but few clinical scenarios. New monitoring methods are being used, such as electrical uterine monitoring, which is noninvasive and does not require ruptured membranes. Electrical uterine monitoring has yet to be incorporated into common clinical practice because of lack of access to this technology, its high cost, and the need for appropriate training of clinical staff. Further work needs to be done to increase the accessibility and implementation of this technique by experts, and further research is needed to implement new practical and useful methods. This review describes current clinical tools for uterine activity assessment during labor and discusses their advantages and shortcomings. The review also summarizes current knowledge regarding novel technologies for monitoring uterine contractions that are not yet in widespread use, but are promising and could help improve our understanding of the physiology of labor, delivery, and preterm labor, and ultimately enhance patient care., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Controversy surrounds the impact of the fetal head station on labor duration and mode of delivery. Although an extensive body of evidence has been published evaluating fetal head station in early labor, there is a paucity of data on the impact of fetal head descent during the second stage., Objective: This study aimed to explore the association between fetal head station at the diagnosis of the second stage of labor and the second stage duration and the risk of operative delivery., Study Design: This is a retrospective cohort study of all singleton vertex deliveries in a single tertiary center (2011-2016). Women were grouped according to fetal head station upon the diagnosis of the second stage of labor as follows: above (S<0), at the level (S=0), and below (S>0) the level of the ischial spine. The duration of the second stage and the risk of operative delivery were compared between the groups and stratified by parity., Results: Overall, 34,334 women met the inclusion criteria. Of these, 18,743 (54.6%) were nulliparous and 15,591 (45.4%) were multiparous. Of the nulliparous women, 8.1%, 35.8%, and 56.1% were diagnosed as having fetal head above, at the level, and below the ischial spine upon second stage diagnosis. Of the multiparous women, 19.7%, 35.6%, and 44.7% were diagnosed as having fetal head above, at the level, and below the ischial spine. Fetal head station upon second stage diagnosis was independently and significantly associated with second stage duration (P<.001); however, its contribution was 4.5-fold among nulliparous women compared with multiparous women. In multivariable analysis, after controlling for maternal age, gestational age at delivery, prepregnancy body mass index, epidural anesthesia, and birthweight, the risk of operative delivery was substantially increased in a dose-dependent pattern for both nulliparous and multiparous women., Conclusion: The fetal head station at the first diagnosis of the second stage is significantly and independently associated with the duration of the second stage and correlated with the risk of operative delivery in both nulliparous and multiparous women (P<.001)., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Controversy surrounds the definition of "normal" and "abnormal" labor., Objective: In this study, we used contemporary labor charts to explore labor patterns in large obstetric population (2011-2016)., Study Design: Detailed information from electronic medical records of live singleton deliveries at term (≥37 weeks of gestation) was extracted. Cases of elective cesarean deliveries, nonvertex presentation, and cesarean deliveries during the first stage of labor were excluded., Results: Overall, 35,146 deliveries were included, of whom 15,948 deliveries (45.3%) were of nulliparous women. Median cervical dilation at admission was not significantly different between nulliparous (median, 4 cm; interquartile range, 3-5 cm) and multiparous women (median, 4 cm; interquartile range, 3-6 cm). In all, 99.3% of the women delivered vaginally. For nulliparous women, the median duration of the first stage of labor was 274 minutes (interquartile range, 145-441 minutes; 95th percentile, 747.5 minutes). Likewise, for multiparous women, the corresponding duration was 133 minutes (interquartile range, 56-244 minutes; 95th percentile, 494 minutes). During the latent phase (cervical dilation at admission, ≤4 cm), the time elapsed to the second stage of labor was 120-140 minutes longer in nulliparous women, whereas the gap between the groups decreased dramatically with advanced cervical dilation on admission. Nulliparous and multiparous women appeared to progress at a similar pace during the latent phase; however, after 5 cm, labor accelerated faster in multiparous women. Epidural anesthesia lengthens duration first and second stages of labor in all parities. Partograms according to cervical dilation at presentation are proposed., Conclusion: Cervical dilation rate is relatively constant between nulliparous and multiparous pregnant women during the latent phase. Time interval of the first stage was far slower than previously described, which allowed labor to continue for a longer period during this stage. These findings may reduce the rate of intrapartum iatrogenic interventions., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Cervical length at midtrimester is a powerful predictor of preterm birth in twin gestations. However, given the fact that, in some cases, cervical shortening may become evident only later during the second trimester, it seems reasonable that serial monitoring of cervical length may improve the detection of preterm birth in women with twins. However, data in support of such a practice are limited and conflicting. The contradictory results may be related to the fact that in most of these studies, the analysis of the predictive value of serial measurements of cervical length was limited to data derived from only two sequential measurements of cervical length, while data on the predictive value of multiple (>2) measurements are scarce., Objective: We sought to determine whether serial measurements of cervical length can improve the prediction of preterm birth in asymptomatic women with twin gestations compared with a single measurement of cervical length at midgestation., Study Design: This was a retrospective cohort study of women with twin pregnancies followed up in a tertiary medical center from 2012 through 2014. All participants underwent routine measurement of cervical length at midgestation and every 2-3 weeks thereafter until 28-32 weeks. For each patient, cervical length was determined at the following time periods: 18+0 to 21+6 weeks (period 1, routine exam), 22+0 to 24+6 weeks (period 2), 25+0 to 27+6 weeks (period 3), and 28+0 to 32+0 weeks (period 4). Measurements of cervical length at periods 2-4 were analyzed in the form of either absolute length (in millimeters) or percent shortening relative to cervical length at period 1. The performance of a stepwise algorithm that incorporated serial measurements of cervical length for the prediction of preterm birth was compared to that achieved with a single measurement of cervical length at period 1., Results: Overall, 441 women with twin pregnancies who were eligible for the study underwent a total of 2374 cervical length measurements. The association of a short cervix (<10th percentile) with preterm birth at <32 weeks persisted in each of the 4 periods of gestation [odds ratio (95% confidence interval): 7.2 (3.1-16.5), 15.3 (6.4-36.7), 10.3 (4.4-24.3), and 23.1(8.3-64.1), respectively]. Compared with a single measurement of cervical length at midgestation (period 1), a stepwise algorithm integrating serial cervical length measurements from all 4 successive gestational age periods resulted in a significant increase in the area under the receiver operating characteristic curve (0.917 vs 0.613, P < .001). Similarly, when a target false-positive rate of 5% was used, the same stepwise algorithm was associated with a higher detection rate (69% vs 28%, P < .001), higher positive likelihood ratio (14.54 vs 5.12), and lower negative likelihood ratio (0.32 vs 0.76) for preterm birth at <32 weeks compared with a single measurement of cervical length at period 1., Conclusion: Integration of serial measurements of cervical length using a stepwise algorithm in asymptomatic women with twin gestations can improve the detection of women at risk of preterm birth. Prospective studies are needed to validate these findings, and to investigate whether improved risk assessment performance is sufficient to offset the additional costs associated with serial cervical length measurements., Competing Interests: statement: The authors report no conflict of interest., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Women with a twin gestation are at increased risk for preterm birth (PTB), and sonographic cervical length (CL) is a powerful predictor for spontaneous PTB. Obstetricians frequently monitor CL in multiple gestations; yet, the optimal method to integrate and interpret the results of serial sonographic CL has not been determined., Objective: We sought to determine whether there are different patterns of cervical shortening in twin gestations, and whether such patterns are related to the risk of PTB., Study Design: We conducted a retrospective study of all women with twins followed up in a single tertiary referral center during 2012 through 2014. All women underwent serial measurements of CL every 2-3 weeks starting from 14-18 weeks and until 28-32 weeks of gestation. Changes in CL were analyzed and classified into distinct patterns that were initially identified by visual inspection of all individual cases. Each pattern was then characterized by several parameters including information about when cervical shortening began, the rate of shortening, and whether a plateau was observed. Locally weighted regression mean profiles were generated to describe each pattern of CL over time. The association of these patterns with spontaneous PTB was determined. The specific characteristics of each pattern that further determined the risk of PTB were identified using multivariable logistic regression analysis., Results: We studied 441 women who had a total of 2826 measurements of CL done. Overall, 4 main patterns of change in CL were identified: pattern I, stable cervix (n = 196); pattern II, early and rapid shortening (n = 18); pattern III, late shortening (n = 109); and pattern IV, early shortening with a plateau (n = 118). The rate of PTB at <34 weeks was lowest in cases of pattern I (11.7%), followed by pattern IV (14.4%) and pattern III (20.2%), and was highest for women with pattern II (44.4%) (P < .001). In cases with pattern III (late shortening), the most important factors affecting the risk of PTB were the shortening rate, the gestational age at the onset of cervical shortening, and the initial plateau of CL. In the case of pattern IV (early shortening with a plateau), it was only the new plateau at which cervical shortening stopped that was associated with the risk of PTB., Conclusion: Changes in sonographic CL over time in twin gestations can be classified into 4 patterns, each associated with a different risk of PTB., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To determine whether the predictive accuracy of sonographic cervical length (CL) for preterm delivery (PTD) in women with threatened preterm labor (PTL) is related to gestational age (GA) at presentation., Study Design: A retrospective cohort study of all women with singleton pregnancies who presented with PTL at less than 34 + 0 weeks and underwent sonographic measurement of CL in a tertiary medical center between 2007 and 2012. The predictive accuracy of CL for PTD was stratified by GA at presentation., Results: Overall, 1077 women who presented with PTL have had sonographic measurement of CL and met the study inclusion criteria. Of those, 223 (20.7%) presented at 24 + 0-26 + 6 weeks (group 1), 274 (25.4%) at 27 + 0-29 + 6 weeks (group 2), 283 (26.3%) at 30 + 0-31 + 6 weeks (group 3), and 297 (27.6%) at 32 + 0-33 + 6 weeks (group 4). The overall performance CL as a predictive test for PTD was similar in the 4 GA groups, as reflected by the similar degree of correlation between CL with the examination to delivery interval (r = 0.27, r = 0.26, r = 0.28, and r = 0.29, respectively, P = .8), the similar area under the receiver-operator characteristic curve (0.641-0.690, 0.631-0.698, 0.643-0.654, and 0.678-0.698, respectively, P = .7), and a similar decrease in the risk of PTD of 5-10% for each additional millimeter of CL. The optimal cutoff of CL, however, was affected by GA at presentation, so that a higher cutoff of CL was needed to achieve a target negative predictive value for delivery within 14 days from presentation for women who presented later in pregnancy. The optimal thresholds to maximize the negative predictive value for delivery within 14 days were 36 mm, 32.5 mm, 24 mm and 20.5 mm for women who presented at 32 + 0 to 33 + 6 weeks, 30 + 0 to 31 + 6 weeks, 27 + 0 to 29 + 6 weeks and 24 + 0 to 26 + 6, respectively., Conclusion: CL has modest predictive accuracy in women with threatened PTL, regardless of GA at presentation. However, the optimal cutoff of CL for the purpose of clinical decision making in women with PTL needs to be adjusted based on GA at presentation., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to investigate the effect of atosiban (Tractocile; Ferring, Limhamn, Sweden), an oxytocin receptor antagonist, on uterine electrical activity in women with preterm labor and to determine whether this information can assist in the prediction of preterm delivery., Study Design: Uterine electrical activity was recorded prospectively in 21 women with preterm labor before and during treatment with Tractocile and, for purpose of comparison, in 4 pregnant women without uterine contractions to set the baseline of uterine electrical activity in a quiescent uterus. Uterine activity was recorded with a noninvasive, 9-channel recorder with an electromyography amplifier and a 3-dimensional position sensor with an automatic data analyzer. Uterine electrical activity was quantified by an electrical uterine monitor (EUM) and measured in microwatts per second (μW/s)., Results: The overall pre-Tractocile EUM index was 3.43 ± 0.58 μW/s, which was significantly higher than baseline uterine activity in women without preterm contractions (2.3 ± 0.11 μW/s; P = .001). During the administration of Tractocile, the EUM index gradually decreased in a relatively constant rate from 3.43 ± 0.58 μW/s to 2.56 ± 0.88 μW/s after 330 minutes of continuous therapy (P < .001). The peak effect of Tractocile was observed 4 hours after the initiation of treatment and was followed by a relative plateau. Women with a latency of <7 days from treatment to delivery were characterized by a distinct EUM-pattern in response to Tractocile, compared with women with a latency of ≥7 days (P < .001). A similar EUM-pattern after the administration of Tractocile was also observed for women who delivered at <37 weeks of gestation compared with the women who delivered at term., Conclusion: Tractocile reduces uterine electrical activity in women with preterm labor. This information can provide more insight into the effects of tocolytic agents and to aid in the risk stratification of preterm delivery in women with preterm contractions., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objective: The objective of the study was to assess the outcome of trial of labor after cesarean (TOLAC) in women with past failed operative vaginal delivery (OVD)., Study Design: A retrospective study of all women who underwent cesarean section (CS) because of a failed OVD in a tertiary medical center between 1996 and 2011. Women who had a subsequent delivery were identified, and the outcome of subsequent delivery was analyzed., Results: Overall, 533 women underwent CS because of failed OVD during the study period. A total of 204 women (38.3%) had a subsequent delivery, of whom 93 (45.6%) had a TOLAC and 111 (54.4%) had a repeat elective CS. The success rate in the TOLAC group was 61.3% (n = 57). The most common indication for repeat CS was lack of progress (72.3%) among the 36 women in whom TOLAC failed (38.7%). The rate of postpartum hemorrhage and prolonged maternal hospitalization was lower in the TOLAC group than in the repeat CS group (2.2% vs 10.8%, P = .02, and 0% vs 8.1%, P = .005). There were no cases of rupture or dehiscence of the uterine scar. Factors associated with failed TOLAC were the occiput-posterior position and prolonged the second stage as the indication for OVD in the index pregnancy, maternal age older than 30 years at the time of subsequent delivery, and a birthweight in the subsequent pregnancy that is higher than the birthweight in the index pregnancy., Conclusion: TOLAC in women who underwent a previous CS because of a failed OVD is associated with a relatively high success rate compared with the reported success rates among women with past CS during the second stage of labor. This information and the risk factors for TOLAC failure can be used when counseling these women regarding mode of delivery in subsequent pregnancy., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objective: To analyze pregnancy outcome in cases of isolated oligohydramnios at preterm., Methods: A retrospective cohort study of singleton pregnancies diagnosed with isolated oligohydramnios at preterm (n = 108). Pregnancy outcome was compared with a matched control group of low-risk preterm pregnancies with normal levels of amniotic fluid in a 3:1 ratio (n = 324)., Results: Pregnancies complicated by isolated oligohydramnios were characterized by a higher rate of preterm deliveries (26.9% vs 12.3%, P < .001), most of which were iatrogenic, and a higher rate of labor induction and cesarean delivery. Neonates with isolated oligohydramnios were characterized by a lower birthweight and a higher rate of neonatal morbidity. These differences were eliminated when the analysis was limited to the subgroup of pregnancies with isolated oligohydramnios that were managed expectantly and delivered spontaneously at term., Conclusion: Adverse pregnancy outcome in cases of isolated oligohydramnios diagnosed at <37 weeks appears to be related to a considerable degree to iatrogenic prematurity., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Objective: We sought to compare neonatal outcome in cases of uncomplicated preterm premature rupture of membranes (PPROM) (ie, no evidence of clinical chorioamnionitis, placental abruption, or fetal distress) with that of spontaneous preterm deliveries (PTDs) and to determine the effect of the latency period., Study Design: The study group included women with PPROM at gestational age 28⁰(/)⁷-33⁶(/)⁷ weeks (n = 488). Neonatal outcome was compared with a matched control group of women with spontaneous PTD (n = 1464)., Results: Neonates in the uncomplicated PPROM group were at increased risk for composite adverse outcome (53.7% vs 42.0%; P < .001), mortality (1.6% vs 0.0%; P < .001), respiratory morbidity (32.8% vs 26.4%; P = .006), necrotizing enterocolitis, jaundice, hypoglycemia, hypothermia, and polycythemia. Neonatal adverse outcome was more likely in cases of latency period >7 days, oligohydramnios, male fetus, and nulliparity., Conclusion: Consultation regarding prematurity-related morbidity in infants exposed to uncomplicated PPROM cannot be extrapolated from PTDs and should be stratified by the duration of the latency period and the other risk factors identified in the current study., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Objective: The purpose of this study was to evaluate pregnancy outcome in women at extremely advanced maternal age (≥ 45 years)., Study Design: We compared the condition of women aged ≥ 45 years (n = 177) in a 10:1 ratio (20-29, 30-39, and 40-44 years.). Subgroup analysis compared the condition of women aged 45-49 years with those women aged ≥ 50 years., Results: The rates of gestational diabetes mellitus and hypertensive complications were higher for the study group, compared with the whole group (17.0% vs 5.6% and 19.7% vs 4.5%, respectively; P < .001), as was the rate of preterm delivery at <37 and <34 weeks of gestation (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.2-3.6 and OR, 3.5; 95% CI, 1.4-9.0, respectively). The rates of cesarean delivery (OR, 31.8; 95% CI, 18.0-56.1), placenta previa, postpartum hemorrhage, and adverse neonatal outcome were significantly higher among the study group. The risk for gestational diabetes mellitus, preeclampsia toxemia, preterm delivery, and neonatal intensive care unit admission was increased for women aged ≥ 50 years., Conclusion: Pregnancy at extreme advanced maternal age is associated with increased maternal and fetal risk., (Copyright © 2010 Mosby, Inc. All rights reserved.)

Objective: The purpose of this study was to assess the clinical characteristics, risk factors, and effects on subsequent pregnancies of intrapartum cervical lacerations., Study Design: A retrospective study of all women who were diagnosed with clinically significant cervical lacerations from 1994-2006. Data were compared with a control group. The outcome of subsequent pregnancies for women in the study and control groups was analyzed., Results: Of 81,047 deliveries, 131 (0.16%) were complicated by cervical lacerations. With multivariate logistic regression analysis, the cervical cerclage, precipitous labor, vacuum extraction, nulliparity, and use of episiotomy were associated independently with cervical lacerations. The outcomes of subsequent pregnancies for women in the cervical-laceration (n = 42) and control (n = 518) groups were similar. There were no cases of recurrent cervical lacerations., Conclusion: Careful inspection of the cervix should be considered in cases of precipitous labor, operative vaginal delivery, or cervical cerclage during pregnancy. Intrapartum cervical lacerations do not appear to affect the outcome of subsequent pregnancies.

Objectives: This study was undertaken to evaluate the accuracy of a single sonographic estimated fetal weight at 29-34 weeks' gestation with respect to birthweight determination in diabetic pregnancies., Study Design: A retrospective cohort study of 423 diabetic pregnancies with detailed fetal measurements at 29-34 weeks' gestation. Multivariate regression analysis was used to predict the birthweight. The percentiles of the estimated fetal weight and the calculated birthweight were compared with the actual birthweight percentile., Results: The mean birthweight percentile at term was significantly higher than the estimated fetal weight percentile at 29-34 weeks' gestation in the women with poor glycemic control, but not the women with good control. On multivariate analysis, the estimated fetal weight, interval from ultrasound to delivery, hemoglobin A1C level, gestational age at ultrasound, and classification of glycemic control were independently associated with the birthweight. Both the estimated fetal weight and the calculated birthweight had a low sensitivity and a low positive predictive value for predicting large-for-gestational-age infants., Conclusion: Accelerated fetal growth is evident primarily in diabetic women with poor glycemic control. These fetuses cannot be identified by a single ultrasound examination at 29-34 weeks' gestation.

Objective: We aimed to compare glycemic control and pregnancy outcome in type I diabetic patients treated by 2 modes of treatment: multiple daily injections of insulin (MDI) and continuous subcutaneous insulin infusions (CSII)., Study Design: In a retrospective, matched-control study, patients treated by MDI were compared with patients treated by CSII in a ratio of 2:1. Level of glycemic control and pregnancy outcome was compared., Results: Overall, 90 women were evaluated; of them 30 were treated by CSII and 60 by MDI. No between-group differences were found in maternal age, nulliparity rate, severity and duration of diabetes, prepregnancy body mass index, and weight gain during pregnancy. The rate of diabetic ketoacidosis (DKA) and neonatal hypoglycemia were significantly higher in the CSII group (13% vs 2%, P = .04) and (35% vs 13%, P = .01), respectively. No significant differences were found in pregnancy outcome measures., Conclusion: In type 1 diabetes, glycemic control and pregnancy outcome are compromised, regardless of treatment modality. CSII may be associated with higher rate of both maternal DKA and neonatal hypoglycemic events.

Objective: The purpose of this study was to identify factors that predict operative vaginal delivery., Study Design: A retrospective cohort study was conducted that included all women who underwent a trial of operative vaginal delivery between 1993 and 2006 at a major tertiary center., Results: Operative vaginal delivery was attempted in 5120 of 83,351 deliveries (6.1%): 4299 vacuum extractions (84.0%) and 821 forceps deliveries (16.0%). Failures occurred in 8.6% of trials, more often with vacuum extraction (10.0% vs 1.3%; P < .001). Most vacuum extraction failures (72.6%) were followed by a trial of forceps delivery, which failed in 3.5% of cases. On multivariate logistic regression analysis, the use of forceps (vs vacuum; odds ratio [OR], 0.4; 95%CI, 0.2-0.7) and administration of analgesia (epidural: OR, 0.4 [95% CI, 0.2-0.7]; intravenous opiates: OR, 0.2 [95%CI, 0.1-0.6]) were associated with a lower risk of failure, persistent occiput posterior position (OR, 2.2; 95% CI, 1.4-3.5) and birthweight >4000 g (OR, 2.8; 95% CI, 1.6-4.9), with a higher risk., Conclusion: Fetal weight and head position should be evaluated carefully before operative vaginal delivery, and the use of analgesia should be encouraged.

Objective: We sought to investigate the relationship between prepregnancy weight, treatment modality (diet or insulin), level of glycemic control, and pregnancy outcome., Study Design: We recruited women with gestational diabetes (GDM) from inner city prenatal clinics. All women were instructed in the use of an intensified management protocol using memory reflectance meters. Outcomes were analyzed according to maternal prepregnancy body mass index (BMI, kg/m 2 ) categories: normal weight (BMI 18.5-24.9), overweight (BMI 25-29.9), and obese (BMI > or =30), and by diet or insulin therapy and glycemic control (mean blood glucose <100 mg/dL = good control). Pregnancy outcome variables included a composite outcome (at least 1 of the following: neonatal metabolic complications, large-for-gestational age or macrosomic infants, NICU admission for >24 hours, and the need for respiratory support) (not including oxygen therapy). In addition to composite outcome, a bivariate analysis was performed for each single variable, including preeclampsia and cesarean section delivery., Results: Four thousand and one women were enrolled. Obese women who achieved targeted levels of glycemic control had comparable pregnancy outcomes to normal weight and overweight women only when they were treated with insulin. Normal weight women treated with diet therapy who achieved targeted levels of glycemic control had good outcomes, but obese women treated with diet therapy who achieved targeted levels of glycemic control, nevertheless, had a 2- to 3-fold higher risk for adverse pregnancy outcome when compared with overweight and normal weight patients with well-controlled GDM. Women with GDM who failed to achieve established levels of glycemic control had significantly higher adverse pregnancy outcomes in all 3 maternal weight groups., Conclusion: In obese women with BMI > or =30 with GDM, achievement of targeted levels of glycemic control was associated with enhanced outcome only in women treated with insulin.

Objective: Untreated gestational diabetes mellitus carries significant risks of perinatal morbidity at all severity levels; treatment will enhance outcome., Study Design: A matched control of 555 gravidas, gestational diabetes mellitus diagnosed after 37 weeks, were compared with 1110 subjects treated for gestational diabetes mellitus and 1110 nondiabetic subjects matched from the same delivery year for obesity, parity, ethnicity, and gestational age at delivery. The nondiabetic subjects and those not treated for gestational diabetes mellitus were matched for prenatal visits., Results: A composite adverse outcome was 59% for untreated, 18% for treated, and 11% for nondiabetic subjects. A 2- to 4-fold increase in metabolic complications and macrosomia/large for gestational age was found in the untreated group with no difference between nondiabetic and treated subjects. Comparison of maternal size, parity, and disease severity revealed a 2- to 3-fold higher morbidity rate for the untreated groups, compared with the other groups., Conclusion: Untreated gestational diabetes mellitus carries significant risks for perinatal morbidity in all disease severity levels. Timely and effective treatment may substantially improve outcome.

Objective: We sought to investigate the association between glyburide dose, degree of severity in gestational diabetes mellitus (GDM), level of glycemic control, and pregnancy outcome in insulin- and glyburide-treated patients., Study Design: In a secondary analysis of our previous randomized study, 404 women were analyzed. The association among glyburide dose, severity of GDM, and selected maternal and neonatal factors was evaluated. Severity levels of GDM were stratified by fasting plasma glucose (FPG) from the oral glucose tolerance test (OGTT). Infants with birth weight at or above the 90th percentile were considered large-for-gestational age (LGA). Macrosomia was defined as birth weight > or =4000 g. Well-controlled was defined as mean blood glucose < or =95 mg/dL. The association between glyburide- and insulin-treated patients by severity of GDM and neonatal outcome was evaluated., Results: The dose received for the glyburide-treated patients was 2.5 mg-32%; 5 mg-23%; 10 mg-17%; 15 mg-8%; and 20 mg-20%. Patients were grouped into low (< or =10 mg) and high (>10 mg) daily dose of glyburide. A comparison between severity of the disease (fasting plasma glucose categories) and highest dose of glyburide revealed a significant difference between the low-95 FPG and the other severity categories (P = .02). Of patients in the well-controlled glycemic group, only 6% required the high dose of glyburide (>10 mg). In patients with poor glycemic control (mean blood glucose >95 mg/dL), 38% received the high dose of glyburide (P = .0001). Comparison between the high glyburide (>10 mg) and the low glyburide dosages (< or =10 mg) revealed that the rate of macrosomia was 16% vs 5% and LGA 22% vs 8%, (P = .01), respectively. No significant difference was found in composite outcome, metabolic complications, and Ponderal Index between the 2 dose groups. Stratification by disease severity revealed a significantly lower rate of LGA for both the glyburide- and insulin-treated subjects. No significant difference was found between metabolic, respiratory, and neonatal intensive care unit (NICU) for patients within each fasting plasma glucose severity category., Conclusion: Glyburide and insulin are equally efficient for treatment of GDM in all levels of disease severity. Achieving the established level of glycemic control, not the mode of pharmacologic therapy, is the key to improving the outcome in GDM.

Objectives: We sought to determine if the rate of preeclampsia is related to the severity of gestational diabetes mellitus (GDM), and if it can be decreased by optimizing glycemic control., Study Design: A retrospective analysis of prospectively collective data of 1813 patients with GDM was performed to determine the rate of preeclampsia. Patients were stratified after treatment was begun by level of glycemic control (well controlled was defined as mean blood glucose <95 mg/dL). The extent of hyperglycemia was analyzed by the level of the abnormality in the oral GTT and by the degree of abnormality of daily glucose control after treatment has begun. Severity of GDM was categorized using fasting plasma glucose (FPG) on a 3-hour oral GTT by 10 mg/dL increments., Results: Overall, preeclampsia was diagnosed in 9.6% (174/1813) of diabetic patients. The GDM subjects who developed preeclampsia were significantly younger, had a higher nulliparity rate, were more obese, and gained significantly more weight during pregnancy. However, no difference was found in glycemic profile characteristics between the 2 groups. A comparison between patients with FPG <105 and FPG >105 revealed that the rate of preeclampsia increased significantly, 7.8% vs 13.8%, (O.R 1.81, 95%CI 1.3-2.51). For GDM patients with only mild hyperglycemia (FPG <105 mg/dL), no significant difference was found in the rate of preeclampsia. Preeclampsia rate was further evaluated in relation to level of glycemic control; for the well-controlled patients (mean blood glucose [MBG] <95 mg/dL, n=994), similar rates of preeclampsia were found between each category of FPG severity. In contrast, in poorly controlled patients (MBG >95 mg/dL, n=819), a comparison between severity threshold of FPG <115 and FPG >115 revealed that the preeclampsia rate was 9.8% vs 18% (O.R 2.56, 95%C.I. 1.5-4.3). In a logistic regression model, only prepregnancy BMI (O.R 2.3, 95%CI 1.16-2.30) and severity of GDM (O.R 1.7, 95%CI 1.21-2.38) were independently and significantly associated with an increased risk of preeclampsia., Conclusion: The rate of preeclampsia is influenced by the severity of GDM and prepregnancy BMI. Optimizing glucose control during pregnancy may decrease the rate of preeclampsia, even in those with a greater severity of GDM.

Objective: A paucity of data exists concerning the normal glycemic profile in nondiabetic pregnancies. Using a novel approach that provides continuous measurement of blood glucose, we sought to evaluate the ambulatory daily glycemic profile in the second half of pregnancy in nondiabetic women., Study Design: Fifty-seven obese and normal weight nondiabetic subjects were evaluated for 72 consecutive hours with continuous glucose monitoring by measurement interstitial glucose levels in subcutaneous tissue every 5 minutes. Subjects were instructed not to modify their lifestyle or to follow any dietary restriction. For each woman, mean and fasting blood glucose values were determined; for each meal during the study period, the first 180 minutes were analyzed., Results: For the study group, the fasting blood glucose level was 75 +/- 12 mg/dL; the mean blood glucose level was 83.7 +/- 18 mg/dL; the postprandial peak glucose value level was 110 +/- 16 mg/dL, and the time interval that was needed to reach peak postprandial glucose level was 70 +/- 13 minutes. A similar postprandial glycemic profile was obtained for breakfast, lunch, and dinner. Obese women were characterized by a significantly higher postprandial glucose peak value, increased 1- and 2-hour postprandial glucose levels, increased time interval for glucose peak, and significantly lower mean blood glucose during the night. No difference was found in fasting and mean blood glucose between obese and nonobese subjects., Conclusion: Glycemic profile characterization in both obese and normal weight nondiabetic subjects provide a measure for the desired level of glycemic control in pregnancy that is complicated with diabetes mellitus.

Objective: A controversy exists regarding the time to monitor blood glucose in the diabetic pregnancy (60 or 120 minutes after meals). Using a novel approach that provides continuous measurement of blood glucose, we sought to determine postprandial glucose profile in the diabetic pregnancy., Study Design: Subjects were connected to a continuous glucose monitoring system for 72 consecutive hours. A continuous glucose monitoring system measures the interstitial glucose levels in subcutaneous tissue every 5 minutes. Women were instructed to record the time of each meal during the study period. For each meal, the first 240 minutes were analyzed., Results: Sixty-five women participated in the study: 26 women were treated by diet alone; 19 women received insulin therapy, and 20 women had type 1 diabetes mellitus. The time interval from meal to peak postprandial glucose levels was similar in all the evaluated types of diabetic pregnancies and in good and poor control insulin-treated patients with gestational diabetes mellitus (approximately 90 minutes). Failure to return to preprandial glucose values within a 3-hour observation period was identified in approximately 50% of the patients. A similar postprandial glucose peak time was obtained for breakfast, lunch, and dinner in all study groups. Postprandial hypoglycemia events were noted in approximately 10% of the meals and occurred about 160 minutes after mealtime., Conclusion: The time interval for postprandial glucose peak in diabetic pregnancies is approximately 90 minutes after meals throughout the day and is not affected by the level of glycemic control. This information should be considered in the treatment of diabetes mellitus in pregnancy.