Maternal and neonatal outcomes in pregnancies complicated by gestational diabetes. a nation-wide study

Objective: To estimate the association between gestational diabetes mellitus (GDM) and adverse pregnancy and neonatal outcomes in Denmark.

Methods: A population-based cohort study including all singleton pregnancies in Denmark from 2004 to 2010 (n?=?403?092). Maternal complications during pregnancy and delivery and fetal complications were classified according to the International Classification of Diseases 10th Revision.

Results: The final study population consisted of 398?623 women. Of these, 9014 (2.3%) had GDM. Data were adjusted for maternal age, parity, smoking, gestational age, birth weight, BMI, gender of the fetus and calendar year. The risk of preeclampsia, caesarean section (both planned and emergency) and shoulder dystocia was increased in women with GDM. In the unadjusted analysis, the risk of thrombosis was increased by a factor 2 in the GDM patients, but in the adjusted analysis this association disappeared. Post-partum hemorrhage was similar in the two groups. The GDM women had an increased risk of giving birth to a macrosomic neonate although the unadjusted analysis did not show any difference between the two groups. Low Apgar score was increased in the GDM, but this association disappeared in the adjusted analysis. Stillbirth was comparable in the two groups.

Conclusions: Women with GDM still have increased incidence of obstetric and neonatal complications, which could imply that treatment of women with GDM should be tightened.     

Obstetrical and neonatal outcomes of pregnancies complicated by endometriosis

Objective: Endometriosis is defined as the presence of endometrial-like tissue outside the uterus, associated with pelvic pain and subfertility, affecting 0.6–10% of the general female population. The association between endometriosis and obstetrical outcomes is not well established. We aimed to evaluate whether endometriosis is associated with a higher incidence of obstetrical and neonatal complications.

Study design: A retrospective cohort study of all deliveries in a university-affiliated tertiary hospital (2007–2014). Eligibility was limited to women with previously diagnosed endometriosis and singleton pregnancies. Fetuses or neonates diagnosed with structural or chromosomal anomalies were excluded. We compared labor and delivery outcomes and immediate neonatal outcomes among women with endometriosis compared with women without endometriosis.

Results: Overall, 61,535 deliveries were eligible for analysis, of which 135 (0.002%) had endometriosis. Women with in the endometriosis group were characterized by higher maternal age, lower parity and higher nulliparity rate, and an earlier gestational age at delivery. Women with endometriosis had higher rate of failure of induction of labor (aOR 5.2, 95%CI 1.8–14.9), cesarean delivery (aOR 5.0, 95%CI 3.3–7.4), postpartum hemorrhage (aOR 3.7, 95%CI 1.6–8.5), placenta accreta (aOR 6.24, 95%CI 2.20–17.67), postpartum hemoglobin <10?mg/dL (aOR 2.03, 95%CI 1.31–3.14), and packed cell transfusion (aOR 3.66, 95%CI 1.94–6.91). No significant differences in neonatal outcomes were observed.

Conclusions: Endometriosis is associated with higher risk of cesarean delivery and postpartum hemorrhage. Our findings suggest appropriate preparations for delivery, such as uterotonic agents and blood products, should be considered in these women.     

Maternal and neonatal outcome of twin pregnancies complicated by single fetal death.

OBJECTIVE: To study the maternal and neonatal outcome of twin pregnancies complicated by the intrauterine death of one fetus after 20 weeks of gestation. DESIGN: Retrospective, observational study of 7 twin pregnancies out of 185 twin pregnancies with the diagnosis of a single intrauterine death over a 5-years period in a university hospital. RESULTS: The incidence of single fetal death in twin gestation after 20 weeks was 3.8% in the study population with a high incidence of intrauterine growth retardation (IUGR) of the remaining fetus and preeclampsia in the further course of pregnancy. The incidence of preterm delivery was 71% with a mean gestational age of 33.0 +/- 1.0 weeks. The median interval from diagnosis of single fetal death to delivery was 10.2 +/- 4.1 days (range 1-28 days). 5 of 7 (71%) cases were delivered by cesarean section for standard obstetrical reasons. Neither perinatal nor neonatal death of the remaining twin were observed. Two cases of neurologic injury were diagnosed after delivery by ultrasound and MRI. No maternal coagulopathy related to single fetal death occurred. CONCLUSION: Expectant management of single fetal death in twin pregnancies might be advisible under close surveillance of both, mother and the surviving fetus.     

Maternal serum cytokine levels in pregnancies complicated by PROM

OBJECTIVE: The aim of the study was to evaluate the maternal serum cytokines levels in pregnancies complicated by premature rupture of membranes (PROM). MATERIALS AND METHODS: Maternal serum of IL-1 beta, IL-4, IL-6, IL-8 and TNF-alfa levels were assessed in patients with PROM between 24-34 weeks of pregnancy (n = 45). Control group consisted of healthy pregnant women (n = 41) at 24-34 weeks of gestation. Serum cytokines concentrations were measured by commercial available enzyme-linked immunosorbent assays. C-reactive protein level and WBC were estimated in both groups. RESULTS: Compared to healthy pregnant, the group of patients with PROM had significantly higher serum levels of IL-1 beta (0.76 pg/ml vs 0.41 pg/ml, p = 0.022), TNF-alfa (1332.46 pg/ml vs 58.01 pg/ml, p < 0.00001) and IL-8 (15.79 pg/ml vs 0 pg/ml, p < 0.00001). CRP concentration and WBC were also significantly higher in serum of pregnant women with PROM then in healthy ones (CRP: 10 mg/l vs 0 mg/l, p = 0.043; WBC: 13,188 +/- 3625/mm3 vs 9132 +/- 1913/mm3, p < 0.00001). No significant differences in IL-6 and IL-4 levels were found between groups. CONCLUSION: Differences in serum maternal levels of cytokines between patients with premature ruptures of membranes and healthy pregnant women suggest that reasons and/or consequences of PROM results in changes in immunological system.     

Maternal and neonatal outcomes in 54 triplet pregnancies managed in an Australian tertiary centre

BACKGROUND: To provide current data on maternal and neonatal outcomes in triplet pregnancies in an Australian population. METHODS: Retrospective case note review of all triplet pregnancies managed within a single Australian tertiary centre. RESULTS: Fifty-four sets of triplets were managed from January 1996 to October 2002. A total of 59% resulted from the use of assisted reproductive technologies. The median gestation at delivery was 32.5 weeks (range: 21-36 weeks); 14% delivered prior to 28 weeks and 43% delivered before 32 weeks. Preterm labour and preterm rupture of membranes were the most common antenatal complications occurring in 57 and 22% of pregnancies, respectively. A total of 93% of pregnancies were delivered by Caesarean section and 37% of mothers experienced at least one post-partum complication. A total of 96% of neonates were liveborn, with a median birthweight of 1644 g (range: 165-2888 g). The two most common neonatal complications were jaundice and hypoglycaemia in 52 and 43% of liveborn neonates, respectively. A total of 28% of neonates were below the 10th centile for gestational age and sex. A total of 8% of neonates demonstrated congenital anomalies. The perinatal mortality at a gestational age of 20-24 weeks was 100%, 22% at 25-28 weeks and zero for those babies born at 29 weeks or beyond. CONCLUSION: Assisted reproductive technologies contribute significantly to the incidence of triplet pregnancies. Gestational age at delivery and perinatal mortality is comparable to published international data. Triplets born in a tertiary centre beyond 28 weeks gestation have a very favourable prognosis in the newborn period.     

Maternal and neonatal outcomes in women with twin pregnancies with excessive gestational weight gain

Objective: To determine if an excessive rate of gestational weight gain (GWG) in twin pregnancies is associated with adverse obstetric outcomes.

Methods: Retrospective cohort study of twin pregnancies delivered at the University of California, San Diego 2001–2014. Women were included if they had adequate or excessive rates of GWG as determined by Institute of Medicine guidelines. Demographic and outcome variables were collected by chart review.

Results: Four hundred and eighty-nine twin pregnancies met inclusion criteria. Of which, 40.5% had adequate rates of GWG and 41.5% had excessive rates of GWG. The rates of preterm birth and gestational diabetes were similar between the two groups. Gestational hypertension and preeclampsia were more common in women with excessive GWG (37.9% versus 19.7%; p?<?0.01). This finding persisted in multivariate analysis. The mean birth weight percentiles were higher in the excessive GWG group and these women were also less likely to have an infant with a birth weight <10th percentile (21.4% versus 35.9%, p?<?0.01).

Conclusions: Excessive GWG is associated with a higher risk for gestational hypertension and preeclampsia, but no other adverse perinatal outcomes. Infants born to mothers with excessive GWG are less likely to be small for gestational age than those born to women with adequate GWG.     

Maternal serum soluble HLA-G in complicated pregnancies

Abstract

Preeclampsia, intrauterine growth retardation (IUGR), oligohydramnios, abortus, preterm birth and premature rupture of the membranes (PROM) are significant complications of pregnancy. Insufficient trophoblastic invasion plays an important role in the pathophysiology of pregnancy complications. Soluble human leukocyte antigen-gestation (HLA-G)1/G5 is a molecule associated with trophoblast invasion. When pregnancy complications are predicted early, strategies to prevent these complications can be implemented. The aim of this study was to investigate the relationship between first trimester maternal serum soluble HLA-G1/G5 levels and high-risk pregnancies. A total of 232 pregnant women were followed prospectively. Maternal blood samples were collected for determination of soluble HLA-G1/G5 levels at 11–14 weeks, during which routine serum free beta human chorionic gonadotropin (βhCG) and pregnancy associated plasma protein-A (PAPP-A) level determinations in addition to nuchal translucency (NT) measurements for Down’s syndrome screening were done during 20–22 weeks gestation. The subjects were classified into normal pregnancy, preeclampsia, oligohydramnios, IUGR, preterm birth and PROM groups. First trimester maternal serum soluble HLA-G1/G5 levels were not significantly different between the groups. First trimester soluble HLA-G1/G5 did not predict high-risk pregnancies. Studies with larger number of cases are need to confirm our findings.     

Maternal serum lipid profile in pregnancies complicated by hypertensive disorders

Plasma lipoprotein, cholesterol and triglycerides were determined in 34 hypertensive pregnant patients and in 17 healthy full term pregnant women. Pregnancy induced hypertension was diagnosed in 21 patients and chronic hypertension in the remaining 13 women. Serum triglyceride levels were significantly elevated in the hypertensive patients. This elevation was not influenced by either the severity or the etiology of the hypertension. The total cholesterol/HDL and the LDL/HDL ratios were significantly elevated in the severely hypertensive patients, and furthermore the LDL/HDL ratio was elevated in patients receiving anti-hypertensive treatment. The lipid profiles found in hypertensive pregnant patients could be associated with enhancement of pathological lipid deposition in predisposed vessels such as the uterine spiral arteries. Furthermore, the hypertriglyceridemia found in the hypertensive patients may be associated with the hypercoagulability reported in pregnancy induced hypertension.     

Maternal renal artery Doppler velocimetry in normotensive pregnancies and pregnancies complicated by hypertensive disorders.

Hypertensive disorders in pregnancy contribute to substantial maternal and perinatal morbidity and mortality. Clinically, these disorders are characterized by hypertension and proteinuria. However, these signs appear some time after the physiologic derangements have been initiated. The primary objectives of this study were as follows: 1) to establish baseline values for the maternal renal artery systolic-diastolic ratio (S/D) as a function of gestational age in normal pregnancies, and 2) to determine whether renal artery blood flow indices can accurately identify those pregnancies complicated by, or destined to develop, hypertensive disorders. Using a pulsed Doppler scanner, maternal renal artery duplex evaluation was performed in four groups of women: normotensive nonpregnant, normotensive pregnant, chronic hypertensive pregnant, and preeclamptic. In 30 normotensive pregnant women followed longitudinally, no change was noted in the renal artery S/D as gestational age advanced, with mean (+/- SD) values of 2.5 +/- 0.20 and 2.6 +/- 0.21 for the left and right sides, respectively. No clinically meaningful discriminations were detected when the four groups were compared. We conclude that maternal renal artery Doppler waveforms are not significantly altered by either pregnancy or hypertensive complications in pregnancy.     

Maternal plasma alpha-fetoprotein in normal and complicated pregnancies.

Plasma alpha-fetoprotein (AFP) has been estimated by radioimmunoassay in healthy non-pregnant adults, some of whom were taking oral contraceptives, and in women with normal and complicated pregnancies. A curve with the 90 per cent range in normal pregnancy was established. The prop&rtion of values below the 5th centile in complicated pregnancies was significantly greater than in uncomplicated pregnancies. However, three-quarters of the estimations in the complicated groups lay within the 90 per cent range. Nor correlation was found between maternal plasma AFP values and the incidence of fetal distress, small-for-dates babies or perinatal mortality. It is concluded that the measurement of maternal plasma AFP is not reliable test for predicting fetal well-being.     

Maternal serum inhibin-A in pregnancies complicated by insulin dependent diabetes mellitus

We have examined whether insulin dependant diabetes mellitus (IDDM) affects maternal serum levels of inhibin-A, a recently described prenatal marker of Down's syndrome, by comparing levels in 169 women with IDDM with levels in 432 nondiabetic pregnant women between 15 and 20 weeks of gestation. There was a small but significant increase in the inhibin-A level in the diabetic women only when levels were corrected for maternal weight: median MoM 1.17 ( P < 0.01 vs controls, Student's t test). The underlying mechanism for this elevation in pregnancies complicated by IDDM currently remains obscure.     

Maternal left ventricular dimension in pregnancies complicated by fetal growth retardation

Previous studies using two-dimensional chest radiographs have found a significant correlation between prematurity, fetal growth retardation, and the size of the maternal heart. Accordingly, we evaluated maternal left ventricular size and function by M-mode echocardiography near the end of gestation in 42 women with suspected fetal growth retardation and in 79 women whose pregnancies were normal. No significant differences were found between the two groups, implying that maternal left ventricular size and function is adequate in pregnancies complicated by "idiopathic" fetal growth retardation.     

Maternal and perinatal outcome of pregnancies complicated by cardiac disease.

OBJECTIVE: The aim of this study was to assess the maternal and perinatal outcome of pregnancies complicated by cardiac disease in a tertiary care center in Egypt. METHODS: During a 1-year period, a total of 86 pregnant women with cardiac disease were admitted. Maternal and perinatal morbidity and mortality were calculated and compared with a control group. RESULTS: Seventy-seven (89.5%) patients were due to rheumatic affection, and 60 patients were classified as NYHA classes I-II. There was one case of maternal mortality (1.16%), and 10 other cases developed life-threatening complications. Two perinatal mortalities (2.32%) occurred in this series. Birth weight of babies born to mothers with functional classes III and IV were significantly lower than those of functional classes I-II and control group. CONCLUSION: Rheumatic heart disease with pregnancy is still predominant in Egypt. Maternal and perinatal morbidity and mortality are strongly correlated to maternal cardiac functional classification.