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OBJECTIVE: The purpose of this study was to determine whether there is a difference in body composition and the factors that are associated with fat mass in the large-for-gestational-age infants of women with gestational diabetes mellitus compared with the large-for-gestational-age infants of women with normal glucose tolerance levels. STUDY DESIGN: Large for gestational age was defined as weight >90th percentile for gestational age, race, and sex on the basis of our population's normative data. Anthropometric measurements and/or total body electrical conductivity estimated body composition that included fat mass, percent body fat, and lean body mass were obtained. Multiple stepwise regression was used to determine factors correlating with fat mass. RESULTS: Fifty cases of women with gestational diabetes mellitus and 52 cases of women with normal glucose tolerance levels were evaluated. Infants of mothers with gestational diabetes mellitus had increased fat mass (662 vs 563 g; P = .02) and percent body fat (16.2% vs 13.5%; P = .002) but decreased lean body mass (3400 vs 3557 g; P = .0009), as compared with infants of mothers with normal glucose tolerance levels, despite similar birth weights. Stepwise regression on all 102 women showed gestational age and a diagnosis of gestational diabetes mellitus correlated with fat mass (r2 = 0.11; P = .001). For gestational diabetes mellitus alone, both gestational age and fasting value of the oral glucose tolerance test correlated with fat mass and percent body fat (r2 = 0.33 [P = .0009] and r2 = 0.26 [P = .005], respectively). CONCLUSION: Large-for-gestational-age infants of mothers with gestational diabetes mellitus have increased fat mass and decreased lean body mass compared with infants of mothers with normal glucose tolerance levels. In gestational diabetes mellitus, gestational age and fasting value of the oral glucose tolerance test correlated best with fat mass. [ABSTRACT FROM AUTHOR]

Objective: This study was undertaken to evaluate the risks and benefits of single-layer uterine closure at cesarean delivery on the index and subsequent pregnancy.Study Design: A retrospective study of women delivered of their first live-born infants by primary low transverse cesarean delivery (1989-2001) and their subsequent pregnancy at our institution was performed.Results: Of 768 women studied, 267 had single-layer and 501 had double-layer uterine closures in the index pregnancy. Single-layer closure was associated with slightly decreased blood loss (646 vs 690 mL, P<.01), operative time (46 vs 52 minutes, P<.001), endometritis (13.5% vs 25.5%, P<.001), and postoperative stay (3.5 vs 4.1 days, P<.001). In the second pregnancy, prior single-layer closure was not associated with uterine rupture after a trial of labor (0% vs 1.2%, P=.30), or other maternal or infant morbidities. Prior single-layer closure was associated with increased uterine windows (3.5% vs 0.7%, P=.046) at subsequent cesarean delivery.Conclusion: Single-layer uterine closure is associated with decreased infectious morbidity in the index surgery, but not uterine rupture or other adverse outcomes in the subsequent gestation. [ABSTRACT FROM AUTHOR]

Behavioral economics research suggests poverty may influence behavior by reducing mental bandwidth, increasing future discounting, and increasing risk aversion. It is plausible these decision-making processes are further impaired in the context of HIV or pregnancy. In this cross-sectional study of 86 low-income women in Philadelphia, HIV was associated with lower mental bandwidth (one of two measures) and lower risk aversion. Pregnancy was not associated with any decision-making factors. In secondary analyses, viral suppression was associated with greater mental bandwidth (one of two measures), and antenatal clinic attendance with lower future discounting. Anti-poverty interventions may be beneficial to improve HIV-related health behaviors., (© 2024. The Author(s).)

Objective: To evaluate whether continuous glucose monitoring (CGM)-derived glycemic patterns observed throughout pregnancy were associated with adverse perinatal outcomes, specifically fetal growth disorders and hypertensive disorders of pregnancy (HDP)., Methods: We conducted a prospective observational study of individuals with viable singleton pregnancies and screening hemoglobin A 1c levels less than 6.5%. Those with preexisting diabetes were excluded. Enrollment occurred at the earliest gestational age before 17 weeks. Participants wore blinded continuous glucose monitors consecutively as willing until delivery. Those with at least 14 days of CGM data were included in analysis. Rates of large-for-gestational-age (LGA) neonates, small-for-gestational age (SGA) neonates, and HDP were assessed. Continuous glucose monitoring-derived glycemic metrics were calculated, including mean glucose level and percent time above and below thresholds. Two-sample t tests were used to compare glycemic metrics between participants with and without adverse perinatal outcomes., Results: Of 937 participants enrolled, 760 met inclusion criteria. Those delivering LGA neonates or who were diagnosed with HDP had higher mean glucose levels (102±9 vs 100±8, P =.01 and 103±8 vs 99±8, P <.001) and spent more time above 120 mg/dL (median 16% vs 12%, P =.006, and 16% vs 12%, P <.001, respectively) and above 140 mg/dL (median 3.9% vs 2.8%, P =.006, and 3.5% vs 2.8%, P <.001, respectively) throughout gestation than those without these outcomes. These findings were present regardless of gestational diabetes mellitus status. Participants with SGA neonates had lower mean glucose levels (97±7 vs 101±8, P =.01) and spent less time above 140 mg/dL (median 1.6% vs 2.3%, P =.01) and more time below 63 mg/dL (median 3.0% vs 2.3%, P =.02) than those without SGA neonates., Conclusion: Individuals with LGA neonates or HDP exhibit a slightly higher mean glucose levels and spend more time hyperglycemic in early pregnancy than those who do not experience these outcomes., Competing Interests: Financial Disclosure Celeste Durnwald reports advisory work for Dexcom for GDM patient facing materials and system implementation. Money was paid to her institution from the Jaeb Center for Health Research. Roy W. Beck reports no personal financial disclosures but reports that his institution has received funding on his behalf as follows: grant funding and study supplies from Dexcom. Rich M. Bergenstal has received research support, has acted as a consultant, or has been on the scientific advisory board for Abbott Diabetes Care, Ascensia, Bigfoot Biomedical, Inc., CeQur, DexCom, Eli Lilly, Embecta, Hygieia, Insulet, Medtronic, Novo Nordisk, Onduo, Roche Diabetes Care, Tandem Diabetes Care, Sanofi, United Healthcare, Vertex Pharmaceuticals and Zealand Pharma. Rich M. Bergenstal's employer, non-profit HealthPartners Institute, contracts for his services and he receives no personal income for any of these activities. ALC reports no personal financial disclosures but reports that his institution has received funding on his behalf as follows; research support from Medtronic, Tandem, Insulet, Abbott, Dexcom, Eli Lilly, NovoNordisk, Sanofi and United Health Group and consultancy fees from Mannkind and NovoNordisk. The other authors did not report any potential conflicts of interest., (Copyright © 2024 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To estimate the association between maternal metformin use for the treatment of early gestational or pre-existing type 2 diabetes and preterm preeclampsia., Methods: This is a planned secondary analysis of the MOMPOD study (Medical Optimization of Management of Overt Type 2 Diabetes in Pregnancy), a randomized trial comparing the effect of adding metformin with insulin treatment on composite neonatal outcome in singleton pregnancies with early gestational or type 2 diabetes. Participants were randomized at 11-23 weeks of gestation to 1,000 mg metformin twice daily or placebo until delivery. A subset of participants had maternal blood collected at 24-30 weeks of gestation, and serum soluble endoglin, apolipoprotein B, vascular cell adhesion molecule-1, soluble fms-like tyrosine kinase 1, placental growth factor, high-sensitivity C-reactive protein, adiponectin, and vascular endothelial growth factor levels were measured. Our primary outcome was preterm preeclampsia , defined as preeclampsia requiring delivery before 37 weeks of gestation. Secondary outcomes included preterm preeclampsia requiring delivery before 34 weeks of gestation and differences in serum biomarkers. Multivariable regression analysis was used to estimate the associations between metformin use and primary or secondary study outcomes., Results: Of 831 participants, 119 (14.3%) developed preeclampsia requiring delivery before 37 weeks of gestation: 57 of 416 (13.7%) in the placebo group and 62 of 415 (14.9%) in the metformin group. Thirty-seven (4.4%) developed preeclampsia requiring delivery before 34 weeks of gestation: 15 (3.6%) receiving placebo and 22 (5.3%) receiving metformin. Compared with placebo, metformin was not associated with a significant difference in the occurrence of preeclampsia before 37 weeks of gestation (adjusted odds ratio [aOR] 1.04, 95% CI, 0.70-1.56) or before 34 weeks (aOR 1.43, 95% CI, 0.73-2.81). Similarly, there was no association between maternal metformin use and serum biomarker levels., Conclusion: Among parturients with early gestational or pre-existing type 2 diabetes, the addition of metformin to insulin was not associated with lower odds of preterm preeclampsia or with serum biomarkers associated with cardiovascular disease risk., Competing Interests: Financial Disclosure Maya Patel reports money paid to her by National Institute of Diabetes and Digestive and Kidney Diseases. Gayle Olson discloses she is the chair of ACOG District XI, sits on the Board of Directors, and receives support from ACOG. Celeste Durnwald reports that money was paid to her institution from DexCom. Christina Scifres reports money paid to her by Visterra/Otsuka Pharmaceuticals. Amy Valent reports that money was paid to her institution from Dexcom and Mannkind. The other authors did not report any potential conflicts of interest., (Copyright © 2024 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To assess the performance of continuous glucose monitoring (CGM)-measured glycemic metrics in predicting development of gestational diabetes mellitus (GDM) and select perinatal complications. Research Methods: In a prospective observational study, CGM data were collected from 760 pregnant females throughout gestation after study enrollment. GDM was diagnosed using the oral glucose tolerance test (OGTT) at 24-34 weeks of gestation. Predictive models were built using logistic and elastic net regression. Predictive performance was assessed by the area under the receiver-operating characteristic (AUROC) curve. Results: The AUROCs of using second trimester percent time >140 mg/dL (TA140) and week 13-14 TA140 in predicting GDM were 0.81 and 0.74, respectively. The AUROCs for predicting large-for-gestational-age (LGA) births and hypertensive disorders of pregnancy (HDP) using second trimester TA140 were both 0.58. When matching the specificity of OGTT, a model using TA140 in weeks 13-14 achieved similar sensitivity to OGTT in predicting HDP (13% vs. 10%, respectively) and LGA (6% for both methods). Elastic net also demonstrated similar AUROC and diagnostic performance with no meaningful improvement by using multiple predictors. Conclusion: CGM-measured hyperglycemic metrics such as TA140 predicted GDM with high AUROCs as early as 13-14 weeks of gestation. These metrics were also similar statistically to the OGTT at 24-34 weeks in predicting perinatal complications, although sensitivity was low for both. CGM could potentially be used as an early screening tool for elevated hyperglycemia during gestation, which could be used in addition to or instead of the OGTT.

Continuous glucose monitoring (CGM) has the potential to revolutionize diabetes management during pregnancy by providing detailed and real-time data to patients and clinicians, overcoming many of the limitations of self-monitoring of blood glucose. Although there are limited data on the role of CGM to improve pregnancy outcomes in patients with type 2 diabetes or gestational diabetes, CGM has been shown to reduce pregnancy complications in patients with type 1 diabetes. Despite the limited data in some populations, given its ease of use and recent U.S. Food and Drug Administration approval with expanding insurance coverage, CGM has gained widespread popularity among pregnant patients with all types of diabetes. It is critical for obstetric clinicians to understand how CGM can be successfully integrated into clinical practice. We present a practical, step-wise approach to CGM data interpretation that can be incorporated into diabetes management during pregnancy and common CGM pitfalls and solutions. Although technology will continue to advance with newer-generation CGM devices and diabetes technology such as automated insulin delivery (not covered here), these key principles form a basic foundation for understanding CGM technology and its utility for pregnant people., Competing Interests: Financial Disclosure Celeste Durnwald receives support from United Health Group, Helmsley Charitable Trust, and Dexcom, Inc. Amy M. Valent receives support from Dexcom, Inc. The other authors did not report any potential conflicts of interest., (Copyright © 2024 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Gestational diabetes mellitus (GDM) is the most prevalent metabolic complication during pregnancy. GDM is associated with adverse perinatal, neonatal, and long-term health consequences. Studies have demonstrated that the use of continuous glucose monitoring (CGM) reduces the incidence of maternal and neonatal complications in pregnant women with type 1 diabetes. Although the use of CGM in GDM has not been well studied, a growing body of evidence is showing potential benefits in the GDM population. This article discusses the advantages and challenges of CGM and provides practical guidelines for using this technology in the GDM population.

Objective: To determine whether continuous glucose monitoring (CGM)-derived glycemic patterns can characterize pregnancies with gestational diabetes mellitus (GDM) as diagnosed by standard oral glucose tolerance test at 24-28 weeks' gestation compared with those without GDM., Research Design and Methods: The analysis includes 768 individuals enrolled from two sites prior to 17 weeks' gestation between June 2020 and December 2021 in a prospective observational study. Participants wore blinded Dexcom G6 CGMs throughout gestation. Main outcome of interest was a diagnosis of GDM by oral glucose tolerance test (OGTT). Glycemic levels in participants with GDM versus without GDM were characterized using CGM-measured glycemic metrics., Results: Participants with GDM (n = 58 [8%]) had higher mean glucose (109 ± 13 vs. 100 ± 8 mg/dL [6.0 ± 0.7 vs. 5.6 ± 0.4 mmol/L], P < 0.001), greater glucose SD (23 ± 4 vs. 19 ± 3 mg/dL [1.3 ± 0.2 vs. 1.1 ± 0.2 mmol/L], P < 0.001), less time in range 63-120 mg/dL (3.5-6.7 mmol/L) (70% ± 17% vs. 84% ± 8%, P < 0.001), greater percent time >120 mg/dL (>6.7 mmol/L) (median 23% vs. 12%, P < 0.001), and greater percent time >140 mg/dL (>7.8 mmol/L) (median 7.4% vs. 2.7%, P < 0.001) than those without GDM throughout gestation prior to OGTT. Median percent time >120 mg/dL (>6.7 mmol/L) and time >140 mg/dL (>7.8 mmol/L) were higher as early as 13-14 weeks of gestation (32% vs. 14%, P < 0.001, and 5.2% vs. 2.0%, P < 0.001, respectively) and persisted during the entire study period prior to OGTT., Conclusions: Prior to OGTT at 24-34 weeks' gestation, pregnant individuals who develop GDM have higher CGM-measured glucose levels and more hyperglycemia compared with those who do not develop GDM., (© 2024 by the American Diabetes Association.)

Ascertaining the utility of continuous glucose monitoring (CGM) in pregnancy complicated by diabetes is a rapidly evolving area, as the prevalence of type 1 diabetes (T1D), type 2 diabetes (T2D), and gestational diabetes mellitus (GDM) escalates. The seminal randomized controlled trial (RCT) evaluating CGM use added to standard care in pregnancy in T1D demonstrated significant improvements in maternal glycemia and neonatal health outcomes. Current clinical guidance recommends targets for percentage time in range (TIR), time above range (TAR), and time below range (TBR) during pregnancy complicated by T1D that are widely used in clinical practice. However, the superiority of CGM over blood glucose monitoring (BGM) is still questioned in both T2D and GDM, and whether glucose targets should be different than in T1D is unknown. Questions requiring additional research include which CGM metrics are superior in predicting clinical outcomes, how should pregnancy-specific CGM targets be defined, whether CGM targets should differ according to gestational age, and if CGM metrics during pregnancy should be similar across all types of diabetes. Limiting the potential for CGM to improve pregnancy outcomes may be our inability to maintain TIR > 70% throughout gestation, a goal achieved in the minority of patients studied. Adverse pregnancy outcomes remain high in women with T1D and T2D in pregnancy despite CGM technology, and this review explores the potential reasons and questions yet to be investigated., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: G.A. has received consultant fees from Dexcom, Insulet and Medscape, and has received research support to her employer Northwestern University from Fractyl Health, Insulet, MannKind, Tandem Diabetes and Welldoc. F.M.B. received funding from Dexcom, Inc. paid to the Joslin Diabetes Center and receives royalties from UpToDate for topics on preexisting diabetes in pregnancy. C.D. has received financial support from Dexcom for advisory role for patient education and development of educational materials, receives royalties from UpToDate for topics on GDM, and has received funding from United Health Group and Helmsley Charitable Trust. D.S.F. reports grants from the Canadian Institute of Health Research and an investigator-initiated grant from Dexcom, in-kind donations from Dexcom and Tandem and speaker honoraria from Novo-Nordisk. G.O. receives research support from Dexcom, Inc, Tandem Diabetes and MannKind Corporation paid to her institution. S.P is a contributing writer for diaTribe, is on the Medical Advisory Board for Medtronic MiniMed, Inc, has received research funding from Dexcom, Inc., Eli Lilly, JDRF, Leona & Harry Helmsley Charitable Trust, NIDDK, and Sanofi US Services, and has received research support from Diasome Pharmaceuticals, Medtronic MiniMed, Inc., and Sanofi US Services.

Introduction: To characterize glucose levels during uncomplicated pregnancies, defined as pregnancy with a hemoglobin A1c <5.7% (<39 mmol/mol) in early pregnancy, and without a large-for-gestational-age birth, hypertensive disorders of pregnancy, or gestational diabetes mellitus (ie, abnormal oral glucose tolerance test)., Research Design and Methods: Two sites enrolled 937 pregnant individuals aged 18 years and older prior to reaching 17 gestational weeks; 413 had an uncomplicated pregnancy (mean±SD body mass index (BMI) of 25.3±5.0 kg/m 2 ) and wore Dexcom G6 continuous glucose monitoring (CGM) devices throughout the observed gestational period. Mealtimes were voluntarily recorded. Glycemic levels during gestation were characterized using CGM-measured glycemic metrics., Results: Participants wore CGM for a median of 123 days each. Glucose levels were nearly stable throughout all three trimesters in uncomplicated pregnancies. Overall mean±SD glucose during gestation was 98±7 mg/dL (5.4±0.4 mmol/L), median per cent time 63-120 mg/dL (3.5-6.7 mmol/L) was 86% (IQR: 82-89%), median per cent time <63 mg/dL (3.5 mmol/L) was 1.8%, median per cent time >120 mg/dL (6.7 mmol/L) was 11%, and median per cent time >140 mg/dL (7.8 mmol/L) was 2.5%. Mean post-prandial peak glucose was 126±22 mg/dL (7.0±1.2 mmol/L), and mean post-prandial glycemic excursion was 36±22 mg/dL (2.0±1.2 mmol/L). Higher mean glucose levels were low to moderately associated with pregnant individuals with higher BMIs (103±6 mg/dL (5.7±0.3 mmol/L) for BMI ≥30.0 kg/m 2 vs 96±7 mg/dL (5.3±0.4 mmol/L) for BMI 18.5-<25 kg/m 2 , r=0.35)., Conclusions: Mean glucose levels and time 63-120 mg/dL (3.5-6.7 mmol/L) remained nearly stable throughout pregnancy and values above 140 mg/dL (7.8 mmol/L) were rare. Mean glucose levels in pregnancy trend higher as BMI increases into the overweight/obesity range. The glycemic metrics reported during uncomplicated pregnancies represent treatment targets for pregnant individuals., Competing Interests: Competing interests: ALC reports no personal financial disclosures but reports that his institution has received funding on his behalf as follows: research support from Medtronic, Tandem, Insulet, Abbott, Dexcom, Eli Lilly, NovoNordisk, Sanofi and UnitedHealth Group and consultancy fees from Mannkind and NovoNordisk. RWB reports no personal financial disclosures but reports that his institution has received funding on his behalf as follows: grant funding and study supplies from Dexcom. RMB has received research support, has acted as a consultant, or has been on the scientific advisory board for Abbott Diabetes Care, Ascensia, Bigfoot Biomedical, CeQur, Dexcom, Eli Lilly, Embecta, Hygieia, Insulet, Medtronic, Novo Nordisk, Onduo, Roche Diabetes Care, Tandem Diabetes Care, Sanofi, UnitedHealthcare, Vertex Pharmaceuticals and Zealand Pharma. RMB’s employer, non-profit HealthPartners Institute, contracts for his services and he receives no personal income for any of these activities. CD reports advisory work for Dexcom for GDM patient-facing materials and system implementation., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Insulin is recommended for pregnant persons with preexisting type 2 diabetes or diabetes diagnosed early in pregnancy. The addition of metformin to insulin may improve neonatal outcomes., Objective: To estimate the effect of metformin added to insulin for preexisting type 2 or diabetes diagnosed early in pregnancy on a composite adverse neonatal outcome., Design, Setting, and Participants: This randomized clinical trial in 17 US centers enrolled pregnant adults aged 18 to 45 years with preexisting type 2 diabetes or diabetes diagnosed prior to 23 weeks' gestation between April 2019 and November 2021. Each participant was treated with insulin and was assigned to add either metformin or placebo. Follow-up was completed in May 2022., Intervention: Metformin 1000 mg or placebo orally twice per day from enrollment (11 weeks -<23 weeks) through delivery., Main Outcome and Measures: The primary outcome was a composite of neonatal complications including perinatal death, preterm birth, large or small for gestational age, and hyperbilirubinemia requiring phototherapy. Prespecified secondary outcomes included maternal hypoglycemia and neonatal fat mass at birth, and prespecified subgroup analyses by maternal body mass index less than 30 vs 30 or greater and those with preexisting vs diabetes early in pregnancy., Results: Of the 831 participants randomized, 794 took at least 1 dose of the study agent and were included in the primary analysis (397 in the placebo group and 397 in the metformin group). Participants' mean (SD) age was 32.9 (5.6) years; 234 (29%) were Black, and 412 (52%) were Hispanic. The composite adverse neonatal outcome occurred in 280 (71%) of the metformin group and in 292 (74%) of the placebo group (adjusted odds ratio, 0.86 [95% CI 0.63-1.19]). The most commonly occurring events in the primary outcome in both groups were preterm birth, neonatal hypoglycemia, and delivery of a large-for-gestational-age infant. The study was halted at 75% accrual for futility in detecting a significant difference in the primary outcome. Prespecified secondary outcomes and subgroup analyses were similar between groups. Of individual components of the composite adverse neonatal outcome, metformin-exposed neonates had lower odds to be large for gestational age (adjusted odds ratio, 0.63 [95% CI, 0.46-0.86]) when compared with the placebo group., Conclusions and Relevance: Using metformin plus insulin to treat preexisting type 2 or gestational diabetes diagnosed early in pregnancy did not reduce a composite neonatal adverse outcome. The effect of reduction in odds of a large-for-gestational-age infant observed after adding metformin to insulin warrants further investigation., Trial Registration: ClinicalTrials.gov Identifier: NCT02932475.

Objective: To determine the association of an elevated hemoglobin A1c (HbA1c) as part of an early pregnancy universal screening protocol and postpartum (PP) weight retention in the absence of a diagnosis of diabetes., Methods: This is a retrospective cohort study of patients who underwent universal HbA1c screening with initial prenatal labs (≤16 weeks) over a 2-year period (2016-2018) at a single urban tertiary care center. An elevated HbA1c was defined as 5.7-6.4%. All patients who delivered ≥32 weeks with documented weights at first prenatal visit, delivery, and PP visit were included. Patients with preexisting or gestational diabetes, multiple gestation, fetal demise, or no glucose tolerance screening were excluded. Body mass index (BMI) was calculated and gestational weight gain was assessed by National Academy of Medicine (NAM) guidelines. The primary outcome was PP weight retention among patients with normal versus elevated HbA1c., Results: 2,284 patients met inclusion criteria, of whom 2015 (88.2%) had a normal HbA1c and 269 (11.8%) had an elevated HbA1c. Compared to patients with a normal HbA1c, patients with an elevated HbA1c were more likely to be non-Hispanic black, multiparous, or publicly insured. They were also more likely to enter pregnancy obese. Patients with an elevated HbA1c gained less weight during pregnancy compared to those with normal HbA1c; however, this was no longer significant after adjusting for pre-pregnancy BMI. In both groups, almost half of patients exceeded NAM guidelines for gestational weight gain during the pregnancy. Patients with an elevated HbA1c had significantly less PP weight retention (2.2 vs. 4.5 kg, p  < .001) compared to patients with a normal HbA1c. After adjusting for differences in baseline characteristics, the association between HbA1c and PP weight retention remained significant ( B  = -0.86, p  < .003). More patients in the elevated HbA1c group returned to their pre-pregnancy weight or less by the PP visit. In all BMI categories, those who exceeded NAM guidelines had greater postpartum weight retention compared to those that met guidelines., Conclusion: Among patients not diagnosed with diabetes, elevated HbA1c in early pregnancy is associated with similar gestational weight gain but significantly less postpartum weight retention compared to those with normal HbA1c.

Background: Screening strategies for gestational diabetes mellitus (GDM), particularly early GDM, have traditionally relied upon the use of clinical risk factors (CRFs). Although commonly used in nonpregnant patients, HbA1c screening is not widely used despite reports of abnormal HbA1c values being predictive of GDM development. The aims of this study are to assess the utility of universal HbA1c screening in predicting GDM and to compare universal screening to targeted CRF-based screening for the diagnosis of GDM., Study Design: This is a retrospective cohort study of patients undergoing universal HbA1c screening at ≤16 completed weeks gestation with a singleton pregnancy between December 2016 and April 2018 at a single urban tertiary care center. Patients with preexisting diabetes (HbA1c ≥6.5%) or patients who did not have glucose tolerance testing were excluded. Patients with HbA1c 5.7-6.4% underwent early two-step GDM screening. Positive screens were diagnosed with early GDM. Normal early screeners underwent repeat 3rd trimester screening. Clinical risk factors for early GDM screening at our institution prior to universal screening were history of GDM, body mass index (BMI) ≥40 kg/m 2 , prior macrosomia (birth weight ≥4000 g) or stillbirth, and polycystic ovary syndrome. Multivariable regression was performed to assess the relationship between HbA1c and GDM. The predictive ability of universal HbA1c screening compared to that of CRFs was evaluated by testing for differences in the area under the curve (AUC) of receiver operating curves (ROCs)., Results: One thousand nine hundred and fifteen patients met inclusion criteria. Two hundred and thirty-one (12.1%) patients had an elevated HbA1c ≥5.7%. Patients with elevated HbA1c were more likely to be older, Black, or obese compared with patients with normal HbA1c values. After adjusting for Black race, BMI, age, and public insurance, the odds of GDM development are 3.50 (95%CI 2.26-5.39) times higher among patients with HbA1c ≥5.7% compared to those with a normal HbA1c. Clinical risk factors for early glucose screening were present in 33% of patients with an elevated HbA1c. The AUC of CRF screening and HbA1c ≥5.7% was 0.72 and 0.75, respectively ( p = .07), after controlling for Black race, BMI, maternal age, and insurance., Conclusions: An elevated HbA1c is associated with an increased risk of GDM. Universal HbA1c screening performs as favorably as CRF based screening for the prediction of GDM.

Objective: To evaluate whether a postpartum text message-based communication platform improves breastfeeding rates., Methods: In a randomized controlled trial, a control group receiving weekly text messages inquiring about infant feeding method was compared with an intervention group receiving educational text messages and personalized, text message-based breastfeeding support. The primary outcome was breastfeeding exclusivity at 6 weeks postpartum. Secondary outcomes included any breastfeeding and formula supplementation at 6 weeks postpartum. A sample size of 190 was planned to achieve 80% power to detect a 50% change in breastfeeding exclusivity from 40% baseline, with a two-sided alpha of 5%. Race was noted to be an effect modifier; therefore, results are presented overall and stratified by self-reported Black race compared with non-Black race., Results: From January 2020 to January 2021, 300 patients were enrolled and 216 were randomized as follows: 110 to control and 106 to intervention. In the cohort, 52.8% were Black, 45.4% had public insurance, and 46.3% were nulliparous. There were no differences in demographic, delivery, or postpartum characteristics between groups. Among the 185 patients (85.6%) with data available for the primary outcome, there was no difference in breastfeeding exclusivity by treatment group (intervention 48.4% vs usual care 41.3%, P =.33). When stratified by race, Black patients in the intervention arm had 2.6 times higher odds of exclusively breastfeeding at 6 weeks postpartum compared with Black patients in the control arm (39.5% vs 20.0%, odds ratio 2.62, 95% CI 1.04-6.59). Enrollment in the intervention arm decreased the Black-non-Black disparity in the primary outcome (20.0% vs 66.7%, P &lt;.001in usual care arm vs 39.5% vs 56.0%, P =.11 in intervention arm). There were no differences in other secondary outcomes., Conclusion: A text message-based communication platform was not associated with breastfeeding exclusivity at 6 weeks postpartum compared with usual care., Clinical Trial Registration: ClinicalTrials.gov , NCT04108533., Competing Interests: Financial Disclosure Celeste Durnwald disclosed receiving payment from Medscape for ACOG 2022 CME morning presentation on continuous glucose monitoring in pregnancy. The other authors did not report any potential conflicts of interest., (Copyright © 2022 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: This study aimed to evaluate the impact of elevated early hemoglobin A1c (HbA1c) values on perinatal outcomes in patients without a diagnosis of diabetes or gestational diabetes., Study Design: This is a retrospective study of patients with a singleton pregnancy who underwent universal HbA1c screening in early pregnancy at an urban tertiary care center between December 1, 2016, and December 31, 2018. Patients with pregestational diabetes mellitus (DM) and gestational DM (GDM) were excluded from analysis. The exposure of interest was HbA1c of 5.7 to 6.4% as measured on routine prenatal bloodwork at or during 16 weeks' gestation. The following pregnancy outcomes were assessed: preterm delivery <37 weeks, hypertensive disorders of pregnancy, shoulder dystocia, macrosomia (birth weight >4,000 g), small or large for gestational age neonate, operative vaginal delivery, third- or fourth-degree lacerations, cesarean delivery, neonatal intensive care unit (NICU) admission, neonatal hypoglycemia, and neonatal hyperbilirubinemia. Multivariable regression was performed to assess the relationship between HbA1c and selected adverse outcomes while controlling for potential confounders RESULTS:  Of the 2,621 patients who met inclusion criteria, 334 (12.7%) had an elevated HbA1c of 5.7 to 6.4%. Patients with an elevated HbA1c were more likely to be older, Black, multiparous, publically insured, obese, or have chronic hypertension than patients with normal HbA1c values. In the unadjusted analysis, patients with an elevated HbA1c were less likely to deliver at term (84.7 vs. 92.4%, p  = 0.006), but more likely to undergo cesarean section (32.8 vs. 27.6%, p  = 0.038), develop hypertensive disorders of pregnancy (31.9 vs. 23.2%, p  = 0.001), or deliver a macrosomic infant (10.5 vs. 6.8%, p  = 0.016) than those with a normal A1c. After adjusting for race, body mass index, insurance status, nulliparity, and age, however, only the relationship between HbA1c and spontaneous preterm birth remained significant (adjusted odds ratio [aOR] = 1.76, 95% confidence interval [CI]: 1.01-3.07)., Conclusion: In our urban population, an elevated early HbA1c was associated with spontaneous preterm birth in nondiabetic patients KEY POINTS: · In nondiabetic patients, early pregnancy HbA1c was associated with selected adverse outcomes.. · Rates of preterm birth, pregnancy-induced hypertension, cesarean section, and macrosomia were higher in patients with an elevated HbA1c.. · The relationship between early pregnancy HbA1c and spontaneous preterm birth remained significant after adjustment.., Competing Interests: None declared., (Thieme. All rights reserved.)

Introduction: There is an urgent need to establish an evidence base for recommendations regarding proportions of macronutrients for optimized nutritional management of gestational diabetes mellitus (GDM). Our study compared isocaloric diets in women with GDM that differed in protein and carbohydrate content with fats held constant. We hypothesized that the glucose area under the curve (AUC) would be lower with the higher protein/lower carbohydrate diet., Research Design and Methods: This study used a random order crossover design within a controlled research unit environment. Nineteen women were randomized to treatment, with 12 participants completing both arms of the study. Blood sampling occurred preprandially and at t  = 30, 60, 120, and 180" relative to meals. Inclusion criteria were confirmed diet-controlled GDMA1, singleton gestation, and with no pre-existing medical comorbidities. Mean gestational age at entrance to study = 32 (±1.76) weeks. Mean prepregnant body mass index of participants = 28.7 (±5.3) kg/m 2 Participants were randomly assigned initially to either an increased protein/low carbohydrate (iPRO30%/CHO35%) diet or a lower protein/higher carbohydrate (LPRO15%/CHO50%) diet for a 36 hour inpatient stay on the research unit. All meals and snacks were prepared in a metabolic kitchen. After a 3-7 day washout period, participants were randomized to the opposite treatment., Results: On day 2 (with confirmed overnight fasting), the average 3-hour pre- through postprandial glucose AUC was lower in iPRO30%/CHO35% treatment arm (17395.20 ± 2493.47 vs. 19172.47 ± 3484.31, p  = 0.01)., Conclusion: This study is the first to demonstrate that a higher protein, lower carbohydrate meal, especially at breakfast, can result in lower postprandial blood glucose values in women with gestational diabetes. A lack of statistically significant differences at other collection time points could have been due to several factors, but most likely due to small sample size. Longer term outcomes of a higher protein diet, including maternal glycemic control, nitrogen balance, and impact on fetal growth outcomes, are needed., Competing Interests: No competing financial interests exist., (© Kimberly K. Trout et al., 2022; Published by Mary Ann Liebert, Inc.)

Objective: Women with obesity and other comorbidities such as hypertension and diabetes are at an increased risk of preeclampsia and perinatal morbidity. This study evaluates whether screening echocardiogram can identify women with obesity at a higher risk of preeclampsia., Methods: We conducted a retrospective cohort study of women with class III obesity (body mass index [BMI] ≥40 kg/m 2 ) and one or more medical comorbidities associated with an increased risk of preeclampsia (such as diabetes, hypertension, and rheumatologic disease) undergoing screening echocardiogram. Abnormal findings were defined as the presence of one or more of the following: diastolic dysfunction, ejection fraction of ≤45%, or cardiac chamber enlargement or hypertrophy. Multivariable logistic regression was used to estimate the odds ratio (OR) of gestational hypertension/mild preeclampsia, severe preeclampsia, and any preterm delivery <37 weeks associated with abnormal echocardiographic findings when controlling for potential confounders., Results: Of 267 eligible women, 174 (64%) underwent screening echocardiograms. Sixty-nine women (40%) had abnormal echocardiograms. Maternal clinical characteristics were similar between women with normal echocardiographic findings and women with abnormal findings. Women with abnormal echocardiograms were more likely to have chronic hypertension (78 vs. 62%, p  = 0.04) and a history of preeclampsia (27 vs. 10%, p  = 0.02). After controlling for confounders, women with abnormal echocardiogram were at an increased risk of hypertensive disorders of pregnancy, OR 6.80 (95% confidence interval [CI] 3.32-13.93, p  = 0.01), and in particular severe preeclampsia, OR 8.77 (95% CI 3.90-19.74, p  = 0.01)., Conclusion: Among pregnant women with class III obesity and medical comorbidities, screening echocardiogram may help identify a subset of women at the highest risk of developing preeclampsia., Key Points: · Women with obesity and comorbid conditions are at a high risk of abnormal echocardiogram.. · Women with obesity, medical comorbid conditions, and abnormal echo are at a high risk of preeclampsia.. · Screening echocardiogram can help identify obese women at the highest risk of severe preeclampsia.., Competing Interests: None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

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)., Competing Interests: None declared., (Thieme. All rights reserved.)

Type 2 diabetes mellitus (DM) is a growing problem among reproductive-aged women. Contemporary trends in obesity and delayed child-bearing are expected to result in an increasing number of pregnancies affected by type 2 DM. Women with known type 2 DM can greatly benefit from preconception care as improved periconception glycemic control and weight loss can decrease the neonatal and maternal risks associated with type 2 DM and pregnancy. Antenatal mainstays of management include frequent blood glucose monitoring, insulin therapy, optimization of coexisting medical conditions, and fetal surveillance. Careful attention to postpartum glucose control, infant feeding choices, and contraceptive counseling are important aspects of immediate postpartum care., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Safe Start is a community health worker program representing a partnership between a high-volume, inner-city, hospital-based prenatal clinic; a community-based organization; a large Medicaid insurer; and a community behavioral health organization to improve perinatal outcomes among publicly insured pregnant women with chronic health conditions in Philadelphia, Pennsylvania. As of June 2019, 291 women participated in the program. Relative to a comparison group (n = 300), Safe Start participants demonstrate improved engagement in care, reduced antenatal inpatient admissions, and shorter neonatal intensive care unit stays.

Objective: To determine the association between cell-free DNA (cfDNA) fetal fraction and gestational diabetes (GDM) in a cohort of women presenting for cfDNA screening for fetal aneuploidy., Methods: A retrospective cohort study of women with singleton pregnancies who had cfDNA screening at a single institution at 10 to 20 weeks gestation between October 2011 and October 2017. Fetal fractions were adjusted for gestational age (GA) using multiples of the median (MoM). Multivariable logistic regression was used to estimate the odds ratio (OR) of GDM controlling for potential confounders., Results: Two thousand six hundred twenty-three pregnancies met criteria. Women with GDM had a lower fetal fraction (0.93 MoM vs. 1.05 MoM, P = .002). However, the association between fetal fraction and GDM was not significant after adjusting for body mass index (BMI) [OR 0.84, 95% confidence interval (CI) 0.52-1.36; P = .48]. Since insulin resistance increases at later GAs, separate analysis on women with GA 14 to 20 weeks was performed. Again, the association between fetal fraction and GDM was not significant after adjusting for BMI, (OR 0.81, 95% CI 0.31-2.12; P = .67)., Conclusion: Low or high fetal fraction of cfDNA was not associated with GDM. Although fetal fraction was lower among women diagnosed with GDM, this relationship was no longer statistically significant once maternal BMI was taken into account., (© 2020 John Wiley & Sons, Ltd.)

Objective: Determine cost differences between cell-free DNA (cfDNA) and serum integrated screening (INT) in obese women given the limitations of aneuploidy screening in this population., Methods: Using a decision-analytic model, we estimated the cost-effectiveness of trisomy 21 screening in class III obese women using cfDNA compared with INT. Primary outcomes of the model were cost, number of unnecessary invasive tests, procedure-related fetal losses, and missed cases of trisomy 21., Results: In base case, the mean cost of cfDNA was $498 greater than INT ($1399 vs $901). cfDNA resulted in lower probabilities of unnecessary invasive testing (2.9% vs 3.5%), procedure-related loss (0.015% vs 0.019%), and missed cases of T21 (0.00013% vs 0.02%). cfDNA cost $87 485 per unnecessary invasive test avoided, $11 million per procedure-related fetal loss avoided, and $2.2 million per missed case of T21 avoided. In sensitivity analysis, when the probability of insufficient fetal fraction is assumed to be >25%, cfDNA is both costlier than INT and results in more unnecessary invasive testing (a dominated strategy)., Conclusion: When the probability of insufficient fetal fraction more than 25% (a maternal weight of ≥300 lbs), cfDNA is costlier and results in more unnecessary invasive testing than INT., (© 2019 John Wiley & Sons, Ltd.)

Background: A woman's prior breastfeeding history may influence future decisions regarding infant feeding. Few quantitative tools utilizing this information have been demonstrated to predict breastfeeding success., Research Aim: To evaluate the efficacy of a prenatal breastfeeding history (BAP) questionnaire administered in prenatal care to predict in-hospital formula supplementation among multiparous women., Methods: This is a prospective observational study of multiparous women with singleton pregnancies who presented to a Baby-Friendly urban tertiary care center for 1st prenatal visit at < 20 weeks' gestation. The BAP tool generates a numerical score, with higher score (≥ 2) indicating prior successful breastfeeding experiences. The primary outcome was occurrence of non-medically indicated formula supplementation during the postpartum hospital stay. Student's t test and Pearson's chi-square test were used to compare continuous and categorical variables. A multivariable logistic regression was performed to assess the relationship of BAP score to formula supplementation. Of 587 women screened, 433 (73.8%) mother-infant dyads were analyzed., Results: Rates of formula supplementation in women with BAP scores ≤ 1 were 67% (156/234) compared with 37% (73/199) in women with higher scores ( p < 0.0001). After controlling for race/ethnicity, insurance, and obesity, women with BAP scores of ≤ 1 were 2.6 times more likely to supplement formula than women with higher scores (a OR 2.62, 95% CI [1.70, 4.04], p < .0001)., Conclusion: In this prospective validation study, women with negative prior breastfeeding experiences, as evidenced by a lower BAP score, were more likely to supplement formula during the postpartum hospital stay.

Competing Interests: Conflict of Interest: None.

Objective: To evaluate whether prenatal care in a specialized diabetes in pregnancy program (DMC) improves compliance with completion of the 2-h 75 g oral glucose tolerance test (2HrOGTT) in GDM women., Methods: A retrospective cohort study of GDM women delivering in a university health system between January 2011 and March 2014 was performed. Women were divided into two groups: those receiving care in prenatal clinics over an 18-month period prior to the establishment of the diabetes in pregnancy clinic (pre-DMC) and those receiving prenatal care in a specialized diabetes in pregnancy clinic (post-DMC). The primary outcome was completion of the 2HrOGTT postpartum. Clinical characteristics associated with 2HrOGTT completion were evaluated. Time trend analysis was performed to evaluate month to month variation in 2HrOGTT compliance for secular trends., Results: A total of 292 women were analyzed, 147 post-DMC and 118 pre-DMC. The 2HrOGTT was ordered more frequently in the post-DMC compared to pre-DMC (90.0 versus 53.0%, p < 0.0001). Rates of completion of the 2HrOGTT were 49.2% post-DMC and 25.0% pre-DMC, p = 0.007. After adjusting for potential confounders, women who received prenatal care post-DMC were 2.98 times more likely to complete the 2HrOGTT compared to those receiving care pre-DMC (OR 2.98 [1.34, 6.62], p = 0.007)., Conclusions: Providers were 5.9 times more likely to order the recommended testing for GDM women who attended the postpartum visit in the post-DMC period. GDM women who receive prenatal care in a specialized diabetes in pregnancy program are more likely to complete the 2HrOGTT in the postpartum period.

Gestational diabetes (GDM) affects up to 200,000 deliveries in the United States each year. With the growing obesity epidemic, delayed childbearing, and multiple gestations, the diagnosis of GDM is expected to continue to rise. GDM unmasks a beta-cell defect that persists after pregnancy and typically worsens over time imparting the increased risk of type 2 diabetes mellitus after the index pregnancy. In addition, coexisting obesity and progressive weight gain are additive factors for progression to type 2 DM. Obstetricians play an integral role in informing GDM women about their lifelong risk of type 2 diabetes (T2DM) and can help bridge the care to primary care physicians, as it relates to recommended screening and long-term follow-up., (Copyright © 2015 Elsevier Inc. All rights reserved.)

A growing body of literature suggests that chronic disease has much of its origins in the fetal response to the intrauterine environment, a concept known as "fetal programming." Longitudinal studies have demonstrated that higher rates of obesity, impaired glucose tolerance, hypertension, and dyslipidemia are evident in the offspring of diabetic women. This review focuses on the implications of intrauterine exposure to an altered maternal metabolic milieu and the risk of childhood obesity and metabolic dysfunction., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objectives: To identify predictors of successful trial of labor in women after one low transverse Cesarean delivery and no prior deliveries, and to assess perinatal morbidity associated with a failed vaginal birth after Cesarean delivery (VBAC)., Methods: Retrospective chart review of women with one low transverse Cesarean delivery in their first pregnancy who delivered their next pregnancy at our institution. Clinical characteristics and intrapartum data were reviewed to identify predictors of successful VBAC. Perinatal outcomes were reviewed to assess morbidity associated with VBAC attempt and failed VBAC., Results: Of 768 women studied, 522 (68%) attempted VBAC and 344 (66%) of these were successful. Uterine rupture occurred in 0.8% of the VBAC group. On initial examination, women with cervical dilation >1 cm, effacement > 50% and station lower than -1 were more likely to deliver vaginally. Women with successful VBAC had more spontaneous labor (85.2 vs. 76.4%, p=0.02) and less oxytocin use (49.7 vs. 70.8%, p < 0.0001). There were no differences in outcomes between failed and successful VBAC, except more frequent 1-min Apgar scores < 5 (10.1 vs. 4.1%, p=0.01) and increased endometritis (9.6 vs. 2%, p=0.0002) with failed VBAC. Compared with elective repeat Cesarean delivery, VBAC attempt was associated with amnionitis (5.9 vs. 0%, p < 0.0001) and low 1- and 5-min Apgar scores (6.1 vs. 2.4%, p=0.03 and 2.3 vs. 0%, p=0.01, respectively), but not endometritis, admission to a neonatal intensive care unit (NICU), ventilation, intraventricular hemorrhage (IVH) or seizures. Failed VBAC had more amnionitis (7.3 vs. 0%, p < 0.0001), postpartum fever (11.2 vs. 2.4%, p=0.0003) and endometritis (9.6 vs. 2.0, p=0.0007) than elective repeat Cesarean delivery and was associated with low 1- and 5-min Apgar scores (10.1 vs 2.4%, p < 0.001 and 2.8 vs. 0%, p=0.01, respectively), but not NICU admission, ventilation, IVH or seizures., Conclusions: Favorable initial pelvic examination, spontaneous labor and a lack of oxytocin use are associated with successful VBAC in women with a single prior low transverse Cesarean delivery and no prior vaginal deliveries. While attempted VBAC and failed VBAC have more maternal infectious morbidity and lower Apgar scores, infant outcomes are similar to those of elective repeat Cesarean delivery.

Objective: The purpose of this study was to determine the value of the protein/creatinine ratio in prediction of 24-hour urine total protein among women with suspected preeclampsia., Study Design: Women who were evaluated for suspected preeclampsia at >or=24 weeks of gestation were studied prospectively if there was no concurrent diagnosis of chronic hypertension, diabetes mellitus, or preexisting renal disease. A protein/creatinine ratio was obtained, which was followed by the initiation of a 24-hour urine evaluation. Positive and negative predictive values and sensitivity and specificity of the protein/creatinine ratio for significant (>or=300 mg) and severe proteinuria (>or=5000 mg) that were based on 24-hour urine total protein were calculated., Results: A total of 220 women were evaluated; 43.2% of the women were black, and 80% of the women had government insurance. Mean maternal and gestational ages were 26.1 years and 36.5 weeks, respectively. Significant and severe proteinuria on 24-hour urine evaluation were identified in 76.4% and 8.2% of cases, respectively. Regression analysis of protein/creatinine ratio and 24-hour urine total protein level showed a poor correlation (r(2)=0.41). Receiver operator characteristic analysis revealed an area under the curve of 0.80, but the shoulder value of 390 mg/g carried a high false-negative rate (45.2%). With a more conservative cutoff value, a protein/creatinine ratio of >or=300 mg/g had a poor negative predictive value (47.5%), a specificity for significant proteinuria (55.8%), with a positive predictive value of 85.5%, and a sensitivity of 81%. For severe proteinuria, a protein/creatinine ratio of >or=5000 mg/g had a poor positive predictive value (61.9%) and sensitivity (72.2%), with a negative predictive value of 97.5%, and a specificity of 96.0%., Conclusion: Protein/creatinine ratio does not exclude adequately the presence of significant proteinuria or predict severe proteinuria and should not be used as an alternative to 24-hour total protein evaluation.

Background: The therapy for native mitral valve endocarditis is in evolution. Antibiotics have significantly improved survival rates, but patients with complications of endocarditis may require surgical treatment., Methods: Between January 1985 and December 1995, 146 patients underwent surgical therapy (repair or replacement) for native mitral valve endocarditis. All patients had documented bacterial endocarditis. Univariate and multivariate analyses were performed to determine predictors of hospital death, long-term event-free survival, and probability of repair. Patients were evaluated in three groups: all patients, patients with acute endocarditis, and patients with chronic endocarditis., Results: There were ten hospital deaths (6.8%). Patients undergoing repair had a lower hospital mortality rate (p = 0.008) then those having replacement. Event-free survival was improved after mitral valve repair in the overall group (p = 0.02) and in the group with healed (chronic) endocarditis (p = 0.05). Although the acute endocarditis group demonstrated an improved event-free survival rate after mitral valve repair versus replacement (74% versus 20% at 6 years), this did not reach statistical significance., Conclusions: We conclude that mitral valve repair is preferable to mitral valve replacement when possible, in patients with complications of endocarditis, as repair results in a lower hospital mortality and an improved long-term survival.