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Objective In the OFFSITE II randomized controlled trial, outpatient cervical ripening with a Foley catheter (CF) in nulliparous patients undergoing elective induction of labor (eIOL) shortened the time from admission to delivery. Given that patients with obesity have protracted labor and higher rates of failed IOL, we sought to determine if outpatient ripening with a CF may be even more beneficial for this high-risk group. Study Design We performed a secondary analysis of the OFFSITE II randomized controlled trial. For this analysis, all patients from the primary trial were classified by their intervention assignment (inpatient vs. outpatient) and also by their admission body mass index (BMI) class (BMI ≥ 30 and BMI Results In patients with BMI ≥ 30, the primary outcome, time from admission to delivery, (18.0 [13.5–20.9] vs. 20.4 [16.6–31.3] hours, p = 0.01), as well as total hospitalization length (3.2 [2.5–3.3] vs. 3.4 [3.1–4.3] days, p = 0.02) were shorter in the outpatient group. There were no differences in rates of chorioamnionitis or endometritis in outpatient compared with inpatient CF. Furthermore, in those with a BMI ≥ 30, the cesarean rate was significantly lower with outpatient CF (19.4% vs. 44.7%, p = 0.03); it was not statistically different in patients with BMI Conclusion In this exploratory retrospective secondary analysis of the OFFSITE II randomized control trial, we found that in patients with BMI ≥ 30 undergoing eIOL, outpatient CF was associated with a lower time from L&D admission until delivery. This was also associated with a shorter time of total hospital duration and decreased the rate of cesarean, a benefit not detected in the overall analysis presented in the primary study. In nulliparas undergoing induction of labor, ripening with outpatient cervical Foley may even more significantly reduce labor duration, total hospital duration, and the rate of cesarean in patients with obesity. Key Points

Objective The aim of this study was to evaluate the association of mild gestational diabetes mellitus (GDM) and obesity with metabolic and cardiovascular markers 5 to 10 years after pregnancy. Study Design This was a secondary analysis of 5- to 10-year follow-up study of a mild GDM treatment trial and concurrent observational cohort of participants ineligible for the trial with abnormal 1-hour glucose challenge test only. Participants with 2-hour glucose tolerance test at follow-up were included. The primary exposures were mild GDM and obesity. The outcomes were insulinogenic index (IGI), 1/homeostatic model assessment of insulin resistance (HOMA-IR), and cardiovascular markers vascular endothelial growth factor, (VEGF), vascular cell adhesion molecule 1 (VCAM-1), cluster of differentiation 40 ligand (CD40L), growth differentiation factor 15 (GDF-15), and suppression of tumorgenesis 2 (ST-2). Multivariable linear regression estimated the association of GDM and obesity with biomarkers. Results Of 951 participants in the parent study, 642 (68%) were included. Lower 1/HOMA-IR were observed in treated and untreated GDM groups, compared with non-GDM (mean differences, −0.24 and −0.15; 95% confidence intervals [CIs], −0.36 to −0.12 and −0.28 to −0.03, respectively). Lower VCAM-1 (angiogenesis) was observed in treated GDM group (mean difference, −0.11; 95% CI, −0.19 to −0.03). GDM was not associated with IGI or other biomarkers. Obesity was associated with lower 1/HOMA-IR (mean difference, −0.42; 95% CI, −0.52 to −0.32), but not other biomarkers. Conclusion Prior GDM and obesity are associated with more insulin resistance but not insulin secretion or consistent cardiovascular dysfunction 5 to 10 years after delivery. Key Points

Objective: To describe cesarean delivery rates and indications at a single center in order to assess the impact of the guidelines published by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine on trends in labor management. Study Design: Retrospective cohort study of patients ≥23 weeks' gestation delivering at a single tertiary care referral center from 2013-2018. Demographic characteristics, mode of delivery, and main indication for cesarean delivery were ascertained by individual chart review. Cesarean delivery indications (mutually exclusive) were: repeat cesarean delivery, non-reassuring fetal status, malpresentation, maternal indications (e.g., placenta previa or genital herpes simplex virus), failed labor (any stage labor arrest), or other (i.e., fetal anomaly, elective). Polynomial (cubic) regression models were used to model rates of cesarean delivery and indications over time. Subgroup analyses further examined trends in nulliparous women. Results: Of the 24,637 patients delivered during the study period, 24,050 were included in the analysis; 7,835 (32.6%) had a cesarean delivery. The rates of overall cesarean delivery were significantly different over time (p

Objective: To measure the association between hypertensive disorders of pregnancy (HDP) and long-term maternal metabolic and cardiovascular biomarkers. Study Design: Follow-up study of patients who completed glucose tolerance testing 5-10 years after enrollment in a mild GDM treatment trial or concurrent non-GDM cohort. Maternal serum insulin concentrations and cardiovascular markers VCAM-1, VEGF, CD40L, GDF-15 and ST-2 were measured, and insulinogenic index (IGI, pancreatic -cell function) and 1/HOMA (insulin resistance) were calculated. Biomarkers were compared by presence of HDP (gestational hypertension or preeclampsia) during pregnancy. Multivariable linear regression estimated the association of HDP with biomarkers, adjusting for GDM, baseline BMI, and years since pregnancy. Results: Of 642 patients, 66 (10%) had HDP: 42 with gestational hypertension and 24 with preeclampsia. Patients with HDP had higher baseline and follow-up BMI, higher baseline BP and more chronic hypertension at follow-up. HDP was not associated with metabolic or cardiovascular biomarkers at follow-up. However, when HDP type was evaluated, patients with preeclampsia had lower GDF-15 levels (oxidative stress/cardiac ischemia), compared to patients without HDP (adjusted mean difference -0.24, 95%CI -0.44, -0.03). There were no differences between gestational hypertension and no HDP. Conclusion: In this cohort, metabolic and cardiovascular biomarkers 5-10 years after pregnancies did not differ by HDP. Patients with preeclampsia may have less oxidative stress/cardiac ischemia postpartum; however, this may have been observed due to chance alone given multiple comparisons. Longitudinal studies are needed to define the impact of HDP during pregnancy and interventions postpartum.

Objective This study aimed to estimate the association between number of maternal comorbidities and duration of expectant management and perinatal outcomes in patients with preeclampsia with severe features. Study Design Retrospective cohort of patients with preeclampsia with severe features delivering live, nonanomalous singletons at 23 to 342/7 weeks' gestation at a single center from 2016 to 2018. Patients delivered for an indication other than severe preeclampsia were excluded. Patients were categorized based on the number (0, 1, or ≥2) of comorbidities present: chronic hypertension, pregestational diabetes, chronic kidney disease, and systemic lupus erythematosus. The primary outcome was proportion of potential expectant management time achieved, that is, days of expectant management achieved divided by total potential expectant management time (days from severe preeclampsia diagnosis to 340/7 weeks). Secondary outcomes included delivery gestational age, days of expectant management, and perinatal outcomes. Outcomes were compared in bivariable and multivariable analyses. Results Of 337 patients included, 167 (50%) had 0, 151 (45%) had 1, and 19 (5%) had ≥2 comorbidities. Groups differed with respect to age, body mass index, race/ethnicity, insurance, and parity. The median proportion of potential expectant management achieved in this cohort was 1.8% (interquartile range: 0–15.4), and did not differ by number of comorbidities (adjusted β: 5.3 [95% confidence interval [CI]: −2.1 to 12.9] for 1 comorbidity vs. 0 and adjusted β: −2.9 [95% CI: −18.0 to 12.2] for ≥2 comorbidities vs. 0). There was no difference in delivery gestational age or duration of expectant management in days. Patients with ≥2 (vs. 0) comorbidities had higher odds of composite maternal morbidity (adjusted odds ratio: 3.0 [95% CI: 1.1–8.2]). There was no association between number of comorbidities and composite neonatal morbidity. Conclusion Among patients with preeclampsia with severe features, the number of comorbidities was not associated with duration of expectant management; however, patients with ≥2 comorbidities had higher odds of adverse maternal outcomes. Key Points

Objective Lymphangioleiomyomatosis (LAM) is a rare, multisystem disease that primarily affects women of reproductive age. Disease progression has been linked to estrogen exposure, and as such many patients are advised to avoid pregnancy. Data are limited regarding the interaction between LAM and pregnancy, and as such we performed a systematic review to summarize available literature reporting outcomes of pregnancies complicated by maternal LAM. Study Design This was a systematic review including randomized controlled trials, observational studies, systematic reviews, case reports, clinical practice guidelines, and quality improvement studies with full-text manuscripts or abstracts in the English language with primary data on pregnant or postpartum patients with LAM. The primary outcome was maternal outcomes during pregnancy as well as pregnancy outcomes. Secondary outcomes were neonatal outcomes and long-term maternal outcomes. This search occurred in July 2020 and included MEDLINE, Scopus, clinicaltrials.gov, Embase, and Cochrane Central. Risk of bias was ascertained using the Newcastle–Ottawa Scale. Our systematic review was registered with PROSPERO as protocol number CRD 42020191402. Results A total of 175 publications were identified in our initial search; ultimately 31 studies were included. Six (19%) studies were retrospective cohort studies and 25 (81%) studies were case reports. Patients diagnosed during pregnancy had worse pregnancy outcomes compared to those diagnosed with LAM prior to pregnancy. Multiple studies reported a significant risk of pneumothoraces during pregnancy. Other significant risks included preterm delivery, chylothoraces, and pulmonary function deterioration. A proposed strategy for preconception counseling and antenatal management is provided. Conclusion Patients diagnosed with LAM during pregnancy generally experience worse outcomes including recurrent pneumothoraces and preterm delivery as compared to patients with a LAM diagnosis prior to pregnancy. Given that there are limited studies available, and that the majority are low-quality evidence and subject to bias, further investigation of the interaction between LAM and pregnancy is warranted to guide patient care and counseling. Key Points

We sought to determine if variation in head circumference (HC) within the range of normal (5th-10th and 90th-95th percentile) is associated with poor neurodevelopmental outcomes (NDO), which defined as mild or moderate delay by Bayley II psychometrics (BSID-II).This is a secondary analysis of a randomized controlled trial assessing the benefits of magnesium for the prevention of cerebral palsy. Fetuses with a normal HC at birth defined as within 5th to 95th percentile were included. NDO were assessed at age 2 with BSID-II. Moderate delay was defined as a score70 and mild delay as85. HC was classified as small normal (5th-10th percentile), normal (10th-90th percentile), and large normal (90th-95th percentile). Logistic regression models adjusted for confounding. Linear regression models estimated the impact for every 1 cm of change in HC.Of 1,236 included infants, 111 (8%) had small normal HC; 1,058 (85%) had normal HC; and 67 (5%) had large normal HC. Baseline characteristics were similar between groups. There was no association with changes in HC within the range of normal and developmental indices. When considered as a continuous variable, every 1 cm increase in HC was also not associated with a significant change in developmental indices.Within the normal range (5th-95th percentile), changes in HC did not correlate with changes in NDO at 2 years as measured by Bayley II scales.· It is unknown if variations in normal HC are associated with poor neurodevelopmental outcomes.. · Alterations in HC within the range of normal (5th-95th percentile) are not associated with adverse NDO.. · When considered as a continuous variable, a 1 cm increase in HC is not associated with adverse NDO.. · Changes in HC within the range of normal do not appear to be a pathologic change altering NDO..

Objective In the antenatal late preterm steroids (ALPS) trial betamethasone significantly decreased short-term neonatal respiratory morbidity but increased the risk of neonatal hypoglycemia, diagnosed only categorically ( Study Design Secondary analysis of infants from ALPS, a multicenter trial randomizing women at risk for late preterm delivery to betamethasone or placebo. This study was a reabstraction of all available charts from the parent trial, all of which were requested. Unreviewed charts included those lost to follow-up or from sites not participating in the reabstraction. Duration of hypoglycemia ( Results Of 2,831 randomized, 2,609 (92.2%) were included. There were 387 (29.3%) and 223 (17.3%) with hypoglycemia in the betamethasone and placebo groups, respectively (relative risk [RR]: 1.69, 95% confidence interval [CI]: 1.46–1.96). Hypoglycemia generally occurred in the first 24 hours in both groups: 374/385 (97.1%) in the betamethasone group and 214/222 (96.4%) in the placebo group (p = 0.63). Of 387 neonates with hypoglycemia in the betamethasone group, 132 (34.1%) received treatment, while 73/223 (32.7%) received treatment in placebo group (p = 0.73). The lowest recorded blood sugar was similar between groups. Most hypoglycemia resolved by 24 hours in both (93.0 vs. 89.3% in the betamethasone and placebo groups, respectively, p = 0.18). Among infants with hypoglycemia in the first 24 hours, the time to resolution was shorter in the betamethasone group (2.80 [interquartile range: 2.03–7.03) vs. 3.74 (interquartile range: 2.15–15.08) hours; p = 0.002]. Persistence for >72 hours was rare and similar in both groups, nine (2.4%, betamethasone) and four (1.9%, placebo, p = 0.18). Conclusion In this cohort, hypoglycemia was transient and most received no treatment, with a quicker resolution in the betamethasone group. Prolonged hypoglycemia was uncommon irrespective of steroid exposure. Key Points

Objective The aim of the study is to evaluate the association between the amount of proteinuria at the time of diagnosis of preeclampsia with severe features (severe preeclampsia [SPE]) and duration of expectant management (EM) and other perinatal outcomes. Study Design This is a retrospective cohort study of patients with SPE delivering live, non-anomalous singletons at 230/7 to 342/7 weeks' estimated gestational age (EGA) at a single tertiary center 2016 to 2018. Patients with proteinuria assessment (24-hour total urine protein or urine protein-to-creatinine ratio extrapolation) within 3 days of SPE diagnosis were included. Patients delivered for an indication other than SPE were excluded. Patients were categorized by amount of proteinuria (mg): none (≤300), mild (301–1,000), moderate (1,001–3,000), and massive (≥3,001). The primary outcome was the proportion of potential EM time achieved (%EM), i.e., days of EM divided by days from SPE diagnosis to 34 weeks. Secondary outcomes included delivery EGA, days of EM, and perinatal outcomes. Bivariable and multivariable analyses compared outcomes across groups. Results Of 295 patients included, 21% had no proteinuria, 33% mild, 19% moderate, and 27% massive. Groups differed by EGA at diagnosis, age, parity, chronic hypertension, and renal disease. %EM was not significantly different between groups (adjusted β coefficient 4.1 [95% CI −5.3, 13.5] for mild proteinuria vs. none, −4.1 [95% CI −14.9, 6.6] for moderate proteinuria vs. none, and −5.6 [95% CI −16.0, 4.7] for massive proteinuria vs. none). Increasing proteinuria was associated with earlier delivery EGA but only days of EM in the mild versus no proteinuria groups. There was no significant association between proteinuria and maternal composite morbidity, but patients with mild and massive proteinuria had higher odds of neonatal composite morbidities compared with no proteinuria. Conclusion Among patients with SPE, proteinuria level was not consistently associated with duration of EM. However, patients with the greatest amounts of proteinuria may have worse neonatal and selected maternal outcomes. Key Points

Objective We sought to determine if there is an association between fibroblast growth factor 21 (FGF21) levels and a history of gestational diabetes mellitus (GDM) in women with and without metabolic dysfunction, defined as a diagnosis of metabolic syndrome or type 2 diabetes (T2DM), 5 to 10 years following participation in a multiple cohort GDM study. Study Design At 5 to 10 years after index pregnancy, women underwent a follow-up visit and were categorized as having no metabolic syndrome, metabolic syndrome, or T2DM. FGF21 levels were compared between women who did and did not have a history of GDM using multivariable linear regression. Results Among 1,889 women, 950 underwent follow-up and 796 had plasma samples analyzed (413 GDM and 383 non-GDM). Total 30.7% of women had been diagnosed with T2DM or metabolic syndrome. Overall, there was no difference in median FGF21 levels in pg/mL between the prior GDM and non-GDM groups (p = 0.12), and the lack of association was observed across all three metabolic categories at follow-up (p for interaction = 0.70). Conclusion There was no association between FGF21 levels and prior history of mild GDM in women with and without metabolic dysfunction 5 to 10 years after the index pregnancy (ClinicalTrials.gov number, NCT00069576, original trial).

Objective The aim of the study is to evaluate the association between amniotomy at various time points during labor induction and maternal and neonatal outcomes among term, nulliparous women. Study Design Secondary analysis of a randomized trial of term labor induction versus expectant management in low-risk, nulliparous women (2014–2017) was conducted. Women met inclusion criteria if they underwent induction ≥38 weeks' gestation using oxytocin with documented time and type of membrane rupture. Women with antepartum stillbirth or fetal anomaly were excluded. The primary outcome was cesarean delivery. Secondary outcomes included maternal and neonatal complications. Maternal and neonatal outcomes were compared among women with amniotomy versus women with intact membranes and no amniotomy at six 2-hour time intervals: before oxytocin initiation, 0 to Results Of 6,106 women in the parent trial, 2,854 (46.7%) women met inclusion criteria. Of these 2,340 (82.0%) underwent amniotomy, and majority of the women had amniotomy performed between 2 and 24 hours. Amniotomy at time intervals ≥2 hours and 3 days. Amniotomy was not associated with postpartum or neonatal complications. Conclusion Among a contemporary cohort of nulliparous women undergoing term labor induction, amniotomy was associated with either lower or similar odds of cesarean delivery and other adverse outcomes, compared with no amniotomy.

Our understanding of COVID-19 in pregnant and postpartum women is rapidly evolving. We present a case from March 2020 of a 25-year-old G2P2002 whose delivery was complicated by preeclampsia with severe features who presented to the emergency department 9 days after cesarean delivery with chest tightness and dyspnea on exertion. On presentation she had severe hypertension, pulmonary edema, elevated brain natriuretic peptide, and high-sensitivity troponin-I, suggesting a diagnosis of hypertensive emergency leading to heart failure with a preserved ejection fraction resulting in pulmonary edema and abnormal cardiac screening tests. However, bilateral opacities were seen on a computed tomography of the chest, and COVID-19 testing was positive. A high index of suspicion for both COVID-19 and cardiovascular complications are critical for optimal patient outcomes and protection of health care workers.

This study aimed to evaluate maternal and neonatal outcomes by method of cervical ripening for labor induction among low-risk nulliparous individuals. This is a secondary analysis of a multicenter randomized trial of labor induction at 39 weeks versus expectant management in low-risk nulliparous participants. Participants undergoing cervical ripening for labor induction in either group were included. Participants were excluded for preripening membrane rupture, abruption, chorioamnionitis, fetal demise, or cervical dilation ≥3.5 cm. Cervical ripening was defined by the initial method used: prostaglandin only (PGE; referent), Foley with concurrent prostaglandin (Foley-PGE), Foley only (Foley), and Foley with concurrent oxytocin (Foley-oxytocin). Coprimary outcomes were adverse maternal and neonatal composites. Secondary outcomes included cesarean delivery and length of labor and delivery (LD) stay. Multivariable analysis was used to adjust for patient characteristics. Of 6,106 participants included in the trial, 2,376 (38.9%) met criteria for this analysis. Of these, 1,247 (52.4%) had cervical ripening with PGE, 290 (12.2%) had Foley-PGE, 385 (16.2%) had Foley, and 454 (19.1%) had Foley-oxytocin. The maternal composite outcome was similar among participants who received Foley-PGE (24.1%, adjusted relative risk [aRR] = 1.21, 95% confidence interval [CI]: 0.96-1.52), Foley (21.3%, aRR = 1.16, 95% CI: 0.92-1.45), or Foley-oxytocin (19.4%, aRR = 1.04, 95% CI: 0.83-1.29), compared with PGE (19.7%). The neonatal composite outcome was less frequent in participants who received the Foley-PGE (2.4%, aRR = 0.35, 95% CI: 0.16-0.75) or Foley (3.6%, aRR = 0.51, 95% CI: 0.29-0.89) but did not reach statistical significance for participants who received Foley-oxytocin (4.6%, aRR = 0.63, 95% CI: 0.40-1.01) compared with PGE only (6.8%). Participants who received Foley-PGE or Foley-oxytocin had a shorter LD stay (adjusted mean difference = -1.97 hours, 95% CI: -3.45 to -0.49 and -5.92 hours, 95% CI: -7.07 to -4.77, respectively), compared with PGE. In term low-risk nulliparous participants, Foley alone or concurrent with PGE is associated with a lower risk of adverse neonatal outcomes than with PGE alone. Length of LD stay was the shortest with concurrent Foley-oxytocin.· Adverse maternal outcomes are similar among different methods of cervical ripening in low-risk women.. · Adverse neonatal outcomes are less frequent with use of Foley alone or in combination with PGE.. · The use of Foley alone, or in combination with other agents, appears to be beneficial..

Objective This study aimed to evaluate the association between clinical and examination features at admission and late preterm birth. Study Design The present study is a secondary analysis of a randomized trial of singleton pregnancies at 340/7 to 365/7 weeks' gestation. We included women in spontaneous preterm labor with intact membranes and compared them by gestational age at delivery (preterm vs. term). We calculated a statistical cut-point optimizing the sensitivity and specificity of initial cervical dilation and effacement at predicting preterm birth and used multivariable regression to identify factors associated with late preterm delivery. Results A total of 431 out of 732 (59%) women delivered preterm. Cervical dilation ≥ 4 cm was 60% sensitive and 68% specific for late preterm birth. Cervical effacement ≥ 75% was 59% sensitive and 65% specific for late preterm birth. Earlier gestational age at randomization, nulliparity, and fetal malpresentation were associated with late preterm birth. The final regression model including clinical and examination features significantly improved late preterm birth prediction (81% sensitivity, 48% specificity, area under the curve = 0.72, 95% confidence interval [CI]: 0.68–0.75, and p-value Conclusion Four in 10 women in late-preterm labor subsequently delivered at term. Combination of examination and clinical features (including parity and gestational age) improved late-preterm birth prediction.

Objective The main purpose of this article is to evaluate whether identification and treatment of women with mild gestational diabetes mellitus (GDM) during pregnancy affects subsequent maternal body mass index (BMI), anthropometry, metabolic syndrome, and risk of diabetes. Study Design This is a follow-up study of women who participated in a randomized controlled treatment trial for mild GDM. Women were enrolled between 5 and 10 years after their index pregnancy. Participants underwent blood pressure, height, weight, and anthropometric measurements by trained nursing personnel using a standardized approach. A nurse-assisted questionnaire regarding screening and treatment of diabetes or hypercholesterolemia, diet, and physical activity was completed. Laboratory evaluation included fasting serum glucose, fasting insulin, oral glucose tolerance test, and a lipid panel. Subsequent diabetes, metabolic syndrome, obesity, and adiposity in those diagnosed with mild GDM and randomized to nutritional counseling and medical therapy (treated) were compared with those who underwent routine pregnancy management (untreated). Multivariable analyses were performed adjusting for race/ethnicity and years between randomization and follow-up visit. Results Four-hundred fifty-seven women with mild GDM during the index pregnancy were included in this analysis (243 treated; 214 untreated) and evaluated at a median 7 years after their index pregnancy. Baseline and follow-up characteristics were similar between treatment groups. Frequency of diabetes (9.2 vs. 8.5%, p =0.80), metabolic syndrome (32.2 vs. 34.3%, p =0.63), as well as adjusted mean values of homeostasis model assessment for insulin resistance (2.5 vs. 2.3, p =0.11) and BMI (29.4 vs. 29.1 kg/m2, p =0.67) were also not different. Conclusion Identification and treatment of women with mild GDM during pregnancy had no discernible impact on subsequent diabetes, metabolic syndrome, or obesity 7 years after delivery.

Objective The objective was to estimate the optimal screen-positive 1-hour 50 g glucose challenge test (GCT) threshold for gestational diabetes (GDM) and predictive characteristics of increasing screen-positive GCT threshold values (135–199 mg/dL) for GDM. Study Design It is a secondary analysis of a multicenter mild GDM study. At 24 to 30 weeks' gestation, women with elevated GCT (135–199 mg/dL) completed a diagnostic 3-hour oral glucose tolerance test (OGTT). A novel change-point analysis method was used to compare the GDM rates for the adjacent GCT values, delineating categories of changing risk such that values within categories have equal risk for GDM. Positive (PPV) and negative (NPV) predictive values for GDM were computed for increasing GCT cut-offs. Results In 7,280 women with both GCT (135–199 mg/dL) and OGTT results, 4 GDM risk-equivalent GCT categories were identified with escalations at 144, 158, and 174 mg/dL (all p-values Conclusion Elevated GCT cut-off values between 135 and 143 mg/dL may carry equivalent GDM risk. No threshold GCT value

Objective The aim of the article is to determine whether maternal body mass index (BMI) influences the beneficial effects of diabetes treatment in women with gestational diabetes mellitus (GDM). Study Design Secondary analysis of a multicenter randomized treatment trial of women with GDM. Outcomes of interest were elevated umbilical cord c-peptide levels (> 90th percentile 1.77 ng/mL), large for gestational age (LGA) birth weight (> 90th percentile), and neonatal fat mass (g). Women were grouped into five BMI categories adapted from the World Health Organization International Classification of normal, overweight, and obese adults. Outcomes were analyzed according to treatment group assignment. Results A total of 958 women were enrolled (485 treated and 473 controls). Maternal BMI at enrollment was not related to umbilical cord c-peptide levels. However, treatment of women in the overweight, Class I, and Class II obese categories was associated with a reduction in both LGA birth weight and neonatal fat mass. Neither measure of excess fetal growth was reduced with treatment in normal weight (BMI Conclusion There was a beneficial effect of treatment on fetal growth in women with mild GDM who were overweight or Class I and Class II obese. These effects were not apparent for normal weight and very obese women.

Objective To evaluate subsequent pregnancy outcomes in women previously identified during an index pregnancy to have subclinical hypothyroidism (SCH). Study Design From 2000 to 2003, thyroid analytes were measured in 17,298 women. Using their index pregnancy thyroid-analyte classification, pregnancy outcomes were compared between the returning cohorts. Results There were 6,985 women previously screened and subsequently delivered at our hospital though 2011 with 230 (3.3%) designated to have SCH and 6,645 (95.1%) euthyroid. Significant differences between the two cohorts included risk for diabetes (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.2 to 2.7, p = 0.005), gestational diabetes (OR 1.74, 95% CI 1.13 to 2.69, p = 0.015), and stillbirth (OR 3.5, 95% CI 1.05 to 11.68, p = 0.042). After adjustment, the increased likelihood of diabetes (adjusted OR 1.58, 95% CI 1.04 to 2.40, p = 0.032) and stillbirth (adjusted OR 3.41, 95% CI 1.01 to 11.49, p = 0.048) persisted. Conclusions Women identified during a previous pregnancy with SCH are at increased risk for some adverse perinatal outcomes during a subsequent pregnancy.

Gestational diabetes mellitus (GDM) affects 2 to 5% of pregnancies depending on the population; some groups have an incidence as high as 14%.1,2 The American College of Obstetricians and Gynecologists states all pregnant women should be screened for GDM either by history, clinical risk factors, or laboratory screening tests.3 Several recent large studies have evaluated the effects of maternal hyperglycemia and pregnancy outcomes. These trials demonstrated treatment of even mild GDM reduced the risks of fetal macrosomia, large-for-gestational-age infants, shoulder dystocia, cesarean delivery, and hypertensive disorders.4,5 There have been fewer research studies examining the impact of maternal hypoglycemia on pregnancy outcomes, but this could potentially impact fetal growth. Several placental hormones including growth hormone, corticotropin-releasing hormone, chorionic somatomammotropin, and progesterone contribute to insulin resistance in pregnancy. Cytokines and tumor necrosis factor-α also contribute to insulin resistance in pregnancy.6 Metabolic changes in pregnancy reflect a patient’s pregravid metabolic status, and therefore the glucose loading test (GLT) may give insight on metabolic profiles outside of pregnancy.7 Altered glucose production and insulin resistance have been studied in hyperglycemic pregnancy states and their relationship to maternal and neonatal outcomes, but less is known about the converse state. Table 1 shows a summary of previous work examining hypoglycemia and the outcomes. Early studies stratified study and control groups by those with intrauterine growth restriction or low-birth-weight infants and then studied their glucose test results.8–10 More recent studies have looked at outcomes of those with mild hypoglycemia, but both studies included those with elevated values on the glucose test in their control group.11,12 However, women with even a single abnormal value on the glucose tolerance test are at risk for macrosomia, neonatal morbidity, cesarean delivery, and preeclampsia, which could complicate the comparison between a low GLT value and other values.13,14 The objective of this study was to evaluate the relationship between a low value (less than 90 mg/dL) on the maternal GLT and maternal and neonatal morbidity outcomes compared with women with a GLT value 90 to 119 mg/dL. Table 1 Summary of previous work examining the effects of maternal hypoglycemia