Preterm delivery in women with pregestational diabetes mellitus or chronic hypertension relative to women with uncomplicated pregnancies. The National institute of Child health and Human Development Maternal- Fetal Medicine Units Network

OBJECTIVE: The purpose of this study was to compare the rates of indicated and spontaneous preterm delivery among women with chronic hypertension or pregestational diabetes mellitus with the rates among healthy women.Study Design: This was a secondary analysis of data from healthy women with singleton gestations enrolled in a prospective observational study for prediction of preterm delivery (control group, n = 2738), women with pregestational diabetes mellitus requiring insulin therapy (n = 461), and women with chronic hypertension (n = 761). The two latter groups were enrolled in a randomized multicenter trial for prevention of preeclampsia. The main outcome measures were rates of preterm delivery, either spontaneous (preterm labor or rupture of membranes) or indicated (for maternal or fetal reasons), and neonatal outcomes. RESULTS: The overall rates of preterm delivery were significantly higher among women with diabetes mellitus (38%) and hypertension (33.1%) than among control women (13.9%). Rates were also significantly higher for delivery at <35 weeks' gestation. Women with diabetes mellitus had significantly higher rates of both indicated preterm delivery (21.9% vs 3.4%; odds ratio, 8.1; 95% confidence interval, 6.0-10.9) and spontaneous preterm delivery (16.1% vs 10.5%; odds ratio, 1.6; 95% confidence interval, 1.2-2.2) than did women in the control group. In addition, they had significantly higher rates of both indicated preterm delivery (odds ratio, 4.8; 95% confidence interval, 3.0-7.5) and spontaneous preterm delivery (odds ratio, 2.1; 95% confidence interval, 1.4-3.0) at <35 weeks' gestation than did control women. Compared with control women those with chronic hypertension had higher rates of indicated preterm delivery at both <37 weeks' gestation (21.9% vs 3.4%; odds ratio, 8.1; 95% confidence interval, 6.2-10.6) and at <35 weeks' gestation (12.1% vs 1.6%; odds ratio, 8.2; 95% confidence interval, 5.7-11.9), but there were no differences in rates of spontaneous preterm delivery. CONCLUSION: The increased rate of preterm delivery among women with chronic hypertension relative to control women was primarily an increase in indicated preterm delivery, whereas the rates of both spontaneous and indicated preterm delivery were increased among women with pregestational diabetes mellitus.     

Preterm delivery in women with pregestational diabetes mellitus or chronic hypertension relative to women with uncomplicated pregnancies

Objective: The purpose of this study was to compare the rates of indicated and spontaneous preterm delivery among women with chronic hypertension or pregestational diabetes mellitus with the rates among healthy women. Study Design: This was a secondary analysis of data from healthy women with singleton gestations enrolled in a prospective observational study for prediction of preterm delivery (control group, N = 2738), women with pregestational diabetes mellitus requiring insulin therapy (n = 461), and women with chronic hypertension (n = 761). The two latter groups were enrolled in a randomized multicenter trial for prevention of preeclampsia. The main outcome measures were rates of preterm delivery, either spontaneous (preterm labor or rupture of membranes) or indicated (for maternal or fetal reasons), and neonatal outcomes. Results: The overall rates of preterm delivery were significantly higher among women with diabetes mellitus (38%) and hypertension (33.1%) than among control women (13.9%). Rates were also significantly higher for delivery at <35 weeks’ gestation. Women with diabetes mellitus had significantly higher rates of both indicated preterm delivery (21.9% vs 3.4%; odds ratio, 8.1; 95% confidence interval, 6.0-10.9) and spontaneous preterm delivery (16.1% vs 10.5%; odds ratio, 1.6; 95% confidence interval, 1.2-2.2) than did women in the control group. In addition, they had significantly higher rates of both indicated preterm delivery (odds ratio, 4.8; 95% confidence interval, 3.0-7.5) and spontaneous preterm delivery (odds ratio, 2.1; 95% confidence interval, 1.4-3.0) at <35 weeks’ gestation than did control women. Compared with control women those with chronic hypertension had higher rates of indicated preterm delivery at both <37 weeks’ gestation (21.9% vs 3.4%; odds ratio, 8.1; 95% confidence interval, 6.2-10.6) and at <35 weeks’ gestation (12.1% vs 1.6%; odds ratio, 8.2; 95% confidence interval, 5.7-11.9), but there were no differences in rates of spontaneous preterm delivery. Conclusion: The increased rate of preterm delivery among women with chronic hypertension relative to control women was primarily an increase in indicated preterm delivery, whereas the rates of both spontaneous and indicated preterm delivery were increased among women with pregestational diabetes mellitus. (Am J Obstet Gynecol 2000;183:1520-4.)     

Hypertensive disorders in twin versus singleton gestations. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units

OBJECTIVE: This study was undertaken to compare rates and severity of gestational hypertension and preeclampsia, as well as perinatal outcomes when these complications develop, between women with twin gestations and those with singleton gestations. STUDY DESIGN: This was a secondary analysis of prospective data from women with twin (n = 684) and singleton (n = 2946) gestations enrolled in two separate multicenter trials of low-dose aspirin for prevention of preeclampsia. End points were rates of gestational hypertension, rates of preeclampsia, and perinatal outcomes among women with hypertensive disorders. RESULTS: Women with twin gestations had higher rates of gestational hypertension (relative risk, 2.04; 95% confidence interval, 1.60-2.59) and preeclampsia (relative risk, 2. 62; 95% confidence interval, 2.03-3.38). In addition, women with gestational hypertension during twin gestations had higher rates of preterm delivery at both <37 weeks' gestation (51.1% vs 5.9%; P <. 0001) and <35 weeks' gestation (18.2% vs 1.6%; P <.0001) and also had higher rates of small-for-gestational-age infants (14.8% vs 7. 0%; P =.04). Moreover, when outcomes associated with preeclampsia were compared, women with twin gestations had significantly higher rates of preterm delivery at <37 weeks' gestation (66.7% vs 19.6%; P <.0001), preterm delivery at <35 weeks' gestation (34.5% vs 6.3%; P <.0001), and abruptio placentae (4.7% vs 0.7%; P =.07). In contrast, among women with twin pregnancies, those who remained normotensive had more adverse neonatal outcomes than did those in whom hypertensive complications developed. CONCLUSIONS: Rates for both gestational hypertension and preeclampsia are significantly higher among women with twin gestations than among those with singleton gestations. Moreover, women with twin pregnancies and hypertensive complications have higher rates of adverse neonatal outcomes than do those with singleton pregnancies.     

Renal disease in women with severe preeclampsia or gestational proteinuria

OBJECTIVE: To identify women with severe preeclampsia or severe gestational proteinuria at high risk of having underlying renal disease. METHODS: Between 1980 and 1999, 86 Japanese women who had severe hypertension, severe proteinuria, or both during pregnancy had postpartum needle biopsies of their kidneys. Diagnoses before biopsies were severe preeclampsia in 74 women and severe gestational proteinuria in 12. We compared clinical characteristics, such as antepartum hematuria and postpartum proteinuria, and maternal and neonatal outcomes with regard to presence of renal disease. RESULTS: Nineteen of 86 women (22.1%, 95% confidence interval [CI] 13.9%, 32. 3%) were diagnosed with underlying renal disease. Immunoglobulin A nephropathy was present in 12. Women with renal disease had a significantly earlier onset of proteinuria than those without (median 11 versus 32 weeks' gestation, P <.001). Eighteen of 19 women with renal disease had proteinuria, hypertension, or both before 30 weeks' gestation. Ten of 12 women with severe gestational proteinuria (83.3%, 95% CI 51.6%, 97.9%) had underlying renal disease. Eight of the 19 women had antepartum hematuria, and seven had elevated serum immunoglobulin A levels. In women with severe preeclampsia, onset before 30 weeks' gestation was the best predictor of underlying renal disease (odds ratio 34.1, 95% CI 3.8, 304.5). Women with renal disease had lower rates of severe hypertension (nine of 19 versus 59 of 67, P <.01) and small-for-gestational-age infants (four of 19 versus 34 of 67, P <.05) than those without renal disease. CONCLUSION: Women who had gestational proteinuria or preeclampsia before 30 weeks' gestation were more likely to have had underlying renal disease.     

Maternal periodontal disease is associated with an increased risk for preeclampsia

OBJECTIVE: To determine if maternal periodontal disease is associated with the development of preeclampsia. METHODS: A cohort of 1,115 healthy pregnant women were enrolled at less than 26 weeks' gestation and followed until delivery. Maternal demographic and medical data were collected. Periodontal examinations were performed at enrollment and within 48 hours of delivery to determine the presence of severe periodontal disease or periodontal disease progression. Preeclampsia was defined as blood pressure greater than 140/90 on two separate occasions, and at least 1+ proteinuria on catheterized urine specimen. The potential effects of maternal age, race, smoking, gestational age at delivery, and insurance status were analyzed, and adjusted odds ratios for preeclampsia were calculated using multivariable logistic regression. RESULTS: During the study period, 763 women delivered live infants and had data available for analysis. Thirty-nine women had preeclampsia. Women were at higher risk for preeclampsia if they had severe periodontal disease at delivery (adjusted odds ratio 2.4, 95% confidence interval 1.1, 5.3), or if they had periodontal disease progression during pregnancy (adjusted odds ratio 2.1, 95% confidence interval 1.0, 4.4). CONCLUSION: After adjusting for other risk factors, active maternal periodontal disease during pregnancy is associated with an increased risk for the development of preeclampsia.     

Effect of magnesium prophylaxis and preeclampsia on the duration of labor

Objective: Our goals were to compare duration of labor at term for (1) women with preeclampsia versus normotensive nulliparous women and (2) nulliparous women with preeclampsia who received magnesium for seizure prophylaxis versus those who did not. Study Design: We performed a retrospective cohort study of all nulliparous, term vaginal deliveries from 1989 through 1995 at University of California, San Francisco. The perinatal database and medical records were reviewed for information on duration of labor, maternal and labor characteristics, and neonatal outcomes. The χ² odds ratio, and Student t tests were used to compare categoric and continuous variables between women with preeclampsia and control women and between women with preeclampsia who did and those who did not receive magnesium. Logistic regression was used to evaluate variables predictive of labor duration. Results: Our study subjects were 4083 normotensive nulliparous women and 154 women with preeclampsia. A sample size calculation revealed that 1764 normotensive control subjects were needed to show a 10% difference in labor duration with 80% power and alpha of 0.05. Among women with preeclampsia, 93 (60%) were treated with magnesium and 61 (40%) were not. More women with preeclampsia than normotensive women had induction of labor and received epidural anesthesia, prostaglandin gel, and oxytocin (P < .003). Total labor duration did not differ between women with preeclampsia and normotensive women (P = .15) or between women with preeclampsia who received magnesium and those who did not (P = .09). In comparison with normotensive women, those with preeclampsia had a higher rate of postpartum hemorrhage (31% vs 22%, P = .005), and the rate was even higher among preeclamptic women treated with magnesium versus those who received no magnesium (34% vs 26%, P = .002). Logistic regression, with prolonged first stage of labor (>12 hours) used as the outcome variable, indicated that epidural anesthesia (odds ratio 2.3, 95% confidence interval 1.9-2.6), oxytocin (odds ratio 1.8, 95% confidence interval 1.6-2.2), and persistent occipitoposterior presentation (odds ratio 1.6, 95% confidence interval 1.1-2.4) were associated with prolonged labor, whereas preeclampsia (odds ratio 0.9, 95% confidence interval 0.7-1.1) and treatment with magnesium were not (odds ratio 1.1, 95% confidence interval 0.9-1.4). Induction (odds ratio 0.5, 95% confidence interval 0.4-0.6) and birth weight <2500 g (odds ratio 0.5, 95% confidence interval 0.4-0.8) were associated with faster labor. Conclusions: In term nulliparous women, neither preeclampsia nor magnesium prophylaxis affected labor duration. (Am J Obstet Gynecol 1999;180:1475-9.)     

Predictors of neonatal outcome in women with severe preeclampsia or eclampsia between 24 and 33 weeks' gestation

OBJECTIVE: We sought to characterize predictors of neonatal outcome in women with severe preeclampsia or eclampsia who were delivered of their infants preterm. STUDY DESIGN: We performed a retrospective analysis of 195 pregnancies delivered between 24 and 33 weeks' gestation because of severe preeclampsia or eclampsia. Multiple logistic regression and univariate chi(2) analysis were performed for the dependent outcome variables of survival and respiratory distress syndrome by use of independent fetal and maternal variables. A P value of <.05 was considered significant. RESULTS: In the multivariate analysis, respiratory distress syndrome was inversely related to gestational age at delivery (P =.0018) and directly related to cesarean delivery (P =.02), whereas survival was directly related to birth weight (P =.00025). There was no correlation in the multivariate analysis between respiratory distress syndrome or survival and corticosteroid use, composite neonatal morbidity, mean arterial pressure, eclampsia, or abruptio placentae. In the univariate analysis respiratory distress syndrome was associated with cesarean delivery (odds ratio, 7.19; 95% confidence interval, 2. 91-18.32). The incidence of intrauterine growth restriction increased as gestational age advanced. Furthermore, intrauterine growth restriction decreased survival in both the multivariate (P =. 038; odds ratio, 13.2; 95% confidence interval, 1.16-151.8) and univariate (P =.001; odds ratio, 5.88; 95% confidence interval, 1. 81-19.26) analyses. CONCLUSION: The presence of intrauterine growth restriction adversely affected survival independently of other variables. Presumed intrauterine stress, as reflected by the severity of maternal disease, did not improve neonatal outcome.     

Gestational diabetes mellitus and pregnancy outcomes among Chinese and South Asian women in Canada

Objective: To determine the association between Chinese or South Asian ethnicity and adverse neonatal and maternal outcomes for women with gestational diabetes compared to the general population. Methods: A cohort study was conducted using population-based health care databases in Ontario, Canada. All 35,577 women aged 15–49 with gestational diabetes who had live births between April 2002 and March 2011 were identified. Their delivery hospitalization records and the birth records of their neonates were examined to identify adverse neonatal outcomes and adverse maternal outcomes. Results: Compared to infants of mothers from the general population (55.5%), infants of Chinese mothers had a lower risk of an adverse outcome at delivery (42.9%, adjusted odds ratio 0.63, 95% confidence interval 0.58–0.68), whereas infants of South Asian mothers had a higher risk (58.9%, adjusted odds ratio 1.15, 95% confidence interval 1.07–1.23). Chinese women also had a lower risk of adverse maternal outcomes (32.4%, adjusted odds ratio 0.58, 95% confidence interval 0.54–0.63) compared to general population women (41.2%), whereas the risk for South Asian women was not different (39.4%, adjusted odds ratio 0.94, 95% confidence interval 0.88–1.02) from that of general population women. Conclusions: The risk of complications of gestational diabetes differs significantly between Chinese and South Asian patients and the general population in Ontario. Tailored interventions for gestational diabetes management may be required to improve pregnancy outcomes in high-risk ethnic groups.     

Association of preeclampsia with high birth weight for age

OBJECTIVE: The purpose of this study was to examine the effect of gestational hypertension and preeclampsia on fetal growth. STUDY DESIGN: A retrospective cohort study was conducted on the basis of 97,270 pregnancies delivered between 1991 and 1996 in 35 hospitals in northern and central Alberta, Canada. Univariate and multivariate logistic analyses were performed to examine the impact of preeclampsia and gestational hypertension on high-birth-weight (> or =4200 g), large-for-gestational-age, low-birth-weight (<2500 g), and small-for-gestational-age babies. RESULTS: The rate of high-birth-weight fetuses in women with gestational hypertension (7. 3%) was higher than in those with normal blood pressure (5.6%). After we controlled for confounders, the adjusted odds ratio of high birth weight was 1.44 (95% confidence interval, 1.21-1.70) in women with gestational hypertension. Preeclampsia was also associated with a statistically nonsignificant (P =.054) increased risk of high birth weight (adjusted odds ratio, 1.40; 95% confidence interval 0. 99-1.98). The rate of large-for-gestational-age babies was significantly higher in women with gestational hypertension (4.5%) and preeclampsia (4.7%) than in those with normal blood pressure (2. 2%), with adjusted odds ratios of 1.50 (95% confidence interval, 1. 22-1.85) for gestational hypertension and 1.87 (95% confidence interval, 1.31-2.67) for preeclampsia. Concurrently, women who had gestational hypertension were also at higher risk of having low-birth-weight (adjusted odds ratio, 2.4; 95% confidence interval, 2.13-2.93) and small-for-gestational-age (adjusted odds ratio, 2.04; 95% confidence interval, 1.68-2.48) babies. Women with preeclampsia were also at markedly higher risk of having low-birth-weight (adjusted odds ratio, 4.14; 95% confidence interval, 3.32-5.15) and small-for-gestational-age (adjusted odds ratio, 2.56; 95% confidence interval, 1.92-3.41) babies. CONCLUSIONS: There is a significant association of preeclampsia and gestational hypertension with large-for-gestational-age infants, in addition to a significant association with low-birth-weight and small-for-gestational-age infants. This study challenges the currently held belief that reduced uteroplacental perfusion is the unique pathophysiologic process in preeclampsia.     

Antiphospholipid antibodies and preeclampsia: a case-control study

OBJECTIVE: To assess the association between the occurrence first of preeclampsia and antiphospholipid antibodies. METHODS: We conducted a prospective case-control study of 180 pregnant women with their first incidents of preeclampsia and no histories of thrombosis or systemic autoimmune diseases. Preeclampsia (n = 180) was defined as blood pressure (BP) at least 140/90 mmHg after 20 weeks' gestation and proteinuria at least 0.3 g per 24 hours. Two control subjects were matched to each case (n = 360). They were pregnant women without hypertension or proteinuria and without histories of thrombosis or systemic autoimmune disease. Lupus anticoagulant (activated partial thromboplastin time, diluted thromboplastin time, platelet neutralization procedure) and anticardiolipin antibodies (immunoenzymatic assays) were assessed in both groups, and the coagulation state (levels of thrombin-antithrombin III complexes, fragments 1 + 2 of prothrombin) was also evaluated. The analysis design was a sequential plan with 5% type I error and 95% power. RESULTS: There was no association between antiphospholipid antibodies and preeclampsia. The odds ratio for the association was 0.95 (95% confidence interval 0.45, 2.61). Antiphospholipid antibodies were detected in eight of 180 preeclamptic women and in 19 of 360 controls. In contrast, there was a clear, confirmed activation of coagulation during preeclampsia. CONCLUSION: Despite evidence of a prothrombotic state during preeclampsia, it is unlikely that antiphospholipid antibodies (lupus anticoagulant and anticardiolipin antibodies) represent risk factors for preeclampsia among women with no previous preeclampsia and no histories of thrombosis or systemic autoimmune disease.     

Second-trimester maternal serum inhibin A concentration as an early marker for preeclampsia.

OBJECTIVE: Maternal serum inhibin A concentration is elevated in established preeclampsia. The aim of this study was to investigate whether this relationship antedates the appearance of the classic signs of preeclampsia. STUDY DESIGN: A retrospective analysis was performed on trisomy 21 screening data from 685 women at between 15 and 19 weeks' gestation. The main outcome measures were preeclampsia and small for gestational age (<5th percentile) infants. RESULTS: Preeclampsia developed in 35 women (5.5%). Women with inhibin A concentration >2.0 multiples of the median were significantly more likely to acquire preeclampsia (P <.00001) and to be delivered of a small for gestational age infant (<5th percentile, P <.00001) than were women with inhibin A concentration 相似文献   

The relationship of one abnormal glucose tolerance test value and pregnancy complications

While an abnormal oral glucose tolerance test (GTT) is known to be associated with an increased risk of pregnancy complications, the impact of one abnormal value is not clear. In 1986 we screened 4618 pregnant women for gestational diabetes at 24-28 weeks' gestation. Eighty-seven percent had normal results; of the 13% with abnormal screening tests, 139 had one abnormal value on the subsequent 3-hour oral GTT. These women were then compared with 725 randomly selected patients with a normal screening test. The frequency of chronic hypertension, cesarean section, 5-minute Apgar score below 7, preterm delivery, shoulder dystocia, congenital malformations, and perinatal mortality did not differ significantly between the groups. The incidence of macrosomia (birth weight above 4000 g) was significantly greater in the study group (18.0%) than in the control group (6.6%) (odds ratio 2.18; 95% confidence interval 1.77-5.37), a relationship that persisted after controlling for confounding risk factors by logistic regression modeling (odds ratio 2.55; 95% confidence interval 1.44-4.52). The incidence of preeclampsia/eclampsia was significantly greater in the study group (7.9%) than in the control group (3.3%) (odds ratio 2.51; 95% confidence interval 1.14-5.52), which also persisted after controlling for confounding risk factors using logistic regression modeling (odds ratio 2.81; 95% confidence interval 1.26-6.28). Our results suggest that patients with one abnormal value on an oral GTT during pregnancy are at risk for delivering macrosomic infants and developing preeclampsia/eclampsia.     

Excessive gestational weight gain in women with gestational and pregestational diabetes

We sought to determine the frequency of excessive gestational weight gain (GWG) and its impact on perinatal outcomes in women with gestational (GDM) and pregestational diabetes mellitus (DM). A retrospective cohort of diabetic women was studied. GWG was categorized by the 2009 Institute of Medicine guidelines. Perinatal outcomes were compared between those women with and without excessive GWG. There were 153 women who met study criteria. There was no difference in excessive GWG between women with GDM and pregestational DM (44.4% versus 38.5%, P?=?0.51) or based on White's class ( P?=?0.17). After adjusting for confounders, excessive GWG was not associated with an increased rate of adverse perinatal outcomes (odds ratio 1.49, 95% confidence interval 0.56 to 2.35) and had similar associations with both pregestational DM and GDM. Although excessive GWG was common in our diabetic population, it was not associated with an increased rate of adverse perinatal outcomes.     

History of abortion,preterm, term birth,and risk of preeclampsia: a population-based study

OBJECTIVE: The objective of this study was to examine the effect of previous abortion and preterm and term birth on the incidence of preeclampsia in subsequent pregnancies. STUDY DESIGN: A population-based retrospective cohort study was conducted that was based on 140,773 pregnancies that had delivered between 1993 and 1999 in 49 hospitals in Northern and Central Alberta, Canada. Multivariate logistic regression was applied to estimate odds ratios, with 95% confidence intervals, and to control for confounding variables. RESULTS: No significant difference was found in the incidence of preeclampsia in nulliparous women with previous abortion (2.6%) as compared to nulliparous women without previous abortion (2.9%; adjusted odds ratio, 0.89; 95% confidence interval, 0.78-1.01; P >.05). A single previous abortion was associated with a slightly decreased risk of preeclampsia (adjusted odds ratio, 0.84; 95% confidence interval, 0.72-0.97; P <.05). However, 2 and > or =3 abortions were not associated with a decreased risk of preeclampsia. In women with no history of previous abortion and term pregnancy, there was no significant difference in incidence of preeclampsia between women who had previous preterm birth (2.7%) and primigravid women (2.8%; adjusted odds ratio, 0.71; 95% confidence ratio, 0.48-1.03; P >.05). However, > or =2 previous preterm births were associated with a decreased risk of preeclampsia (adjusted odds ratio, 0.28; 95% confidence interval, 0.09-0.84; P <.01). The incidence of preeclampsia was markedly lower in multiparous women who previously delivered at term (0.9%) as compared to the incidence in primigravida women (2.9%; adjusted odds ratio, 0.29; 95% confidence interval, 0.26-0.33; P <.001). The adjusted odds ratios of preeclampsia for women with 1, 2, 3, and > or =4 previous term pregnancies were 0.32 (95% confidence interval, 0.28-0.36), 0.27 (95% confidence interval, 0.22-0.34), 0.22 (95% confidence interval, 0.15-0.33), and 0.21 (95% confidence interval, 0.12-0.35), respectively. CONCLUSION: A history of term pregnancy (> or =37 weeks) conveys a substantial "protection" against preeclampsia in the subsequent pregnancy.     

Maternal complications and perinatal outcomes associated with gestational hypertension and severe preeclampsia in Taiwanese women.

BACKGROUND/PURPOSE: The role of proteinuria in disease severity of preeclampsia and gestational hypertension has not been determined. The objective of this study was to compare the effects of disease severity on maternal complications and pregnancy outcome between women with severe preeclampsia and women with gestational hypertension. METHODS: A retrospective case-control study using daily records from the birth registry for the years 1994 to 2003 was conducted. Cases (n = 364) were defined as women with severe preeclampsia. Controls (n = 249) were selected from women with gestational hypertension. The outcome measures were maternal complications and perinatal-related factors. RESULTS: Women with severe preeclampsia had an increased risk of intrauterine growth restriction (adjusted odds ratio [aOR], 2.16; 95% confidence interval [CI], 1.10-4.24; p = 0.026). Risk factors associated with severe preeclampsia patients were lack of prenatal care (aOR, 2.95; 95% CI, 1.45-5.99), systolic blood pressure >or= 180 mmHg (aOR, 14.3; 95% CI, 1.69-121.0), and diastolic blood pressure >or= 105mmHg (aOR, 21.2; 95% CI, 6.99-64.3) compared with women with gestational hypertension in Model I. When we added proteinuria as a variable, two significant risk factors, diastolic blood pressure >or= 105mmHg (aOR, 18.2; 95% CI, 4.85-68.3) and significant proteinuria (aOR, 1.01; 95% CI, 1.006-1.014), were associated with severe preeclampsia patients in Model II. A subgroup of women with gestational hypertension and proteinuria had an increased risk of placental abruption (unadjusted OR, 4.36; 95% CI, 1.05-18.1) and disseminated intravascular coagulation (unadjusted OR, 6.46; 95% CI, 1.05-39.8). Finally, maternal complications (aOR, 2.59; 95% CI, 1.34-5.04) became the single significant factor associated with gestational hypertension and proteinuria. CONCLUSION: Proteinuria may play a role in the progression of gestational hypertension to severe forms of preeclampsia associated with subsequent maternal complications and extremely-low-birth-weight babies.     

Perinatal outcomes in gestational diabetes: a comparison of criteria for diagnosis

OBJECTIVE: The purpose of this study was to compare the perinatal outcomes of women after diagnosis of gestational diabetes by the current American College of Obstetricians and Gynecologists-National Diabetes Data Group recommendations with outcomes after diagnosis by the American Diabetes Association criteria. STUDY DESIGN: We identified records of 242 women who had had the standard 3-hour oral glucose tolerance test between 1995 and 1999 at the Regional Medical center in Memphis. Patients were categorized into 1 of 3 groups as follows: euglycemic control subjects (n = 69), subjects with gestational diabetes diagnosed by the National Diabetes Data Group criteria (n = 130), and subjects with gestational diabetes diagnosed by the American Diabetes Association criteria (n = 43). Maternal and infant charts were reviewed. Primary outcomes included frequency of cesarean delivery, preeclampsia, and macrosomia. In univariate analysis the chi2 test was used to compare group differences, and in multivariate analysis we used stepwise logistic regression and controlled for confounding factors. RESULTS: No differences existed among the 3 groups regarding maternal race, body mass index, history of preeclampsia, or family history of diabetes. The frequency of overall cesarean delivery, of cesarean delivery for macrosomia or arrest disorder, of preeclampsia, and of macrosomia did not differ significantly among the 3 groups. Neonatal hypoglycemia was more frequent in the groups with a diagnosis by the American Diabetes Association criteria (23.3%) and by the National Diabetes Data Group criteria (16.2%) than in the control subjects (7.2%), reaching near significance (P =.057). In the multivariate analysis, cesarean delivery for macrosomia or an arrest disorder correlated negatively with parity and positively with body mass index. Preeclampsia was associated with African American race and body mass index; macrosomia correlated with a history of macrosomia and familial diabetes. Neonatal hypoglycemia was more common in the American Diabetes Association group (odds ratio, 2.45; 95% confidence interval, 1.004-5.97) and in the insulin-requiring National Diabetes Data Group category (odds ratio, 3.71; 95% confidence interval, 1.20-11.44). CONCLUSION: The benefits of defining an additional high-risk population of women with gestational diabetes by the American Diabetes Association criteria are unclear. Further large-scale prospective clinical trials are required.     

Fetal weight and progression of diabetic retinopathy

OBJECTIVE: To test the hypothesis that progression of diabetic retinopathy in pregnancy is associated with reduced fetal growth and related neonatal morbidity. METHODS: Women with type 1 diabetes (n = 205) were enrolled before 14 weeks' gestation in a prospective study of diabetes in pregnancy and treated with intensive insulin therapy. They had serial ophthalmologic evaluations before 20 weeks' gestation and in late gestation or postpartum. Subjects were divided into two groups based on whether retinopathy progressed (progression group) or remained unchanged (no progression group). RESULTS: Retinopathy progressed in 59 of 205 women (29%) and was associated with advanced White classification (P =.001): three (5%) were class B, 14 (23%) class C, 24 (41%) class D, and 18 (30%) class F-RF. Reduced fetal growth was associated with progression of retinopathy. Mean birth weight was lower (P =.02), and more infants were small for gestational age (P =.02) and had low birth weights (P =.02) in the progression group. More large-for-gestational-age infants were noted in the no-progression group (P =.04). Birth weight percentile distributions showed a shift of the curve to the left in the progression group (P =.03). There were no differences in gestational age at delivery, macrosomia, preterm delivery, respiratory distress syndrome, neonatal hypoglycemia, or neonatal death. Small for gestational age was associated with chronic hypertension (odds ratio [OR] 6.4; 95% confidence interval [CI] 1.5, 27.9) and retinopathy progression (OR 4.7; 95% CI 1.2, 23.8). CONCLUSION: Development and progression of diabetic retinopathy during pregnancy were associated with reduced fetal growth manifested as increased rate of small-for-gestational-age and low-birth-weight infants.     

Neonatal sepsis and death after multiple courses of antenatal betamethasone therapy

OBJECTIVE: This study was undertaken to compare the effects of single versus multiple courses of betamethasone therapy on the frequencies of neonatal outcomes and perinatal infectious morbidity among singleton pregnancies complicated by preterm delivery. STUDY DESIGN: We performed a nonconcurrent prospective analysis of singleton pregnancies delivered between 24 and 34 weeks' gestation after antenatal betamethasone exposure. Patients were categorized into two groups according to betamethasone exposure: (1) two 12-mg doses in a 24-hour interval on admission (single-course group) and (2) repeated dosing after the initial single course (multiple-course group). All patients received prophylactic antibiotics for group B streptococci. Any patients with ruptured membranes for >24 hours before delivery were excluded. Data were analyzed with the Student t test, the chi(2) test, and the Fisher exact test. Multiple logistic regression analyses were performed to examine the effect of each steroid dosing regimen on early-onset neonatal sepsis and neonatal death. P <.05 was considered significant for all 2-tailed tests. RESULTS: A total of 453 patients were included, with 267 in the single-course group and 186 in the multiple-course group. The two groups were similar with respect to maternal demographic characteristics, gestational age at delivery, mode of delivery, birth weight, and maternal group B streptococcal colonization. Multiple courses were significantly associated with early-onset neonatal sepsis (odds ratio, 5.00; 95% confidence interval, 1.3-23. 2), chorioamnionitis (odds ratio, 9.96; 95% confidence interval, 2. 1-64.6), endometritis (odds ratio, 3.61; 95% confidence interval, 1. 7-8.1), and neonatal death (odds ratio, 2.92; 95% confidence interval, 1.3-6.9). The frequencies of the other neonatal outcomes analyzed, including respiratory distress syndrome and grade III or IV intraventricular hemorrhage, were similar between the 2 groups. Multiple logistic regression analyses confirmed that multiple courses of antenatal betamethasone were independently associated with early-onset neonatal sepsis (odds ratio, 1.25; 95% confidence interval, 1.1-1.9) and neonatal death (odds ratio, 1.70; 95% confidence interval, 1.1-1.9). CONCLUSIONS: Multiple courses of antenatal betamethasone are associated with increased risks of perinatal infectious morbidity and neonatal death.     

Recurrence of ischemic placental disease

OBJECTIVE: To test the hypothesis that the presence of preeclampsia, small for gestational age (SGA)-birth, and placental abruption in the first pregnancy confers increased risk in the second pregnancy. METHODS: A retrospective cohort study entailing a case-crossover analysis was performed based on women who had two consecutive singleton live births (n=154,810) between 1989 and 1997 in Missouri. Small for gestational age was defined as infants with birth weight below the 10th centile for gestational age. Risk and recurrence of ischemic placental disease was assessed from fitting logistic regression models after adjusting for several confounders. RESULTS: Preeclampsia in the first pregnancy was associated with significantly increased risk of preeclampsia (odds ratio 7.03, 95% confidence interval 6.51, 7.59), SGA (odds ratio 1.16, 95% confidence interval 1.06, 1.27), and placental abruption (odds ratio 1.90, 95% confidence interval 1.51, 2.38) in the second pregnancy. Similarly, women with SGA and abruption in the first pregnancy were associated with increased risks of all other conditions in the second pregnancy. CONCLUSION: Women with preeclampsia, SGA, and placental abruption in their first pregnancy--conditions that constitute ischemic placental disease--are at substantially increased risk of recurrence of any or all these conditions in their second pregnancy. Although causes of these conditions remain largely speculative, these entities may manifest through a common pathway of ischemic placental disease with significant risk of recurrence.     

Weight gain during pregnancy in adolescence: predictive ability of early weight gain

Pregnancy weight gains were examined at 4-week intervals from 12-36 weeks' gestation and total gain assessed at delivery in a cohort of 2008 pregnant women aged 18 or less at entry to prenatal care. As early as 12 weeks' gestation, there was a significant association between the amount of weight gained and infant birth weight measured at the time of delivery. At 16 weeks' gestation, gains below the 25th percentile were associated with an increased risk of low birth weight (LBW) (adjusted odds ratio 1.56; 95% confidence interval 1.01-2.43), and by 20 weeks' gestation, the risk of LBW was doubled (adjusted odds ratio 2.00; 95% confidence interval 1.34-2.99). Also at 16 weeks, there was a doubling in the risk of excessive fetal size or macrosomia (adjusted odds ratio 2.31; 95% confidence interval 1.31-4.10) associated with maternal weight gain above the 75th percentile. These results suggest that an increased risk of certain poor pregnancy outcomes is detectable late in the first or early in the second trimester. Consequently, weight gain monitoring may be important early in pregnancy.