Amniotic fluid index and estimated fetal weight for prediction of fetal macrosomia: a prospective observational study

Objective: The purpose of this study was to assess the value of combining the estimated fetal weight (EFW) and amniotic fluid index (AFI) measured in term patients early in labor with intact membranes for prediction of macrosomia.

Methods: In a single center, prospective observational study, 600 patients in the first stage of labor before rupture of membranes in whom ultrasonography was performed to measure AFI and EFW, and these data were analyzed statistically to evaluate prediction of fetal macrosomia.

Results: Macrosomia occurred in 64 cases (10.6%). The AFI was significantly higher in the macrosomic group (p?=?0.001). It was noted that the area under receiver operating characteristic (ROC) curves for EFW was 0.93 and that of AFI was 0.67. Based on suggested combined EFW and AFI cutoffs of 4000?g and 164?mm, respectively, the positive predictive value (PPV) for combined parameters (92.3%) was higher than that of EFW (75%) and that of AFI (27%) and the likelihood ratio for combination (93.7%) was higher than that of EFW (24.7%) and that of AFI (21%).

Conclusion: Combined use of EFW and AFI improves prediction of macrosomia at birth rather than the EFW alone.     

碱性成纤维细胞生长因子与妊娠期糖尿病及巨大儿的关系

目的：探讨孕妇胎盘中碱性成纤维细胞生长因子（bFGF）的水平与妊娠期糖尿病及巨大儿的关系。方法采用实时荧光定量 PCR 方法检测妊娠期糖尿病（GDM）孕妇生产巨大儿（新生儿体重≥4000 g,12例,GDM巨大儿组）和正常体重儿（2500 g≤新生儿体重＜4000 g,12例,GDM正常儿组）及正常产妇生产巨大儿（12例,巨大儿组）和正常体重儿（12例,正常儿组）胎盘中 bFGF 的含量,比较4组差异。结果以正常儿组为阴性对照, GDM正常儿组和正常儿组的 bFGF 相对表达量为（4.47±3.73）和（1.64±1.20）,GDM正常儿组 bFGF 的表达量升高;以巨大儿组为阴性对照,GDM巨大儿组和巨大儿组 bFGF 相对表达量为（1.73±1.61）和（1.11±0.64）,GDM巨大儿组 bFGF 表达量升高;以 GDM正常儿组为阴性对照,GDM正常儿组和 GDM巨大儿组 bFGF 相对表达量为（1.36±1.14）和（1.23±1.23）,GDM巨大儿组 bFGF 表达量降低;以正常儿组为阴性对照,正常儿组和巨大儿组bFGF 表达量为（1.64±1.20）和（1.53±1.60）,巨大儿 bFGF 表达量降低;差异均有统计学意义。以总体正常儿组为阴性对照,总体正常儿组和合并巨大儿组 bFGF 相对表达量为（1.68±1.67）和（1.51±1.71）,合并巨大儿组bFGF 相对表达量降低,差异有统计学意义。结论妊娠期糖尿病孕妇的胎盘中 bFGF 表达量增加;巨大儿时胎盘中 bFGF 表达降低。     

Does fetal macrosomia affect umbilical artery Doppler velocity waveforms in pregnancies complicated by gestational diabetes?

Objectives: We aimed to establish whether macrosomic fetuses in pregnancies complicated by gestational diabetes (GDM) show different Pulsatility Index (PI) values in umbilical artery (UA) than in non-macrosomic fetuses.

Methods: We considered 106 pregnant women with GDM. Doppler recordings of UA-PI were performed at 34–41 weeks and related to neonatal birthweight. Pregnancies were divided in two groups according to birthweight, macrosomic group (>4000?g) and controls (<4000?g), and according to birthweight centile,?>90th centile and?<90th centile. Differences in UA-PI and maternal and fetal characteristics between groups were tested.

Results: Mean UA-PI was significantly lower in newborns with birthweight?>4000?g than in controls (PI?=?0.69; 95% CI 0.64–0.74 versus PI?=?0.87; 95% CI 0.84–0.90, p?<?000.1). Mean UA-PI was significantly lower in newborns with birthweight centile?>90th centile than in controls (PI?=?0.79; 95% CI 0.74–0.84 versus PI?=?0.87; 95% CI 0.83–0.90; t?=?2.653; p?=?0.01). Linear regression analysis revealed a significant correlation between UA-PI and neonatal birthweight and between UA-PI and neonatal birthweight centile.

Conclusions: Macrosomic fetuses of pregnancies complicated by GDM show lower values of UA-PI compared with controls. Despite UA-PI results, a variable related to macrosomia its role in the management of these pregnancies remains to be established.     

妊娠期营养不良对大鼠糖、脂代谢及子代出生体重的影响

目的 研究妊娠期营养不良(营养过剩及营养不足)对大鼠糖、脂代谢及子代出生体重的影响.方法 Wistar大鼠从确定妊娠第1天起按摄入食物的不同,分别分为高脂高热量组、正常饮食组及低热量饮食组,每组10只.比较孕鼠妊娠期体重变化以及妊娠晚期血清甘油三酯、高密度脂蛋白、低密度脂蛋白、空腹血糖、胰岛素的水平、口服葡萄糖耐量试验和胰岛素释放试验结果的差异,观察各组子代出生体重及仔鼠巨大儿和低体重的发生率.采用单因素方差分析、LSD或DunnettT3检验、卡方检验进行统计学分析.结果 高脂高热量饮食组大鼠妊娠期体重明显增加,妊娠晚期血清甘油三酯及低密度脂蛋白分别为(1.68±0.13) mmol/L及(0.57±0.04) mmol/L,均高于正常饮食组[(0.78±0.08) mmol/L及(0.35±0.07) mmol/L),P均＜0.01],而高密度脂蛋白低于正常饮食组[(0.56±0.06) mmol/L与(1.09±0.08) mmol/L,P＜0.05];低热量饮食组甘油三酯、低密度脂蛋白及高密度脂蛋白分别为[(0.47±0.06) mmol/L、(0.21±0.06) mmol/L及(0.42±0.05) mmol/L],均低于正常饮食组(P均＜0.05).营养不良组(高脂高热量饮食组和低热量饮食组)孕鼠均出现了糖耐量受损,口服葡萄糖耐量试验和胰岛素释放试验异常;高脂高热量饮食组鼠妊娠晚期空腹血糖高于正常饮食组[(6.63±0.53) mmol/L与(4.90±0.26) mmol/L,P＜0.05],低热量饮食组空腹血糖为(4.18±0.26) mmol/L,与正常饮食组比较,差异无统计学意义(P＞0.05).3组孕鼠妊娠晚期空腹血清胰岛素水平比较,差异均无统计学意义.高脂高热量饮食组子代平均出生体重高于正常饮食组[(6.14±0.31)g与(5.73±0.26)g,P＜0.05],仔鼠巨大儿发生率高于正常饮食组[19.20％(19/99)与7.84％(8/102),P＜0.05];低热量饮食组子代平均出生体重为(4.54±0.23)g,低于正常饮食组(P＜0.05),仔鼠巨大儿发生率为13.40％(11/76),高于正常饮食组(P＜0.05);低体重儿发生率高于正常饮食组[15.90％(13/76)与3.92％(4/102),P＜0.05];仔鼠总数量少于正常饮食组(76只与102只)(P＜0.05),高脂高热量饮食组仔鼠总数量为99只,少于正常饮食组,但差异无统计学意义(P＞0.05).结论 妊娠期营养不良可引起大鼠妊娠期脂质代谢异常、糖耐量受损和胰岛素抵抗,同时也对子代出生体重,包括仔鼠巨大儿及低体重儿的发生率产生不良影响.     

Obstetric and perinatal outcome in women with twin pregnancy and gestational diabetes

Objective: The aim of this study was to evaluate pregnancy complications and obstetric and perinatal outcomes in women with twin pregnancy and GDM. Study Design: An observational multicentre retrospective study was performed and 534 pregnant woman and 1068 twins infants allocated into two groups, 257 with GDM and 277 controls, were studied. Main Outcome Measures: Pregnant women characteristics, hypertensive complications, preterm delivery rate, mode of delivery and birthweight were analysed. Results: Pregnant women with GDM were older (p?<?0.001) and had higher body mass index (p?<?0.001) than controls. GDM was associated with higher risk of prematurity in twin pregnancy (odds ratio 1.64, 95% confidence interval [1.14–2.32], p?=?0.005). This association was based on the association with other pregnancy complications. Birthweight Z-scores were significantly higher in the GDM group (p?=?0.02). The rate of macrosomia was higher in the GDM group (p?=?0.002) and small for gestational age (SGA) babies were significantly less frequent (p?=?0.03). GDM was an independent predictor of macrosomia (p?=?0.006). Conclusion: The presence of GDM in twin pregnancy was associated with a higher risk of hypertensive complications, prematurity and macrosomia, but significantly reduces the risk of SGA infants. Prematurity was related to the presence of other associated pregnancy complications.     

Excessive gestational weight gain predicts large for gestational age neonates independent of maternal body mass index

Objective: To determine the effects of maternal pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) on large-for-gestational-age (LGA) birth weight (≥90th % ile). Methods: We examined 4321 mother-infant pairs from the Ottawa and Kingston (OaK) birth cohort. Multivariate logistic regression (controlling for gestational and maternal age, pre-pregnancy weight, parity, smoking) were performed and odds ratios (ORs) calculated. Results: Prior to pregnancy, a total of 23.7% of women were overweight and 16.2% obese. Only 29.3% of women met GWG targets recommended by the Institute of Medicine (IOM), whereas 57.7% exceeded the guidelines. Adjusting for smoking, parity, age, maternal height, and achieving the IOM’s recommended GWG, overweight (OR 1.99; 95%CI 1.17–3.37) or obese (OR 2.64; 95% CI 1.59–4.39) pre-pregnancy was associated with a higher rate of LGA compared to women with normal BMI. In the same model, exceeding GWG guidelines was associated with higher rates of LGA (OR 2.86; 95% CI 2.09–3.92), as was parity (OR 1.49; 95% CI 1.22–1.82). Smoking (OR 0.53; 95%CI 0.35–0.79) was associated with decreased rates of LGA. The adjusted association with LGA was also estimated for women who exceeded the GWG guidelines and were overweight (OR 3.59; 95% CI 2.60–4.95) or obese (OR 6.71; 95% CI 4.83–9.31). Conclusion: Pregravid overweight or obesity and gaining in excess of the IOM 2009 GWG guidelines strongly increase a woman’s chance of having a larger baby. Lifestyle interventions that aim to optimize GWG by incorporating healthy eating and exercise strategies during pregnancy should be investigated to determine their effects on LGA neonates and down-stream child obesity.     

Increased composite maternal and neonatal morbidity associated with ultrasonographically suspected fetal macrosomia

Objective: To determine the composite risk of maternal and neonatal morbidity in pregnancies with suspected fetal macrosomia. Methods: In a retrospective study of laboring women delivering singleton, term neonates, we defined 3 groups of patients by estimated fetal weight (EFW) in grams, using ultrasound: (1) <4000, (2) 4000–4499, and (3) 4500+, and tested them for association with a composite outcome using multivariable logistic regression models. The measure of composite morbidity included: shoulder dystocia, third/fourth degree perineal laceration, postpartum hemorrhage, maternal length of stay (LOS)≥ 5 days, neonatal birth trauma, meconium aspiration syndrome, perinatal infection, and neonatal LOS ≥ 5 days. Because of potential interactions between diabetes and birthweight, women with maternal diabetes were examined separately. Results: Of 8,843 deliveries, the proportion with composite morbidity by group was: (1): 26.2%, (2): 41.2%, and (3): 63.6% (p < 0.0001). The OR (95% CI) for groups (2) and (3) were: 1.9 (1.2–2.9) and 2.1 (0.6–7.2), for diabetics (9.7% of the final study population), and 2.3 (1.9–2.7) and 3.9 (2.2–6.9), for non-diabetics. Conclusions: Suspected fetal macrosomia appeared associated with increased risk for a composite measure of childbirth morbidity.     

Increasing pre-pregnancy body mass index is predictive of a progressive escalation in adverse pregnancy outcomes

Objective: To evaluate the association between pre-pregnancy body mass index (BMI) and adverse pregnancy outcomes using a large administrative database. Methods: Retrospective cohort study of California women delivering singletons in 2007. The association between pre-pregnancy BMI category and adverse outcomes were evaluated using multivariate logistic regression. Results: Among 436,414 women, increasing BMI was associated with increasing odds of adverse outcomes. Obese women (BMI?=?30–39.9) were nearly 3x more likely to have gestational diabetes (OR?=?2.83, 95% CI?=?2.74–2.92) and gestational hypertension/preeclampsia (2.68, 2.59–2.77) and nearly twice as likely to undergo cesarean (1.82, 1.78–1.87), when compared to normal BMI women (BMI?=?18.5–24.9). Morbidly obese women (BMI ≥ 40) were 4x more likely to have gestational diabetes (4.72, 4.46–4.99) and gestational hypertension/preeclampsia (4.22, 3.97–4.49) and nearly 3x as likely to undergo cesarean (2.60, 2.46–2.74). Conclusion: There is a strong association between increasing maternal BMI and adverse pregnancy outcomes. This information is important for counseling women regarding the risks of obesity in pregnancy.     

Waiting for postterm in healthy women,is it an accident waiting to happen?

Abstract

Objective: To establish whether postterm pregnancies are associated with adverse perinatal outcomes in a linear fashion.

Study design: A retrospective cohort study investigating perinatal outcomes in singleton term (≥37 weeks gestation) and postterm pregnancies was conducted. Deliveries occurred between the years 1988 and 2010. Parturients were classified into three groups according to their gestational age: 37–39?+?6, 40–41?+?6 and over 42 weeks’ gestation (postterm). Statistical analysis included multiple logistic regression model to control for possible confounders.

Results: Out of 202?462 deliveries, meeting the inclusion criteria, during the study period, 47.7% occurred at 37–39?+?6 weeks, 47.4% occurred at 40–41?+?6 weeks and 4.9% were postterm. Fertility treatments, diabetes mellitus, hypertensive disorders, intrauterine growth restriction (IUGR) and premature rupture of membranes (PROM) were less likely to be associated with postterm pregnancies. However, postterm was found as a significant risk factor for labor complications and adverse perinatal outcome including perinatal mortality. Using a multivariable logistic regression model, controlling for confounders such as maternal age and macrosomia, postterm was found to be an independent risk factor for perinatal mortality (adjusted OR?=?1.5; 95% CI?=?1.20–2.0; p?<?0.001).

Conclusion: Although postterm pregnancies were less likely to be associated with obstetrical risk factors and complications such as fertility treatments, diabetes mellitus, hypertensive disorders, IUGR and PROM, postterm is an independent risk factor for perinatal mortality.     

Beckwith–Wiedemann syndrome with overlapping Perlman syndrome manifestation

Abstract

Beckwith–Wiedemann syndrome (BWS) is an overgrowth syndrome known as exomphalos-macroglossia – gigantism syndrome. Prognosis is good, prenatal diagnosis is important for pregnancy management but might be difficult due to clinical overlap with other syndromes. Perlman syndrome is an overgrowth syndrome with high perinatal mortality, most frequent antenatal findings include polyhydramnios, macrosomia, visceromegaly, nephromegaly and foetal ascites. Authors present a case of prenatally diagnosed BWS with severe ascites as first antenatal finding and lethal course, signs more typical of Perlman syndrome. This combination of clinical signs has not been published yet and may contribute to specification of possible prenatal manifestation of BWS.