Predictive factors of subsequent insulin requirement for glycemic control during pregnancy at diagnosis of gestational diabetes mellitus.

OBJECTIVE: To determine maternal and biological parameters at diagnosis of gestational diabetes mellitus (GDM) as predictors of antenatal insulin therapy (AIT) for glycemic control. METHODS: In this planned secondary analysis of a prospective observational study, we recruited women diagnosed with GDM between July 1, 2014, and October 31, 2015. Maternal and biological parameters were analyzed as predictors of AIT using multivariable logistic regression analyses. Predictive accuracy of a cut-off value for a biological predictor was determined using the area under the receiver operating characteristic curve (AUC) and the Youden index (J). RESULTS: Of 200 women included (mean gestational age 22 ± 6 weeks), 72 (36%) required AIT. No maternal characteristic was associated with AIT. Glycated hemoglobin (HbA1c; adjusted odds ratio [aOR] 3.15, 95% CI 1.03-9.69) and elevated 1-hour oral glucose tolerance test (OGTT; aOR 1.23, 95% CI 1.13-1.46) were predictors of AIT. Analyses suggested inaccurate prediction of AIT, with an optimal cut-off HbA1c value of 5.4% (J=0.14; AUC 0.58, 95% CI 0.48-0.67), and an optimal 1-hour plasma glucose OGTT value of 1.77 mg/dL (J=0.24; AUC 0.62, 95% CI 0.50-0.74). CONCLUSION: HbA1c at diagnosis of GDM and elevated 1-hour OGTT were independent predictors of AIT for glycemic control. Clinicaltrials.gov: NCT02159378.

Predictors of failed intrauterine balloon tamponade for persistent postpartum hemorrhage after vaginal delivery.

OBJECTIVE: To identify the predictors of intrauterine balloon tamponade (IUBT) failure for persistent postpartum hemorrhage (PPH) after vaginal delivery. DESIGN: Retrospective case-series in five maternity units in a perinatal network. SETTING: All women who underwent IUBT for persistent PPH after vaginal delivery from January 2011 to December 2015 in these hospitals. METHODS: All maternity apply the same management policy for PPH. IUBT, using a Bakri balloon, was used as a second line therapy for persistent PPH after failure of bimanual uterine massage and uterotonics to stop bleeding after vaginal delivery. Women who required another second line therapy (embolization or surgical procedures) to stop bleeding after IUBT were defined as cases, and women whom IUBT stopped bleeding were defined as control group. We determined independent predictors for failed IUBT using multiple regression and adjusting for demographics with adjusted odds ratios (aORs) and 95% confidence intervals (95% CI). RESULTS: During the study period, there were 91,880 deliveries in the five hospitals and IUBT was used in 108 women to control bleeding. The success rate was 74.1% (80/108). In 28 women, invasive procedures were required (19 embolization and 9 surgical procedures with 5 peripartum hysterectomies). Women with failed IUBT were more often obese (25.9% vs. 8.1%; p = 0.03), duration of labor was shorter (363.9 min vs. 549.7min; p = 0.04), and major PPH (≥1,500 mL) before IUBT was more frequent (64% vs. 40%; p = 0.04). Obesity was a predictive factor of failed IUBT (aOR 4.40, 95% CI 1.06-18.31). Major PPH before IUBT seemed to be another predictor of failure (aOR 1.001, 95% CI 1.000-1.002), but our result did not reach statistical significativity. CONCLUSION: Intrauterine balloon tamponade is an effective second line therapy for persistent primary PPH after vaginal delivery. Pre-pregnancy obesity is a risk factor of IUBT failure.

Predictive factors for successful cervical ripening using a double-balloon catheter after previous cesarean delivery.

OBJECTIVE: To identify predictors of successful cervical ripening using double-balloon catheter (DBC) for labor induction among women with previous cesarean delivery (PCD) and unfavorable cervix at term. METHODS: The present prospective observational study was conducted among women who underwent cervical ripening with DBC at a French tertiary care hospital between January 1, 2014, and December 31, 2017. Inclusion criteria were PCD; singleton term fetus; cephalic presentation; and unfavorable cervix (Bishop score <6). Indications for DBC were gestational diabetes mellitus, intrahepatic cholestasis of pregnancy, pre-eclampsia, prolonged pregnancy, fetal growth restriction, or prenatal suspicion of macrosomia. The primary outcome was Bishop score of at least six after DBC removal. RESULTS: Among the 105 patients included, the initial Bishop score was 2.5 ± 1.5; successful cervical ripening occurred among 74 (70.5%) women; and vaginal delivery occurred among 46 (43.8%). The mean time from DBC insertion to delivery was 19.3 ± 6.7 hours. No adverse events were observed. Predictors of successful cervical ripening were initial Bishop score of at least three (adjusted odds ratio [aOR] 12.74, 95% confidence interval [CI] 2.78-58.47); PCD during labor (aOR 4.38, 95% CI 1.10-17.45); and internal cervical os open (aOR 4.94, 95% CI 1.44-17.01). CONCLUSION: Several factors were found to predict successful cervical ripening using DBC.

Efficacy of serum procalcitonin to predict spontaneous preterm birth in women with threatened preterm labour: a prospective observational study.

BACKGROUND: A hypothesis of preterm parturition is that the pathogenesis of spontaneous preterm birth (sPTB) may be associated with an inflammatory process. Based on this theory, we have hypothesized that an inflammatory biomarker, procalcitonin (PCT), may be a good predictive marker of sPTB at the admission for threatened preterm labour (TPL). The present study was aimed to investigate the association between serum PCT and sPTB in women with TPL and to evaluate whether PCT levels may predict sPTB in women with TPL within 7 or 14 days. METHODS: In a prospective observational laboratory-based study, women with singleton pregnancies, TPL between 24 and 36 weeks and intact membranes, were enrolled between January 2014 and June 2016. Participants received routine medical management of TPL (tocolysis with atosiban, antenatal corticosteroids, and biological tests at admission (C-reactive protein, white blood cell count, and PCT measured on electrochemiluminescence immunoassay)). The primary endpoint was sPTB before 37 weeks of gestation. The value of serum PCT levels to predict sPTB within 7 or 14 days were evaluated using receiver-operating curves (ROC) analysis. RESULTS: A total of 124 women were included in our study. PCT levels did not statistically differ between women with sPTB (n = 30, 24.2%) and controls (n = 94) (median in ng/mL [interquartile range]: 0.043 [0.02-0.07] compared to 0.042 [0.02-0.13], respectively; P = 0.56). PCT levels did not also statistically differ between women with sPTB within 7 days (n = 7, 5.6%) or 14 days (n = 12, 9.7%) after testing and controls. Moreover, subgroup analysis revealed no difference among PCT levels at admission between 24 and 28 weeks, between 28 and 32 weeks and over 32 weeks, and controls. On the basis of the receiver-operating characteristic curve, the highest sensitivity and specificity corresponded to a PCT concentration of 0.038 ng/mL, with poor predictive values for sPTB within 7 or 14 days. CONCLUSION: Serum PCT was not relevant to predict sPTB within 7 or 14 days in women admitted with TPL between 24 and 36 weeks, and thus it is not a suitable biological marker to confirm the hypothesis of an inflammatory process associated with preterm parturition. TRIAL REGISTRATION: Clinicaltrials.gov ( NCT01977079 ), Registered 24 October 2013.

Efficacy of maternal and biological parameters at the time of diagnosis of gestational diabetes mellitus in predicting neonatal morbidity.

OBJECTIVE: Gestational diabetes mellitus (GDM) is independently associated with an increased risk of maternal-fetal complications. Improved glycemic control allows reducing perinatal morbidity and mortality and, specifically, the risk of macrosomia and shoulder dystocia which are the most common complications associated with GDM. Nonetheless, a need for early antenatal predictor of neonatal morbidity in women suffering from GDM is required. The objective of the study was to evaluate the efficacy of different maternal, biological, and antenatal parameters at the time of diagnosis of GDM or perinatal variables as predictors of neonatal morbidity. STUDY DESIGN: This was a prospective observational study recruited all pregnant women with diagnosis of GDM at first- or second-trimester in a tertiary care hospital from July 2014 to October 2015. Different antenatal parameters (maternal weight, weight gain during pregnancy, history of GDM, history of macrosomia, serum fructosamine, HbA1c) were obtained at the time of diagnosis of GDM. Mode of delivery was also analyzed. Neonatal morbidity was defined by at least one of the following criteria: preterm birth <37 weeks, macrosomia, shoulder dystocia, respiratory distress syndrome, 5-min Apgar score <7, pH < 7.10 and admission to the NICU (neonatal intensive care unit) for 24 h. Univariate and logistic regression analyses were performed to determine independent antenatal predictors of neonatal morbidity. RESULTS: Two hundred pregnant women with diagnosis of GDM were included. The mean gestational age at the time of diagnosis of GDM was 22 ±â€¯6 weeks. Insulin was required in 72/200 (36%) women for glycemic control during pregnancy. Neonatal morbidity occurred in 21% (n = 42). In the univariate analysis, neonatal morbidity was associated with nulliparity (50% compared to 32%, p = 0.03), induction of labor (36% compared to 27%, p = 0.03) and cesarean section (36% compared to 12%, p < 0.01). Multivariable logistic regression analysis found a significant association between nulliparity and neonatal morbidity (adjusted odds ratio [OR] 2.3, 95% confidence interval [CI] 1.1-4.7). Cesarean delivery was also significantly associated with neonatal morbidity (aOR 7.6, 95% CI 2.9-20). CONCLUSION: This suggests that nulliparity was an efficient antenatal predictor of neonatal morbidity at the time of diagnosis of GDM. Cesarean section was also associated with neonatal morbidity in women with GDM.

Iterative epidural blood patch for recurrent spontaneous intracranial hypotension during pregnancy.

A 30-year-old woman at 28 weeks presented with sudden onset of intense headache, epigastric pain, hot flushes, nausea, vomiting, and stiff neck. Cerebral magnetic resonance imaging showed pathognonomic signs of spontaneous intracranial hypotension (SIH). Epidural blood patch was performed 2 times during pregnancy for symptoms relief in spite of medical treatments. No other recurrence was noted until the spontaneous delivery. SIH is a rare entity during pregnancy which may be diagnosed using magnetic resonance imaging. Iterative Epidural blood patch should be proposed to patients with SIH during pregnancy because it allowed faster symptoms improvement and patient relief with complete recovery than medical treatment only.