The presence of hepatitis B surface antigen and deoxyribonucleic acid in amniotic fluid and cord blood.

OBJECTIVE: It is uncertain whether neonatal infection with hepatitis B, despite treatment after delivery with immunoglobulin and vaccine, is the result of prior in utero transmission of the virus or treatment failure. Furthermore, the potential risk of hepatitis B transmission from the mother to the fetus at the time a genetic amniocentesis is performed is also a concern. In an attempt to better elucidate these controversies, amniotic fluid and cord blood specimens obtained from pregnant women positive for hepatitis B surface antigen were analyzed for the presence of hepatitis B surface antigen and hepatitis B deoxyribonucleic acid. STUDY DESIGN: This study was a prospective longitudinal analysis that identified hepatitis B surface antigen-positive patients who presented for amniocentesis. Cord blood was obtained from these patients at the time of delivery. Cord blood was also obtained from a group of hepatitis B surface antigen-positive patients for whom no amniocentesis was performed. All samples were analyzed for the presence of hepatitis B surface antigen and hepatitis B deoxyribonucleic acid. RESULTS: A total of 121 hepatitis B surface antigen-positive pregnant women were identified. In the 72 pregnancies in which amniocentesis was not performed, 18% of the cord blood samples were positive for hepatitis B surface antigen and 4% were positive for hepatitis B deoxyribonucleic acid. Of 47 amniocentesis fluid samples, 32% were positive for hepatitis B surface antigen but all were negative for hepatitis B virus deoxyribonucleic acid. Of 30 cord blood samples from patients who underwent an amniocentesis, 27% were positive for hepatitis B surface antigen, but all were negative for hepatitis B virus deoxyribonucleic acid. CONCLUSIONS: This study found that hepatitis B viral deoxyribonucleic acid is rarely present in cord blood and was not identified in amniotic fluid obtained by amniocentesis. This finding suggests that in utero transmission of the virus is rare prior to the onset of labor. These data further confirm the reports in the current literature that the risk of hepatitis B transmission to the fetus during amniocentesis is low. Because hepatitis B surface antigen can exist as an isolated entity devoid of nuclear material, in some cases this protein may be able to traverse the placental and amniotic membrane barrier in a manner similar to other proteins, such as alpha-fetoprotein. Recommendations for genetic amniocentesis in women positive for hepatitis B surface antigen are discussed.

Trisomy 13 in one fetus from a twin gestation after intracytoplasmic sperm injection. A case report.

BACKGROUND: Intracytoplasmic sperm injection (ICSI) is an assisted reproductive technique used in the treatment of severe male factor infertility. Reports of chromosomal aberrations in some fetuses conceived following ICSI have raised concern that the technique may contribute to the development of genetic disease. CASE: Trisomy 13 occurred in one of twin fetuses of a 28-year-old woman who underwent ICSI. This case is unique because it is the first reported one of an autosomal trisomy complicating one fetus from a twin gestation conceived by ICSI. It is also the first case describing an autosomal trisomy following ICSI in a woman under the age of 35. CONCLUSION: Chromosomal abnormalities associated with ICSI may be accounted for by factors other than advanced maternal age. Chromosomal aberrations may be related to the procedure itself. Therefore, patients should be advised of the possibility of aneuploidy in association with ICSI, and genetic amniocentesis should be considered regardless of maternal age.

Intra-amniotic infection in patients with preterm prelabor rupture of membranes. Pathophysiology, detection, and management.

The recent increase in knowledge about infection and preterm delivery has engendered many new questions and should make us rethink our long held beliefs and management strategies. Although this article focused primarily on infection as an important factor in the pathogenesis of PPROM, multiple other causes do exist. The various serologic and amniotic fluid assays that can identify activation of the host immune and inflammatory responses as a consequence of the microbial invasion of the amniotic cavity detailed in the preceding paragraphs are very promising but not yet available for clinical use. These tests identify the fetus in the early stages of an infectious process, before the full clinical manifestations of chorioamnionitis. Should such fetuses be treated with antibiotics in an effort to sterilize the amniotic cavity? Should patients with documented microbial invasion be delivered immediately or is there room for a more conservative management with aggressive antibiotic in utero treatment, altering the natural course of PPROM, avoiding extremely preterm deliveries? Certainly many questions remain unanswered. Continuing the search for information on the relationship between infection and PPROM can only add hope to one day finding an option for prevention, because many and probably most cases of PPROM are apparently caused by infection, and the opportunity for preventing this problem most probably lies here.

Outcomes of extremely low-birth-weight infants between 500 and 750 g.

OBJECTIVE: The purpose of this study was to describe morbidity, mortality, and developmental outcomes among extremely low-birth-weight infants (500-750 g). STUDY DESIGN: This retrospective cohort study included 167 live-born infants born at Long Beach Memorial Medical Center between January 1990 and December 1995. RESULTS: Mortality rates were 86% among infants <600 g and 44% among those > or =600 g, and the rate decreased with increasing gestational age. The absence of chorioamnionitis (P =.01) and the use of antepartum corticosteroids (P <.0001) or neonatal surfactant (P =.0001) were associated with survival. Sixty-four percent of studied infants had respiratory distress syndrome, and 17% had grade III or IV intraventricular hemorrhage. Among the 63 survivors 57% were tested at 30 months of corrected age with the Bayley Scales of Infant Development. Mild or significant delays were seen on the mental development index in 68% of these cases and on the psychomotor development index in 58% of cases. CONCLUSION: Morbidity and mortality rates and the rate of developmental delay among infants with birth weights between 500 and 750 g were significant.

Obstetric emergencies precipitated by malignant brain tumors.

OBJECTIVE: Our goal was to present a case series of pregnancy-associated malignant brain tumors. STUDY DESIGN: A review was conducted from 1978-1998 at 5 hospitals. RESULTS: Ten women were diagnosed with a malignant brain tumor during pregnancy (n = 8) or post partum (n = 2). Patients diagnosed antenatally exhibited severe symptoms, manifest between 27 and 32 weeks' gestation. Six were emergently delivered of their infants because of maternal deterioration, and 2 were delivered electively in the early third trimester after documentation of fetal pulmonary maturity. There were 4 maternal deaths and 1 neonatal death; all of the other infants maintained viability. CONCLUSIONS: Malignant brain tumors rarely occur in pregnancy. In contrast to reports that describe an indolent course, each of the 8 antenatal patients experienced a neurologic crisis. If symptoms are amenable to pharmacologic control, we advocate delivery in the early third trimester after documentation of fetal pulmonary maturity. To minimize temporal lobe or cerebellar herniation in neurologically unstable patients, a consideration should be made for cesarean delivery with the patient under general anesthesia, followed by immediate neurosurgical decompression.

Incidence of intrapartum maternal risk factors for identifying neonates at risk for early-onset group B streptococcal sepsis: A prospective study.

OBJECTIVE: In mid-1996 and early 1997, the Centers for Disease Control and Prevention, The American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics all published guidelines outlining 2 potential strategies for the purpose of preventing neonatal sepsis caused by group B Streptococcus. One of these approaches involves treating pregnant women intrapartum with antibiotics if any of the following risk factors develop: delivery at <37 weeks' gestation, membrane rupture for >/=18 hours' duration, or temperature during labor of >/=38 degrees C. However, to date there have been no population-based studies that have ascertained the percentage of pregnant women eligible to receive intrapartum antibiotic chemoprophylaxis if these risk factors were used. Our objective was to perform a large patient-based study at >1 institution evaluating all deliveries for the presence of maternal risk factors by using the definitions of the current guidelines. STUDY DESIGN: A prospective cohort study was initiated in 1995 at 3 private community hospitals and 1 private referral center. The study population was composed of 5410 consecutively delivered patients from the 4 different hospitals. Every pregnancy was analyzed for gestational age at delivery, duration of membrane rupture, temperature during labor, and use of intrapartum antibiotic chemoprophylaxis. RESULTS: Of the 5410 patients, a total of 455 (8. 4%) were delivered of their neonates before 37 weeks' gestation, 421 (7.8%) had rupture of membranes for at least 18 hours' duration, and 378 (7.0%) had an intrapartum temperature of >/=38 degrees C. Overall, 1071 pregnant women (19.8% of the population studied) had >/=1 of the defined risk factors. CONCLUSIONS: These data suggest that, if the current risk factor strategy is used, 19.8% of the delivering population would potentially be candidates for intrapartum antibiotic chemoprophylaxis.

The capture rate of at-risk term newborns for early-onset group B streptococcal sepsis determined by a risk factor approach.

OBJECTIVE: Currently, the Centers for Disease Control and Prevention, The American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics recommend that health care providers for pregnant women implement 1 of 2 strategies for the potential prevention of early-onset neonatal group B streptococcal sepsis. Both algorithms recommend intrapartum antibiotic chemoprophylaxis for patients delivered of their neonates at <37 weeks' gestation. The basic difference lies in the management of the term pregnancy. One protocol suggests treatment of all patients with term pregnancies with a positive culture for group B Streptococcus obtained at 35 to 37 weeks' gestation. The second approach recommends treatment on the basis of risk factors of membrane rupture of >/=18 hours' duration or intrapartum temperature of >/=38 degrees C. The capture rate of at-risk neonates determined by the risk factor strategy is quoted as being approximately 70%; however, the basis for this percentage was from studies that used slightly different definitions than the current guidelines and never separated the term from the preterm newborn. Our objective was to prospectively collect every case of blood culture-proven early-onset neonatal group B streptococcal sepsis and determine whether risk factors, as currently defined, were present that might have warranted maternal intrapartum antibiotic chemoprophylaxis. STUDY DESIGN: A prospective study was initiated on July 1, 1987, and completed on December 31, 1996. Every patient that was delivered of a neonate in whom early-onset group B streptococcal sepsis developed was analyzed in detail for possible intrapartum risk factors. RESULTS: A total of 49 cases of early-onset group B streptococcal sepsis occurred in 46,959 deliveries. Of these 49 newborns, 9 (18%) were delivered at <37 weeks' gestation. The remaining 40 newborns were delivered at term, and only 12 (30%) were delivered with an intrapartum risk factor of either membrane rupture of >/=18 hours' duration or temperature of >/=38 degrees C or both. CONCLUSIONS: On the basis of the data from this study and the current literature, the risk factor approach with the current guideline recommendations would capture <50% of the term newborns in whom sepsis develops.

The evolution of Linitis plastica as a consequence of advanced gastric carcinoma in pregnancy.

A 40-year-old multigravid woman was examined on multiple occasions during pregnancy because of persistent gastrointestinal symptoms. A metastatic, unresectable gastric carcinoma that had evolved to linitis plastica was diagnosed at 26 weeks' gestation. The patient was delivered of a viable infant at 27 weeks' gestation, and she died of disease 1.5 months after the diagnosis was made.

Relapse of acute lymphoblastic leukemia in pregnancy: survival following chemoirradiation and autologous transfer of interleukin-2-activated stem cells.

Four cases of relapse of acute lymphoblastic leukemia (ALL) in pregnancy have been reported previously. During the past 2 decades, ALL has become curable in a majority of children, many of whom have entered their reproductive years. Thus, additional occurrences of relapsing ALL during pregnancy can be anticipated. We present the fifth case in the English-language medical literature of recurrent ALL in pregnancy. A 20-year-old woman with ALL experienced a relapse during the third trimester of her first pregnancy. Reinduction therapy was started with vincristine and prednisone and the baby was delivered 3 weeks later. Umbilical cord blood was collected and stored. The patient then received intensive chemotherapy with whole body radiotherapy and autologous peripheral blood stem cell rescue. The ALL has been in second remission for 22 months. Our patient is the only current survivor of a relapse of ALL during pregnancy. In addition, the collection of umbilical cord blood from a pregnant woman with leukemia has not been reported previously.

Meconium has no lecithin or sphingomyelin but affects the lecithin/sphingomyelin ratio.

OBJECTIVE: Although a few studies have evaluated the effect of meconium on the lecithin/sphingomyelin ratio for testing of fetal lung maturity, to date these studies have assessed only the lecithin-sphingomyelin ratio of amniotic fluid contaminated with meconium. The purpose of this study was (1) to determine whether meconium by itself has a lecithin/sphingomyelin ratio and, if so, (2) to determine whether the lecithin/sphingomyelin ratio is constant. STUDY DESIGN: A lecithin/sphingomyelin ratio was obtained by standard thin-layer chromatography on the first meconium stool of 20 neonates between 31 weeks and term. A quantitative assay was then performed on a sample from each gestational age (7 samples ranging from 31 weeks to term) to confirm the presence of lecithin and sphingomyelin. RESULTS: The 20 samples had atypical thin-layer chromatographic migratory patterns in the zones for lecithin and sphingomyelin. The presumed lecithin/sphingomyelin ratios ranged from 1.1 to 3.6, with no correlation with gestational age. However, the quantitative assay did not detect the presence of lecithin or sphingomyelin in any of the analyzed samples. CONCLUSIONS: Meconium does not appear to contain lecithin or sphingomyelin but has an unidentified moiety whose migratory pattern, as shown by qualitative standard thin-layer chromatography, is similar to that of lecithin with sphingomyelin. Therefore the presence of meconium in amniotic fluid may falsely raise or lower the lecithin/sphingomyelin ratio and confuse fetal lung maturity interpretations.

Potential consequences of widespread antepartal use of ampicillin.

OBJECTIVE: Recommendations for the use of antenatal antibiotics in obstetrics have increased in the past few years, especially for prophylaxis against group B streptococci, for prolongation of the latency time in patients with preterm premature rupture of the membranes, and as an adjuvant treatment in preterm labor. Our objective was to determine whether the use of antenatal ampicillin affects the incidence of and resistance of early-onset neonatal sepsis with organisms other than group B streptococci. STUDY DESIGN: A prospective cohort study was performed between January 1, 1991, and December 31, 1996. Every case of blood culture-proven neonatal sepsis was prospectively surveyed. The type of bacteria isolated, drug resistance, antenatal antibiotic use and treatment indication, gestational age at delivery, and other antenatal and outcome variables were gathered. Early-onset neonatal sepsis was defined as disease onset within 7 days after birth. RESULTS: A total of 42 cases of early-onset neonatal sepsis among 29,897 neonates delivered were found during the 6-year period. Of these, 15 cases were due to group B streptococci and 27 were the result of non-group B streptococcal organisms (21 gram-negative rods and 6 gram-positive cocci). Among the 27 non-group B streptococcal cases, 15 mothers had received antenatal ampicillin and 13 of the 15 bacterial isolates from these neonates (87%) were resistant to ampicillin, versus only 2 ampicillin-resistant isolates (17%) among the 12 cases in which no antenatal antibiotics were administered (P = .0004). Of the 15 mothers who were treated with ampicillin, 13 received more than 1 dose. In evaluating each year of the study, the overall administration of antibiotics to pregnant women in the antenatal period increased from <10% in 1991 to 16.9% in 1996. The incidence of early-onset neonatal sepsis with group B streptococci decreased during this time, whereas the incidence of early-onset sepsis with non-group B streptococcal organisms, especially Escherichia coli, increased. CONCLUSIONS: The increased administration of antenatal ampicillin to pregnant women may be responsible for the increased incidence of early-onset neonatal sepsis with non-group B streptococcal organisms that are resistant to ampicillin. At this time penicillin G, rather than ampicillin, is therefore recommended for prophylaxis against group B streptococci. In addition, future studies are needed to determine whether alternate approaches, such as immunotherapy or vaginal washing, could be of benefit.

A "bloodless cesarean section" and perinatal transmission of the human immunodeficiency virus.

OBJECTIVE: Perinatal transmission of the human immunodeficiency virus is the main pathway for children to become infected with this virus; however, the relative contribution and timing of this transmission, whether transplacental or by exposure through the birth process, have not yet been elucidated. An obvious question is whether the mode of delivery has an impact on this transmission rate. However, a routine cesarean section will primarily diminish the duration of exposure of maternal bodily fluids to the neonate but does not prevent the baby from being exposed to maternal blood coming from the uterine incision. The purpose of this study was to determine whether the rate of perinatal transmission of human immunodeficiency virus could be significantly lowered by delivering the baby with minimal to no exposure to maternal blood or bodily fluids by the use of a surgical technique termed a "bloodless cesarean section." STUDY DESIGN: We performed a prospective cohort study in a group of pregnant women infected with human immunodeficiency virus and evaluated the rate of transmission of this virus to the neonate on the basis of the mode of delivery. One group of patients was delivered by means of a "bloodless cesarean section," in which the baby was delivered and not exposed to any maternal blood or bodily fluid. The control group gave birth either by vaginal delivery or by routine cesarean section. All of the newborns were followed up for a minimum of 15 months or until negative findings were confirmed. Multiple antenatal, intrapartum, and postdelivery variables were collected and analyzed. RESULTS: A total of 108 patients were included in this study and 14 neonates became infected with human immunodeficiency virus (13%). Three of 53 infants delivered by a bloodless cesarean section (5.7%) became infected compared with 11 of 55 control patients (20.0%). This was significant at P = .02 and represented an absolute difference in percentage between the 2 groups of 14.3%, which corresponds to a 71.5% relative reduction in transmission risk (z = 2.27, P = .012). Since the use of zidovudine greatly influences the perinatal transmission rate of human immunodeficiency virus, the study data were reanalyzed with the exclusion of patients who used antenatal or intrapartum zidovudine. Two of 32 infants in the bloodless cesarean section group (6.3%) were infected compared with 9 of 38 in the control group (23.7%). This was significant at P = .04 and revealed an absolute difference in percentage of 17.4%, which corresponds to a 73.4% relative reduction in transmission risk (z = 2.15, P = .016). There was no difference in the transmission rate between the bloodless cesarean section patients who did not use zidovudine (2/32, 6.3%) and the patients who did use zidovudine from the entire study population (3/38, 7.9%). CONCLUSION: In the absence of zidovudine usage, these data show that 70% to 75% of the perinatal transmission of human immunodeficiency virus to a newborn occurs from exposure to maternal blood and bodily fluids at the time of birth. This information is important for patients unable to take zidovudine or other antiretroviral agents, but more important, it introduces the concept of other treatment options for the future.

Can shoulder dystocia be predicted? Preconceptive and prenatal factors.

OBJECTIVE: To evaluate the predictability of shoulder dystocia using preconceptive and prenatal risk factors. STUDY DESIGN: Data from 1,622 term patients with prenatal care prior to 20 weeks who delivered single, vertex fetuses during a consecutive 12-month period were analyzed. Two groups were chosen. The first group was patients whose fetuses experienced shoulder dystocia during delivery (cases). The second group (controls) consisted of the remaining patients, whose fetuses had not experienced shoulder dystocia. The two groups were compared with regard to demographics and pregnancy characteristics. RESULTS: Factors not significantly different between the two groups included were obesity, multiparity, history of diabetes, short maternal stature, postdatism and advanced maternal age. The incidence of macrosomia was significantly higher (P < .001) in cases (35.4%) than in controls (4.8%). Other factors associated with shoulder dystocia were previous shoulder dystocia, concurrent diabetes, prior delivery of a fetus > 4,000 g and excessive weight gain during pregnancy. Many factors previously associated with shoulder dystocia were found to be nonsignificant in our study. CONCLUSION: Macrosomia appears to be the single important factor associated with shoulder dystocia which, even in the presence of significant risk factors, remains largely unpredictable.

Ultrasonographic detection of ureteral jets in normal pregnancy.

OBJECTIVE: Our purpose was to determine the impact of normal physiologic urodynamic alterations of pregnancy on the detection of ureteral jets into the bladder with use of transabdominal color Doppler ultrasonography. STUDY DESIGN: We conducted a prospective cohort study of 125 healthy asymptomatic gravid women without any history of past or current renal disease, all with singleton pregnancies between 13.4 and 37.7 weeks' gestation. Right and left ureteral jets were recorded over a 5-minute period with use of color Doppler transabdominal ultrasonography and a full bladder. Each kidney was graded by the severity of the hydronephrosis. No hydronephrosis was grade 0, mild hydronephrosis was grade 1, and moderate hydronephrosis was grade 2. There were no cases of severe hydronephrosis. RESULTS: There were 56 grade 0 cases on the right versus 93 grade 0 cases on the left (p < 0.0001), 53 versus 30 grade 1 cases (right vs left, p < 0.003) and 16 versus 2 grade 2 cases (right vs left, p < 0.0009). In the subgroup where both kidneys were grade 0 the mean number of right ureteral jets 5 mm was 14.7 versus 15.1 for the left ureteral jets (p = 0.73). In the grade 1 subgroup mean right versus left ureteral jets was 15.4 versus 16.6 (p = 0.65). For the grade 2 subgroup mean right versus left ureteral jets was 15.5 versus 21.0 (p = 0.32). There were 4 of 125 unilateral absent ureteral jets on the right versus 0 of 125 on the left (p = 0.122). CONCLUSION: Our data demonstrate that ureteral jets can be readily detected during pregnancy independent of the gestational age. In addition, it does not appear that the physiologic urodynamic alterations of pregnancy affect the frequency or symmetry of ureteral jets. Thus identification of ureteral jets can be used in the workup of suspected urolithiasis in pregnant patients.

Septic shock in pregnancy associated with legionella pneumonia: case report.

We report the first case of legionella infection in pregnancy complicated by sepsis and hemodynamic compromise. Legionnaires' disease is rarely found in pregnancy, possibly because subacute infections may often be overlooked and empiric therapy of pneumonia in pregnancy may be curative without definitive etiologic diagnosis.

The risk of periventricular-intraventricular hemorrhage with vacuum extraction of neonates weighing 2000 grams or less.

OBJECTIVE: The objective of this retrospective study was to test the hypothesis that vacuum extraction of neonates with a birth weight < or = 2000 gm is associated with an increased risk of periventricular-intraventricular hemorrhage (PV-IVH). STUDY DESIGN: One hundred sixty-eight neonates weighing < or = 2000 gm were entered into this case control study. Fifty-six neonates delivered by silicone-rubber vacuum comprised the study group. For every infant born by vacuum-assisted delivery, two spontaneously delivered neonates served as controls (n = 112) and were matched for best obstetric gestational age (within 1 week), delivery date within 1 year, and birth weight < or = 2000 gm. Maternal and neonatal medical records were reviewed for demographic variables, antenatal complications, indication for vacuum-assisted delivery, neonatal birth weight, Apgar scores, umbilical cord blood gas values, and neonatal morbidity including the incidence of PV-IVH. All perinatal outcome variables were compared between the vacuum-assisted and spontaneously delivered groups. RESULTS: Both groups were similar with regard to maternal age, parity, antepartum complications, gestational age at delivery, neonatal birth weight, and gender. Both groups were also similar with regard to the incidence of 1-minute Apgar score < 5, small for gestational age, cephalhematoma, birth trauma, respiratory distress syndrome, hyperbilirubinemia, and sepsis. There was a significant increased incidence of 5-minute Apgar scores < 7 in the vacuum-assisted group (p = 0.04). No significant difference was observed in the incidence of PV-IVH grades 1 through 4 (21.4% vacuum group vs 16.1% control group, odds ratio 1.42, 0.58 to 3.45). CONCLUSION: Indicated use of the silicone-rubber vacuum to assist vaginal delivery of neonates weighing < or = 2000 gm does not appear to be associated with an increased risk of PV-IVH or other neonatal complications.

Droperidol and diphenhydramine in the management of hyperemesis gravidarum.

OBJECTIVE: Hyperemesis gravidarum is a common pregnancy complication requiring hospitalization. Continuous droperidol infusion and bolus intravenous diphenhydramine were instituted as treatment. We compared the number and length of hospitalizations for hyperemesis gravidarum, readmissions for this diagnosis, and pregnancy outcome in patients receiving this treatment protocol with a historic group of patients receiving other forms of parenteral therapy for hyperemesis gravidarum. STUDY DESIGN: All patients hospitalized with a diagnosis of hyperemesis gravidarum between January 1992 and January 1994 were offered the droperidol-diphenhydramine protocol. These patients were compared with patients admitted between January 1990 and January 1992 with a diagnosis of hyperemesis gravidarum but who were not treated with droperidol at any time or with diphenhydramine as primary therapy for the control of severe nausea and vomiting. Data regarding the number and length of hospitalizations and readmissions for hyperemesis gravidarum were compared, as were maternal and perinatal outcomes. RESULTS: Patients treated with the droperidol-diphenhydramine protocol had significantly shorter hospitalizations (3.1 +/- 1.9 vs 3.8 +/- 2.4 days, p = 0.028), fewer days per pregnancy hospitalized for hyperemesis (3.5 +/- 2.3 days vs 4.8 +/- 4.3 days, p = 0.018), and fewer readmissions with this diagnosis (15.0% vs 31.5%, p = 0.015). There were no significant differences in maternal or perinatal outcomes. CONCLUSION: Droperidol and diphenhydramine infusion is a beneficial, cost-effective therapy for the treatment of hyperemesis gravidarum.

Preterm delivery from 34 to 37 weeks of gestation: is respiratory distress syndrome a problem?

Our purpose was to evaluate the necessity of using tocolytic agents for preterm labor and the benefit of conservative management for preterm premature rupture of membranes from 34 to 37 weeks' gestation. All patients who had accurate obstetric dates and were delivered between 34 and 37 weeks' gestation with no other medical or obstetric problems were retrospectively evaluated for inclusion in the study. The rates of respiratory distress syndrome and other neonatal outcomes were evaluated. A total of 416 patients met criteria for admission into the study. During the thirty-fourth week of pregnancy the incidence of respiratory distress syndrome was 14.9% (p<0.05). Other neonatal complications were also more frequent in deliveries occurring during the thirty-fourth week of pregnancy than in those occurring in the thirty-fifth or thirty-sixth week. Fetal lung maturity studies should be considered and delivery possibly delayed through the thirty-fourth week of gestation to decrease neonatal morbidity in our population.

Postprandial versus preprandial blood glucose monitoring in women with gestational diabetes mellitus requiring insulin therapy.

BACKGROUND: The fetuses of women with gestational diabetes mellitus are at risk for macrosomia and its attendant complications. The best method of achieving euglycemia in these women and reducing morbidity in their infants is not known. We compared the efficacy of postprandial and preprandial monitoring in achieving glycemic control in women with gestational diabetes. METHODS: We studied 66 women with gestational diabetes mellitus who required insulin therapy at 30 weeks of gestation or earlier. The women were randomly assigned to have their diabetes managed according to the results of preprandial monitoring or postprandial monitoring (one hour after meals) of blood glucose concentrations. Both groups were also monitored with fasting blood glucose measurements. The goal of insulin therapy was a preprandial value of 60 to 105 mg per deciliter (3.3 to 5.9 mmol per liter) or a postprandial value of less than 140 mg per deciliter (7.8 mmol per liter). Obstetrical data and information on neonatal outcomes were collected. RESULTS: The prepregnancy weight, weight gain during pregnancy, gestational age at the diagnosis of diabetes and at delivery, degree of compliance with therapy, and degree of achievement of target blood glucose concentrations were similar in the two groups. The mean (+/- SD) change in the glycosylated hemoglobin value was greater in the group in which postprandial measurements were used (-3.0 +/- 2.2 percent vs. 0.6 +/- 1.6 percent, P < 0.001) and the infants' birth weight was lower (3469 +/- 668 vs. 3848 +/- 434 g, P = 0.01). Similarly, the infants born to the women in the postprandial-monitoring group had a lower rate of neonatal hypoglycemia (3 percent vs. 21 percent, P = 0.05), were less often large for gestational age (12 percent vs. 42 percent, P = 0.01) and were less often delivered by cesarean section because of cephalopelvic disproportion (12 percent vs. 36 percent, P = 0.04) than those in the preprandial-monitoring group. CONCLUSIONS: Adjustment of insulin therapy in women with gestational diabetes according to the results of postprandial, rather than preprandial, blood glucose values improves glycemic control and decreases the risk of neonatal hypoglycemia, macrosomia, and cesarean delivery.