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This study aimed to investigate the association between maternal insulin resistance (IR) in the late second trimester and pregnancy outcomes, as well as to identify risk factors of IR among women with gestational diabetes mellitus (GDM).A retrospective study was conducted among 2647 women diagnosed with GDM. IR was evaluated using the homeostasis model assessment method for IR (HOMA-IR) in the late second trimester (between 24 and 28 weeks), and the lipid profiles were measured at the same time. Patients were divided into groups based on quartiles of HOMA-IR. The information on pregnancy outcomes and risk factors was extracted from the medical records of all participants and entered electronically. Logistic regression models were used to analyze the associations between HOMA-IR and pregnancy outcomes, as well as the associations between risk factors and HOMA-IR.Greater IR was associated with cesarean delivery, preterm delivery, macrosomia, and large for gestational age newborns, but only significantly associated with preterm delivery after adjustment for potential confounders (P .001). Prepregnancy body mass index (BMI), weight gain before diagnosis of GDM, and triglycerides were significantly related with IR in the late second trimester (P .001). Besides, the total area under the curve of the diagnostic 75-g oral glucose tolerance test and glycosylated hemoglobin A1c increased from the lowest to the highest HOMA-IR groups.Increasing IR in the late second trimester predicts adverse pregnancy outcomes especially for preterm delivery in women with GDM. Additionally, prepregnancy BMI and weight gain before diagnosis of GDM are independent risk factors for the development of IR.背景: 本研究旨在探讨妊娠期糖尿病(gestational diabetes mellitus, GDM)患者中孕期后期的胰岛素抵抗水平(insulin resistance, IR)与其妊娠结局的关系, 及GDM患者IR相关的危险因素。 方法: 本研究为回顾性研究, 共纳入2647名GDM患者。回顾临床资料, 采用妊娠24至28周指标计算稳态模型评估IR水平(homeostasis model assessment insulin resistance, HOMA-IR)以评价患者中孕期后期IR水平, 并于同期检测患者血脂水平。根据HOMA-IR的四分位值将患者分为四组。患者的妊娠结局及相关危险因素由患者病历提取并电子录入。Logistics回归模型被用于分析HOMA-IR与妊娠结局的关系, 及各危险因素与HOMA-IR的关系。 结果: 更高水平的IR与剖宫产分娩、早产、巨大儿及大于胎龄儿相关, 但经混杂因素校正后仅与早产结局显著相关(P.001)。孕前体重指数(body mass index, BMI)、GDM诊断前孕期体重增长及甘油三酯水平与中孕期后期的IR水平显著相关(P.001)。此外, 75克口服糖耐量诊断试验曲线下面积与糖化血红蛋白A1c水平在HOMA-IR四分组中逐渐升高。 结论: 中孕期后期IR水平增加可预测GDM患者不良妊娠结局特别是早产的发生。另外, 孕前BMI及GDM诊断前孕期体重增长是中孕期后期高IR水平的独立危险因素。.

The "delayed infection hypothesis" states that a paucity of infections in early childhood may lead to higher risks of childhood leukemia (CL), especially acute lymphoblastic leukemia (ALL). Using prospectively collected data from six population-based birth cohorts we studied the association between birth order (a proxy for pathogen exposure) and CL. We explored whether other birth or parental characteristics modify this association. With 2.2 × 106 person-years of follow-up, 185 CL and 136 ALL cases were ascertained. In Cox proportional hazards models, increasing birth order (continuous) was inversely associated with CL and ALL; hazard ratios (HR) = 0.88, 95% confidence interval (CI): (0.77-0.99) and 0.85: (0.73-0.99), respectively. Being later-born was associated with similarly reduced hazards of CL and ALL compared to being first-born; HRs = 0.78: 95% CI: 0.58-1.05 and 0.73: 0.52-1.03, respectively. Successive birth orders were associated with decreased CL and ALL risks (P for trend 0.047 and 0.055, respectively). Multivariable adjustment somewhat attenuated the associations. We found statistically significant and borderline interactions between birth weight (p = 0.024) and paternal age (p = 0.067), respectively, in associations between being later-born and CL, with the lowest risk observed for children born at

Objective To assess potential risk factors in identifying women at risk for gestational diabetes mellitus (GDM). Methods The present study included data collected as part of a prospective cohort study, and included women with singleton pregnancies who underwent initial prenatal examination at a tertiary women and children's hospital in Guangzhou, China between February 1, 2012, and December 31, 2015. Maternal characteristics and medical history were investigated to evaluate associations with GDM. A risk factor scoring system for the prediction of GDM was generated using logistic regression. Results Overall, 1129 (13.5%) of 8381 women were diagnosed with GDM. Women older than 35 years had a 3.95‐fold increased risk of GDM (95% confidence interval 2.80–5.58) compared with women aged 16–25 years; obese women had a 6.54‐fold higher risk (95% confidence interval 3.50–12.23) compared with underweight women. A risk scoring system was established based on age, body mass index, family history of diabetes, weight gain, and history of GDM. Screening for women with a score of 12 or more would have reduced the number undergoing oral glucose tolerance testing by 2131 (25.4%) patients with a sensitivity of 87% for GDM detection. Conclusion The assessment of risk factors for GDM could provide a foundation for improving risk‐based screening strategies in this and similar populations.

Key Content Cardiovascular diseases are the leading causes of death in women and account for the majority of deaths in women living in the UK. Pregnancy is a ‘stress test' for cardiometabolic conditions, identifying women at increased risk during and after pregnancy. Antenatal and postnatal care may therefore be key times for primary and secondary prevention. Given the growing burden of cardiometabolic diseases, pressure is mounting to integrate screening, management and preventative programs into maternity services. Learning Objectives Be familiar with the long‐term consequences that can follow gestational diabetes and hypertensive diseases of pregnancy. Understand the evidence for interventions before and after birth to prevent future morbidity and mortality. Recognise the important role of obstetricians in linking secondary care with primary and preventative care services to prevent cardiovascular and metabolic diseases. Ethical Issues What is the role of the obstetrician in contributing to women's lifelong wellbeing?

Key content There are currently more than 100 different population-based and customised charts in use, hence definitions of small-for-gestational-age (SGA) are inconsistent. Over 130 countries have adopted the World Health Organization Child Growth Standards. These standards recognise that all children can achieve similar growth if environment, nutrition and health are optimal. The INTERGROWTH-21st Project was a large-scale, multicountry study that measured fetal growth of babies in utero and at birth in mothers in whom environmental, social, medical and pregnancy conditions were optimal. International standards for fetal measurement and the assessment of newborn size at birth will enable continuity of measurement from the pregnancy to childhood. Learning objectives Understand that 97% of variation in fetal growth is caused by factors unrelated to ethnicity. When conditions for growth are optimal, fetal growth is strikingly similar around the world. Ethical issues Consider poor fetal growth as a human rights issue: what is the legacy for individuals and societies where undernutrition has occurred in the first 1000 days of life? Recognise that, as obstetricians, we have a duty to help the most disadvantaged. The practice of ‘customising’ for ethnicity could normalise suboptimal growth.

Fetal measurements have been a contentious issue in ultrasound departments worldwide for decades. With a plethora of literature on measuring planes, mathematical formulae, local charts, and differences in fetal size due to various factors, deciding which charts to use can be confusing. Australia has not been immune to this issue. In 2001, ASUM recommended the use of the Campbell Westerway charts for CRL, BPD, OFD, HC, AC, FL & HL, which were formulated from an Australian population. Despite this recommendation, there are currently at least eight fetal growth charts in clinical use around Australia. 1 Unfortunately, it is not uncommon to find different charts on different machines within the same department, which is confusing for follow‐up growth studies, and affects parents, clinicians and researchers alike. For example, a baby diagnosed as small for gestational age (SGA) by one practitioner is later that day found to be ‘normal’ with a different reference chart at the referral hospital. This makes counselling challenging: why does this difference exist? Is it due to the chart or the quality of scanning? Is the baby at risk or not? The issue illustrates the problem of a lack of uniform ultrasound reporting, which may be particularly noticeable in countries like Australia where scans are commonly performed in small private practices. In general terms, fetal growth can be assessed using charts that are: 1 Derived from the observed distributions of fetal size for gestational age in a defined population 2 Customised on the basis of maternal characteristics such as maternal parity, height and ethnicity including an estimate of fetal weight based on Hadlock's proportionality equation 3 Standards derived from a healthy population purposely selected to reflect optimal growth, based on observed measurements of fetuses that are free from adverse constraints on growth and which are independent of time or place. SGA is most commonly defined as the 10th centile of estimated fetal weight (EFW) or abdominal circumference (AC). It must be realised that the apparent ‘prevalence’ of SGA will always be close to the 10th centile when reference or customised charts are used. This is despite the fact that the prevalence of other perinatal conditions differs greatly around the world: for example, differences in rates of pre‐eclampsia or gestational diabetes are readily accepted, without a call for local definitions, demonstrating the illogical nature of insisting on an SGA prevalence that is “fixed” at 10%. So which fetal biometry charts should be used from the hundreds available around the world? After over five decades of obstetric ultrasound there has been no implementation of an international standard. Contrast this with the consensus on optimal growth in paediatrics. Since the 1970s, it has been observed that growth in children depends more on their environment and nutritional state, than ethnic origin. 2 In 1996, the WHO Multicentre Growth Reference Study (MGRS) was established to prove whether this hypothesis was indeed correct for babies born in diverse populations around the world. Across six countries, researchers followed the growth and development of 8406 healthy, breast‐fed babies until 5 years of age. 3 They demonstrated that, under such conditions, growth was remarkably similar in childhood. 4 This led to the release of the WHO Child Growth Standards in 2006 and these have subsequently been adopted in over 130 countries. 5 In Australia, national unification of child growth monitoring occurred in 2012, when the NHMRC recommended the WHO Child Growth Standards for use in all infants aged 0 to 2 years of age. 6 The current situation in fetal medicine Identifying babies experiencing poor or excessive growth in utero is challenging. Despite ASUM recommending the Campbell Westerway charts in 2000,7 there has been no consensus on fetal growth monitoring, no publication of an ‘Australian standard’, and consequently several charts have been used. For most practitioners, the choice of fetal growth chart is determined either by their institutional protocol, professional society, imaging software program, or the default chart installed by the ultrasound machine manufacturer. However, charts differ greatly not only in the centile thresholds and trajectories, but also the quality of the studies upon which they were based: two comprehensive systematic reviews evaluated the quality of published ultrasound charts for fetal dating with crown‐rump length 8 and fetal growth monitoring. 9 Across the 112 studies identified, there were several important potential sources of methodological bias including: failure to define gestational age accurately; inconsistent population definitions and inclusion and exclusion criteria; lack of image standardisation protocols, and retrospective analysis of images captured for clinical purposes. This resulted in a large amount of variation in centile thresholds when different charts were used: for example, the 10th centile for AC at 36 weeks' gestation ranged from 276 to 292 mm even among the best studies. Open in a separate window Figure 1 Abdominal circumference.

Objective To assess the use of fetal foot length for predicting gestational age in stillborn fetuses in Vietnam and the ability of this measurement to differentiate early from late fetal deaths. Methods In a prospective case series, gestational age was determined from either certain first day of last menstrual period or early ultrasound scan. Foot length was measured, with a non-elastic tape measure, from the heel to the tip of the longest toe. Agreement of observed and predicted foot length for gestational age was tested, as well as the influence of fetal characteristics. Results Accurate gestational age and foot length were available for 52 of 107 participants. Strong agreement was demonstrated between observed and predicted values of foot length across gestations (95% confidence interval, –4.7 to 4.3 weeks). Accuracy of fetal foot length in predicting gestational age was affected by growth restriction but not fetal gender, maceration, or congenital anomalies. Fetal foot length of 55 mm or greater demonstrated a sensitivity and specificity of 88% in identifying late fetal deaths. Conclusion Foot length is a good differentiator of early and late fetal death, which is important for the global recording of the number of stillbirths.

Background: Over 2.6 million babies are stillborn every year mostly in low- and middle-income countries, where cause of death remains often unexplained. Aim: To determine the applicability and utility of the Perinatal Society of Australia and New Zealand (PSANZ) Clinical Practice Guideline (CPG) for Perinatal Mortality in reducing the proportion of unexplained stillbirths in a hospital setting in Vietnam. Methods: An analytic cross-sectional study of stillborn babies born at a major maternity facility in Vietnam. Maternal history, external physical examination of the baby and placental macroscopic examination were performed. Two experienced classifiers independently assigned PSANZ perinatal death classification (PDC). This was compared to cause of death documented in the hospital records. Results: 107 stillborn babies were born to 105 mothers. The proportion of stillborn babies classified as unexplained was reduced from 52.3 to 24.3% (P

A method is described for assessing the strength of evidence for differences in the trends in chemical concentrations in stream water between catchments. A smoothing spline technique is used to model changes in water quality as a result of changes in flow rates, seasonal effects and an underlying trend. The method involves fitting the model twice, once with the underlying trends constrained to be identical for each river and once with the trends unconstrained. Statistical properties are assessed by simulation methods that allow for the autocorrelation in the residuals from the unconstrained fit. The method is applied to data from two streams in the Balquhidder catchments in the Highlands of Scotland and to data from the Dee, Don and Ythan rivers in the north-east of Scotland. Copyright © 2003 John Wiley & Sons, Ltd.

A series of 910 frozen section examination of skin lesions is presented, and the results are analysed in detail and compared with others in the literature. The difficulties in histological diagnosis are discussed and contrasted with those of clinical diagnosis especially of pigmented lesions. Summary In 910 consecutive frozen section examinations of skin lesions nine false positive reports were submitted, but only two were of major importance. False negative reports occurred with malignant melanomas when the lesion was small or heavily pigmented, and with other malignant lesions when the specimens were large (sampling error). Frozen section examination accurately identifies lesions that tend to be mistaken for malignant melanoma on clinical examination.