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ObjectiveTo characterize the relationship between hemoglobin A1c (HbA1c) levels and glucose tolerance across pregnancy and postpartum.Design and ParticipantsIn a longitudinal study of pregnant women with gestational diabetes risk factors (N = 102), we performed oral glucose tolerance testing (OGTT) and HbA1c measurements at 10–15 weeks of gestation, 24–30 weeks of gestation (N = 73), and 6–24 weeks postpartum (N = 42). Complete blood counts were obtained from clinical records. We calculated HbA1c-estimated average glucose levels and compared them with mean OGTT glucose levels (average of fasting, 1- and 2-hour glucose levels). Linear mixed effects models were used to test for longitudinal changes in measurements.ResultsMean OGTT glucose increased between 10–15 and 24–30 weeks of gestation (β = 8.1 mg/dL, P = .001), while HbA1c decreased during the same time period (β = –0.13%, P < .001). At 10–15 weeks of gestation and postpartum the discrepancy between mean OGTT glucose and HbA1c-estimated average glucose was minimal (mean [standard deviation]: 1.2 [20.5] mg/dL and 0.16 [18.1] mg/dL). At 24–30 weeks of gestation, the discrepancy widened (13.2 [17.9] mg/dL, β = 12.7 mg/dL, P < .001, compared to 10–15 weeks of gestation, with mean OGTT glucose being higher than HbA1c-estimated average glucose). Lower hemoglobin at 24–30 weeks of gestation was associated with a greater discrepancy (β = 6.4 mg/dL per 1 g/dL lower hemoglobin, P = .03 in an age- and gestational age-adjusted linear regression model).ConclusionsHbA1c accurately reflects glycemia in the 1st trimester, but underestimates glucose intolerance in the late 2nd trimester. Lower hemoglobin level is associated with greater underestimation. Accounting for gestational age and maternal hemoglobin may improve the clinical interpretation of HbA1c levels during pregnancy.

BACKGROUND: Women with gestational glucose intolerance, defined as an abnormal initial gestational diabetes screening test, are at risk for adverse pregnancy outcomes even if they do not have gestational diabetes. We previously defined gestational diabetes physiologic subtypes based on the primary underlying physiology leading to hyperglycemia and found that women with different subtypes had differential risk of adverse outcomes. Physiologic subclassification has not yet been applied to women with gestational glucose intolerance. OBJECTIVE: We defined gestational glucose intolerance physiologic subtypes based on the presence of insulin resistance, insulin deficiency, or mixed pathophysiology, and aimed to determine if these subtypes are at differential risk for adverse outcomes. We hypothesized that women with the insulin resistant subtype of gestational glucose intolerance would have the greatest risk of adverse pregnancy outcomes. STUDY DESIGN: In a hospital-based cohort study, we studied women with gestational glucose intolerance (glucose loading test 1-hour glucose ≥140 mg/dL, N=236) and normal glucose tolerance (glucose loading test 1-hour glucose

Background Thrombotic thrombocytopenic purpura (TTP) is a rare but serious complication in pregnancy that places the mother and fetus at high risk for morbidity and mortality. This case illustrates novel pregnancy complications associated with this rare medical condition. Case presentation A 31-year-old G3P0020 at 28 weeks and 1 day was admitted with severe thrombocytopenia and was ultimately diagnosed with TTP. With therapeutic plasma exchange (TPE), maternal status improved. At 28 weeks 6 days, however, non-reassuring fetal testing prompted cesarean delivery with placental abruption noted intraoperatively. Pathology examination confirmed placental abruption and also revealed multiple placental infarcts. Conclusion While medical management of TTP can significantly improve the health of the mother, this case highlights the potential role of TTP in abruption and other placental pathology and thus, the need for close fetal surveillance throughout an affected pregnancy.

Background: Women with gestational diabetes mellitus (GDM) and gestational glucose intolerance (GGI, abnormal initial GDM screening test) and their infants have an increased risk of adverse perinatal outcomes including large for gestational age birth weight (LGA), pregnancy-related hypertension, neonatal intensive care unit (NICU) admission, and cesarean delivery. We expanded a prior analysis defining physiologic subtypes of GGI categorized by insulin resistance, insulin deficiency, or mixed pathophysiology. We aimed to determine if GGI subtypes are at differential risk for adverse outcomes. Methods: We applied homeostasis model assessment (HOMA2) to fasting glucose and insulin levels at 16–20 weeks’ gestation to assess insulin resistance and deficiency, defined using the 50th percentile in 220 women with a normal glucose loading test (GLT) at 24–30 weeks’ gestation. We defined GGI as GLT 1-hr glucose ≥140 mg/dL (n=245) and normal glucose tolerance (NGT) as GLT 1-hr glucose Results: Of women with GGI, 49.0% had the insulin resistant subtype (IR, n=120), 30.6% had the insulin deficient subtype (ID, n=75), 15.9% had mixed pathophysiology (MP, n=39), and 4.5% had no evidence of IR or ID (n=11). GLT results and GDM diagnosis were similar among GGI subtypes. We found increased odds of LGA (primary outcome) in women with IR compared to women with NGT (OR 1.97 [1.17–3.32], p=0.01) in an unadjusted model; this was attenuated in an adjusted model with BMI (adjusted OR 1.43 [0.82–2.49], p=0.21). There was a trend toward increased odds of LGA in women with ID (adjusted OR 1.87 [0.92–3.80], p=0.09) and no increased odds in women with MP (adjusted OR 1.33 [0.50–3.57], p=0.57) compared to NGT. The odds of pregnancy-related hypertension in the IR subtype were increased (adjusted OR 1.68 [1.02–2.77], p=0.04) compared to women with NGT; women with ID (adjusted OR 0.91 [0.44–1.88], p=0.79) or MP (adjusted OR 1.13 [0.48–2.67], p=0.78) did not have increased odds. Neither infants of women with IR nor ID had increased odds of NICU admission overall, yet among women with BMI Conclusion: Insulin resistant GGI is a high-risk subtype for adverse perinatal outcomes. Using HOMA2 to delineate subtypes may provide opportunities for a personalized approach to GGI/GDM.

Objective: This study aims to compare outcomes of antenatal testing in women who received testing between 40 weeks and 40+6 weeks versus those who received testing at ≥41 weeks. Materials and methods: This retrospective study included women without maternal comorbidities, who were referred for outpatient antenatal testing for gestational age ≥40 weeks. We compared women who received antenatal testing between 40 and 40+6 weeks (Group 1), to those who were only tested at ≥41 weeks (Group 2). Results: A total of 827 Group 1 and 244 Group 2 pregnancies were evaluated. One-hundred and eighty-nine (18%) were sent to labor and delivery (L&D) for further evaluation. There were no significant differences between groups in terms of being sent or admitted to labor and delivery, the reason for which women were sent, induction of labor, mode of delivery, neonatal length of stay, or admission to intensive care. Conclusion: Pregnancies tested at 40 weeks were identified as abnormal and sent to L&D at the same rate as those tested at 41 weeks. Therefore, it may be reasonable to initiate fetal surveillance at the estimated date of delivery.

The biologic mechanism(s) regulating the length of gestation are currently poorly understood. After peaking at the blastocyst stage, the average telomere lengths have been reported to shorten during the remainder of gestation in the placenta and fetal membranes in both human and mouse pregnancies, thereby providing a potential countdown biologic clock. These previous studies have reported changes in the average telomere lengths, whereas it has now been shown that the shortest telomeres, not the average telomere lengths, are the mediators of telomere dysfunction which limits cellular survival and results in aging.These studies sought to assess for the first time a significant increase in short telomeres in the fetal membrane and placental tissue near the end of pregnancy in the mouse.Placental and fetal membrane tissues were harvested from timed-pregnant CD-1 mice on gestational days 14-18 prior to the onset of parturition. Telomere lengths were determined for 30 DNA samples (5 each for gestational days 14, 16, and 18 from placentas and fetal membranes) using a commercial high-throughput quantitative fluorescence in situ hybridization technique. Quantitative measurements of representative short telomeres (ie, 3 kb and 5 kb telomere fragments) were performed for 29-30 DNA samples (4-7 each for gestational days 14, 15, 16, 17, and 18 from placentas, fetal membranes, and maternal liver) using a real-time quantitative polymerase chain reaction modification of the classic telomere restriction fragment technique.The median telomere lengths of fetal membrane tissue decreased from gestational days 14-18 (18,705-16,364 kb) and were significantly shorter than telomeres in placental tissue (P.05). Representative histograms for the distribution of telomere lengths in mouse fetal membranes (as shown in the Figure) confirm a curve skewed to the left (toward shorter telomere lengths).The relative quantity of the representative short telomeres (ie, 3 kb and 5 kb fragments) increased significantly as gestation progressed in both placenta and fetal membrane tissue. In gestational day 18 fetal membranes, the relative quantity of 3 kb and 5 kb telomeres increased 5.5-fold and 9.3-fold compared with gestational day 14 tissues (P.05). In placental tissue the relative quantity of 3 kb and 5 kb telomeres increased 9.3-fold and 7.8-fold compared with gestational day 14 tissues (P.05). Studies performed using adult liver tissue demonstrated little variation of the representative short telomeres and no significant difference between the nonpregnant and pregnant samples.These mouse studies have demonstrated that the distribution of telomere lengths in fetal membrane and placental tissues are skewed toward shorter lengths and that the quantity of representative short telomeres increase significantly prior to parturition. The telomere gestational clock is a novel hypothesis supported by several preliminary mouse studies and interesting associations in human pregnancies between maternal conditions and telomere lengths. (eg, stress, education, pollution, neighborhood quality, and race). As such, the current hypothesis generating study provides a foundation for future research regarding the potential role for a telomere-based biologic clock that determines gestational length in human and other mammalian pregnancies.

Objectives Despite limited data, antenatal testing has been initiated in many institutions for women with morbid obesity given their increased risk of stillbirth. Therefore, our objective was to evaluate the obstetrical implications of antenatal testing in the morbidly obese population. Study Design We performed a retrospective cohort study of women undergoing antenatal testing from January 2011 through December 2012 who delivered at our institution. The exposed group was women undergoing antenatal testing with morbid obesity (body mass index [BMI] ≥ 40 kg/m(2)). This group was subdivided into two groups: group 1, which included women undergoing testing for morbid obesity alone, and group 2, which included women undergoing testing for morbid obesity with an additional medical comorbidity. The unexposed group (group 3) comprised nonmorbidly obese women (BMI

Background Emphasis on the development of designated programs for bariatric surgery as a method of quality improvement has increased; however, the data on the effect of these programs on the clinical outcome are insufficient. The aim of the present study was to consider the effect of the implementation of a bariatric clinical program on patient outcomes in a high-volume academic setting. Methods We implemented a focused bariatric clinical program to establish common clinical pathways and improve the critical clinical processes. To evaluate the effect of this program, we studied outcome and quality indicators, such as caseload, average length of stay (ALOS), and mortality, readmission, and complication rates during the 6-year period since the introduction of the program. Results From June 2000 to June 2006 (financial year 2001–2006), 1886 Roux-en-Y gastric bypass procedures were performed at our institution, with 7 deaths (.37%). During this period, we observed a progressive decrease in the ALOS from 6.7 days in 2001 to 3.2 days in 2006, a significant reduction of the 30-day readmission rates from 15.7% in 2001 to 8.1% in 2006, and a reduction of the observed overall complication rate from 18.6% in 2001 to 4.8% in 2006. Conclusion We observed a significant improvement in patient outcomes with the introduction of a designated bariatric surgery program. Additional studies of the validity of these quality indicators are needed to determine the true effect of these quality improvement programs.