Comparison of Perinatal Outcomes According to the Majority of Physicians: Obstetrics Versus Endocrinology

Purpose@#To compare the perinatal outcomes among the majority of physicians who manage pregnancies complicated by gestational diabetes mellitus (GDM), particularly those who require insulin treatment. @*Methods@#We conducted a retrospective study involving 206 singleton pregnant women diagnosed with GDM between January 2017 and September 2022. The study participants were divided into 2 groups according to the majority of physicians (obstetrics vs. endocrinology). We compared the maternal characteristics and perinatal outcomes between the 2 groups and performed a subgroup analysis of preterm birth cases. @*Results@#During the study period, 206 pregnant women were diagnosed with GDM and 36.9% (76 of 206) required insulin treatment. Among the GDM A2 pregnancies, 26 patients visited or consulted endocrinologists, and 50 patients were managed by obstetricians. There were no significant differences in maternal characteristics and perinatal outcomes between the two groups. Eighteen infants were delivered before 37 weeks of gestation (12 in the obstetrician group and 6 in the endocrinologist group). In preterm-delivered patients, the birth weight was heavier in the endocrinology group (median [range], 2.66 [1.98–3.77] vs. 3.71 [2.48–4.17], p=0.025) despite similar gestational age at delivery (median [range], 35.5 [33.1–36.5] vs. 36.0 [34.2–36.6], p=0.511). However, there were no significant differences in perinatal outcomes, including the rate of neonatal hypoglycemia, oxygen treatment and the duration of neonatal intensive care unit admission. @*Conclusion@#Our data show that GDM can be managed by obstetricians even in cases requiring insulin treatment.

Association between gestational age at delivery and lymphocyte-monocyte ratio in the routine second trimester complete blood cell count / 영남의대학술지

Background@#We aimed to determine whether routine second trimester complete blood cell (CBC) count parameters, including neutrophil-lymphocyte ratio (NLR), lymphocyte-monocyte ratio (LMR), and platelet-lymphocyte ratio (PLR), could predict obstetric outcomes. @*Methods@#We included singleton pregnancies for which the 50-g oral glucose tolerance test and CBC were routinely performed between 24 and 28 weeks of gestation in our outpatient clinic from January 2015 to December 2017. The subjects were divided into three groups according to their pregnancy outcomes as follows: group 1, spontaneous preterm births, including preterm labor and preterm premature rupture of membranes; group 2, indicated preterm birth due to maternal, fetal, or placental causes (hypertensive disorder, fetal growth restriction, or placental abruption); and group 3, term deliveries, regardless of the indication of delivery. We compared the CBC parameters using a bivariate correlation test. @*Results@#The study included 356 pregnancies. Twenty-eight subjects were in group 1, 20 in group 2, and 308 in group 3. There were no significant differences between the three groups in neutrophil, monocyte, lymphocyte, and platelet counts. Although there was no significant difference in NLR, LMR, and PLR between the three groups, LMR showed a negative correlation with gestational age at delivery (r=−0.126, p=0.016). @*Conclusion@#We found that a higher LMR in the second trimester was associated with decreased gestational age at delivery. CBC parameters in the second trimester of pregnancy could be used to predict adverse obstetric outcomes.

Coronavirus Disease 2019 and Pregnancy

With the continued fight against coronavirus disease 2019 (COVID-19), new guidelines on its management are emerging; however, information on COVID-19 and pregnancy remains limited. Therefore, this study aimed to review the guidelines of the American College of Obstetricians and Gynecologists, Society for Maternal Fetal Medicine, and Royal College Obstetrics and Gynecology and International Society of Ultrasound in Obstetrics and Gynecology.

Postnatally diagnosed coexisting congenital diaphragmatic hernia with pulmonary sequestration: a report of two cases

While the associations between pulmonary sequestration (PS) and congenital diaphragmatic hernia (CDH) are known, CDH may be obscured by PS and thus, overlooked on prenatal ultrasonography when coexisting with PS. We present 2 cases of postnatally diagnosed CDH combined with PS. In both cases, PS was prenatally diagnosed as an isolated lung mass, while CDH was confirmed only after birth. Both newborns were sufficiently stable that management was not required immediately after birth. PS may function as an “anatomical barrier” to prevent herniation of the abdominal contents into the chest, thus acting as a “protector” providing normal lung maturation throughout pregnancy. If PS is suspected prenatally, coexisting CDH may be obscured; thus, close prenatal care and counseling of the parents regarding the possibility of CDH are essential. These infants should be delivered at a tertiary center, and imaging should be performed to exclude coexisting CDH.

Postnatally diagnosed coexisting congenital diaphragmatic hernia with pulmonary sequestration: a report of two cases

While the associations between pulmonary sequestration (PS) and congenital diaphragmatic hernia (CDH) are known, CDH may be obscured by PS and thus, overlooked on prenatal ultrasonography when coexisting with PS. We present 2 cases of postnatally diagnosed CDH combined with PS. In both cases, PS was prenatally diagnosed as an isolated lung mass, while CDH was confirmed only after birth. Both newborns were sufficiently stable that management was not required immediately after birth. PS may function as an “anatomical barrier” to prevent herniation of the abdominal contents into the chest, thus acting as a “protector” providing normal lung maturation throughout pregnancy. If PS is suspected prenatally, coexisting CDH may be obscured; thus, close prenatal care and counseling of the parents regarding the possibility of CDH are essential. These infants should be delivered at a tertiary center, and imaging should be performed to exclude coexisting CDH.

Comparison of perinatal outcomes in late preterm birth between singleton and twin pregnancies

OBJECTIVE: To determine whether late preterm twin neonates have a more favorable perinatal outcome than singleton late preterm neonates. METHODS: We studied 401 late preterm births between 34+0 and 36+6 weeks of gestation, from January 2011 to December 2014 in our institution. We compared the maternal and neonatal characteristics and perinatal outcomes between singleton and twin pregnancies. Perinatal outcomes included Apgar score, admission to the neonatal intensive care unit (NICU) or special care nursery, duration of NICU stay, and the rate of composite morbidity (antibiotic use, hypoglycemia, hypocalcemia, hyperbilirubinemia requiring phototherapy, respiratory support, and respiratory distress syndrome). RESULTS: A total of 289 neonates were in the singleton group and 112 in the twin group. The twin group showed smaller mean birth weight despite of longer gestational age at delivery. In addition, there were significant differences in the indication of delivery and cesarean section rate between the 2 groups. Overall, the risk of composite morbidity was similar between 2 groups (odds ratio, 1.4; 95% confidence interval, 0.8 to 2.4). CONCLUSION: Our findings suggest that late preterm twins do not show a more favorable outcome than singleton late preterm births.

Incarceration of a pedunculated uterine fibroid in an umbilical hernia

Uterine fibroids are common benign tumors that may cause an umbilical hernia in patients with increased intra-abdominal pressure due to pregnancy, obesity, ascites, and intra-abdominal tumors. However, the simultaneous occurrence of uterine fibroids and umbilical hernias, or fibroids and an associated umbilical hernia, during pregnancy has rarely been reported. Here, we present the case of a fibroid presenting as an incarcerated umbilical hernia in a menopausal patient.

How high is too high in cutoff levels from 50-g glucose challenge test

OBJECTIVE: To determine the highest 50-g glucose challenge test (GCT) value that indicates no further diagnostic test is needed to confirm a diagnosis of gestational diabetes mellitus (GDM) under the criteria of National Diabetes Data Group (NDDG) or the Carpenter and Coustan (C&C) and fasting glucose thresholds from the International Association of Diabetes and Pregnancy Study Group (IADPSG). METHODS: We collected the 50-g GCT results from 16,560 pregnancies and identified 2,457 gravidas with positive 50-g GCT (≥130 mg/dL) values who underwent the 100-g glucose tolerance test. We investigated GDM prevalence in pregnancies with positive 50-g GCT according to the respective diagnostic thresholds and determined the 50-g GCT cutoff values with 100% positive predictive value for GDM under each diagnostic threshold. RESULTS: Twelve point five percent (306/2,457), 20.0% (492/2,457), and 9.6% (235/2,457) met the diagnostic criteria of GDM with the application of NDDG, C&C criteria, and fasting glucose thresholds from IADPSG (≥92 mg/dL), respectively. We also found that the prevalence of GDM increased with increasing 50-g GCT values using each diagnostic criterion. Importantly, we identified that all subjects with a 50-g GCT value ≥223, ≥217, or ≥228 mg/dL can be exclusively diagnosed as having gestational diabetes according to the criteria of NDDG, C&C, and fasting glucose thresholds from IADPSG, respectively. CONCLUSION: We propose that women with a 50-g GCT screening value ≥228 mg/dL can be reliably omitted from further confirmative tests for GDM, such as 100- or 75-g glucose tolerance test.

Heterotopic pregnancy after a single embryo transfer

Heterotopic pregnancy is a rare and life-threatening condition which is defined as coexistent intrauterine and ectopic gestation. The risk of ectopic and heterotopic pregnancy is increasing due to the increased risk of multiple pregnancies with the aid of assisted reproductive technologies. However, it hardly happens in the setting of single embryo transfer, since single embryo transfer significantly reduces the incidence of multiple pregnancies. Surprisingly, we experienced a case of heterotopic pregnancy after a single embryo transfer caused by coincidental natural pregnancy during assisted reproductive technologies. An infertile woman who underwent, during her natural cycle, transfer of a single embryo that had been cryopreserved for 3 years was found to be heterotopically pregnant. After an early and successful management with laparoscopic right salpingectomy, she finally reached at full-term vaginal delivery.

Post-cerclage ultrasonographic cervical length can predict preterm delivery in elective cervical cerclage patients

OBJECTIVE: To evaluate the usefulness of transvaginal ultrasound measurements of cervical length before and after elective prophylactic cervical cerclage in predicting preterm delivery before 32 weeks of gestation. METHODS: Women who underwent an elective cerclage operation at 14 to 19 weeks of gestation and who delivered between January 2004 and December 2009 were enrolled in this study (n=52). Ultrasonography was performed to measure cervical length before and after cerclage. The primary outcome was defined as preterm delivery before 32 weeks of gestation. A receiver operating characteristic curve was used to determine the most discriminating cut-off values of ultrasonographic cervical parameters predictive of preterm delivery before 32 weeks of gestation. RESULTS: Among the 52 patients studied, ten delivered before 32 weeks of gestation. Among the ultrasonographic cervical parameters compared, only the cervical length after cerclage was significantly different (shorter) in patients who delivered before 32 weeks of gestation (P=0.037) compared to that of those who delivered after 32 weeks of gestation in univariate and multivariate analyses (odds ratio, 0.402; 95% confidence interval, 0.174 to 0.925; P=0.021). The receiver operating characteristic curve showed that a cervical length of 25 mm or less after cerclage was predictive of preterm delivery before 32 weeks of gestation (area under curve, 0.71; 95% confidence interval, 0.56 to 0.87; P=0.029) with a sensitivity of 91.0% and a specificity of 30.0%. CONCLUSION: Patients with a cervical length less than 25 mm after elective cerclage may be at higher risk of preterm delivery before 32 weeks of gestation.

Spontaneous Restoration of Unrecognized Uterine Inversion / 대한주산의학회잡지

We report a case of unrecognized uterine inversion was restored spontaneously without surgical intervention. Initially, the case was diagnosed as uterine atony and not uterine inversion and was managed successfully with uterine artery embolization. However, a partial uterine inversion was detected on a subsequent scheduled pelvic examination. Fortunately, her uterus was completely restored without any surgical intervention on eighth week after delivery.

Erratum: Author's name correction

The Editorial Office of Obstet Gynecol Sci would like to correct the author's name. The Editorial Office apologizes for any inconvenience that it may have caused.

Antepartum Use of Antibiotics / 대한주산의학회잡지

Antibiotics are among the most commonly prescribed medicines during pregnancies for various reasons. The antepartum use of antibiotics requires the consideration of maternal physiologic change, its effects to fetuses and drug-resistance. Usually, antibiotics are prescribed to pregnant women complicated with preterm labor, preterm premature ruptures of the membranes, urinary tract infection or sexually transmitted diseases. In this article, we reviewed the antepartum use of antibiotics in obstetrical management.

Comparison of neonatal outcomes and intrapartum events in full term vaginal deliveries conducted by staff versus resident physicians

OBJECTIVE: The objective of this study was to compare the neonatal outcomes and intrapartum events conducted by staff versus resident physicians in full term vaginal deliveries. METHODS: We divided study population (n = 5,007) into two groups: staff versus resident physicians. These two groups were sub-divided; faculty versus fellow and senior versus junior resident, respectively. The maternal characteristics, neonatal outcomes including Apgar score, admission to the neonatal intensive care unit and umbilical arterial pH and intrapartum event which was defined as the occurrence of shoulder dystocia and vacuum delivery were also investigated. RESULTS: There was no difference in neonatal outcomes between two groups. The group delivered by staff had a higher rate of nulliparity, large for gestational age and intrapartum events than the resident physician group. The subgroup analysis revealed a higher rate of vacuum delivery in the group delivered by faculty and senior members than the group delivered by fellows and junior members. CONCLUSION: There was no significant difference in neonatal outcomes between the two groups; staff versus resident physicians in full term vaginal deliveries in low-risk pregnant women. Also, experienced obstetricians might tend to participate in difficult labors and would prefer applying vacuum compared to the obstetricians with fewer experiences.

Cushing syndrome in pregnancy secondary to adrenal adenoma

We report a case of Cushing syndrome secondary to adrenal adenoma presenting with hypertension and oligohydramnios during pregnancy. The tumor was confirmed by magnetic resonance imaging at 28 week 3 day weeks of pregnancy and was removed surgically at 29 week 1 day weeks of gestation. After surgery, hypertension subsided and amniotic fluid volume returned to normal range. The gravid woman subsequently delivered a healthy infant at term.

Interpregnancy interval after a previous preterm birth and subsequent preterm birth risk / 대한산부인과학회지

OBJECTIVE: To investigate the recurrent preterm birth (PTB) risk in women with a history of previous PTB, and whether the interpregnancy interval or the indication for previous PTB is associated with the recurrent PTB risk. METHODS: A retrospective analysis was conducted on a group of 325 women whose first delivery ended at preterm and subsequently delivered their second birth. Data regarding delivery dates, gestational age at delivery and indication for PTB in the first and second pregnancies, respectively, were collected from medical records. Interpregnancy interval was defined as the period of time between the first PTB and subsequent conception. The patients were divided into six groups based on the interpregnancy intervals (48 months). RESULTS: The recurrent PTB rate in the study population was 24.3%, which was significantly higher than PTB rate in the control groups (primipara, 15.5%, P<0.001; multipara who delivered at term in their first pregnancy, 11.8%, P<0.001). The recurrent PTB rate was lowest in the 6-12 months interpregnancy interval group, and highest in the 36-48 months group. However, the rate of recurrent PTB was not significantly different among the six different interpregnancy interval groups (chi square test, P=0.394, linear-by-linear association test, P=0.343). In addition, there was no association between the indication for previous PTB and the recurrent PTB rate. CONCLUSION: Although the risk of PTB was increased in women with a history of PTB, the risk was not influenced by the interpregnancy interval or the indication for previous PTB.

Microarray versus magnetic resonance imaging prediction of lymph node metastasis in patients with cervical squamous cell carcinoma / 부인종양

OBJECTIVE: We investigated whether microarray-based gene expression profiling of primary tumor biopsy material could be used to predict lymph node (LN) metastasis in patients with uterine squamous cell carcinoma by comparing this approach with magnetic resonance imaging. METHODS: Forty three primary cervical cancer samples (16 with LN metastasis and 27 without LN metastasis) from radical hysterectomy with pelvic LN dissection were obtained, RNA was isolated, and oligonucleotide gene chips (Macrogen, Seoul, Korea) were hybridized. The samples were randomly divided into training (31 samples) and test (12 samples) sets. A prediction model for LN metastasis from the training set was developed by support vector machine methods using a 10-fold cross-validation and it was tested for its prediction accuracy by applying it to the test set. We evaluated pelvic LN status by MRI with newly designed criteria in these patients and compared the accuracy of MRI with microarray. In addition, we created a new approach by a combination of both. RESULTS: The "LN prediction model" derived from the signature of 156 distinctive genes had a prediction accuracy of 83% when applied to the independent test set. MRI showed an accuracy (69%) for the prediction of LN metastasis. The combination model with MRI findings and microarray improved prediction accuracy over MRI alone but the improvement was not statistically significant (74% and 69%, respectively; p=0.688). CONCLUSION: Current data show that the prediction of LN metastasis can be allowed by DNA microarray of the primary tumor biopsy, alone or in combination with MRI.