Effects of diabetic pregnancy on the fetus and newborn

Diabetes in pregnancy is unique because of the diversity of problems that can affect the embryo/fetus beginning with conception. Considerable effort has been devoted to understanding the basic developmental biology from observing young embryos in vitro or in vivo. Maternal glucose control has been identified as an important event. The preponderance of evidence indicates that rigid glucose control will minimize the incidence of anomalies incurred before 9 weeks of pregnancy. Later events are related to fetal hyperinsulinemia. These include fetal macrosomia, respiratory distress syndrome, neonatal hypoglycemia, neonatal hypocalcemia, and neonatal hypomagnesemia. Control of maternal metabolism can have a significant impact on each of the above. Finally, the long-term effects of maternal diabetes are as diverse as the pathogenetic events during pregnancy. Surprisingly, there is a significant transmission rate of 2% of type I diabetes if the mother has insulin-dependent diabetic mother, whereas the rate is 6% for the father. The Diabetes in Early Pregnancy Study showed that good maternal control was associated with normal neurodevelopmental outcome.     

Fetal and maternal analgesia/anesthesia for fetal procedures

For many prenatally diagnosed conditions, treatment is possible before birth. These fetal procedures can range from minimal invasive punctions to full open fetal surgery. Providing anesthesia for these procedures is a challenge, where care has to be taken for both mother and fetus. There are specific physiologic changes that occur with pregnancy that have an impact on the anesthetic management of the mother. When providing maternal anesthesia, there is also an impact on the fetus, with concerns for potential negative side effects of the anesthetic regimen used. The question whether the fetus is capable of feeling pain is difficult to answer, but there are indications that nociceptive stimuli have a physiologic reaction. This nociceptive stimulation of the fetus also has the potential for longer-term effects, so there is a need for fetal analgesic treatment. The extent to which a fetus is influenced by the maternal anesthesia depends on the type of anesthesia, with different needs for extra fetal anesthesia or analgesia. When providing fetal anesthesia, the potential negative consequences have to be balanced against the intended benefits of blocking the physiologic fetal responses to nociceptive stimulation.     

Effect of thrombocytopenia on mode of analgesia/anesthesia and maternal and neonatal outcomes

Abstract

Objectives: The purpose was to correlate the use of regional analgesia/anasthesia among women with different degrees of thrombocytopenia relative to women with normal platelet counts, and note maternal and neonatal outcome, and mode of delivery.

Methods: A case-control paradigm was developed based on women who delivered during 2007–2011 with platelet counts ≤80?000/mm³. For each woman in this “severe” thrombocytopenic group, an age- and parity-matched control was found who delivered a singleton within the same year but whose platelets were either 81?000–150?000/mm³ (“moderate” thrombocytopenia) or ≥151?000/mm³ (normal platelet counts).

Results: 168 women were identified for each group; mean maternal age (28.4 years), mean gravidity (4.3), mean parity (3.7), mean gestational age (39.2 weeks) and mean birth weight (3283?g) were comparable. However, only in the severe thrombocytopenic women were there very early preterm deliveries, lowest birth weight, lowest Apgar scores, the greatest number with serious post-partum hemorrhage (>500?ml); use of regional analgesia/anesthesia was lowest, and percent cesarean sections highest.

Conclusions: This study highlights potential for adverse maternal outcome of post-partum hemorrhage and adverse neonatal outcomes of prematurity, low birth weight, and low Apgar scores (but not neonatal death), and limited regional analgesia/anesthesia in women who present at delivery with severe (≤80?000/mm³) thrombocytopenia.     

Effects of hypoxia on the mother and fetus with emphasis on maternal air transport

Transportation by air ambulance of pregnant mothers from peripheral hospitals to specialized institutions is becoming increasingly common. There are potential hazards to the fetus because of the altitude during flight, particularly in the presence of partially compromised placental function. Adult and fetal neurohumoral and metabolic responses to acute hypoxia tend to protect the fetus for a limited time period. These include maintenance of uterine blood flow, redistribution of blood flow to essential fetal organs, temporary decrease in fetal oxygen consumption, and dependence on anaerobic metabolism. These compensations are adequate for the normal fetus but may not protect the already compromised fetus from the deleterious effects of hypoxia.     

Impact of maternal pheochromocytoma on the fetus and neonate

Pheochromocytoma during pregnancy is rare but potentially harmful to the mother and fetus. Fetal risks are mainly determined by the vasoconstrictive effects of maternal catecholamine on uteroplacental circulation, because the fetus is protected from the direct effects of high catecholamine levels at the placental interface. Uteroplacental insufficiency may lead to spontaneous abortion, fetal growth restriction, premature delivery, and fetal hypoxia, followed by fetal distress and/or birth asphyxia. Adrenalectomy is recommended during the second trimester. When a diagnosis is made during the late second or third trimester, appropriate medical treatment until term and planned delivery with concurrent or delayed adrenalectomy can result in good fetal outcomes. Moreover, when adrenalectomy is planned after delivery, there is concern regarding the potential of antihypertensive drugs to be transferred to breast milk. It is generally known that early detection and proper treatment of pheochromocytoma during pregnancy decrease maternal and fetal mortality. However, in recent case series, antenatal maternal pheochromocytoma diagnosis did not significantly decrease the risk of fetal and neonatal mortality and morbidity, contrary to the maternal death and complication rates. Although intrauterine ischemia and hypoxia due to uteroplacental insufficiency can affect the long-term outcomes of neonates, no systematic studies have been performed.