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The sacral agenesis syndrome is a severe congenital abnormality consisting of agenesis of the lumbar spine, sacrum, and coccyx, as well as hypoplasia of the lower extremities. It is considered the most characteristic of all congenital anomalies associated with maternal diabetes mellitus. We describe the sonographic and radiologic findings of agenesis of the lumbosacrococcygeal spine with lower limb and genital hypoplasia in the offspring of a woman with both diabetic retinopathy and nephropathy. The diagnosis was established at 25 weeks' gestation and was confirmed by radiologic evaluation of the neonate.

Objective To describe the clinical outcome of infants born to mothers with gestational diabetes mellitus (GDM) and preexisting insulin-dependent diabetes mellitus (IDDM). Setting A tertiary care regional perinatal center with a specialized diabetes-in-pregnancy program. Design Case series. Results Five hundred thirty infants were born to 332 women with GDM and 177 women with IDDM. Thirty-six percent of these 530 newborns were large for gestational age, 62% were appropriate for gestational age, and only 2% were small for gestational age. Seventy-six (14%) of all infants were born before 34 weeks' gestation, 115 (22%) between 34 and 37 weeks of gestation, and 339 (64%) at term. Two hundred thirty-three infants (47%) were admitted to the neonatal intensive care unit due to respiratory distress syndrome (RDS), prematurity, hypoglycemia, or congenital malformation. Hypoglycemia (more common among infants of maternal diabetic classes C through D-R) was documented in 137 (27%) of all newborns. One hundred eighty-two infants (34%) had RDS of varying severity. Polycythemia (5% of infants), hyperbilirubinemia (25%), and hypocalcemia (4%) were other morbidities present. Two hundred forty-four infants were admitted for routine care and enteral feedings. Forty-three of these newborns required subsequent transfer to the neonatal intensive care unit for treatment of hypoglycemia (16 cases), RDS (19 cases), or both (8 cases). Routine care failures were more common among infants whose mothers had advanced diabetes, but less frequent among breast-fed infants. Conclusions With modern management, fewer morbidities can be expected in infants of diabetic mothers. Those infants born to women with IDDM remain at risk for hypoglycemia, which can be treated in one half of the cases by enteral feedings alone. The majority of cases of RDS are mild and require short admissions to special care nurseries. Optimal care of infants of diabetic mothers is based on prevention, early recognition, and treatment of common conditions. Severe congenital malformations, significant prematurity, RDS, recurrent hypoglycemic episodes, and asymptomatic infants of women with advanced IDDM should be admitted to special care nurseries. Breast-feeding among women with GDM and IDDM should be encouraged.

Gestational diabetes (GDM) affects 3% to 5% of pregnancies in the United States. Clinical recognition and adequate treatment of women with significant hyperglycemia during pregnancy is important to minimize perinatal morbidities associated with GDM, including macrosomia, shoulder dystocia, hyperbilirubinemia, and hypoglycemia. Although the majority of women will achieve adequate glycemic control with diet and exercise, approximately 30% to 40% require pharmacologic treatment. Insulin administration has been the standard therapy for dietary failures until recent years. Insulin therapy has the disadvantages of patient discomfort, inconvenience of injections, and expense of supplies thereby potentially compromising compliance. Therefore, an effective alternative to insulin is desirable for both the patient and physician. A recent large scale randomized clinical trial conducted byLanger et al compared the efficacy of glyburide with insulin for the treatment of gestational diabetes. They found no difference between groups in mean maternal blood glucose, the frequency of large-forgestational-age (LGA) infants and infants larger than 4000 g, neonatal respiratory complications, neonatal hypoglycemia, and neonatal intensive care unit admission. Several smaller studies have reported success in achieving good glycemic control with glyburide, but with slightly higher failure rates. A recent American College

Coronary heart disease and myocardial infarction are uncommon complications during pregnancy. Women with insulin-dependent diabetes mellitus (IDDM) have a much greater risk of serious coronary heart disease, but few cases of myocardial infarctions occurring during pregnancy have been reported. Significant maternal morbidity has been reported in half of these cases. This is a case of a myocardial infarction occurring at 21 weeks of gestation in a patient with class R/F IDDM and the subsequent pregnancy management as well as a review of the literature concerning Class H IDDM in pregnancy.

Objective: To determine outcomes in pregnancies complicated by class F diabetes mellitus cared for at a single center, and to assess renal function in these women. Methods: A retrospective review (1988–1994) of all pregnant women with class F diabetes was performed, as well as an evaluation of current renal function. Results: Forty-six pregnancies in 45 women reached a mean (± standard deviation) gestational age of 35.8 ± 2.3 weeks, with a mean birth weight of 2623 ± 818 g. No deliveries occurred before 30 weeks and 39 (84%) were at least 34 weeks. Perinatal survival was 100%. Women with initial serum creatinine exceeding 1.5 mg/dL or more than 3 g/24 hours proteinuria had an increased risk of early delivery, lower birth weight, preeclampsia, and cesarean delivery. Twenty-four individuals (53%) developed preeclampsia and seven met criteria for severe preeclampsia. By the third trimester, 26 women (58%) had greater than a 1 g/24 hour increase in proteinuria and 16 (36%) demonstrated more than a 15% fall in creatinine clearance. Follow-up was obtained in 34 subjects with a mean duration of 2.8 years. Individuals with initial creatinine clearance greater than 90 mL/minute and less than 1 g of protein per 24 hours had less loss of renal function at follow-up, as measured by creatinine clearance. At follow-up, mean protein excretion had decreased 1.9 g/24 hours from third-trimester values, but eight women (24%) maintained protein excretion exceeding 3 g/24 hours. Conclusion: Modern management of class F patients can result in good perinatal outcomes. Renal function studies early in pregnancy can be used to define the risk of perinatal morbidity and long-term progression of renal disease.

Objective We evaluated whether improvements in pregnancy outcomes after treatment of mild gestational diabetes mellitus differed in magnitude on the basis of fetal gender. Study Design This is a secondary analysis of a masked randomized controlled trial of treatment for mild gestational diabetes mellitus. The results included preeclampsia or gestational hypertension, birthweight, neonatal fat mass, and composite adverse outcomes for both neonate (preterm birth, small for gestational age, or neonatal intensive care unit admission) and mother (labor induction, cesarean delivery, preeclampsia, or gestational hypertension). After stratification according to fetal gender, the interaction of gender with treatment status was estimated for these outcomes. Results Of the 469 pregnancies with male fetuses, 244 pregnancies were assigned randomly to treatment, and 225 pregnancies were assigned randomly to routine care. Of the 463 pregnancies with female fetuses, 233 pregnancies were assigned randomly to treatment, and 230 pregnancies were assigned randomly to routine care. The interaction of gender with treatment status was significant for fat mass ( P = .04) and birthweight percentile ( P = .02). Among women who were assigned to the treatment group, male offspring were significantly more likely to have both a lower birthweight percentile (50.7 ± 29.2 vs 62.5 ± 30.2 percentile; P P = .0005,) whereas these differences were not significant among female offspring. There was no interaction between fetal gender and treatment group with regard to other outcomes. Conclusion The magnitude of the reduction of a newborn's birthweight percentile and neonatal fat mass that were related to the treatment of mild gestational diabetes mellitus appears greater for male neonates.

Planning and Development linked Patient Discharge Data and Birth Cohort File from January 1, 1991 through December 31, 2008. We identified maternal risk factors for delivery 39 weeks using candidate variables drawn from the literature, and assessed them using bivariate analyses and logistic regression. RESULTS: Pregnancy-associated and chronic non-reproductive organ-based and systemic diseases, including diabetes, hypertensive disorders, and heart, lung and renal disease, increased significantly over the study period. Older women were disproportionately affected by these health problems, and women with these conditions at any age were more likely to deliver early. Our comparison of fetal and neonatal deaths with live births prior to 39 weeks show a robust correlation, with significant declines in fetal and neonatal death rates accompanying the rise early births. CONCLUSION: Maternal health problems influence birth before 39 weeks to a significantly greater degree than maternal age in this cohort. Providers and consumers wishing to safeguard fetuses and their mothers in the setting of increasingly complicated gestational environments may be driving the trend toward earlier birth without increasing perinatal mortality.

Objective To compare maternal and neonatal outcomes in women undergoing second-stage cesarean delivery after a trial of operative vaginal delivery with those in women undergoing second-stage cesarean delivery without such an attempt. Methods This study is a secondary analysis of the women who underwent second-stage cesarean delivery. The maternal outcomes examined included blood transfusion, endometritis, wound complication, anesthesia use, and maternal death. Neonatal outcomes examined included umbilical artery pH less than 7.0, Apgar score of 3 or less at 5 minutes, seizures within 24 hours of birth, hypoxic ischemic encephalopathy, stillbirth, skull fracture, and neonatal death. Results Of 3,189 women who underwent second-stage cesarean delivery, operative vaginal delivery was attempted in 640. Labor characteristics were similar in the two groups, with the exception of the admission-to-delivery time and cesarean indication. Those with an attempted operative vaginal delivery were more likely to undergo cesarean delivery for a nonreassuring fetal heart rate tracing (18.0% compared with 13.9%, P=.01), have a wound complication (2.7% compared with 1.0%, odds ratio [OR] 2.65, 95% confidence interval [CI] 1.43-4.91), and require general anesthesia (8.0% compared with 4.1%, OR 2.05, 95% CI 1.44-2.91). Neonatal outcomes, including umbilical artery pH less than 7.0, Apgar score of 3 or less at 5 minutes, and hypoxic ischemic encephalopathy, were more common for those with an attempted operative vaginal delivery. This was not significant when cases with a nonreassuring fetal heart rate tracing were removed. Conclusion Cesarean delivery after an attempt at operative vaginal delivery was not associated with adverse neonatal outcomes in the absence of a nonreassuring fetal heart rate tracing. Level of evidence II.

OBJECTIVES: The purpose of the study was to investigate whether amnion cells contain functional insulin-like growth factor-I receptors. STUDY DESIGN: To test whether human amnion cells contain insulin-like growth factor-I receptors, radioligand binding studies, affinity cross-linking studies, and Northern blot analysis were conducted in primary amnion cells and in an immortal amnion cell line (WISH). To test whether the insulin-like growth factor-I receptors on amnion cells are functional, cytochalasin B-inhibitable 2-deoxyglucose uptake was measured after stimulating the cells with insulin-like growth factor-I. RESULTS: Radioligand binding studies demonstrated that primary amnion cells and WISH cells contained a single class of high-affinity receptors with an apparent dissociation constant of 0.18 ± 0.04 nmol/L and a receptor concentration of 79 ± 26.2 fmol/mg protein and dissociation constant of 0.44 ± 0.03 nmol/L and a receptor concentration of 33.3 ± 6.45 fmol per 106 cells, respectively. Affinity cross-linking studies revealed two major insulin-like growth factor-I binding sites, 135 and 270 kd. Both primary amnion cells and WISH cells exhibited cytochalasin B-inhibitable tritiated 2-deoxyglucose uptake in response to insulin-like growth factor-I treatment. Finally, treatment of WISH cells caused tyrosine phosphorylation of three proteins (molecular weight, 116, 95.4, and 83.5 kd) was observed by Western blotting with antiphosphotyrosine antibodies. CONCLUSION: These results provide the first evidence that human amnion epithelial cells contain functional high-affinity insulin-like growth factor-I receptors that mediate glucose transport.

As a result of extensive experiences in multiple centers and a review of the current literature, we conclude that a plasma glucose level obtained 1 hour after a 50 gm oral glucose challenge is the “best” gestational diabetes mellitus screening test. This universal screening is performed at least once during pregnancy. The screening threshold should be no higher than 140 mg/dl, or an unacceptable loss in sensitivity occurs. Universal screening for gestational diabetes mellitus is justified by morbidity reduction, cost, and protocol simplicity and ease. (Am J Obstet Gynecol 1991;165:493-6.)

This study was undertaken to evaluate the effect of change of shift for physicians and nurses on complications associated with cesarean delivery.17,996 term women undergoing an unscheduled cesarean delivery in 13 centers from 1999-2000 were included. Maternal and neonatal morbidities were evaluated by time of infant delivery vis-à-vis nursing change of shift (6 AM-8 AM, 2 PM-4 PM, 10 PM-12 AM vs all other hours). The sample was then limited to weekdays only and physician shift changes were evaluated (physician shift change 6 AM-8 AM, 5 PM-7 PM vs all others). A composite of 30 maternal morbidities was also evaluated by logistic regression, controlling for potentially confounding factors.Physician change of shift had no measurable effect on maternal and neonatal outcomes. Neonatal facial nerve palsies were increased at nursing change of shift (5 vs 0) as were hysterectomies (33 [0.24%] vs 23 [0.53%]; P.007). Nursing change of shift had no impact on composite maternal morbidity after controlling for age, race, insurance, medical problems, prior incision type, weekend day, and prenatal care (odds ratio = 0.98; 95% confidence interval = 0.89-1.08).Physician change of shift does not appear to be associated with an increase in morbidities. However, cesarean delivery during nursing change of shift is associated with increased risk of neonatal facial nerve palsy and hysterectomy. Further investigation is needed to understand the cause of this association.

Background Whether low-dose aspirin prevents preeclampsia is unclear. It is not recommended as prophylaxis in women at low risk for preeclampsia but may reduce the incidence of the disease in women at high risk. Methods We conducted a double-blind, randomized, placebo-controlled trial in four groups of pregnant women at high risk for preeclampsia, including 471 women with pregestational insulin-treated diabetes mellitus, 774 women with chronic hypertension, 688 women with multifetal gestations, and 606 women who had had preeclampsia during a previous pregnancy. The women were enrolled between gestational weeks 13 and 26 and received either 60 mg of aspirin or placebo daily. Results Outcome data were obtained on all but 36 of the 2539 women who entered the study. The incidence of preeclampsia was similar in the 1254 women in the aspirin group and the 1249 women in the placebo group (aspirin, 18 percent; placebo, 20 percent; P = 0.23). The incidences in the aspirin and placebo groups for each of the four hi...

CELESTE DURNWALD, ALBERT FRANCO, MARK LANDON, The Ohio State University, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Columbus, Ohio OBJECTIVE: To compare maternal and perinatal outcomes of women with Type 1 and Type 2 diabetes mellitus. STUDY DESIGN: A 3 year observational study of women with Type 1 and 2 diabetes mellitus (DM). Clinical characteristics, diabetic therapy and perinatal/neonatal outcomes were prospectively collected. RESULTS: 70 women with Type 1 DM and 67 women with Type 2 DM were evaluated. Women with Type 1 DM were younger (26.7 vs 31.3 years, p!0.0001) and more likely to have vascular disease (17.1 vs 3%, p=0.009). Racial distribution, insurance status, overweight/obese pregravid BMI (R25kg/m) and preexisting hypertension were similar between groups. Both preterm delivery (36.7 vs 37.5 weeks, p=0.01) and preeclampsia (30 vs 11.9%, p=0.01) were more common in Type 1 DM. Glycemic control was similar in Type 1 and 2 DM (HgBA1C 6.5 vs 6.1, p=0.07). No difference in total insulin requirements was observed between groups in 1st (0.77 vs 0.64 units/kg, p=0.12), 2nd (0.95 vs 0.91 units/kg, p=0.69), and 3rd (1.06 vs 1.15 units/kg, p=0.44) trimesters of pregnancy, however, the rate of increase in insulin dosage was lower in Type 1 compared with Type 2 DM between 1st and 2nd trimester (0.16 vs 0.28 units/kg, p=0.03), 2nd and 3rd trimester (0.11 vs 0.25 units/kg, p=0.01). A higher rate of NICU admission (28.6 vs 12%, p=0.02) and longer hospital stay (6.7 vs 3.6 days, p=0.002) was present in infants of Type 1 DM. After controlling for gestational age at delivery, rate of NICU admission was not different between groups (p=0.24). Rates of LGA and macrosomia were also similar in Type 1 and 2 DM (30 vs 29.9%, p=1.0 and 14.3 vs 23.9%, p=0.19, respectively), as were birth weight (3286 vs 3466 grams, p=0.12) and ponderal index (2.70 vs 2.68, p=0.88). CONCLUSION: Perinatal outcomes of well controlled Type 1 DM are comparable to those of Type 2 DM, except for a higher rate of preeclampsia and earlier gestational age at delivery. Remarkably, total insulin requirements were similar between Type 1 and 2 DM, although rate of increase in insulin dosage between trimesters is significantly less in Type 1 DM.

CATED BY LUPUS J. PATRICIA DHAR, LYNETTE ESSENMACHER, JOEL AGER, ROBERT SOKOL, Wayne State University School of Medicine, Internal Medicine/Rheumatology, Detroit, MI Wayne State University, Center for Health Care Effectiveness Research, Detroit, MI Wayne State University, Obstetrics/Gynecology, Detroit, MI OBJECTIVE:The objective of this study was to evaluate whether fetal growth has improved or gestational duration has increased over time. We hypothesized improved outcomes that might be attributable to advances in lupus intervention. STUDY DESIGN: A cohort analysis of pregnancy outcomes from 1985-2002 in women with lupus was performed at our center. The Wayne State University Lupus Registry was linked to the Wayne State University Perinatal Database to obtain all pregnancies in women with lupus delivered at our institution. The control population consisted of demographically similar non-lupus pregnancies from the Wayne State University Perinatal Database RESULTS: There were 473 singleton deliveries in 327 women with lupus delivered at our institution. To ensure statistical independence, we calculated the mean birth weight and gestational age in the first pregnancy per parturient delivered at our center, leaving us with 327 pregnancies in 327 womenwith lupus (first pregnancy group). The control group consisted of 78,905 deliveries at our center during the same period. The mean birthweight and gestational age for the first pregnancy group was significantly decreased (2790 grams and 36 weeks, respectively) compared to the control group (P < 0.0001). Gestational age and birthweight did not significantly change over time. However, when birthweight percentiles over time were analyzed, a statistically significant increase in fetal growth was seen (r = 0.098, r2 = 0.10, P = 0.041). CONCLUSION: Fetal growth in pregnancies complicated by lupus improved over the 18 years of this study. Because there were no major changes in the characteristics of the sample, we speculate that this improvement might reflect advancing technology of care and improved intervention, as originally hypothesized, most notably aggressive thrombophilia assessments and treatment, as well as concurrent rheumatologic care during pregnancy. Any change in ‘‘spontaneous’’ gestational duration over timemight be hidden by changes in obstetric intervention.

Home glucose monitoring with the use of reflectance meters is an important adjunct in the care of pregnant women with insulin-dependent diabetes. The accuracy of reflectance meters for the assay of capillary glucose specimens has been well documented. The present preliminary study was undertaken to determine the utility of outpatient screening for gestational diabetes mellitus with the use of a reflectance meter (Accu-Chek, Boehringer Mannheim Co.). One hundred twenty-five patients in our high-risk practice had a standard 50 gm glucose load at 26 to 28 weeks' gestation. Capillary glucose values were measured on site with the Accu-Chek. Venous plasma glucose levels were measured by the central laboratory chemistry analyzer. While the laboratory (x) and meter (y) glucose determinations between the two sets of values were highly correlated (R = 0.89, p less than 0.001), there was a significant difference in their average values (x = 111.74, y = 136.35, p less than 0.0001). With the use of a receiver operator characteristic curve, a meter value of 160 mg/dl was determined as the optimal threshold for performing a 3-hour glucose tolerance test. The sensitivity and specificity with the use of a meter value of 160 mg/dl were 93% and 96%, respectively, for detecting an abnormal screening test in venous plasma (greater than or equal to 135 mg/dl). A total of 32 glucose tolerance tests were performed, with four patients included who had venous values less than 135 mg/dl. All eight patients with gestational diabetes mellitus were correctly identified. These data suggest that a glucose reflectance meter can be used for accurate outpatient screening of gestational diabetes mellitus. The potential advantages of capillary blood glucose screening include both cost and efficiency. Patients with abnormal screening values can be promptly identified and scheduled for a follow-up 3-hour glucose tolerance test.

Extracts of thirteen normal pituitaries from five men, three premenopausal women, and five postmenopausal women were fractionated by Sephadex G-100 chromatography; alpha subunit, TSH-β, LH-β, and FSH-β, as well as complete TSH, LH, and FSH, were measured by radioimmunoassay (RIA) in each fraction collected. In spite of variability in subunit content among normal pituitaries, a consistent excess of free alpha subunits relative to the sum of all free pituitary beta subunits was demonstrated in each normal pituitary (P < 0·025); the alpha to beta subunit ratio ranged from 1·29–8·31. In addition, in normal pituitary extracts the ratio of free alpha to alpha combined with beta subunits in the complete glycoprotein hormones generally exceeded 1 (mean 1·57), although the free alpha to combined alpha excess was not statistically significant. In extracts of pituitaries from two hypothyroid and four hyperthyroid patients, the excess of alpha to all pituitary beta subunits persisted. Centrifugation of pituitary extracts at 35 000g, rather than 1500g, prior to gel chromatography decreased the small percentage of void volume immunoactivity in both complete glycoprotein hormone and subunit RIAs, suggesting that it may have been caused by adsorption to membrane components in the extracts. Different methods of preparing the pituitary homogenates did not change the amount or ratio of alpha to beta subunits extracted. Heterogeneity was observed in pituitary alpha and TSH-β by gel chromatography, suggesting that differences in the amount of glycosylation existed among intrapituitary free alpha and TSH-β subunits. These studies, as well as prior studies of de novo subunit biosynthesis and in vivo secretory rates, support the concept that the excess content of free alpha to all free beta subunits in the pituitary reflects greater synthesis of alpha subunits; beta subunit synthesis appears to be the limiting factor in the production of complete TSH, LH, and FSH.

Despite improvement in perinatal outcome over the past several decades, controversy still exists regarding both the management and pathophysiology of pregnancy complicated by diabetes mellitus. In this article, potential factors contributing to morbidity observed in the offspring of diabetic women are considered. The clinical management of insulin-dependent and gestational diabetes is also discussed.

With the introduction of silicone indwelling cerebrospinal fluid (CSF) shunts in the 1960s, the prognosis for children with hydrocephalus changed dramatically. These individuals are leading normal and productive lives today. Many women with CSF shunts are not entering the childbearing years. Previously, only 13 cases of pregnancy occurring in patients with CSF shunts have been reported. We present two cases here and review the complications and outcome of the other reported cases. Shunt malfunction appears to be common in pregnancy due to increased intraperitoneal pressure and the enlarging uterus. Rarely is surgical correction or premature delivery necessary. A successful pregnancy ending in the vaginal delivery of a term infant can be expected in the majority of these patients.

Serial ultrasound examinations were performed during the third trimester in 79 pregnant women with diabetes to establish the onset of accelerated fetal growth. At least three ultrasound examinations were performed, with a minimum scan interval of 2 weeks. Growth curves constructed for femur length and head circumference were similar for fetuses appropriate for gestational age (n = 48) and fetuses large for gestational age (n = 31). The mean changes in femur length and head circumference (expressed as centimeters per week during the early and late third trimesters) did not differ statistically between these two groups. Abdominal circumference growth was clearly accelerated at 32 weeks' gestation in the large for gestational age group (mean +/- SD, 1.36 +/- 0.16 cm/wk) compared with the appropriate for gestational age group (0.901 +/- 0.21 cm/wk, p less than 0.001). With use of a receiver operator characteristic curve, a change in abdominal circumference of 1.2 cm/wk over the period of 32 to 39 weeks' gestation was determined to be an optimal cutoff for detecting excessive fetal growth (sensitivity 84%, specificity 85%). A change in abdominal circumference 1.2 cm/wk was present in 4/4 large-for-gestational age fetuses (less than 4000 gm), in 17/21 (81%) of fetuses with birth weights 4000 to 4499 gm, and in 5/6 (83%) whose weight exceeded 4500 gm. It appears that improved detection of the fetus large for gestational age in diabetic pregnancies may be accomplished by the use of serial ultrasonography during the third trimester.

In summary, accurate identification of fetal growth disorders remains a difficult clinical challenge. Many diagnostic parameters have been devised to diagnose these conditions, however, no single test alone allows a confident antenatal diagnosis of IUGR or macrosomia to be established. Until new criteria or new methods such as Doppler analysis of umbilical artery flow permit a more accurate prediction of growth disturbances, multiple parameters should be monitored. Evaluation of the amniotic fluid volume, BPD, FL, AC, and EFW should be included in all studies. In high risk cases (unexplained oligohydramnios, previous history of growth retardation, poor nutritional status, abnormal sonographic parameters, maternal obesity, diabetes mellitus, etc.) additional measurements such as the HC/AC ratio and the FL/AC ratio should also be evaluated. Similarly, evaluation of suspected excessive fetal growth requires careful evaluation of AC measurements. Patients with suspected growth disorders should be reevaluated with serial scans at 2 to 3 weeks intervals. Careful monitoring of fetuses with suspected IUGR and macrosomia may decrease much of the morbidity and mortality associated with these conditions.

Several years ago, most obstetricians would have thought that any disease severe enough to require parenteral nutrition would also lead to infertility or early pregnancy loss. Women with many complex disease states have now been successfully treated by TPN during pregnancy, resulting in favorable outcomes for both mother and fetus. Theoretically, these patients, if not supplied with an adequate amount of essential nutrients by TPN, might have experienced excessive perinatal morbidity and mortality. The difficulties involved with studying maternal-fetal exchange processes in humans leave considerable gaps in our current knowledge about nutritional requirements during normal pregnancy. Some have suggested that subtle degrees of malnutrition may jeopardize normal growth and development. In states of severe protein calorie malnutrition, there remains little doubt that intrauterine growth is diminished. In such cases in which there is poor maternal weight gain, it may be critical to initiate some method of nutritional support. Whereas TPN during pregnancy has been sporadically employed in the treatment of cases of suspected fetal growth retardation, limited experience with this therapy suggests that at present we primarily direct treatment toward patients with specific disease states that are accompanied by overt malnutrition. Parenteral nutrition support should begin only after a period of adequate nutritional assessment and monitoring. If such support is necessary, TPN should be administered by a team of qualified knowledgeable individuals who are very familiar with the techniques. The relatively high rate of premature delivery associated with patients requiring TPN during pregnancy requires the presence of an intensive care nursery in the institution.

The mean peak systolic to end-diastolic (S/D) umbilical artery ratio was measured in 291 Doppler studies performed during pregnancy in 35 insulin-dependent diabetic women. A normal decline was observed in the umbilical artery S/D ratio, from 4.2 +/- 0.21 at 18 weeks to 2.18 +/- 0.22 at 38 weeks. There was no significant correlation between mean third-trimester S/D and either glycosylated hemoglobin (r = 0.25) or mean blood glucose levels (r = 0.15). Fetuses of women with vascular disease (class F/R or chronic hypertension) had a mean third-trimester S/D of 3.0 or higher in five of ten cases, compared with three of 25 in patients with uncomplicated diabetes (P less than .03). Mean second- and third-trimester S/D ratios differed significantly in patients with and without vascular disease: 4.34 +/- 0.7 and 3.2 +/- 0.65 versus 3.72 +/- 0.42 and 2.55 +/- 0.32, respectively (P less than .03). Two of three women without vascular disease who demonstrated an elevated mean S/D ratio developed preeclampsia and delivered appropriate for gestational age infants. In women with vascular disease, four of five with an abnormal mean third-trimester umbilical artery S/D ratio were delivered of growth-retarded infants, whereas all five with normal umbilical artery S/D ratios had appropriate for gestational age infants. In three of the abnormal cases, elevated S/D ratios were present in the second trimester before ultrasound documentation of fetal growth retardation.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship between glycemic control and perinatal outcome was assessed in a relatively uniform population of 75 White Class B through D pregnant diabetic women. All patients used glucose reflectance meter self-monitoring and performed a minimum of four determinations daily. Mean capillary blood glucose was calculated from a minimum of 16 weeks of determinations. Regression analysis confirmed a correlation between these values and third-trimester hemoglobin A1 (p less than 0.001). The study population was divided into two groups on the basis of mean capillary blood glucose values: group I, mean capillary blood glucose less than 110 mg/dl (43 patients) (mean = 96.8 +/- 7.1); group II, mean capillary blood glucose greater than 110 mg/dl (32 patients) (mean = 126 +/- 9.0). Of the 32 patients in group II, eight had mean capillary blood glucose greater than or equal to 130 mg/dl. The degree of maternal glycemic control appeared to affect perinatal outcome. At least one form of infant morbidity was present in 33% of group I infants compared with 53% of group II. Significant differences were observed for the incidence of hypoglycemia (p less than 0.05), macrosomia (p less than 0.05), and respiratory distress syndrome (p less than 0.01). One of six group I infants delivered at 35 to 36 weeks developed respiratory distress syndrome, compared with four of seven group II patients. The appearance of phosphatidylglycerol in amniotic fluid appeared delayed in group II patients at term. These data suggest that maintaining mean capillary blood glucose values less than 110 mg/dl may serve to reduce several major forms of morbidity in the infant of the diabetic mother. This information is helpful in establishing objectives for glycemic control in pregnant women using self-monitoring techniques.

Pregnancy in patients with gestational diabetes mellitus (GDM) is associated with increased perinatal morbidity. Whether the perinatal mortality rate, particularly the fetal death rate, is greater in these patients remains controversial. The present study was undertaken to review the role of antepartum fetal monitoring in 69 patients with GDM controlled by diet only (class A) and 28 women requiring insulin therapy (class AB). Hypertension complicated 21.6% of these pregnancies. Antepartum fetal surveillance included outpatient nonstress testing, urinary estriol assays, maternal assessment of fetal activity, and clinical estimation of fetal weight. All insulin-requiring patients as well as fourteen class A patients with identifiable risk factors underwent testing. No perinatal deaths occurred. Only six patients required intervention for suspected fetal jeopardy and four of these women had hypertension. Macrosomia was correctly identified in only 6 of 16 infants weighing 4000 g or more. This study suggests that, in GDM, an outpatient program of fetal testing, using primarily the nonstress test and maternal assessment of fetal activity, can be employed in patients requiring insulin as well as class A patients with identifiable risk factors. This protocol resulted in a low rate of unnecessary intervention and good perinatal outcome. The risks for abnormal antepartum testing results appear increased in GDM with hypertension and prolonged pregnancy.

The management of pregnancies complicated by both insulin-dependent and gestational diabetes mellitus has changed dramatically in the United States during the past 15 years. Recommended programmes of care have been outlined in a Technical Bulletin published by the American College of Obstetricians and Gynecologists in 1986, as well as in the summary of the Second International Workshop Conference on Gestational Diabetes Mellitus in 1984 (Freinkel et al. 1985), at which the American College of Obstetricians and Gynecologists was also represented. However, even these documents do not agree, particularly in their approach to screening for gestational diabetes mellitus. This study was undertaken, therefore, to determine the state of the art in the care of pregnancies complicated by both gestational and insulin-dependent diabetes mellitus in the United States.

Sonographic evaluation of 43 pregnant women with diabetes mellitus was performed in the third trimester of gestation for evidence of fetal macrosomia. The width of the soft tissues of the shoulder from the skin surface to the proximal humerus was compared with previously reported measurements for their ability to predict fetal macrosomia. The abdominal circumference and shoulder soft tissue measurements were the best individual predictors of macrosomia, but a combination of an abdominal circumference greater than the 90th percentile for gestational age or a shoulder soft tissue width greater than 12 mm was the best predictor with a sensitivity of 96%, specificity of 89%, and accuracy of 93%. The shoulder soft tissue width should be evaluated for evidence of macrosomia in diabetic pregnancies.

Over a 5-year period we have managed 63 diethylstilbestrol-exposed pregnant patients with a standardized protocol requiring weekly cervical examination and decreased physical activity of the patient. Twenty-six patients (42%) underwent a prophylactic cerclage for a history of second-trimester loss or a hypoplastic cervix on initial clinical examination (group I). Thirty-six patients (58%) were followed expectantly (group II). Sixteen patients (44%) in group II demonstrated cervical change and required an emergency cerclage. Twenty-one patients were managed expectantly with no cerclage. The gestational age at delivery for group I was 37.7 +/- 2.80 versus 34.5 +/- 6.9 weeks for patients without a cerclage (p = 0.04). There were no perinatal deaths if a cerclage was performed, whereas there were five deaths (24%) in the group without cerclage. The five deaths occurred at a mean gestational age of 24.40 +/- 4.0 weeks and a mean birth weight of 614.00 +/- 441.73 gm. Patients with a hypoplastic cervix or prior reproductive loss had a better outcome with early cerclage than patients with a normal cervix followed expectantly. We presently lack a reliable method to detect the diethylstilbestrol-exposed patient at greatest risk for perinatal loss. Based on our experience we believe that placement of a cerclage early in pregnancy should be a strong consideration.

The sera of 12 patients with elevated serum concentrations of α-subunit (α) were fractionated by gel chromatography on Sephadex G-100. The partition coefficients (Knv) of serum α, measured by RIA in each fraction collected, were compared to the Kav of cochromatographed iodinated pituitary human TSHα. Six patients had nonneoplastic disorders (2 postmenopausal women, 1 hypothyroid patient, 2 patients with chronic renal failure, and 1 with TSH-mediated hyperthyroidism). Six patients had neoplastic disorders (3 with TSH-secreting pituitary tumors and 3 with malignant carcinoid tumors). The mean Kav of serum a from the 12 patients was 0.39 ± 0.04, compared to 0.45 ± 0.04 for cochromatographed iodinated pituitary TSHα (P < 0.001). There was no difference in Kav between neoplastic and nonneoplastic serum α. Gel chromatography of 18 normal human pituitary extracts revealed no significant difference in Kav values between immunoactiveintrapituitary α and cochromatographed iodinated pituitary TSHα. In contrast to th...

Acetaminophen is a common drug used in pregnancy. A 32-year-old woman ingested 64 g of acetaminophen at 15 weeks of gestation. Treatment with N-acetylcysteine was given within 24 hours. The patient nonetheless developed severe hepatic necrosis and her hospital course was complicated by adult respiratory distress syndrome. With aggressive supportive treatment, the mother survived and delivered a viable infant at 32 weeks' gestation. The possible mechanisms of acetaminophen toxicity in the mother and the fetus are discussed.(Obstet Gynecol 67:750, 1986)