Obstetrical correlates and perinatal consequences of neonatal hypoglycemia in term infants.

OBJECTIVE: To determine independent perinatal and intrapartum factors associated with neonatal hypoglycemia. METHOD: Of singleton pregnancies delivered at term in 2013; 318 (3.8%) neonates diagnosed with hypoglycemia were compared to 7955 (96.2%) neonate controls with regression analysis. RESULTS: Regression analysis showed that independent prenatal factors were multiparity (odds-ratio [OR] = 1.61), gestational age (OR = 0.68), gestational diabetes (OR = 0.22), macrosomia (OR = 4.87), small for gestational age neonate [SGA] (OR = 6.83) and admission cervical dilation (OR = 0.79). For intrapartum factors, only cesarean section (OR = 1.57) and last cervical dilation (OR = 0.92) were independently significantly associated with neonatal hypoglycemia. For biologically plausible risk factors, independent factors were cesarean section (OR = 4.18), gentamycin/clindamycin in labor (OR = 5.35), gestational age (OR = 0.59) and macrosomia (OR = 5.62). Mothers of babies with neonatal hypoglycemia had more blood loss and longer hospital stays, while neonates with hypoglycemia had worse umbilical cord gases, more neonatal hypoxic conditions, neonatal morbidities and NICU admissions. CONCLUSION: Diabetes was protective of neonatal hypoglycemia, which may be explained by optimum maternal glucose management; nevertheless macrosomia was independently predictive of neonatal hypoglycemia. Cesarean section and decreasing gestational age were the most consistent independent risk factors followed by treatment for chorioamnionitis and SGA. Further studies to evaluate these observations and develop preventive strategies are warranted.

Attitudes and practices of healthcare providers regarding gestational diabetes: results of a survey conducted at the 2010 meeting of the International Association of Diabetes in Pregnancy Study Group (IADPSG).

OBJECTIVE: To investigate the attitudes and practices of healthcare providers regarding gestational diabetes mellitus and to identify differences between provider types and geographical locations. RESEARCH DESIGN AND METHODS: A survey was distributed to participants at the 2010 GDM Pasadena II: International Conference regarding management of gestational diabetes. RESULTS: Of 250 distributed surveys, there was a 60.8% (n = 152) response rate. Most responders believed it was cost beneficial to treat and screen for gestational diabetes. Approximately 2/3 accepted that the diagnosis of Type 2 diabetes could be made in pregnancy. For the diagnosis of gestational diabetes, c. 60% opted for a one-step screen while 30% opted for a two-step screen. Most responders were comfortable treating a non-pregnant woman with Type 2 diabetes. Ninety per cent of responders initiated antenatal testing at 32-34 weeks for medication-treated gestational diabetes, with a wider variation for diet-treated gestational diabetes. Obstetricians were less comfortable than other providers in treating a non-pregnant woman with Type 2 diabetes, but were more likely to prescribe glyburide. Providers in the USA, compared with those from other countries, were more likely to perform a Caesarean section based on fetal weight, use glibenclamide (glyburide), initiate exercise post-delivery and less likely to check 2-h postprandial glucose levels. At least 80% of responders routinely screened for Type 2 diabetes at 6-12 weeks post-delivery. CONCLUSION: There are differences internationally and by provider types in attitudes and management regarding gestational diabetes. These findings may be useful in developing strategies for implementing the recent guidelines by the International Association of the Diabetes and Pregnancy Study Groups.

Demographic, institutional and obstetrical risk factors for postpartum haemorrhage mortality.

This study, initially presented at the SMFM Annual Conference in San Diego on 29 January 2009, sought to explore the risk factors for mortality from postpartum haemorrhage (PPH). A total of 138,316 cases of PPH from 1991 to 2000 were identified using the California Health Discharge Database. Data analysed included demographic information and clinical risk factors. PPH increased from 1.9% to 2.8%, while mortality rate decreased during the study period (1991-2000). Logistic regression showed that hysterectomy, hypertensive disorders, abruption, transverse caesarean delivery, and classical caesarean delivery, increased risk for PPH mortality, while manual placental extraction, episiotomy, and laceration repairs decreased risk. Two geographical regions, Inland Empire and Orange County, were associated with increased PPH mortality, despite having lower incidence of PPH. Teaching status and investor ownership of hospitals increased the risk of PPH mortality. There was no associated change in mortality based on hospital quality rating.

A comparison of the effectiveness of single-dose vs multi-dose antenatal corticosteroids in pre-term neonates.

The purpose of this study was to compare the outcome between exposure to single vs multiple courses of antenatal corticosteroids (AC) in pre-term births. The study involved 704 neonates delivered between 24-32 weeks. Maternal and perinatal outcome were compared between 294 (42%) neonates who received no AC; 257 (36%) who received single AC and 153 (22%) who received multiple AC. Any AC compared with no AC showed decreased composite neonatal morbidity (51% vs 62%, p = 0.004, odds ratio (OR) = 0.6), neonatal death (52% vs 62%, p = 0.004, OR = 0.6) and hyaline membrane disease (45% vs 57%, p = 0.002, OR = 0.6) with increased chorioamnionitis (17% vs 11%, p = 0.037, OR = 1.6) and pulmonary oedema (12% vs 1%, p = 0.0001, OR = 13). Multiple AC compared with single AC was associated with increased positive maternal cultures (44% vs 31%, p < or =0.005, OR = 1.8), small for gestational age infants (35% vs 21%, p = 0.001, OR = 2) and intraventricular haemorrhage (45% vs 34%, p <0.05, OR = 1.6). Multiple corticosteroid courses when compared with single corticosteroid course did not further reduce composite neonatal morbidity but increased the risk of positive maternal cultures and neonatal small for gestational age and intraventricular haemorrhage.

The impact of antenatal cocaine use on maternal characteristics and neonatal outcomes.

OBJECTIVE: To determine the risk factors and evaluate maternal and neonatal outcomes associated with antenatal cocaine use. METHODS: This was a retrospective case-control study of 200 cocaine-exposed maternal-neonatal pairs and 200 controls from 1991 to 2000. RESULTS: Cocaine-using mothers tended to be older, African American, multiparous and incarcerated and they utilized less prenatal care. However, 79% of Hispanics abusing cocaine were primarily English speaking. Cocaine use correlated with syphilis (36 vs. 1%, p = 0.000) and premature rupture of membranes (23 vs. 0%, p = 0.000), fetal demise (5 vs. 0%, p = 0.004), preterm delivery (40 vs. 6%, p = 0.000). Cocaine-exposed infants delivered earlier (36 vs. 39 weeks, p = 0.000), had lower birth weights (2660 vs. 3305 g, p = 0.000), more respiratory distress syndrome (14 vs. 4%, p = 0.001), congenital syphilis (12 vs. 1%, p = 0.000) and longer hospital stays (10 vs. 3 days, p = 0.000); 75% were placed in foster care or adoption and 37.5% had neonatal withdrawal syndrome. There was a stronger positive correlation between neonatal withdrawal and maternal urine toxicology (rho = 0.443, p = 0.000) than with neonatal urine screen (rho = 0.278, p = 0.003). CONCLUSION: Cocaine use in pregnancy is associated with acculturation, lack of prenatal care, and significant social and obstetric complications resulting in increased neonatal morbidity secondary to prematurity, congenital infection and withdrawal syndrome.

The relationship between placental histopathology findings and perinatal outcome in preterm infants.

OBJECTIVE: To determine the correlation between placental histopathology findings and perinatal outcome in preterm infants. METHODS: Placental histopathology in 774 neonates delivered at 24-32 weeks between 1992 and 2000 was classified as follows: 254 (33%) had histological chorioamnionitis, 263 (34%) had coagulation-related lesions, 228 (30%) had vasculopathy. Perinatal outcome was compared between cases positive and negative for each histopathological classification. RESULTS: Histological chorioamnionitis occurred in 46% of cases with premature rupture of membranes and 45% with preterm labor. Positivity versus negativity for histological chorioamnionitis was associated with earlier presentation (191 vs. 205 days, p = 0.0001) and delivery (199 days vs. 209 days, p = 0.0001), increased risk of intraventricular hemorrhage (71% vs. 23%, p = 0.001, odds ratio (OR) 2.2), bronchopulmonary dysplasia (26% vs. 15%, p = 0.0001, OR 2), retinopathy (36% vs. 24%, p = 0.001, OR 1.8), neonatal sepsis (28% vs. 13%, p = 0.0001, OR 2.5) and neonatal death (12% vs. 7%, p = 0.012, OR 2). Vasculopathy versus no vasculopathy was associated with decreased birth weight (1245 g vs. 1341 g, p = 0.011), decreased Apgar score at 5 min (20% vs. 13%, p = 0.011, OR 1.7) and necrotizing enterocolitis (6% vs. 2%, p = 0.001, OR 4). Cases positive for coagulation-related lesions correlated only with necrotizing enterocolitis (5% vs. 2%, p = 0.02, OR 2.6). CONCLUSIONS: The presence of histological chorioamnionitis significantly increases the risk of earlier delivery and neonatal mortality. Vascular and coagulation placental findings increase the risk of necrotizing enterocolitis.

Gastroschisis complicated by midgut atresia, absorption of bowel, and closure of the abdominal wall defect.

We present a case of gastroschisis that was associated with progressive resorption of the extra-abdominal bowel loops and dilation of intra-abdominal bowel loops. After preterm delivery at 32 weeks, a small paraumbilical remnant was present. There was complete atresia of most of the jejunum, ileum, cecum, and the proximal half of the transverse colon. At laparotomy, the jejunum was anastomosed to the transverse colon. The neonate developed short gut syndrome and eventually received a liver and intestinal transplant.

Serial sonographic findings in a fetus with congenital hiatal hernia.

A continuum of prenatal findings in a case of hiatal hernia is described. Second-trimester scans showed absence of fetal stomach and polyhydramnios suggestive of esophageal atresia. Third-trimester scans revealed a dilated tubular structure in the thoracic cavity with intermittent visualization of an intra-abdominal small stomach. A diagnosis of hiatal hernia was entertained. After birth, the diagnosis of a dilated esophagus with the stomach herniated into the thoracic cavity through a very lax esophageal hiatus was confirmed and the baby underwent corrective surgery.

Prenatal sonographic diagnosis of bladder outlet obstruction caused by a ureterocele associated with hydrocolpos and imperforate hymen.

We report a case of prenatal bladder obstruction due to a single system ureterocele associated with hydrocolpos. Ultrasound at 22 weeks demonstrated an enlarged bladder. Serial scans showed progressive ipsilateral obstructive uropathy, contralateral hydronephrosis, and oligohydramnios. Neonatal endoscopic decompression and hymenotomy was performed with residual decreased ipsilateral renal function and dilation. Prenatal bladder obstruction may cause permanent renal damage.

Prenatal diagnosis of fetal anomalies in a regional tertiary center: the role of a maternal fetal medicine unit--a review of 6,877 deliveries.

OBJECTIVE: To determine the accuracy of anomalies detection and to evaluate the role of maternal-fetal medicine (MFM) specialists. METHODS: This was a retrospective study of birth defects. Patients were divided into: 1) if ultrasound was reviewed by MFM specialists; 2) Others, if reviewed by other ultrasonologists. Fisher's exact test or Pearson's chi2 test were used for statistical analysis. RESULTS: Birth defects occurred in 204/6,877 (3%) neonates with 291 distinct birth defects. Prenatal diagnosis was possible in 181 (62%). In 16 (5.5%) late prenatal diagnosis was possible. MFM specialists correctly diagnosed 53/62 (85%) vs. 56/132 (42%) in Others (P < 0.001). Late diagnosis was possible in 12 cases of gastrointestinal anomalies, three of hydrocephaly and one of skeletal dysplasia; five were correctly diagnosed by MFM specialists and two by Others. CONCLUSIONS: Involvement of ultrasonologists with particular expertise in fetal scanning may improve accuracy of prenatal diagnosis. A repeat third trimester ultrasound may be useful in detecting late-evolving anomalies.

Prepregnancy body mass index, weight gain during pregnancy, and perinatal outcome in a rural black population.

Relationships between body mass index (BMI) and weight gain with perinatal outcome and birthweight were examined. BMI was calculated on 582 consecutive pregnant women who delivered at or >37 weeks gestational age. Statistical analysis was done using Chi-square tests, analysis of variance, and multiple logistic regression. Of those studied, 13% were underweight, 39% normal, 13% overweight, and 35% obese. Obesity was associated with increasing age (P < .01), multiparity (P < .01), previous cesarean delivery (P < .01), previous macrosomia (P = .01), previous fetal death (P = .03), hypertensive disorders (P < .01), gestational diabetes (P = .02), cesarean delivery (P = .03), and neonatal intensive care unit admission (NICU) (P = .01). The underweight group had the most low birthweight (LBW) infants and the lowest mean birthweight. Ideal weight gain occurred in 31%, inadequate weight gain in 34%, and excessive weight gain in 35%. Inadequate weight gain had increased asthma (P < .05), and hyperemesis (P = .03). Women with ideal weight gain had less smokers (P < .01), fetal distress (P < .05), cesarean delivery (P = .02), and preeclampsia (P < .001). The mean birthweight was highest in the excessive weight gain (P < .01). With multivariate analysis, previous LBW, BMI, and tobacco use were significant predictors of LBW. Normal BMI and ideal weight gain in pregnancy is associated with decreased perinatal complications and an optimum birthweight.

Clinical and pathologic correlates of stillbirths in a single institution.

BACKGROUND: To evaluate risk factors, placental and pathologic determinants of stillbirths. METHODS: A retrospective analysis of stillbirths > or = 25 weeks was performed. Clinical data was compared to a randomized control group. Statistical analysis included chi square test, student t test, and logistic regression. RESULTS: One hundred and fifteen stillbirths and 193 controls were analyzed. Maternal age, nulliparity, tobacco use, previous induced abortions, anticardiolipid antibodies, elevated maternal serum alpha feto protein, twins, and amniocentesis, were significantly associated with stillbirth. Logistic regression analysis showed only maternal age, tobacco use, small for gestational age (SGA), previous induced abortions, decreasing gestational age as independent significant variables. The stillbirth baby was 6.8 times more likely to be SGA and 11.9 times more likely to be preterm. Primary pathologic diagnoses were placental factors (37%), cord complications (28%), and fetal causes (15%), 17% had maternal risk factors only and 3% had no known risk factors. Diagnosis was suggested by pathology in 40% of cases. CONCLUSIONS: Stillbirth delivery is associated with older, nulliparous patients with prenatal complications resulting in intrauterine growth retardation and prematurity. Perinatal histopathologic examination is important in diagnosis. Utilizing an extensive testing protocol will reduce the diagnosis of unexplained stillbirth.

Adenosine mediates metabolic and cardiovascular responses to hypoxia in fetal sheep.

1. In seven unanaesthetized fetal sheep (> 80% term), isocapnic hypoxia (arterial partial pressure of O2, Pa,O2, approximately 15 mmHg) was induced for 1 h by lowering maternal inspired PO2. Fetal hypoxia was also produced during intra-arterial administration of the adenosine receptor antagonist 8-(p-sulphophenyl)-theophylline (8-SPT). The fetal 8-SPT infusion was begun just prior to hypoxia and was stopped when fetal Pa,O2 was returned to normal. 2. Hypoxia induced a progressive fetal acidosis, a rise in mean arterial pressure, a transient fall in heart rate and a decrease in breathing movements. 8-SPT significantly reduced the metabolic acidosis and abolished the hypertension and bradycardia without altering hypoxic inhibition of fetal breathing. Administration of the vehicle for 8-SPT during hypoxia did not significantly affect the normal fetal metabolic and cardiovascular responses to acute O2 deprivation. 3. It is concluded that adenosine mediates the fetal bradycardia and hypertension produced by hypoxia, indicating that adenosine modulates fetal autonomic responses to acute oxygen deficiency. Secondly, adenosine contributes to fetal metabolic acidaemia, suggesting that adenosine also modulates fetal glycolytic responses to hypoxia.

Adenosine modulates hypoxia-induced atrial natriuretic peptide release in fetal sheep.

The effects of adenosine on atrial natriuretic peptide (ANP) secretion were determined in chronically catheterized fetal sheep (> 0.8 term). Adenosine was infused into the the right jugular vein for 1 h at 8 +/- 0.4 (5 fetuses), 160 +/- 8 (6 fetuses), and 344 +/- 18 micrograms.min-1.kg estimated fetal wt-1. Fetal arterial blood gases and pH were generally unaffected by adenosine, although mean arterial CO2 tension increased transiently by 2-5 Torr and pH fell progressively during the highest rate of infusion. During the intermediate and high infusion rates, fetal hemoglobin concentrations increased by 11-13% and mean fetal heart rate rose by 18% from a control value of approximately 167 beats/min. Mean arterial pressure was not affected during adenosine infusion. Adenosine significantly increased fetal plasma ANP levels, with maximum concentrations 1.80, 2.36, and 2.51 times greater than control means (142-166 pg/ml) for the respective infusion rates of 8, 160, and 344 micrograms.min-1.kg estimated fetal wt-1. In seven fetuses, reducing fetal arterial O2 tension by approximately 9-10 Torr from a control of 23 +/- 1.3 Torr increased plasma ANP concentrations approximately 2.4 times the control mean of 176 pg/min. Adenosine-receptor blockade with 8-(p-sulfophenyl)-theophylline reduced by 50% the maximum hypoxia-induced rise in plasma ANP concentrations. It is concluded that adenosine causes a dose-dependent rise in fetal plasma ANP concentrations and modulates fetal ANP release during hypoxia.

Maternal and fetal cardiorespiratory responses to adenosine in sheep.

OBJECTIVE: We determined the cardiorespiratory effects of maternal adenosine administration on the ewe and fetus. STUDY DESIGN: Adenosine was infused intravenously to five pregnant ewes as graded (25 to 400 micrograms/min per kilogram) and constant (200 micrograms/min per kilogram) infusions and as a single injection (200 micrograms/kg). Heart rate, arterial pressure, and arterial blood gases and pH were monitored in the ewe and fetus; the data were analyzed with two-way analysis of variance with Duncan's test. RESULTS: Graded adenosine infusion produced a dose-dependent rise in maternal heart rate and hemoglobin concentration and a fall in diastolic and mean arterial pressures, effects that were maintained during 1 hour of constant infusion. Single injections transiently lowered diastolic pressure and induced a biphasic change in heart rate consisting of a bradycardia followed by a tachycardia with a return to control values. Adenosine administration to the ewe did not affect maternal arterial blood gases and systolic pressure nor alter fetal heart rate, arterial pressure, or arterial blood gases. CONCLUSION: Although adenosine causes cardiovascular changes in pregnant ewes, the effects are well tolerated and do not significantly affect the cardiorespiratory status of the fetus.

Cigarette smoking during pregnancy: acute effects on uterine flow velocity waveforms.

OBJECTIVE: To determine the acute effects of smoking during pregnancy on selected characteristics of the flow velocity waveform of the uterine artery. METHODS: We studied 19 chronic smokers at a mean (+/- standard error) gestational age of 28 +/- 1 weeks. After informed consent was given, the uterine artery was located using ultrasound imaging with color flow mapping. The characteristic waveform was imaged by pulsed Doppler ultrasonography. Maternal heart rate and blood pressure and the systolic-diastolic ratio (S/D) and resistance index of the uterine artery were measured before (-10 and -1 minutes), during (+5 and +10 minutes), and after (+20 and +30 minutes) smoking two standard cigarettes in succession. RESULTS: Maternal heart rate increased 27%, systolic blood pressure increased 8%, and diastolic blood pressure increased 19% with smoking (P < .001). The uterine artery S/D and resistance index decreased from 2.33 to 2.02 and from 0.55 to 0.49, respectively (P < .001). CONCLUSION: The acute effects of smoking on maternal systemic hemodynamics probably influence the flow velocity waveform of the uterine artery and preclude any definitive interpretation of acute changes in downstream resistance.

Umbilical artery velocimetry in predicting perinatal outcome with intrapartum fetal distress.

The aim of this study was to see whether umbilical artery Doppler velocimetry predicts intrapartum fetal distress evidenced by poor perinatal outcome. Umbilical velocimetry was performed on 102 parturients with a presumptive diagnosis of fetal distress based on fetal heart rate (FHR) patterns. A mean systolic-diastolic ratio (S/D) of 3 or more after 30 weeks' gestation was considered abnormal. Poor perinatal outcome was defined by any of the following: small for gestational age, low Apgar score, acidosis, meconium below the vocal cords, prolonged neonatal hospital stay, neonatal intensive care unit admission, and neonatal morbidity. Eighty-two patients had normal S/Ds and 20 had abnormal ratios. Eighteen neonates (90%) in the abnormal-SD group had at least one adverse outcome, compared with only 13 (15.8%) of those with a normal S/D, a statistically significant difference (P less than .001). Umbilical artery S/D used as a screening tool to detect poor perinatal outcome had a sensitivity of 65-100%, specificity of 83-92%, positive predictive value of 20-81%, negative predictive value of 91-100%, and a kappa index of 0.24-0.63. These findings suggest that umbilical artery Doppler velocimetry may be useful as an adjunct in the assessment of intrapartum FHR patterns suggesting fetal distress.

A beltless tocodynamometer--a preliminary report.

The clinical usefulness of a newly developed beltless external tocodynamometer system was evaluated in a group of 56 patients in active, early, premature, or false labor. The uterine activity records so obtained were compared with those made in the same patients using the tocodynamometer with belt (49 patients) and the intrauterine pressure catheter (seven patients). The records were classified as "usable" if the baseline was above zero and the peak of the recorded contraction was at least 15 mmHg above the baseline. Both systems were studied under similar clinical conditions. Overall, of the 7434 minutes of recordings in 49 patients using the beltless system, 7008 minutes (94%) were usable. In contrast, only 2515 out of 5667 minutes (45%) of recordings made with the belted system were usable (P less than .001). Seven additional patients were monitored simultaneously with the beltless tocodynamometer and the intrauterine pressure catheter systems. Of the 1367 minutes' total monitoring time, the recovery rates of usable data for the beltless and intrauterine pressure catheter systems were 85 and 87%, respectively (P = not significant). These preliminary results indicate that the beltless system is a convenient, simple-to-use external tocodynamometric system that assesses uterine activity more efficiently than the belted system.