Delayed interval delivery in the setting of placental abruption: a case report.

BACKGROUND: Attempts at delayed interval deliveries in multifetal gestations have become more common. However, selection criteria are imperative to success, and placental abruption is generally considered a contraindication. CASE: A woman with a diamniotic-dichorionic twin gestation at 23 weeks presented after a motor vehicle accident with placental abruption, hypofibrinogenemia an intrauterine fetal demise of twin A. She was expectantly managed, and the hypofibrinogenemia was nonprogressive. One week later, after delivery of twin A, a delayed interval delivery was attempted with tocolysis and antibiotics. Prolongation of the pregnancy allowed the delivery of a viable neonate. CONCLUSION: Delayed interval delivery can be a reasonable option in the setting of placental abruption if maternal hemodynamic status is closely monitored and the patient is thoroughly counseled.

First trimester adipocytokine concentrations and risk of developing gestational diabetes later in pregnancy.

OBJECTIVE: Adipocytokines are important regulators of insulin resistance. The aim of this study was to compare maternal adipocytokines in early pregnancy among women diagnosed with and without gestational diabetes (GDM) months later. DESIGN: A nested case-control study. PATIENTS: Adiponectin, resistin and interleukin-6 (IL-6) were measured in 59 nulliparous women (30 women with GDM and 29 controls) in plasma obtained in early pregnancy. Patients underwent routine testing for GDM in late pregnancy. MEASUREMENTS: Adiponectin was measured using radioimmunoassay. Resistin and IL-6 were measured by ELISA. Statistical analysis included Student's t-test, logistic regression and Pearson's correlation. RESULTS: Groups were not different by baseline descriptors or obstetric outcomes. Mean gestational age at sampling was 9.3 +/- 2.6 weeks. Adiponectin was lower (P < 0.001) in women who later developed GDM compared to controls (4.3 +/- 0.4 vs. 6.9 +/- 0.6 microg/ml). Adiponectin was negatively associated with the development of GDM (P = 0.002; OR: 0.70, 95% CI: 0.56, 0.88) and the association persisted in multivariable analysis controlling for confounders (P = 0.01; OR: 0.69, 95% CI: 0.52, 0.92). Women with first trimester adiponectin concentrations < 25th% were 10 times more likely to be diagnosed with GDM (OR 10.2; 95% CI 1.3, 78.7). Early adiponectin concentrations negatively correlated with BMI (P = 0.01; r = -0.32) and subsequent 50 g glucose challenge (P = 0.03; r =-0.29). Mean resistin and IL-6 concentrations were not different between the two groups. CONCLUSIONS: Women with GDM have evidence of altered adipocyte function as measured by adiponectin early in pregnancy, months before the clinical diagnosis of GDM is traditionally made.

Uric acid concentrations in early pregnancy among preeclamptic women with gestational hyperuricemia at delivery.

OBJECTIVE: We investigated changes in serum uric acid across pregnancy in women with gestational hyperuricemia at delivery, with and without preeclampsia, compared with normal pregnant and women with preeclampsia without gestational hyperuricemia. STUDY DESIGN: This was a nested case-control study of 116 controls, 27 women with preeclampsia with predelivery hyperuricemia, 37 women with preeclampsia without predelivery hyperuricemia, and 35 women with gestational hypertension with hyperuricemia at delivery but without proteinuria. Serum uric acid and creatinine was measured across pregnancy. RESULTS: Women with predelivery hyperuricemia, with and without preeclampsia, had increased uric acid concentrations across pregnancy compared with controls, after 25 weeks' gestation compared with women with preeclampsia without predelivery hyperuricemia. Adjusting for differences in glomerular filtration by serum creatinine accounted for part but not all of the increase in serum uric acid among women with preeclampsia and predelivery hyperuricemia. CONCLUSIONS: Among women with hyperuricemia at delivery, elevations in uric acid occur early. Multiple mechanisms may contribute to increased uric acid including changes in renal function.

Induction of labor with oxytocin increases cesarean section rate as compared with oxytocin for augmentation of spontaneous labor in nulliparous parturients controlled for lumbar epidural analgesia.

STUDY OBJECTIVES: To study labor outcomes in parturients receiving oxytocin for augmentation or induction of labor, in the presence of labor epidural analgesia. DESIGN: Retrospective study of data from a continuous quality improvement database. SETTING: Tertiary-care hospital with more than 8000 deliveries per annum. MEASUREMENTS AND MAIN RESULTS: Of the 1671 healthy nulliparous women with singleton pregnancies and who requested labor epidural analgesia at our institution, 675 patients received oxytocin during elective induction of labor, whereas 996 patients received oxytocin for augmentation of spontaneous labor. Measured variables were cervical dilatation at time of epidural analgesia request, epidural insertion to 10-cm time, duration of stage 2 of labor, normal spontaneous vaginal delivery rate, cesarean section rate, operative vaginal delivery rate, and baby weight. Women admitted for induction of labor requested epidural analgesia sooner than those who had their labor augmented (p < 0.001). The incidence of cesarean section was higher in the induced group (p = 0.008). CONCLUSION: Patients who have their labor induced request analgesia sooner and are at a higher risk of cesarean section than are patients who go into labor spontaneously. Any study that purports to assess the effects of epidural analgesia in labor should distinguish between induced and augmented/spontaneous labor.

Homocysteine and folic acid are inversely related in black women with preeclampsia.

Black women have an increased risk of preeclampsia compared with white women. Plasma homocysteine is increased in preeclampsia. Homocysteine concentrations are affected by nutritional deficiencies, particularly decreased folic acid and B12, leading to increased homocysteine. Previous studies have reported racial differences in nutritional intake including folic acid. Therefore, we investigated whether there were racial differences in plasma homocysteine, folic acid, and vitamin B12 among women with preeclampsia. We tested for an association between homocysteine and folic acid and B12, and we hypothesized an inverse relationship of homocysteine and folic acid in preeclampsia, more so in black women in whom preeclampsia developed. Black women with preeclampsia (n=26) had elevated homocysteine concentrations (8.7+/-1.4 micromol/L) compared with black women with normal pregnancy (n=52, 7.6+/-0.5 micromol/L), white women with preeclampsia (n=34, 7.5+/-0.6 micromol/L), and white women with normal pregnancy (n=48, 5.5+/-0.3 micromol/L). Folic acid concentrations were lower in black women (14.1+/-0.8 ng/mL) compared with white women (18.5+/-0.9 ng/mL, P<0.01). However, plasma homocysteine was inversely related to folic acid only among black women with preeclampsia (r=-0.23, P=0.01). These racial differences may have implications for the higher rates of preeclampsia in this group and may have long-term implications for future cardiovascular risk. Racial differences in diet, adherence to folic acid supplementation, or interactions of nutritional and maternal factors warrant further study by race and pregnancy status.