The impact of gestational diabetes and hypothyroidism on the third-trimester ultrasound parameters and in adverse perinatal outcomes: a retrospective cohort study

Objective: To assess the impact of gestational diabetes and hypothyroidism on the third-trimester ultrasound parameters and in adverse perinatal outcomes.

Methods: We performed a retrospective cohort study with 817 singleton pregnant women between 26w0d and 37w6d of gestation which were divided in four groups: 56 gestational diabetes mellitus (GDM), 63 hypothyroidism, 14 GDM?+?hypothyroidism, and 684 controls. The following ultrasound parameters were assessed: mean uterine artery pulsatility index (PI), umbilical artery PI, middle cerebral artery PI, single deepest pocket (SDP) and cerebroplacental ratio (CPR). Adverse perinatal outcomes were the following: low birth weight, macrosomia, and Agar score at 1st min?<7. These four groups were compared using the Kruskall–Wallis and χ² tests.

Results: Pregnant women from GDM showed higher weight (p?<?0.001), BMI (p?<?0.001), SDP (p?<?0.001) and newborns with higher birth weight (p?=?0.008) and macrosomia (p?=?0.02) than other groups. Comparing with control, hypothyroidism showed higher SDP (p?<?0.05).

Conclusion: Pregnant women with GDM showed higher risk of macrosomic newborns than other three groups. Both pregnant women with GDM and hypothyroidism showed higher SDP than normal pregnancies.     

Diabetes mellitus following gestational diabetes: role of subsequent pregnancy

Objective  This study was designed to determine the rate of diabetes up to 13 years after pregnancies complicated by gestational diabetes and to identify risk factors for developing diabetes. The role of a subsequent pregnancy, with and without gestational diabetes, was also examined.
Design  This was a retrospective cohort study of women with gestational diabetes.
Population and setting  Women who had gestational diabetes in their first pregnancy between 1989 and 2002 were identified through a population-based perinatal database in Nova Scotia, Canada.
Methods  Subsequent diagnoses of diabetes, up to 13 years after the first pregnancy, were obtained from physician billing and hospital discharge databases. Cox proportional hazards regression models were used to estimate adjusted relative risks (RR) and 95% confidence intervals.
Main outcome measures  Diagnosis of diabetes after pregnancy.
Results  Of the 1401 nulliparous women with gestational diabetes, 251 women (17.9%) developed diabetes in the follow-up period. The cumulative incidence at 1, 5, and 10 years was 5.9, 14.8, and 22.2%, respectively. Factors significantly associated with an increased risk of developing diabetes mellitus included a pre-pregnancy weight of ≥86 kg (RR = 1.8, 95% CI 1.2–2.9), insulin therapy during the index pregnancy (RR = 4.1, 95% CI 2.1–7.9), neonatal hypoglycaemia (RR = 2.6, 95% CI 1.6–4.2), and a subsequent pregnancy with gestational diabetes (RR = 2.3, 95% CI 1.6–3.4).
Conclusion  Indicators of the severity of gestational diabetes, defined by insulin use, neonatal hypoglycaemia, and recurrent gestational diabetes in a subsequent pregnancy, are important in predicting a subsequent diagnosis of diabetes. Our findings do not support the theory that subsequent pregnancy, per se , increases the risk of developing diabetes.     

Three-dimensional ultrasound in the imaging of multifetal pregnancy

The great advances in imaging techniques, such as high-resolution probes and three-dimensional ultrasound, have enabled us to image multifetal pregnancies from the time β-human chorionic gonadotropin is positive. The importance of three-dimensional sonographic evaluation of multifetal pregnancy before 12 weeks of gestation, using multiplanar sections and surface rendering, should be emphasized. In this review, we also discuss the importance of three-dimensional ultrasound imaging in second- and third-trimester multifetal pregnancy, and in the assessment of fetal weight and amniotic fluid volume. Finally, we outline the importance of novel techniques: three-dimensional power Doppler and four-dimensional ultrasound in the field of multifetal pregnancy and in performance of interventional procedures. Because three-dimensional ultrasound is still a novel sonographic modality, many of its potential utilities await studies to prove efficacy and cost-effectiveness.     

The influence of obesity and gestational diabetes mellitus on accretion and the distribution of adipose tissue in pregnancy

OBJECTIVE: The purpose of this study was to evaluate the effect of pregravid obesity and gestational diabetes mellitus (GDM) on the longitudinal accretion and distribution of adipose tissue in pregnancy. STUDY DESIGN: Women with normal glucose tolerance and GDM were evaluated before conception, early (12-14 weeks) and late (33-36 weeks) in gestation. Fat mass, lean body mass, and percent body fat were assessed longitudinally with hydrodensitometry. Serial biceps, triceps, subscapular, iliac, costal, mid thigh, and lower thigh skinfold measurements quantified the changes in fat mass distribution. Pregravid obesity was defined as >25% body fat. RESULTS: Subjects included 19 patients with GDM (5 lean women, 14 obese women), and 33 patients with normal glucose tolerance (controls; 12 lean women, 21 obese women). GDM and control subjects were similar in pregravid percent body fat (29.6% vs 27.9%, P=.47) and fat mass (20.8 kg vs 18.2 kg, P=.37). Values for subjects with GDM and controls were also similar in terms of percent body fat, fat mass, and weight gained (change in percent body fat, -0.7% vs 1.9% [P=.07]; change in fat mass, 3.8 kg vs 5.0 kg [P=.08]; change in weight, 12.0 kg vs 13.2 kg [P=.35]). Lean subjects gained more percent body fat compared with obese subjects (change in percent body fat, 3.3% vs 0.1% [P=.004]) but gained similar amounts of fat mass (change in fat mass, 4.7 kg vs 4.2 kg [P=.58]), lean body mass (7.6 kg vs 8.8 kg [P=.18]), and weight (change in weight, 12.3kg vs 13.0 kg [P=.61]) The distribution of adipose tissue that was accumulated as estimated with skinfold measurements was similar between patients with GDM and glucose tolerance (P>.05 for all changes in skinfolds), but significantly different between lean and obese patients (P<.05 for all changes in skinfolds). Lean women gained a predominance of adipose tissue peripherally over that in obese women. CONCLUSION: Lean women accrue significantly more fat mass than obese women, regardless of glucose tolerance. Pregestational obesity rather than GDM influences the distribution of adipose accretion.     

Early detection of ectopic pregnancy by transvaginal ultrasound

Summary Transvaginal (TVU; 19 patients) and transabdominal ultrasound (TAU; 24 patients) were compared in their ability to visualize an ectopic pregnancy. The direct visualization of ectopic pregnancy (EUP) was 25% with TAU and 94.7% with TVU. All women had a proven EUP in laparoscopy. TAU approach showed a significant inferiority (P<0.02) and TVU a superiority (P<0.08) in comparison to clinical examination. 83% of 43 women had spotting. Nonspecific signs for EUP like fluid in the pouch of Douglas was seen in 20.9%. Thin endometrium was seen in 6.9%, in 37.2% the thickness of endometrium was under 10 mm, in 55.8% more than 10 mm. An intrauterine pseudogestation sac was detected in 6.9%, corpus luteum formation in 37.2%.     

Plasma hCG and ultrasound in suspected ectopic pregnancy

The value of plasma hCG determinations (based on the recognition of β-subunit of hCG) and ultrasound was examined in 48 cases of suspected ectopic pregnancy. In 11 patients with the final diagnosis of ectopic pregnancy (23%), the plasma hCG was clearly subnormal (0.37–3.96 IU/ml), with only one exception, where a normally developed fetus was operated from the fallopian tube (hCG 21.1 IU/ml in the 8th wk). The plasma hCG levels allowed differentiation of the non-pregnant cases from the normal intrauterine pregnancies and the ectopic cases, but not at all between the different forms of intrauterine early pregnancy failures and ectopic pregnancies. By ultrasound, however, it was possible to reliably diagnose intrauterine pregnancies from the 7th wk of amenorrhea onwards, and to classify them into the normal and pathological subgroups. The direct demonstration of ectopic pregnancy by ultrasound is problematic, but the exclusion of intrauterine pregnancy by this method, combined with the simultaneous plasma hCG determination by sensitive and rapid method, can be recommended for primary examinations in suspected ectopic pregnancy.     

宫外孕多普勒超声的影像特征

目的:探讨超声检查诊断异位妊娠的临床价值,提高输卵管妊娠的早期检出率。方法:对113例早期异位妊娠患者经腹超声的声像图特征进行回顾性分析。结果:超声检查具有捕获图像清晰、准确、快速的特点,对不典型、未破裂的输卵管妊娠可获得早期诊断。结论:超声是诊断异位妊娠的最直接、最重要的方法,并对早期诊断输卵管妊娠有重要的临床价值。     

孕前肥胖与妊娠期糖尿病关系的研究

目的 探讨孕前肥胖与妊娠期糖尿病（ＧＤＭ）之间的关系方法 采用队列研究对６１４例孕妇进行调查,于孕２４～２８周对其进行ＧＤＭ筛检。结果 孕前体质指数（ＢＭＩ）≥２５ｋｇ／ｍ＾２的人群ＧＤＭ发病率高于ＢＭＩ〈２５ｋｇ／ｍ＾２的人群,随孕前腰围增大,ＧＤＭ发病率逐渐升高。非条件Ｌｏｇｉｓｔｉｃ回归分析表明,孕前ＢＭＩ、孕前腰围是ＧＤＭ重要的有统计学意义的危险因素。结论 孕前肥胖是ＧＤＭ独立的危险因素,控制孕前肥胖是预防ＧＤＭ发生的重要措施。     

A comparison of women's, providers' and ultrasound assessments of pregnancy duration among termination of pregnancy clients in South Africa

Objective  To compare providers' and women's estimates of duration of pregnancy with ultrasound estimates for determining medical abortion eligibility.
Design  Cross-sectional study.
Setting  Public termination of pregnancy (TOP) services in three provinces.
Sample  A total of 673 women attending the above services for TOP.
Methods  Women participating in a medical abortion feasibility study in South Africa provided estimates of pregnancy duration and date of last menstrual period (LMP). Each woman also had clinical and ultrasound exams. We compared estimates using the four methods, calculating the proportion of women in the 'caution zone' (≤8 weeks gestation by woman or provider estimate and >8 weeks by ultrasound).
Main outcome measures  Mean gestational age by each method; difference between provider and LMP estimates and ultrasound estimates; and percentage of women in the 'caution zone'.
Results  Women's estimates of pregnancy duration were 19 days fewer than ultrasound estimates (95% CI =−27 to 63). Mean provider- and LMP-based estimates were two (95% CI =−30 to 35) and less than one day(s) (95% CI =−46 to 51) fewer than ultrasound estimates. Comparing provider and ultrasound estimates, 15% of women were in the 'caution zone'; this fell to 12% if estimates of 9 weeks or fewer were considered acceptable.
Conclusions  Provider estimates of gestational age were sufficiently accurate for determining eligibility for medical abortion. LMP-based estimates were also accurate on average, but included more extreme differences from ultrasound estimates. Medical abortion could be provided in TOP facilities without ultrasound or with ultrasound on referral.     

The potential for the use of insulin lispro in pregnancy complicated by diabetes

The target of improved perinatal outcome in diabetic pregnancies may be achieved by new insulin preparations that more closely mirror the physiological response of insulin and not exclusively the traditional means of strict adherence to diet and frequent blood glucose testing.

No insulin preparation has been systematically tested in pregnancy; it is a responsibility of all clinicians who look after pregnant diabetic women to record the outcomes of IL-treated pregnancies.

More data is needed before this preparation can be either recommended in pregnancy or alternatively avoided.     

双胎妊娠的孕期管理

多胎妊娠的管理中,应当关注多胎妊娠的绒毛膜性,不同绒毛膜其胎儿并发症不同,母体并发症和合并症包括妊娠期糖尿病、早产和子痫前期的发病率亦明显增加,需要进行严密监测,以减少母胎不良结局的发生。     

妊娠合并糖尿病患者无症状菌尿的研究

目的针对妊娠合并糖尿病人群无症状菌尿的检出率、发生时期、主要病原菌、对妊娠结局的影响以及治疗的必要性等方面进行的前瞻性的相关性研究.方法选取2002年10月～2003年5月于北京大学第一医院产前保健并分娩的孕妇,分为病例组(67例)和对照组(21例),在其孕中期诊断入院时和孕晚期行清洁中段尿培养.对其尿培养结果结合临床资料进行统计学处理和分析.结果妊娠期糖尿病(GDM)、妊娠期糖耐量受损(GIGT)和糖尿病合并妊娠患者无症状菌尿的检出率分别为10.5%(4/38)、8.7%(2/23)和16.6%(1/6).在GDM孕中期的尿培养病原菌为表皮葡萄球菌和奇异变形杆菌;孕晚期为鲁氏不动杆菌和粪肠球菌.在GIGT孕中期的尿培养病原菌为草绿色链球菌和大肠杆菌.在糖尿病合并妊娠孕晚期的尿培养病原菌为粪肠球菌.病例组无症状菌尿的检出率分别与对照组比较,在统计学上差异无显著性,病例组之间亦无统计学差异.在孕中期发现的4例尿培养阳性患者给予相应的抗生素治疗后,在孕晚期的尿培养均为阴性;在孕晚期发现的3例尿培养阳性患者,其在孕中期的尿培养结果为阴性.病例组中已追踪到妊娠结局的43例患者中,只有1例妊娠期糖尿病患者早产;其余均足月分娩,新生儿结局良好.结论无症状菌尿在妊娠合并糖尿病的孕妇中有一定的检出率,可发生在妊娠的不同时期.本研究显示无症状菌尿的致病菌种较分散,针对抗生素敏感试验的临床治疗有效,说明对妊娠合并糖尿病的孕妇有筛查无症状菌尿的必要性.     

The impact of pre-pregnancy body mass index on the risk of gestational diabetes

Objective: To evaluate the effect of pre-pregnancy body mass index (BMI) on the risk of developing gestational diabetes mellitus (GDM) in a large unselected population. Methods: We performed a case control study using data collected in The Consortium on Safe Labor database. The association between BMI and GDM was evaluated both using BMI weight categories adopted by the National Institute of Health, and separately using BMI as a continuous variable. Multiple logistic regression analyses were used to evaluate the effects of BMI, age, ethnicity, parity, chronic hypertension and antenatal steroid use on the risk of GDM. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to approximate relative risks of GDM. A p value of <0.05 was considered significant. Results: After controlling for other factors, the risk of GDM increased with an increasing BMI across all weight categories. For each 1?kg/m² increase of BMI the OR of developing GDM was 1.08 (95% CI 1.08–1.09) and for each 5?kg/m² increase, the OR was 1.48 (95% CI 1.45–1.51). Conclusions: GDM is a multifactorial disorder and pre-pregnancy BMI plays an important role in that risk. Modest changes in pre-pregnancy BMI may decrease the risk of GDM substantially.     

Prediction of outcome in twin pregnancy with first and early second trimester ultrasound

Abstract

Objective: To establish if first or second trimester biometry is a useful adjunct in the prediction of adverse perinatal outcome in twin pregnancy.

Methods: A consecutive cohort of 1028 twin pregnancies was enrolled for the Evaluation of Sonographic Predictors of Restricted growth in Twins (ESPRiT) study, a prospective study conducted at eight academic centers. Outcome data was recorded for 1001 twin pairs that completed the study. Ultrasound biometry was available for 960 pregnancies. Biometric data obtained between 11 and 22 weeks were evaluated as predictors of a composite of adverse perinatal outcome (mortality, hypoxic ischemic encephalopathy, periventricular leukomalacia, necrotizing enterocolitis, respiratory distress, or sepsis), preterm delivery (PTD) and birthweight discordance greater than 18% (18% BW). Outcomes were adjusted for chorionicity and gestational age using Cox Proportional Hazards regression.

Results: Differences in crown-rump length (CRL) were not predictive of adverse perinatal outcome. Between 14 and 22 weeks, a difference in abdominal circumference (AC) of more than 10% was the most useful predictor of adverse outcome, PTD and 18% or more BW discordance in all twins. Overall the strongest correlation was observed for intertwin differences in biometry between 18 and 22 weeks.

Conclusion: Biometry in the early second trimester can successfully identify twin pregnancies at increased risk. Intertwin AC difference of greater than 10% between 14 and 22 weeks gestation was the best individual predictor of perinatal risk in all twins. Sonographic biometry in the early second trimester should therefore be utilized to establish perinatal risk, thus allowing prenatal care to be improved.     

应用胰岛素泵短期强化治疗妊娠期糖尿病疗效分析

目的研究连续皮下胰岛素输注(CSII,简称胰岛素泵)短期强化治疗妊娠期糖尿病的临床效果。方法选择2003年1月至2006年12月上海市第一人民医院产科治疗的58例妊娠期糖尿病患者,分为CSII组及胰岛素多次皮下注射组(MSII组),并根据血糖检测结果调整胰岛素用量,比较两组血糖控制达标时间、日均胰岛素用量,以及母儿并发症的发生情况。结果两组血糖控制水平相比差异无统计学意义(P>0.05)。但CSII组血糖控制达标时间[(3.14±1.04)d]较MSII组[(7.79±2.14)d]缩短约4.65d,差异有统计学意义(P<0.01)。CSII组日均胰岛素用量[(29.08±10.99)U]较MSII组[(43.51±9.81)U]亦明显减少(P<0.01)。两组母儿并发症如妊娠期高血压疾病、早产以及孕妇低血糖的发生率比较差异均有统计学意义(P<0.05)。结论胰岛素泵短期强化治疗妊娠期糖尿病具有快速稳定的控制高血糖的作用,并可减少低血糖的发生,其临床应用效果优于传统的胰岛素多次皮下注射方式。     

妊娠期高血糖的诊断及管理

妊娠期高血糖（HIP）母儿不良结局明显增加,不仅近期并发症增加,远期发展为糖尿病风险也明显增加。妊娠期高血糖包括孕前糖尿病合并妊娠（PGDM）和妊娠期糖尿病（GDM）。我国二孩政策全面放开后,高危人群比例增加,HIP孕妇比例将进一步增加。对于妊娠期高血糖的筛查、诊断、管理策略及母儿的远期随访等问题均应引起关注。