Parental Age and the Risk of Gestational Hypertension and Preeclampsia.

OBJECTIVES: To determine the effect of maternal age (MA) and paternal age (PA) on the risk of gestational hypertension, preeclampsia, and eclampsia in women who delivered on the Texas-Mexico border. METHODS: A cohort study using birth certificate data (singleton pregnancies, years 2005-2010) from El Paso County, Texas, was conducted. Six parental age-exposure categories were created with MA 20 to 34 years and PA younger than 35 years serving as the referent. A directed acyclic graph was created. Adjusted risk ratios for the composite outcome of gestational hypertension, preeclampsia, or eclampsia were calculated using Poisson regression. RESULTS: A total of 85,114 records were identified, with a majority of the mothers being of Hispanic ethnicity (89.2%). The incidence of the composite outcome ranged from 2.8% in the MA 20 to 34 years old and PA 35 years and older group to 4.4% in the MA younger than 20 years old and PA 35 years and older group. Compared to the MA 20 to 34 years old and PA younger than 35 years group, women in the MA 35 years and older and PA 35 years and older groups were more likely to experience the outcome (adjusted risk ratio 1.57, 95% confidence interval 1.39-1.77, P < 0.0001). CONCLUSIONS: Couples in which both parents are 35 years old and older should be counseled on the increased risk of gestational hypertension or preeclampsia/eclampsia.

Amount of polyhydramnios attributable to diabetes may be less than previously reported.

AIM: To evaluate the frequency and the quantity of polyhydramnios attributable to diabetes in pregnancy. METHODS: The charts of patients with a four-quadrant amniotic fluid index (AFI) ≥ 20 cm and either a diagnosis of diabetes or a diabetes screening test during the index pregnancy were retrospectively reviewed. AFI was stratified into 5 categories and the frequency of diabetes was evaluated for each group. The frequency of polyhydramnios attributable to diabetes was compared to the frequency of polyhydramnios in the setting of fetal anomalies or no known cause. RESULTS: One thousand five hundred and forty-five patients were included in the study. Eight point five percent (n = 131) had diabetes and no other cause for polyhydramnios. Eleven point two percent (173) had antenatally diagnosed anomalies. For all categories of AFI except the largest (> 40.9 cm) the most common cause of polyhydramnios was idiopathic. In patients with diabetes the AFI was most likely to be between 26 cm and 35.9 cm. CONCLUSION: The rate of polyhydramnios in this study is 8.5%. Patients with diabetes most commonly have mild polyhydramnios between 26 and 35.9 cm of fluid on a four-quadrant AFI.

Retrospective evaluation of continuous rate infusion of regular insulin intravenously for the management of feline diabetic ketoacidosis.

The use and efficacy of continuous rate infusion (CRI) of regular insulin intravenously for the treatment of feline diabetic ketoacidosis was retrospectively evaluated. The study focused on the rate of glucose decline, time to resolution of inappetence, time to long-term injectable insulin, and length of hospital stay. Review of medical records from 2009 to 2011 identified 10 cases that met the inclusion criteria. Six cats were existing diabetics, 3 of whom had recent insulin changes. Five cats had concurrent diseases. The mean time to long-term injectable insulin was 55 hours. The mean length of hospitalization was 3.8 days. Five cats survived to discharge. In 5 patients, an insulin CRI permitted a short hospital stay and transition to long-term injectable insulin. Many cats with diabetic ketosis or diabetic ketoacidosis are prior diabetics with concurrent disease and/or a history of recent insulin changes.

Évaluation rétrospective du taux d'infusion continu d'insuline régulière par intraveineuse pour la gestion de l'acidocétose diabétique féline. L'utilisation et l'efficacité de l'infusion à taux continu (ITC) de l'insuline régulière par intraveineuse pour le traitement de l'acidocétose ont été évaluées rétrospectivement. L'étude a porté sur le taux de diminution du glucose, le temps de résolution de l'inappétence, le délai jusqu'à l'insuline injectable à long terme et la durée du séjour à l'hôpital. L'examen des dossiers médicaux de 2009 à 2011 a identifié 10 cas qui satisfaisaient aux critères d'inclusion. Six chats étaient déjà diabétiques et 3 d'entre eux avaient présenté des changements récents de l'insuline. Cinq chats avaient des maladies concomitantes. Le délai moyen jusqu'à l'insuline injectable à long terme était de 55 heures. La durée moyenne de l'hospitalisation était de 3,8 jours. Cinq chats ont survécu au congé. Chez 5 patients, un ITC d'insuline a permis un court séjour à l'hôpital et une transition à l'insuline injectable à long terme. Plusieurs chats atteints d'acétose diabétique ou d'acidocétose diabétique étaient déjà diabétiques avec une maladie concomitante et/ou une anamnèse de changements récents de l'insuline.(Traduit par Isabelle Vallières).

Is the protocol for induction of labor in singletons applicable to twin gestations?

OBJECTIVE: To evaluate the success of induction of labor in twin gestations using standard protocols for misoprostol and oxytocin designed for singleton gestations. STUDY DESIGN: This retrospective cohort study involved all diamniotic twin gestations that were induced at > or = 32 weeks' gestation with intact membranes. Two singleton pregnancies were matched for each twin pregnancy. Use of intravaginal misoprostol and low-dose intravenous oxytocin was based on ACOG management guidelines. RESULTS: A small proportion (40 of 430 [9.3%]) of twins met the inclusion criteria for an induction of labor. Misoprostol was utilized less frequently with twins than with singletons (55% vs. 78%, p = 0.02) because of the higher preinduction Bishop score. Doses of oxytocin were comparable between the 2 groups. A high rate of vaginal delivery was seen in the twin and singleton groups (85.0% vs. 80.0%, p = 0.62) with similar neonatal outcomes. CONCLUSION: A standard protocol of labor induction for singleton gestations would apply for twins with overall favorable intrapartum outcomes.

Pulmonary embolism and amniotic fluid embolism in pregnancy.

Amniotic fluid embolism and pulmonary embolism are 2 of the most common causes of maternal mortality in the developed world. Symptoms of pulmonary embolism include tachycardia, tachypnea, and shortness of breath, all of which are common complaints in pregnancy. Heightened awareness leads to rapid diagnosis and institution of therapy. Amniotic fluid embolism is associated with maternal collapse. There are currently no proven therapies, although rapid initiation of supportive care may decrease the risk of mortality.

Metformin compared with glyburide in gestational diabetes: a randomized controlled trial.

OBJECTIVE: To compare the efficacy of metformin with glyburide for glycemic control in gestational diabetes. METHODS: Patients with gestational diabetes who did not achieve glycemic control on diet were randomly assigned to metformin (n=75) or glyburide (n=74) as single agents. The primary outcome was glycemic control. Secondary outcomes were drug failure rate and neonatal and obstetric complications. RESULTS: In the patients who achieved adequate glycemic control, the mean fasting and 2-hour postprandial blood glucose levels were not statistically different between the two groups. However, 26 patients in the metformin group (34.7%) and 12 patients in the glyburide group (16.2%) did not achieve adequate glycemic control and required insulin therapy (P=.01). CONCLUSION: In this study, the failure rate of metformin was 2.1 times higher than the failure rate of glyburide when used in the management of gestational diabetes (95% confidence interval 1.2-3.9). CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00965991. LEVEL OF EVIDENCE: I.

A randomized clinical trial comparing vaginal misoprostol versus cervical Foley plus oral misoprostol for cervical ripening and labor induction.

We compared labor induced by vaginal misoprostol versus a supracervical Foley catheter and oral misoprostol. Singleton pregnancies at > or = 24 weeks' gestation were randomized to either an initial 25-microg dose of intravaginal misoprostol, followed by 50-microg intravaginal doses at 3- to 6-hour intervals, or a supracervical Foley balloon and 100 microg of oral misoprostol at 4- to 6-hour intervals. Primary outcome was time from induction to delivery. One hundred twenty-six women were randomized to vaginal misoprostol alone (group I) and 106 women to Foley and oral misoprostol (group II). The groups were similar in age, weight, gestational age, parity, indication for induction of labor, and oxytocin use. Cesarean delivery rates at 37% and cesarean indications were similar ( P = 0.25). The time from induction to delivery in group II (12.9 hours) was significantly shorter than that in group I (17.8 hours, P < 0.001). Uterine tachysystole occurred less often in the vaginal misoprostol group (21% versus 39%, P = 0.015). Compared with vaginal misoprostol, delivery within 24 hours was significantly more likely with a Foley balloon and oral misoprostol. The use of terbutaline and peripartum outcomes were similar in the two groups.

Recurrent risk of adverse pregnancy outcome.

It is an unfortunate fact that all pregnancies do not end with healthy babies and healthy mothers. Families who have experienced an adverse pregnancy outcome require accurate information about the risk of recurrence to plan future childbearing. This article examines the recurrence risk of four complications of pregnancy: gestational diabetes, preterm delivery, stillbirth, and preeclampsia. Combined, these four complications are responsible for approximately 24% of maternal and neonatal morbidity and mortality.

Metformin and insulin in the management of gestational diabetes mellitus: preliminary results of a comparison.

OBJECTIVE: To compare glycemic control and neonatal outcomes in women with gestational diabetes mellitus (GDM) treated with metformin vs. insulin. STUDY DESIGN: Women with GDM not controlled with diet and exercise were randomized to metformin (n = 32) or insulin (n = 31). The levels of glycemic control as well as maternal/neonatal complications were evaluated. RESULTS: The mean (+/- SD) fasting and 2-hour postprandial blood glucose did not differ statistically between the 2 treatment groups. No patient failed metformin and required insulin. The majority (27/32) were easily controlled on the initial dosage (500 mg twice a day). Gestational age at entry and delivery (p = 0.077, 0.412) were similar. The difference in the rate of cesarean delivery was not statistically significant between the 2 groups (p = 0.102). Neonatal statistics were also not different between the metformin and insulin groups: birth weight, Apgar score at 5 minutes, respiratory distress syndrome, hyperbilirubinemia, neonatal hypoglycemia and neonatal intensive care unit admission (p = 0.144-0.373). CONCLUSION: Based on these preliminary data, metformin appears to be an effective alternative to insulin in the treatment of GDM.

Consumptive coagulopathy associated with Gorham syndrome and subsequent Kasabach-Merritt syndrome during pregnancy: a case report.

BACKGROUND: Gorham and Kasabach-Merritt syndrome are rare diagnoses that can complicate pregnancy by increasing the risk of pelvic fracture and consumptive coagulopathy, respectively. CASE: A 23-year-old woman, gravida 2, para 0101, with a prenatal diagnosis of Gorham syndrome from her previous pregnancy was admitted at 32 weeks' gestation with severe back and flank pain. Computed tomographic findings revealed multiple lytic lesions of the pelvis in addition to large hemangiomas. Similar to her first pregnancy, she quickly developed consumptive coagulopathy and required prompt preterm delivery. The postoperative course was complicated by prolonged intensive care and multiple transfusions. CONCLUSION: The consumptive coagulopathy associated with Gorham syndrome and secondary Kasabach-Merritt syndrome can mimic severe preeclampsia, especially when recurrent.

Elective induction of labor.

Induction of labor rates have more than doubled nationwide in the past 15 years. The increase in medically induced inductions was slower than the overall increase, suggesting that inductions for marginal or elective reasons rose more rapidly. Elective inductions seem to account for at least half of all inductions and 10% of all deliveries. Whether the experience of an elective induction is satisfactory to the patient, obstetrician, and intrapartum crew warrants more widespread attention. Cesarean rates are high for nulliparas undergoing an induction with an unfavorable cervix. Prospective studies are limited or nonexistent to recommend induction of labor for elective or marginal indications. Until more prospective work is performed, it will be difficult to evaluate the true impact of the elective induction of labor on population-wide cesarean delivery rates. Strategies for increased obstetrician awareness are proposed through practice guidelines and through clinical research trials.

Consequences of routine delivery at 38 weeks for A-2 gestational diabetes.

OBJECTIVE: To report our intrapartum experience with routine delivery at 38 weeks of gestation of A-2 diabetic pregnancies requiring primarily oral hypoglycemic therapy. METHODS: This retrospective study consisted of 143 consecutive women with gestational diabetes not controlled with diet alone (A-2). Each underwent a routine trial of labor at 38 weeks of gestation. The preinduction condition of the cervix, need for oxytocin, and primary cesarean rates were primary endpoints. For comparison, a control group during that same period consisted of 137 consecutive diet-controlled diabetic (A-1) pregnancies with the same eligibility criteria who underwent expectant management at 38 weeks. RESULTS: The study group was more likely to have an unfavorable cervix (75% versus 45%; p < 0.001) and to require oxytocin (76% versus 56%; p < 0.001). Early onset meconium was less common in the study group (3.5% versus 13.1%; p < 0.01). Primary cesarean rates were low and not different between the study and control groups (12.7% versus 11.7%; p < 0.8). The only stillbirth was in the control group and was associated with a tight double nuchal cord encirclement. Mean birth weights and the frequency of birth weights > 4000 g were not different between groups. Shoulder dystocia, low Apgar scores, and admissions to the special care nursery were infrequent in either group. No respiratory difficulties requiring resuscitation or prolonged nursery care were encountered. CONCLUSION: Routine delivery at 38 weeks in an A-2 diabetic population is not associated with additional intrapartum morbidity or a greater need for cesarean delivery.

Evaluation of the cationic trypsinogen gene for potential mutations in miniature schnauzers with pancreatitis.

The purpose of this study was to evaluate the cationic trypsinogen gene in miniature schnauzers for possible mutations. Genetic mutations have been linked with hereditary pancreatitis in humans. Four miniature schnauzers were selected on the basis of a clinical history of pancreatitis. One healthy miniature schnauzer and 1 healthy mixed breed canine were enrolled as controls. DNA was extracted from these canines using a commercial kit. Primers were designed to amplify the entire canine cationic trypsinogen cDNA sequence. A polymerase chain reaction (PCR) was performed and products were purified and sequenced. All sequences were then compared. The healthy control canine, a healthy miniature schnauzer, and the 4 miniature schnauzers with pancreatitis showed identical sequences of the cationic trypsinogen gene to the published sequence. We conclude that, in contrast to humans with hereditary pancreatitis, mutations of the cationic trypsinogen gene do not play a major role in the genesis of pancreatitis in the miniature schnauzer.

The advantages and disadvantages of endoscopy.

Endoscopy is generally a very safe and effective tool in the diagnosis and therapy of various gastrointestinal (GI) disorders, and must be used in conjunction with other diagnostic modalities. Endoscopy should not be a substitute for a complete work-up. There are many advantages of endoscopy, including minimal morbidity and mortality, and the sensitivity of this modality in the diagnosis of mucosal disorders of the GI tract. However, complications may occur, and there are limitations to endoscopy. This article will provide an overview of when to choose GI endoscopy and when other procedures might provide more information.

Spinal mast cell tumor in a dog.

A 6-year-old, spayed female rottweiler was referred for left forelimb lameness followed by tetraparesis. A mast cell tumor compressing the spinal cord at the level of the sixth cervical to first thoracic (C6-T1) vertebrae was diagnosed based on cervical myelography and necropsy findings. This was considered a primary extracutaneous mast cell tumor, as no evidence of disease was found elsewhere. This is the first report of a primary mast cell tumor in this location.