Abnormal glucose screening in pregnancy in patients with normal oral glucose tolerance tests as a screening test for fetal macrosomia

Minor abnormalities of carbohydrate metabolism in pregnancy are a risk factor for delivery of a macrosomic infant. However, the 50-g 1-h oral glucose screen at 28 weeks is not a useful screening test for macrosomia in pregnant patients with normal glucose tolerance tests, because a positive screen does not raise the probability of delivering a macrosomic infant sufficiently to warrant intervention.     

Maternal insulin to lower the risk of fetal macrosomia in diabetic pregnancy

Fetal macrosomia is a well-recognized adverse outcome associated with gestational diabetes. Weekly measurement of fasting and postprandial glucose should identify those with fasting (greater than or equal to 100 or 105 mg/dl) or postprandial (greater than or equal to 120 mg/dl 2 hours after a meal) hyperglycemia who are at increased risk for perinatal mortality. If the prevention of macrosomia is desired, the use of prophylactic insulin, initiated as early as possible, but at the latest before 36 weeks' gestation, without regard to glycemia is effective. Alternatively, glucose self-monitoring (four to six times daily with institution of insulin treatment when fasting glucose exceeds some arbitrary threshold such as 90 mg/dl or postprandial values exceed a threshold such as 100 mg/dl) is likely to be equally effective with fewer patients requiring insulin injections.     

Comparison of glucose polymer and glucose for screening and tolerance tests in pregnancy

Forty-eight of 100 pregnant women received a 100-g (nonfasting) glucose screening test at about 28 weeks' gestation, followed by a 100-g glucose tolerance test. Another 52 received a 100-g (nonfasting) glucose polymer screening test followed by a 100-g glucose polymer tolerance test. Mean plasma glucose one hour after the glucose screening test was significantly lower than after the glucose polymer screening test. A further 178 women received a glucose polymer screening test and a glucose polymer tolerance test (230 in total). These women and the infants they delivered were studied to derive diagnostic criteria for the 100-g glucose polymer tolerance test by correlating maternal carbohydrate tolerance with indexes of neonatal metabolic performance, and to determine an adequate method of screening for carbohydrate intolerance of pregnancy (gestational diabetes). Diagnostic criteria similar to those of O'Sullivan and Mahan were also developed for the glucose polymer tolerance test. These values are up to 5% lower than those recommended by the National Diabetes Data Group (1979) for the 100-g glucose tolerance test.     

Risk factor screening for abnormal glucose tolerance in pregnancy.

OBJECTIVES: To assess the prevalence and association of frequently used screening risk factors for gestational diabetes mellitus (GDM) and to compare the validity and cost of universal screening with risk factor screening. METHOD: A cross-sectional survey of 768 pregnant women at > or = 24 weeks' gestation who were attending the antenatal clinic at the Hospital Universiti Kebangsaan Malaysia (HUKM) was made. Risk factors were determined using a questionnaire. An abnormal oral glucose tolerance test was defined as a 2-h post-prandial blood sugar level of > or = 7.8 mmol/l. RESULTS: A total of 191 pregnant mothers (24.9%) had GDM. The most commonly identified screening factors were positive family history of diabetes mellitus (31.4%), history of spontaneous abortion (17.8%), vaginal discharge and pruritis vulvae in current pregnancy (16.0%), and maternal age greater than 35 years (14.7%). Five hundred and thirteen mothers (66.8%) had at least one risk factor. All screening risk factors, except past history of diabetes mellitus in previous pregnancy and maternal age, were not significantly associated with abnormal glucose tolerance (GT). Risk factor screening gave a sensitivity of 72.2% and a specificity of 35.0%. Universal screening would cost RM 12.06 while traditional risk factor screening would cost RM 11.15 per identified case and will have missed 53 of the 191 cases. CONCLUSIONS: Risk factor screening scored poorly in predicting GDM. Cost analysis of universal compared with traditional risk factor screening showed a negligible difference. Thus universal screening appears to be the most reliable method of diagnosing GDM.     

Smoking in pregnancy: relevance of maternal screening tests on fetal outcome

A number of laboratory parameters were estimated in 54 pregnant women in order to assess whether changes induced by smoking could reflect weight gain in the fetus. There was a significant correlation between maternal weight gain index, oestriol levels, antithrombin III levels and reticulocyte synthesis with infant and placental weight gain. One or more of these tests was found abnormal in 27% of normal pregnant patients, 72% of light smokers, and 89% of heavy smokers.Several other parameters were found to be significantly altered in smoking compared to non-smoking pregnant patients; however, these bore no relationship to infant and placental parameters.These studies indicate that laboratory assessment of a number of maternal parameters could be of some value in determining the likelihood of depressed weight gain by infants of smoking mothers.     

Abnormal second trimester screening for fetal chromosomal abnormalities as a predictor of adverse pregnancy outcome

Second-trimester maternal serum markers (triple test) is common used to estimate of the fetal risk of genetic abnormalities and open neural tube defects. Positive results of the triple test concomitant with the normal fetus karyotype pattern can also predict the adverse pregnancy outcome. Many authors have been indicated such false positive results of the triple test in the cases of the uterine myomas, PIH, IUGR, and IUD. OBJECTIVE: The purpose of this study was to determine the association between abnormal second trimester Down syndrome screening markers and adverse pregnancy outcome. MATERIAL AND METHODS: A total of 775 pregnant women underwent maternal serum screening. Pregnancy complications were studied in the groups of pregnancies with structurally and chromosomally normal fetuses--with: elevated AFP > 1,89MoM, elevated beta-hCG > 1,69MoM or low beta-hCG < 0,48MoM. RESULTS: Increased maternal serum AFP > 1,89MoM were found to be significantly associated with IUGR, PIH and placental pathology. Increased beta-hCG > 1,69MoM were significantly associated with PIH and IUGR. Finally decreased beta-hCG < 0,48MoM were found to be significantly associated with IUGR, PIH and IUD. CONCLUSION: Triple test can be used not only for the detection of fetal chromosomal and NTD abnormalities but also for the detection of high-risk pregnancies.     

Abnormal pregnancy sonogram: selective indication for fetal karyotype

The inability to make a definitive diagnosis in the fetus with a sonographically identified abnormality often results in parental and physician uncertainty. An antenatal chromosome evaluation could resolve this uncertainty. Forty-one fetuses with an abnormal ultrasound examination were tested for karyotypic abnormality using a variety of specimens. Nearly one-third (13 of 41) of these fetuses had various chromosome abnormalities. There were only seven survivors in this series, underscoring the often poor prognosis when a significant ultrasound defect is detected antenatally. Knowledge of the fetal chromosome constitution in the setting of an abnormal ultrasound has important epidemiologic, cost-benefit, counseling, and pregnancy management implications.     

Combination of screening tests for fetal abnormalities in the first and second pregnancy trimesters

OBJECTIVE: Screening for fetal abnormalities in the second trimester of pregnancy, based on the concentrations of various markers in serum and maternal age, has become widely used in the past decade. In the first trimester fetal malformations are associated with high values for fetal NT. DESIGN: We propose a new screening method in which measurements obtained during both trimesters are integrated to provide a single estimate of a woman's risk of having a pregnancy affected by genetic syndrome. MATERIAL AND METHODS: Study groups comprised 775 pregnant women where examinations were done between 11th-14th and 15th-19th pregnancy weeks. Nuchal translucency thickness was measured by ultrasound examination in both trimesters of pregnancy. AFP, -HCG and oestriol were measured by ELISA assays. Derived risks were then calculated. RESULTS: Eight fetal aneuploidies were diagnosed. When we used a risk of 1:250 as the cutoff to define a positive result on the integrated test, the rate of detection of fetal abnormalities was 100%, with a false positive rate of 0.6%. CONCLUSION: Integrated test, which is a combination of the ultrasound examination and the triple test allows to achieve high sensitivity and the decrease in the percentage of false positive results, which leads to the reduction in the number of amniocentesis to be performed.     

Threatened abortion: A risk factor for poor pregnancy outcome, a population-based screening study

OBJECTIVE: The purpose of this study was to determine whether patients with first-trimester threatened abortion are at increased risk for poor pregnancy outcome. STUDY DESIGN: A large prospective multicenter database was studied. Subjects were divided into three groups: (1) no bleeding, (2) light bleeding, and (3) heavy bleeding. Univariate and multivariable logistic regression analyses were used. RESULTS: The study comprised 16,506 patients: 14,160 patients without bleeding, 2094 patients with light bleeding, and 252 patients with heavy bleeding. Patients with vaginal bleeding, light or heavy, were more likely to experience a spontaneous loss before 24 weeks of gestation (odds ratio, 2.5 and 4.2, respectively) and cesarean delivery (odds ratio, 1.1 and 1.4, respectively). Light bleeding subjects were more likely to have preeclampsia (odds ratio, 1.5), preterm delivery (odds ratio, 1.3), and placental abruption (odds ratio, 1.6). Heavy vaginal bleeding subjects were more likely to have intrauterine growth restriction (odds ratio, 2.6), preterm delivery (odds ratio, 3.0), preterm premature rupture of membranes (odds ratio, 3.2), and placental abruption (odds ratio, 3.6). CONCLUSION: First-trimester vaginal bleeding is an independent risk factor for adverse obstetric outcome that is directly proportional to the amount of bleeding.     

Pemphigus in pregnancy: a reevaluation of fetal risk

Pemphigus vulgaris, a bullous dermatosis, rarely occurs during pregnancy. Previous reviews have suggested that pemphigus has no significant effect on pregnancy. A case report of pemphigus occurring during pregnancy and resulting in an intrauterine death is presented. A reevaluation of the literature indicates that maternal pemphigus is associated with a significant risk of fetal mortality.     

Fetal macrosomia as a risk factor for shoulder dystocia during vacuum extraction

Objective: Vacuum extraction of a macrosomic fetus is considered a risk factor for shoulder dystocia (SD). We evaluated maternal and fetal outcomes following vacuum extraction of macrosomic infants.

Methods: A retrospective cohort study conducted in two large teaching hospitals. All deliveries of macrosomic infants by vacuum extraction and vaginal delivery were compared. The primary outcome measure was SD. Secondary outcome measures were severe perineal lacerations and postpartum hemorrhage. For statistical analysis, we used McNemar’s test and χ² or Fisher’s exact tests. Odds ratios were analyzed via a logistic regression model.

Results: From 2003 to 2013, there were 6019 (5.45%) deliveries of macrosomic fetuses, and 230 (0.21%) were delivered by vacuum extraction. There were 23 (10%) and seven (3.04%) cases of SD in the study and control groups, respectively. The risk of SD was significantly higher in the study group (p?>?0.05). We found a significant association between SD and vacuum delivery [p?=?0.003; OR?=?3.54 (95% CI: 1.49–8.42)]. The composite adverse neonatal outcome rate was 6.5% (15/230) and 1.7% (4/230) in the study and control groups, respectively (p?=?0.009).

Conclusion: Vacuum extraction of a macrosomic infant is a risk factor for shoulder dystocia but not for postpartum hemorrhage or severe vaginal tears.     

Abnormal cervical cytology: a risk factor for endometrial cancer recurrence

The objective of this study was to evaluate the relationship between cervical cytology, histologic type, and risk of endometrial cancer recurrence. We performed a retrospective study of patients undergoing surgery for endometrial carcinoma. Risk factors for recurrence including histology, tumor grade, nodal status, myometrial invasion, peritoneal washings, stage, and cervical cytology were assessed. Abnormal cervical cytology was defined as the presence of any endometrial cells on Pap smear. Papillary serous and clear cell carcinomas were considered high-risk histologies. Univariate and multivariate analyses of risk factors for recurrence were performed. Thirty-nine (9%) patients developed recurrent endometrial cancer. More patients with abnormal Pap smears recurred (12% versus 4%, P < 0.05). For endometrioid adenocarcinoma, abnormal cervical cytology occurred in 61% and 7% recurred, while with high-risk histologies, 84% had abnormal cervical cytology and 19% recurred (P < 0.05). Other significant predictors of recurrence on univariate analysis were myometrial invasion, nodal status, washings, stage, and histology. On multivariate analysis, only nodal status remained a significant predictor of recurrence. Abnormal cervical cytology is associated with increased risk of endometrial cancer recurrence. Abnormal cervical cytology occurs more frequently in high-risk histologies, which are known to have a higher risk of recurrence. On multivariate analysis, only nodal spread remains a significant predictor of recurrence.     

Size of trials for evaluation of antenatal tests of fetal wellbeing in high risk pregnancy

A retrospective study of maternity records from 1977-1985 (38,000 deliveries) was conducted to determine the number of stillbirths that might have been prevented by a new method of antenatal assessment. During this period there were 240 stillbirths, 154 of which involved a normally formed fetus who died prior to the onset of labour. After a review of the literature, a set of risk factors were selected relevant to stillbirth. Such factors were found in 60% of the study group, compared with 38% of control patients. Seventy-five of the normally formed 'antepartum stillbirths' occurred in the high-risk group after 31 weeks gestation, so that a perfect method of prediction and treatment, applied from 31 weeks onwards, would potentially have prevented half of the 154 deaths in this study. Since intensive monitoring and the subsequent intervention cannot attain such perfection, an assessment was made, using realistic sensitivity and specificity values and other reasonable assumptions, to show that approximately one third of antepartum stillbirths might have been prevented by a new method for monitoring of all high-risk pregnancies. A sensitivity analysis was used to test this conclusion over a range of possible test performance values. The implications of these findings for clinical trials and cost-utility analysis are discussed.     

The analysis of risk factors for fetal macrosomia and the complications in the course of pregnancy and delivery of macrosomic baby

Newborns weighing 4000g or heavier, are defined as macrosomic. OBJECTIVES: The purpose of this study was to present the risk factors of macrosomia, the course of pregnancy and the frequency of maternal outcomes associated with the delivery of macrosomic fetuses. MATERIALS AND METHODS: The retrospective analysis included 670 gravidas hospitalized at The Department of Reproduction and Obstetrics, Medical University of Wroclaw, between 1999 and 2004, who delivered babies weighing at least 4000g. RESULTS: The majority of macrosomic neonates (80%) were given birth to by women over the age of 25, who gained over 15 kilos in the course of the pregnancy. Macrosomy tends to affect primiparas most frequently. The medium duration of macrosomic pregnancy was 40.61 +/- 1.15 weeks. The percentage of deliveries by cesarean section amounts to 38.5%. Vaginal deliveries are burdened with significant risk of maternal complications. CONCLUSIONS: Women over 30, medium height or tall, who gain over 15 kilos during the pregnancy, tend to deliver macrosomic babies. Multiparas who had given birth to the marosomic babies once before, are predisposed to deliver macrosomic neonate in the following pregnancy. On the basis of our studies, we have determined 4kg as a borderline birth weight for increased frequency of parturient canal injuries.