Renal growth during pregnancy in insulin-dependent diabetic women

Kidney volume was measured during pregnancy in insulin-dependent diabetic women by an ultrasound technique and prognostic value of these measurements evaluated. A prospective study was performed on 87 pregnant women with insulin-dependent diabetes attending the maternity clinic of Aarhus Kommunehospital. Patients with proliferative retinopathy alone, hydronephrosis, or nephrotic syndrome were excluded. The patients were grouped according to onset and duration of diabetes and to vascular lesions; group I (n=35, White class B+C), group II (n=11, White class D⁰), groun III (n=26, White class D⁺, and group IV (n=15, White class F+F/R). The patients visited the hospital every 2 weeks during pregnancy for general obstetric and glycaemic control and blood sampling. The volume of both kidneys was measured by a computerized nephrosonograph during the three terms of pregnancy, the puerperium and 4 months postpartum. The kidney volume increased significantly in all four groups from first to third trimester. In the third trimester the kidney volumes were 375±68 ml (I), 341±50 ml (II), 362±63 ml (III), and 343±54 ml (IV). The kidney volume in the third trimester was positively correlated with creatinine clearance (r=0.33,P<0.01) and inversely correlated with creatinine in serum (r=−0.27,P=<0.02). Total kidney volume decrease (in percent) defined as the difference of maximal volume and value at 4 months postpartum was inversely correlated to albuminuria in the third trimester (r=−0.25,P<0.05) and vascular lesions of the patients: (mean±SEM) 37±4% (I), 25±7% (II), 19±5% (III), and 11±7% (IV),P<0.01. In the puerperium, kidney volume decreased significantly from third trimester in groups I, II, and III, whereas we observed no change in group IV. Six of 15 women in groups II and III with kidney volume <300 ml and normoalbuminuria in the first trimester developed persistent microalbuminuria after pregnancy (P<0.02). The renal volume in insulin-dependent diabetic women increases significantly during pregnancy and is inversely related to the vascular lesions of the patients. The decrease in renal volume after pregnancy is related to the albuminuria at the end of pregnancy. Women with long-standing diabetes, White class D (=groups II+III), and kidney volume <300 ml in the first trimester have a high risk of developing permanent microalbuminuria after pregnancy.     

White coat hypertension and pregnancy outcome.

The presence and outcome effect of white coat hypertension in pregnancy was determined with 24-h ambulatory blood pressure (BP) monitoring. Sixty women presenting with high clinic BP (>/=140/90 mm Hg) in the second trimester were included. Patients were divided into two groups based on daytime ambulatory BP findings: <135/85 mm Hg, white coat hypertension (n = 37); >/=135/85 mm Hg, 'true' hypertension (n = 23). Complicated pregnancy outcome was defined as the presence of pre-eclampsia and/or intrauterine growth restriction. Groups were compared for pregnancy outcome and for background and delivery factors. The predictive value of ambulatory BP measurements for pregnancy outcome was determined. Pregnancy outcome was better in the white coat hypertension group than in the true hypertension group: pre-eclampsia-3 (8.1%) vs 13 (56.5%) (P = 0.0046); intrauterine growth restriction-5 (13.5%) vs 10 (43.4%) (P = 0. 0139); and preterm delivery-11 (29.7%) vs 15 (65.2%) (P = 0.015). Night-time ambulatory BP measurements were the best predictor of complicated pregnancy, followed by daytime and 24-h measurements. We conclude that second trimester ambulatory BP monitoring can be used to differentiate patients who have white coat hypertension, which is associated with a better pregnancy outcome than true hypertension.     

Vascular placental pathology in high-risk groups: definition and synopsis

The vascular placental pathology (VPP) is associated with many etiologies. Some are the consequence of a maternal genetic or acquired predisposition. Others are associated with a chronic maternal disease (hypertension, lupus, obesity, diabetes, ...). Finally, some others are associated with placental implantation leading to fetal ischemia (multiple pregnancy, chorioangioma, primiparity, feto-placental hydrops) or to environmental (altitude) or nutritional factors (famine and specific alimentary depressions). We classify these factors into three categories according to the risk level (moderate, significant and elevated). While any of these factors can increase the risk of VPP, no one is sufficiently sensitive or specific in predict inevitable onset of VPP. In most cases VPP results from a combination of two (or more) risk factors. The risk factors of VPP classified as moderate include age (> or = 35 years), increased blood pressure during the second trimester of pregnancy, a new paternity, dietetic factors or environmental factors, smoking and controlled diabetes (class B, C), or inactive systemic diseases. Risk is significantly elevated among obese (BMI > or = 25), primiparous women, women with a past familial history (first degree) of preeclampsia or eclampsia, cocaine use or association of tobacco and caffeine use, increased placental mass (associated with twin pregnancy, fetal hydrops or molar pregnancy), uncontrolled diabetes, lupus, active scleroderma. Risk is considered to be high among patients with chronic hypertension, women with a past history of preeclampsia, diabetes (class D, F, R), patients with active systemic disease or with antiphospholipid antibodies or women with lupus or renal lesions and/or proteinuria as well as chronic kidney disease resulting in proteinuria, hypertension and renal insufficiency. Finally, the risk of VPP is considered to be increased in the presence of acquired thrombophilia. It remains moderate in the presence of isolated genetic thrombophilia, except in forms presenting with multiple genetic mutations or associated with an hyperhomocysteinemia. A "high-risk group" is defined among women with past history of deep venous thromboembolic events outside pregnancy, or with a past history of placental vascular pathology (intra-uterine death, placental abruptio, severe and precocious placental, intra-uterine growth retardation, early and repetitive fetal loss) and who, in addition, present with acquired thrombophilia (antiphospholipid antibodies, thrombocytemia), unique homozygous genetic thrombophilia, amultiple genetic thrombophilia or unique heterozygous genetic thrombophilia associated with hyperhomocysteinemia. Prophylactic treatment of acquired thrombophilia and of the multiple genetic forms or associated with hypercysteinemia is a logical rationale, particularly among women with a past history of placental vascular pathology, or with a past history of venous thromboembolic events. On the contrary, prophylaxis using low-molecular-weight heparin in the event of asymptomatic genetic thrombophilic mutations and for women without a past history of deep venous thromboembolism or vascular placental pathology remains controversial.     

Pregnancy in congenital cardiac disease: an increasing challenge for cardiologists and obstetricians -- a prospective multicenter study

OBJECTIVES: Aim of this study was to assess the occurrence of pregnancy-related complications of mother and child during pregnancy, delivery and puerperium in women with CCD prospectively. STUDY DESIGN, POPULATION: This prospective multicenter study included 122 pregnancies in 106 women with CCD (72 with, 34 without previous cardiac surgery). Patient age was 17-44, median 26 years. Cardiac and non-cardiac complications, mode of delivery, abortion, and CCD of the newborn were assessed. RESULTS: Initially all women were in Functional Class I or II. Worsening during pregnancy occurred in 25.5% (n=27), mainly during the second and third trimester. Significant problems due to bleeding, hypertension, rhythm disturbances, endocarditis, liver congestion, increasing cyanosis or death, occurred in 11.3%. Twelve per cent of deliveries were premature. Five women had therapeutic abortion, nine spontaneous abortions, nine preterm births, and one intrauterine death. Seventy-nine per cent (n=85) delivered spontaneously; 21.3% (n=23) had caesarean section. Of the 111 live born children, 5.4% (n=6) had a CCD. CONCLUSIONS: Most women with CCD and a good functional class before pregnancy tolerate pregnancy without major problems. However, pregnancy may induce serious cardiac and obstetric complications. The specific risks require an individualized multidisciplinary patient-management by experienced physicians.     

Cation metabolism and the effects of circulating factors in pregnancy induced hypertension]

In order to clarify the pathophysiological significance of changes in intracellular ionized calcium and sodium levels in pregnancy induced hypertension (PIH), the intracellular ionized calcium concentration in platelets (p-[Ca2+]i) and the intracellular ionized sodium concentration in red blood cells (r-[Na+]i) were measured simultaneously in PIH women in the third trimester. p-[Ca2+]i in the first trimester showed a slightly greater increase than in the women of normal luteal phase. In the second trimester, p-[Ca2+]i decreased significantly compared to first trimester, and the third trimester and first trimester levels were the same. In women with mild and severe PIH, the levels in both groups were significantly increased compared with that in normal pregnant women. Thus mechanisms not associated with platelet activation were considered as the cause of the increase of p-[Ca2+]i of women with PIH. r-[Na+]i in mild and severe PIH were also significantly increased compared to normal pregnancy. No correlation between p-[Ca2+]i and r-[Na+]i and diastolic blood pressure was observed in normal pregnancy, but a positive correlation was observed in PIH. When the male platelets were incubated with serum from non-pregnant or normal pregnant women, p-[Ca2+]i did not show any significant changes. On the other hand, p-[Ca2+]i was significantly increased after the incubation with serum from PIH women. Moreover, p-[Ca2+]i was significantly increased after the incubation with 17 beta-estradiol, parathyroid hormone (PTH), or endothelin-1 (ET-1). These data suggest that the increase of p-[Ca2+]i and r-[Na+]i in PIH is important in the initiation and maintenance of hypertension by influencing peripheral vascular resistance, and also various factors in the serum of PIH women may contribute to the accumulation of intracellular ionized calcium in patients with PIH.     

Plasma corticotropin-releasing hormone concentrations during pregnancy and parturition

Plasma CRH was measured in maternal plasma throughout the third trimester of pregnancy, during labor, and postpartum. CRH levels were also measured in arterial and venous umbilical cord plasma samples. In normal pregnant women, plasma CRH increased from 50 +/- 15 (+/- SEM) pg/mL at 28 weeks gestation (n = 41) to 1462 +/- 182 pg/mL at 40 weeks (n = 55) and 1680 +/- 101 pg/mL (n = 65) in labor. Women with pregnancy-induced hypertension (n = 49) had plasma CRH levels significantly elevated above this normal range. Similarly, women who subsequently went into premature labor had raised levels several weeks before the onset of labor. After delivery, plasma CRH returned to normal within 15 h. Total plasma cortisol levels varied little throughout the third trimester, but increased during labor and remained elevated 2-3 days postpartum. There was, therefore, no correlation between plasma cortisol and CRH, implying that this placental CRH is not primarily involved in the control of the maternal hypothalamo-pituitary adrenal axis during pregnancy. The concentrations of CRH in umbilical cord plasma samples were considerably lower than those in the maternal circulation and were close to those in normal nonpregnant adults.     

Renal abnormalities in normotensive insulin-dependent diabetic offspring of hypertensive parents.

To assess the effects of genetic predisposition of essential hypertension on early renal function in recent insulin-dependent diabetics, we studied inulin, para-aminohippuric, sodium, and lithium clearances in 69 unselected diabetics with (n = 20) and without (n = 49) a family history of essential hypertension. Despite similar metabolic control, glomerular filtration rate and mean arterial pressure were significantly higher in diabetics with than in those without a family history of hypertension. However, no difference was found between the two groups regarding renal vascular resistance, sodium excretion, or fractional proximal and distal sodium reabsorption. Renal responses to acute captopril (75 mg) administration were evaluated in 27 patients (six with family history of hypertension). Captopril decreased filtration fraction and mean arterial pressure similarly in both groups, whereas glomerular filtration rate and renal vascular resistance decreased more dramatically in diabetics with family history of hypertension. These findings indirectly suggest an abnormal response to angiotensin of vascular tone in recent diabetics with familial predisposition to hypertension. Renal response to acute nicardipine (2.5 mg i.v.) administration was analyzed in 24 patients (five with family history of hypertension). In both groups, nicardipine similarly decreased mean arterial pressure and renal vascular resistance and induced a marked natriuretic effect due to a predominant reduction in proximal reabsorption of sodium. However, the increase in sodium excretion was twofold to threefold more pronounced in diabetics with a family history of hypertension. Whether these early renal abnormalities may contribute to the risk of diabetic nephropathy, as suggested by retrospective studies, remains to be determined.     

Higher cholesterol and insulin levels in pregnancy are associated with increased risk for pregnancy-induced hypertension

Hyperinsulinemia and dyslipidemia are known to be associated with essential hypertension but their role in pregnancy-induced hypertension remains unclear. We performed a case-control study comparing cholesterol, insulin, and glucose levels in the early third trimester of pregnancy among 31 women who developed pregnancy-induced hypertension (PIH) (either preeclampsia [n = 6] or nonproteinuric gestational hypertension [n = 25]), with 31 women remaining normotensive through pregnancy. As compared with women remaining normotensive, women subsequently developing PIH had higher fasting cholesterol levels (279 v 247 mg/dL; P = .02) and higher fasting insulin levels (13.3 v 7.9 microU/mL; P = .03), although fasting glucose levels and levels of glucose and insulin after glucose load did not differ significantly between groups. In comparing hypertensive subgroups, fasting insulin levels were significantly higher among women who subsequently developed preeclampsia, but not among those subsequently developing nonproteinuric gestational hypertension. Although women developing PIH had higher pregravid body mass index (25.1 v 22.6 kg/m2, P = .06), fasting cholesterol and insulin levels were associated with risk for PIH even after adjustment for body mass index and age (relative risks for one unit increase, respectively: 1.02 (P = .03) and 1.12 (P = .03). Higher fasting cholesterol and insulin levels in mid- to late pregnancy are associated with increased risk for PIH. These observations support a role for insulin resistance in the development of this complication of pregnancy.     

Differences in circadian pattern of ambulatory pulse pressure between healthy and complicated pregnancies

With the use of ambulatory monitoring, a circadian blood pressure pattern has been shown to characterize normotensive as well as hypertensive pregnant women. However, the potential differences between healthy and complicated pregnancies in pulse pressure, an independent marker of cardiovascular risk in the general population, have not yet been investigated. We analyzed 2523 blood pressure series sampled for 48 hours once every 4 weeks from the first obstetric visit until delivery in 245 women with uncomplicated pregnancies, 140 with gestational hypertension, and 49 who developed preeclampsia. Compared with uncomplicated pregnancies, a statistically significant elevation in the 24-hour mean of pulse pressure is found in complicated pregnancies in all trimesters (P<0.001). Results further indicate similar 24-hour mean of pulse pressure between gestational hypertension and preeclampsia in the first trimester of pregnancy (P=0.158). The increase in pulse pressure among women who developed preeclampsia compared with women with gestational hypertension, although small, was statistically significant in the second trimester (1.4 mm Hg; P=0.010) and, to a larger extent, in the third trimester of pregnancy (1.8 mm Hg; P<0.001). The differences in pulse pressure between healthy and complicated pregnancies, observed already in the first trimester of gestation, are found when systolic and diastolic blood pressure for women with a later diagnosis of gestational hypertension or preeclampsia are within the accepted range of normotension. Moreover, ambulatory pulse pressure provides higher sensitivity than clinic measurements for the diagnosis of hypertension in pregnancy.     

Plasma atrial natriuretic factor levels during normal pregnancy and pregnancy complicated by diabetes mellitus and hypertension

Atrial natriuretic factor (ANF) may play a role in the regulation of the changes of blood volume and vascular reactivity during pregnancy and when pregnancy is complicated by hypertension. Reports of plasma ANF levels during pregnancy are conflicting. We have prospectively studied plasma ANF levels during pregnancy in 25 women, and compared these with 20 age-matched non-pregnant women. Five women developed hypertension during pregnancy and a further five who remained normotensive had insulin-dependent diabetes mellitus. Plasma ANF was 6.8 +/- 1.2 (mean +/- SEM) and 6.3 +/- 0.9 pmol/l during weeks 8-15 and 24-31 of normal pregnancy (n = 15; vs non-pregnant levels (4.0 +/- 0.6 pmol/l) P less than 0.05, n = 20). Levels were 4.3 +/- 0.8 and 3.9 +/- 0.4 pmol/l during weeks 16-23 and 32-39. In the diabetic patients and in the group who developed hypertension levels were at no time different from the uncomplicated pregnancy group. Serum aldosterone increased as pregnancy progressed, but plasma renin activity remained unchanged. As plasma ANF was not different between those who did, and those who did not develop hypertension, early measurement of it will not predict who will and who will not develop hypertension during pregnancy.     

Contribution of angioplasty of a fibromuscular angiodysplasic renal artery during early-onset gestational hypertension

This clinical case illustrates the management difficulties encountered during gestational hypertension and its impact on maternal and foetal outcome. Typically, preeclampsia occurs at the end of the second trimester. If blood pressure remains high early during pregnancy, a secondary cause of hypertension such as renal artery fibromuscular dysplasia should be explored. A renal vascular etiology can be safely ruled out with a duplex ultrasound. In this particular case of renal vascular hypertension in a patient with a single kidney, angioplasty appeared to be the sole solution and was efficient.     

Outcome of critical foot ischaemia in longstanding diabetic patients: a retrospective cohort study in a specialised tertiary care centre

BACKGROUND: We sought to establish risk factors predicting the outcome of foot lesions in longstanding diabetic patients with critical foot ischaemia (CFI). PATIENTS AND METHODS: We investigated retrospectively 98 consecutive diabetic patients with ischaemic foot lesions. The patients (mean age 70 years, duration of diabetes 21 years) were jointly cared for by specialised diabetologists and vascular surgeons; 75 patients were treated by arterial revascularisation. RESULTS: Good outcome (lesions healing) was observed in 53 patients (54%). Bad outcome was observed in 45 patients: not healing lesions (n = 5), major amputation (n = 19), and death in relation to the foot lesion (n = 21). Patients with good and bad outcome did not differ regarding age, sex, smoking status, type, duration and treatment of diabetes mellitus, presence of neuropathy, coronary heart disease, stroke, previous amputations, current revascularization, and localization of the foot lesion. The risk of bad outcome was increased 8.9 times in patients on dialysis for end-stage renal disease; 7.0 times if surgical complications were present; and 5.4 times with C-reactive protein (CRP) above the second quintile (cut-off value 8 mg/dl). CONCLUSION: Management of longstanding diabetic patients with ischaemic foot lesions leaves room for improvement. Dialysis treatment, elevated CRP levels and surgical complications were strongly predictive of non-healing lesions, major amputation and death.     

Fetal RHD genotyping in maternal serum during the first trimester of pregnancy

Fetal RHD genotype determination is useful in the management of sensitized RhD-negative pregnant women. It can be ascertained early during pregnancy by chorionic villus sampling (CVS) or amniocentesis. However, these procedures are invasive, resulting both in an increased risk of fetal loss and in an increased severity of immunization due to fetomaternal haemorrhage. A reliable determination of RHD genotype by fetal DNA analysis in maternal serum during the first trimester of pregnancy is reported in this study. One hundred and six sera from RhD-negative pregnant women were obtained during the first trimester of pregnancy. These sera were tested for the presence of RHD gene using a new real-time polymerase chain reaction assay and the results compared with those obtained later in pregnancy on amniotic fluid cells and by RHD serology of the new-born. All sera from women carrying a RhD-positive fetus (n = 62) gave positive results for RHD gene detection and sera from women carrying a RhD-negative fetus (n = 40) were negative. The high level of accuracy of fetal RHD genotyping obtained in this study could enable this technique to be offered on a routine basis for the management of RhD-negative patients during the first trimester of pregnancy.     

Primary hyperaldosteronism: a frequent cause of residual hypertension after successful endovascular treatment of renal artery disease

BACKGROUND: Poor blood pressure control in renal artery disease patients after percutaneous renal angioplasty (PTRA), with or without stenting (PTRAS), may be due to pre-existing hypertension. Primary hyperaldosteronism is much more frequent than was previously suspected. We hypothesized that residual hypertension observed in some renal artery disease patients after technically successful endovascular treatment may be due to primary hyperaldosteronism. METHODS: Only patients free of significant residual artery stenosis were included in the study. Aldosterone and renin were measured in 52 renal artery disease patients (8 with fibrodysplastic and 44 with atherosclerotic lesions), in whom successful PTRA/PTRAS had been performed previously. An aldosterone-to-renin ratio > or = 23 pg/ml per pg/ml was considered as the cut-off value for performing tests to confirm the diagnosis of primary hyperaldosteronism. RESULTS: Residual hypertension (blood pressure > or = 160/90 mmHg) was observed in 24/52 patients (46%) after revascularization. A raised aldosterone-to-renin ratio was found in nine subjects (17.3%), eight of whom had poor blood pressure control (33% of patients with residual hypertension). A diagnosis of primary hyperaldosteronism was confirmed in seven patients (four atherosclerotic, three fibrodysplastic). All fibrodysplastic subjects with unresponsive blood pressure after PTRA were affected by primary hyperaldosteronism. Primary hyperaldosteronism was confirmed in 9% (4/44) of the atherosclerotic patients (19% of subjects with residual hypertension). No specific clinical features were associated with the subsequent blood pressure control. CONCLUSIONS: Primary hyperaldosteronism is a frequently neglected cause of residual hypertension despite technically successful endovascular treatment of renal artery disease.     

Serum amylase and lipase activities in normal pregnancy: a prospective case-control study

OBJECTIVE: The diagnosis of acute pancreatitis during pregnancy is usually based on the association of upper abdominal pain, nausea or vomiting, and elevated serum amylase or lipase activities. The changes in these enzymatic activities have not been clearly established during normal pregnancy. The aim of this study was therefore to evaluate serum amylase and lipase activities in healthy pregnant women. METHODS: Serum amylase and lipase activities were measured in 103 pregnant women (first trimester, n = 34; second trimester, n = 36; third trimester, n = 33) and in 103 nonpregnant women matched for age and not receiving oral contraception. RESULTS: Serum amylase activity was similar in pregnant women and nonpregnant women during all trimesters of pregnancy. Serum lipase activity was significantly lower during the first trimester of pregnancy compared to nonpregnant women (48.6+/-27.6 vs 59.2+/-29.3 IU/L, p < 0.05) and compared to the third trimester (48.6+/-27.6 vs 76.3+/-35.8 IU/L, p < 0.001). Serum lipase activity was not statistically different between pregnant and nonpregnant women during the second and third trimesters. CONCLUSION: An increase in serum amylase and lipase activities during pregnancy should be taken into account, as in nonpregnant women.     

Blood pressure patterns in normal pregnancy, gestational hypertension, and preeclampsia

With the aim to describe the daily pattern of blood pressure during the trimesters of pregnancy in clinically healthy women as well as in pregnant women who developed gestational hypertension or preeclampsia, we analyzed 1494 blood pressure series systematically sampled by ambulatory monitoring for 48 hours every 4 weeks after the first obstetric visit in 124 women with uncomplicated pregnancies, 55 with gestational hypertension, and 23 with a final diagnosis of preeclampsia. The circadian pattern of blood pressure variation for each group and trimester of gestation was established by population multiple-component analysis. A highly statistically significant circadian pattern represented by a linear model that includes components with periods of 24 and 12 hours is demonstrated for systolic and diastolic blood pressure for all groups of pregnant women in all trimesters (P:<0.001 in all cases). The differences in circadian rhythm-adjusted mean between complicated and uncomplicated pregnancies are highly statistically significant in all trimesters (always P:<0.001). There is also a statistically significant difference in circadian amplitude (extent of daily change) of blood pressure between healthy and complicated pregnancies in all trimesters (always P:<0.004). Results further indicate similar circadian characteristics between women who later developed gestational hypertension or preeclampsia in the first trimester of pregnancy. The difference between these 2 groups in circadian mean is statistically significant in the second trimester for systolic (P:=0.022) but not for diastolic blood pressure (P:=0.986). In the third trimester, the difference in circadian mean is highly statistically significant for both variables (P:<0.001). The differences in blood pressure between healthy and complicated pregnancies can be observed as early as in the first trimester of pregnancy. Those highly significant differences are found when both systolic and diastolic blood pressure for women with a later diagnosis of gestational hypertension or preeclampsia are well within the accepted normal physiological range of blood pressure variability. These differing changes in the circadian pattern of blood pressure with advancing gestational age between healthy and complicated pregnancies offer new end points that may lead to an early identification of hypertensive complications in pregnancy as well as to the establishment of prophylactic intervention.     

One-year clinical follow-up with the serpentine balloon expandable stent: report of the first 100 patients.

BACKGROUND: We recently reported a high technical and 30-day clinical success rate among the first 100 patients treated with the tubular, serpentine design, stainless steel, balloon-expandable stent (beStent) in Israel. The present study examined the clinical results in these patients after the first year. METHODS: Seventy-eight men and 22 women were included in the study. Previous myocardial infarction, bypass surgery and percutaneous transluminal coronary angioplasty had occurred in 52%, 12% and 26% of the patients, respectively. Diabetes mellitus was present in 30 patients and hypertension in 34 patients. One hundred and forty-eight stents of 15, 25, and 35 mm lengths were used. The indications for stenting were suboptimal results (n = 85), bailout conditions (n = 10) or for the prevention of restenosis (n = 8), and lesion types were A (n = 10), B1 (n = 29), B2 (n = 20), and C (n = 44). All patients were clinically monitored with regular visits at 1, 3, 6, 9 and 12 months. RESULTS: Overall, the 12-month event-free survival rate was 82%. Subacute thrombosis occurred in two patients. There were two non-cardiac deaths, one O-wave myocardial infarction, six elective bypass surgeries and 12 target lesion revascularizations. Event-free survival was significantly higher for those with lesions shorter than 15 mm than for those with lesions longer than 15 mm (90% versus 67%, P = 0.003), and for women compared with men (96% versus 78%, P = 0.02). CONCLUSIONS: The initial experience with the beStent shows favorable long-term results with an overall event rate of 18% for this subset of relatively complex lesions; higher event rates were observed for longer lesions.     

Pregnancies in women with diabetic nephropathy: long-term outcome for mother and child

Summary In order to improve the basis upon which to advise women with diabetic nephropathy about pregnancy, we studied the effect of diabetic nephropathy on the course of pregnancy, perinatal out-come, infant development and long-term outcome of the mothers. All pregnancies of women with diabetic nephropathy (defined as proteinuria >400 mg/day (n=26), creatinine clearance <80 ml/min and hypertension in the first trimester (n=10)) followed at our centre from 1982 to 1992 were identified (34 White class F and 2 White class T) and the women and their children re-examined in the spring 1993. From the first to the third trimester the percentage of women with proteinuria over 3 g/day increased from 14 to 53% and those treated with anti-hypertensive medication from 53 to 97%. There were no intrauterine or perinatal deaths, but one child died suddenly 4 weeks postpartum. Of 36 new-borns (gestational week at birth 36(3), birth weight 2384(834) g)), 11 were born before week 34 and 8 had respiratory distress syndrome. Renal function in the first trimester, diastolic blood pressure in the third trimester and an HbA_1c above normal were predictive of gestational age at delivery and low birth weight (stepwise regression analysis). At follow-up of the children (n=35, age 4.5 (0.4–10) years) the majority (n=27) were normally developed but seven had psychomotor retardation (four of them major). One child had a severe motor retardation due to a congenital anomaly. At follow up, 21 of the 29 mothers had preserved renal function (creatinine 1.3 (0.8–4.3) mg/dl and 8 had developed end stage renal disease and required dialysis (2 of whom were White class T) within 3 (1–9) years postpartum. Of those, 4 women (3 White F and 1 White T) had died. Pregnancy did not seem to specifically accelerate the rate of decline of renal function. In women with diabetic nephropathy perinatal mortality can be prevented but perinatal and long-term infant morbidity remains elevated. Women with severely impaired renal function before pregnancy are at risk for serious morbidity when their children are still young. Improvement might be made if all women were to receive specialized care and counselling before, throughout and after pregnancy.Abbreviations ESRD end-stage renal disease - DSST Denver developmental test     

Immunoreactive corticotropin-releasing factor is present in human maternal plasma during the third trimester of pregnancy

Immunoreactive (IR) corticotropin-releasing factor (CRF)-like activity was detectable in the majority of plasma samples obtained from women in the third trimester of pregnancy (68.7 +/- 23.6 pg/ml (14.4 +/- 4.9 fmol/ml); mean +/- SE, n = 15), but not in plasma (less than 10 pg/ml) from first (n = 9) or second (n = 11) trimester of pregnancy, 1 day post partum (n = 7), non-pregnant women (n = 10), or in plasma obtained from patients with Cushing's disease (n = 2) or Nelson's syndrome (n = 1), or in basal (n = 6) or ether-stressed (n = 6) rat plasma. Gel filtration of third trimester pooled plasma revealed that the majority of such material eluted with Kav of rat CRF (1-41). The IR CRF (1-41)-sized material eluted with the identical retention time as rat CRF in a reverse phase high performance liquid chromatography (HPLC) system. The detection of IR CRF exclusively in third trimester maternal plasma, together with our previous demonstration that material physicochemically indistinguishable from it is present in human term placental extracts, suggests that the placenta may be the source of plasma IR CRF.     

Hypertension in Pregnancy Is a Risk Factor for Microalbuminuria Later in Life

The authors aimed to compare renal function by estimated glomerular filtration rate and albuminuria in 3 groups of women: nulliparous women, women with a history of normotensive pregnancies, and women with a history of at least one hypertensive pregnancy. Women who participated in the second Family Blood Pressure Program Study visit (2000–2004) and had serum creatinine and urine albumin measurements (n=3015) were categorized as having had no pregnancy lasting >6 months (n=341), having had only normotensive pregnancies (n=2199), or having had at least 1 pregnancy with hypertension (n=475) based on a standardized questionnaire. Women who reported having had at least one pregnancy with hypertension were significantly more likely to be hypertensive (75.6% vs 59.4%, P<.001), diabetic (34.2% vs 27.3%, P≤.001), and have higher body mass index (32.8 vs 30.5, P<.001) than those who reported normotensive pregnancies. There was a significantly greater risk of microalbuminuria (urine albumin‐creatinine ratio >25 mg/g) in those who reported at least one pregnancy with hypertension (odds ratio, 1.37; confidence interval, 1.02–1.85; P=.04) than in those with normotensive pregnancies, after adjusting for risk factors for chronic kidney and cardiovascular disease. Hypertension in pregnancy is associated with an increased risk of future microalbuminuria.