Baseline renal function and adverse outcomes in pregnancies complicated by pregestational diabetes.

OBJECTIVE: To examine the relationship between baseline renal function (serum creatinine, urine protein to creatinine ratio) in women with diabetes and adverse pregnancy outcomes. STUDY DESIGN: This was a retrospective cohort study of singleton pregnancies with pregestational diabetes and baseline renal function tests <20 weeks gestational age (wga) from the years 2007 to 2013. Those with baseline creatinine ≥1.2 mg/dL were excluded due to the association of renal disease with adverse outcomes. The primary outcome was the development of preeclampsia with severe features at <34 wga. Secondary outcomes were preeclampsia at any gestational age, preterm birth, indicated preterm birth, small for gestational age, and a neonatal adverse outcomes composite. The relationship between baseline renal function and the primary outcome was assessed with ROC curves. Objective cutoffs were determined by the Liu method. Outcomes were compared using univariable and multivariable analyses. RESULTS: Baseline renal function was assessed in 321 women with pregestational diabetes. With baseline serum creatinine <1.2 mg/dL serum creatinine was not associated with preeclampsia <34 weeks (AUC 0.47, 95% CI = 0.32-0.63). Urine protein to creatinine (UPC) ratio was moderately associated with preeclampsia <34 weeks with area under curve (AUC) 0.56 (0.39-0.74). Baseline creatinine above the Liu cutoff (0.65 mg/dL) was not significantly associated with primary or secondary outcomes (Table 1). UPC above the Liu cutoff (0.21) was significantly associated with severe preeclampsia <34 wga (24% vs 3.7%, aOR = 6.6, 95% CI = 2.1-20.8), with development of preeclampsia at any gestational age (56% vs 23.4%, aOR = 3.3, 95% CI = 1.4-7.9), and preterm birth (80% vs 36.2%, aOR 6.5 95% CI = 2.3-18.1). CONCLUSION: Creatinine was not associated with adverse pregnancy outcomes at thresholds <1.2 mg/dL in women with pregestational diabetes. Those with a baseline UPC ≥ 0.21 have an increased risk of preeclampsia and preterm delivery. Baseline 24 hr urine protein should be obtained in these patients to aid in counseling and future diagnosis of preeclampsia.Key PointsBaseline renal function tests are recommended in patients with pregestational diabetes, but values associated with pregnancy risk are poorly defined.This study evaluated the relationship between baseline renal function tests in patients with pregestational diabetes and adverse pregnancy outcomes.We found urine protein to creatinine ratio ≥0.21 to be associated with the development of severe preeclampsia <34 weeks gestational age as well as preeclampsia at any gestational age.

Influence of Estimated Fetal Weight on Labor Management.

OBJECTIVE: Prior studies suggest knowledge of estimated fetal weight (EFW), particularly by ultrasound (US), increases the risk for cesarean delivery. These same studies suggest that concern for macrosomia potentially alters labor management leading to increased rates of cesarean delivery. We aimed to assess if shortened labor management, as a result of suspected macrosomia (≥4,000 g), leads to an increased rate of cesarean delivery. STUDY DESIGN: This is a secondary analysis of a retrospective cohort study at a single tertiary center in 2015 of women with singleton pregnancies ≥36 weeks with documented EFW by US within 3 weeks or physical exam on admission. Women were excluded if an initial cervical exam was ≥6 cm or no attempt was made to labor. In addition, patients were excluded for the diagnosis of hypertension, diabetes, or prior cesarean delivery, as these comorbidities influence the use of US, labor management, and cesarean delivery independent of fetal weight. Patients were classified as EFW of ≥4,000 and <4,000 g. Secondary analysis examined the impact of US within 3 weeks of admission when compared with physical exam at the time of admission. The primary maternal outcomes were duration of labor and cesarean delivery. Duration of labor was evaluated as total time from 4 cm to delivery (with 4-cm dilation being a surrogate marker for active labor), length of time allowed from 4 cm until the first documented cervical change (or delivery), and time in second stage of labor (complete dilation to delivery). Cesarean delivery for arrest of labor was a secondary outcome. Student's t-test, Mann-Whitney U-test, chi-squared test, and Fisher's exact test were used for univariate data analysis as appropriate. RESULTS: Of 1,506 patients included, 54 (3.5%) had EFW of ≥4,000 g. Women with EFW of ≥4,000 g had a larger body mass index, higher fetal birth weight, were more likely to be undergoing induction of labor, had a more advanced gestational age, and were more likely to have had an US within 3 weeks of delivery. They were more likely to undergo cesarean delivery (29.6 vs. 9.3%, adjusted odds ratio [AOR]: 2.7, 95% confidence interval [CI]: 1.3-5.5) despite not having shortened labor times. When analyzing this population by method of obtaining EFW, those with EFW based on US rather than external palpation were more likely to undergo cesarean delivery (13.1 vs. 7.9%, AOR: 1.5, 95% CI: 1.01-2.12), again without having shortened labor times. CONCLUSION: EFW of ≥4,000 g and use of US to estimate fetal weight do not appear to shorten labor management despite being associated with an increased risk of cesarean delivery.

Outcomes of Medically Indicated Preterm Births Differ by Indication.

OBJECTIVE: We aim to examine whether outcomes of preterm birth (PTB) are further modified by the indication for delivery. STUDY DESIGN: We performed a retrospective cohort study of all singletons delivered at 23 to 34 weeks from 2011 to 2014. Women were classified by their primary indication for delivery: maternal (preeclampsia) or fetal/obstetric (growth restriction, nonreassuring fetal status, and vaginal bleeding). The primary neonatal outcome was a composite of neonatal death, cord pH <7 or base excess < - 12, 5-minute Apgar ≤3, C-reactive protein during resuscitation, culture-proven sepsis, intraventricular hemorrhage, and necrotizing enterocolitis. Secondary outcomes included the individual components of the primary outcome. Groups were compared using Student's t-test and chi-squared tests. Logistic regression was used to adjust for confounding variables. RESULTS: Of 528 women, 395 (74.8%) were delivered for maternal and 133 (25.2%) for fetal/obstetric indications. Compared with those delivered for a maternal indication, those with a fetal/obstetric indication for delivery had an increased risk of the composite neonatal outcome (adjusted odds ratio [AOR]: 1.9, 95% confidence interval [CI]: 1.13-3.21) and acidemia at birth (AOR: 4.2, 95% CI: 1.89-9.55). CONCLUSION: Preterm infants delivered for fetal/obstetric indications have worsened outcomes compared with those delivered for maternal indications. Additional research is needed to further tailor counseling specific to the indication for delivery.

Impact of Intended Mode of Delivery on Outcomes in Preterm Growth-Restricted Fetuses.

BACKGROUND: Scheduled cesarean is frequently performed for fetal growth restriction due to concerns for fetal intolerance of labor. OBJECTIVE: We compared neonatal outcomes in preterm growth-restricted fetuses by intended mode of delivery. STUDY DESIGN: We performed a retrospective cohort study of indicated preterm births with prenatally diagnosed growth restriction from 2011 to 2014 at a single institution. Patients were classified by intended mode of delivery. The primary outcome was a composite of adverse neonatal outcomes, including perinatal death, cord blood acidemia, chest compressions during neonatal resuscitation, seizures, culture-proven sepsis, necrotizing enterocolitis, and grade III-IV intraventricular hemorrhage. Secondary analysis was performed examining the impact of umbilical artery Dopplers. RESULTS: Of 101 fetuses with growth restriction, 75 underwent planned cesarean deliveries. Of those induced, 46.2% delivered vaginally. Delivery by scheduled cesarean was not associated with a decreased risk of the composite outcome (adjusted odds ratio [aOR], 1.61; 95% confidence interval [CI], 0.45-5.78), even when only those with abnormal umbilical artery Dopplers were considered (aOR, 2.8; 95% CI, 0.40-20.2). CONCLUSION: In this cohort, planned cesarean was not associated with a reduction in neonatal morbidity, even when considering only those with abnormal umbilical artery Dopplers. In otherwise appropriate candidates for vaginal delivery, fetal growth restriction should not be considered a contraindication to trial of labor.

Maternal and Neonatal Outcomes in Indicated Preterm Births Based on the Intended Mode of Delivery.

OBJECTIVE: To compare maternal and neonatal outcomes in women who underwent induction of labor or planned cesarean delivery in indicated preterm births before 34 weeks of gestation. METHODS: We conducted a retrospective cohort study of all indicated singleton preterm births (23-34 weeks of gestation) in a tertiary center from 2011 to 2014. The primary maternal outcome was a composite of early postpartum hemorrhage, blood transfusion, operative complications, postpartum complications, and clinical chorioamnionitis. The primary neonatal outcome was a composite of neonatal death, cardiopulmonary resuscitation in the delivery room, grade 3 or 4 intraventricular hemorrhage, necrotizing enterocolitis, culture-proven sepsis, birth trauma, arterial cord gas pH less than 7 or base excess less than -12, and 5-minute Apgar score 3 or less. Outcomes were compared by intended mode of delivery (induction of labor compared with cesarean) and adjusted for confounders. In secondary analyses, maternal and neonatal outcomes based on the intended mode of delivery were stratified by gestational age (23-27 6/7, 28-31 6/7, and 32-33 6/7 weeks of gestation). RESULTS: Of 629 patients with indicated early preterm births during the study period, 331 (53%) underwent induction of labor, of whom 208 (63%) delivered vaginally. Induction of labor was not associated with an increased risk of the primary maternal (16.3% compared with 19.5%, adjusted odds ratio [OR] 0.8, 95% CI 0.5-1.3) or neonatal composite outcome (14.5% compared with 35.9%, adjusted OR 0.7, 95% CI 0.4-1.1). Analyses stratified by gestational age were consistent with the overall analysis. CONCLUSION: Maternal and neonatal outcomes do not differ based on the intended mode of delivery. Induction of labor should be considered when early preterm birth is indicated.

Características y perspectivas de las familias que están en espera de adoptar a un niño con síndrome de Down / No disponible

La adopción de niños con necesidades especiales es una experiencia relativamente nueva. En los 1950s, rara vez se consideró la adopción como una opción si el niño tenía retraso mental. En los ochenta, sin embargo, la tendencia había cambiado en relación con la adopción de niños con necesidades especiales. De acuerdo con el Comité Nacional de Adopción en 1985, el 27,6% de todas las adopciones de niños sin relación familiar en USA fue para niños con necesidades especiales. Y a mediados de los noventa la cifra aumentó al 48,5% para niños con discapacidad. Desde que se publicaron los primeros estudios a finales de los 60 sobre la posibilidad de que la amniocentesis permitía detectar las aberraciones cromosómicas, incluida la trisomía 21, cientos de miles de mujeres han utilizado esta técnica y a muchas se les ha informado que su feto tenía síndrome de Down. Con frecuencia se aconseja a los matrimonios que lo tienen dos opciones: continuar o interrumpir el embarazo. Una tercera es la de continuar el embarazo y dar el niño para adopción después del nacimiento. Hasta hace poco, no se hablaba tradicionalmente de la adopción porque muchos profesionales no eran conscientes de que existían familias que deseaban adoptar niños con necesidades especiales. Aunque existe mayor conocimiento, muchos ginecólogos no están todavía familiarizados con esta posibilidad. Se dispone de poca información sobre la naturaleza de las familias que están interesadas en la adopción de niños con síndrome de Down. Un estudio francés de 1988 mostró que el 19% de los bebés con síndrome de Down nacidos en las regiones de París y Marsella entre 1981 y 1990 fueron ofrecidos en adopción por sus padres biológicos pero sólo la mitad fueron finalmente adoptados. En Inglaterra, una agencia informó a finales de los 90 que en menos de una década había puesto en adopción a 35 niños con síndrome de Down. Los investigadores concluyeron que la adopción de estos niños no sólo era una posibilidad realista sino que en general hay un número suficiente de familias para elegir, de modo que se encuentre una casa adecuada para cada niño. Todos los días algunas familias reciben la noticia de que su feto o su bebé recién nacido tienen síndrome de Down. Estas personas se enfrentan a una decisión difícil. Si la información se recibe durante el embarazo, las opciones consisten en continuarlo y tener el niño, continuarlo y poner al niño en adopción o terminar el embarazo. Si el diagnóstico de síndrome de Down se hace en el momento del nacimiento, sólo quedan las dos primeras opciones. En el momento actual existe muy poca información sobre la disponibilidad y naturaleza de las familias y las personas que están en espera para adoptar niños con síndrome de Down. El objetivo de este estudio es identificar las características de estas familias e individuos y las razones que apoyan su decisión. Además este estudio confía en ofrecer a la comunidad médica una mayor conciencia sobre la posibilidad de que se adopten fetos identificados con el síndrome de Down (AU)

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Characteristics and perspectives of families waiting to adopt a child with Down syndrome.

PURPOSE: The study's purpose was to obtain information on the characteristics and perspectives of families interested in adopting children with Down syndrome. METHODS: A questionnaire-based survey was administered to individuals and families on a waiting list to adopt children with Down syndrome. Information on (1) demographic, (2) family structure, (3) Down syndrome exposure, (4) Down syndrome knowledge, (5) reasons for considering adoption, (6) adoption process, and (7) perspective on raising children with Down syndrome was assessed. RESULTS: From 199 mailed surveys, there were 72 respondents (36.2%) of whom six had previously adopted a child with Down syndrome. Forty-eight percent learned of the possibility of adopting children with Down syndrome through the Internet, whereas only one respondent obtained this information from a medical professional. The primary reasons for considering adoption were that prospective adoptive families were equipped with the necessary resources and had previous positive experiences with individuals who have Down syndrome. CONCLUSIONS: Many families are eager to adopt children with Down syndrome. Interest in this option stems from having resources to care for these children and previous positive experiences with individuals with Down syndrome. Information regarding adoption was rarely obtained from health care providers. When counseling pregnant women diagnosed with a Down syndrome fetus, adoption should be discussed so that all options regarding pregnancy management may be explored.