Flexible treatment of gestational diabetes modulated on ultrasound evaluation of intrauterine growth: a controlled randomized clinical trial.

OBJECTIVES: In order to prevent abnormalities of fetal growth still characterizing pregnancies complicated by Gestational Diabetes (GDM), in the present study we evaluated a therapeutic strategy for GDM based on ultrasound (US) measurement of fetal insulin-sensitive tissues. METHODS: All GDM women diagnosed before 28th week immediately started diet and self-monitoring of blood glucose; after 2 weeks they were randomized to conventional (C) or modified (M) management. In C the glycemic target (GT) was fixed at 90 fasting/120 post-prandial mg/dl; in M GT varied, according to US measurement of the Abdominal Circumference (AC) centile performed every 2 weeks: 80/100 if AC > or =75th, 100/140 if AC<75th. Therapy was tailored to mean fasting (FG) and postprandial glycemia (PPG). RESULTS: Globally, 229 women completed the study, 78 in C, 151 in M. Use of insulin was 16.7% in C, 30.4% in M (total groups), significantly more frequent in M than in C (59.7% vs 15.4%) when considering only women with AC > or =75th c. Mean metabolic data were similar in the 2 groups, but in M a tightly-optimized subgroup, resulting from the lowering of GT due to AC > or =75th, coexisted with a less-controlled one, whose higher GT was justified by AC<75th. Pregnancy outcome was better in M, with lower (p<0.05*) rate of LGA* (7.9% vs 17.9%), SGA (6.0% vs 9.0%) and Macrosomia* (3.3% vs 11.5%). CONCLUSIONS: Our data show the value of a flexible US-based approach to the treatment of GDM. This model does not necessarily involve a generalized aggressive treatment, allowing to concentrate therapeutical efforts on a small subgroup of women showing indirect US evidence of fetal hyperinsulinization. Such a selective approach allowed to obtain a near-normalization of fetal growth, with clear advantages on global pregnancy outcome.

Pregnancy outcome in 100 women with autoimmune diseases and anti-Ro/SSA antibodies: a prospective controlled study.

Anti-Ro/SSA antibodies are associated with neonatal lupus but are also considered a possible cause for unexplained pregnancy loss and adverse pregnancy outcome. In a large multicentres cohort study we have prospectively followed 100 anti-Ro/SSA positive women (53 systemic lupus erythematosus (SLE)) during their 122 pregnancies and 107 anti-Ro/SSA negative women (58 SLE) (140 pregnancies). Anti-Ro/SSA antibodies were tested by immunoblot and counterimunoelectrophoresis. Mean gestational age at delivery (38 vs 37.9 weeks), prevalence of pregnancy loss (9.9 vs 18.6%), preterm birth (21.3 vs 13.9%), cesarean sections (49.2 vs 53.4%), premature rupture of membranes (4.9 vs 8.1%), preeclampsia (6.6 vs 8%), intrauterine growth retardation (0 vs 2.3%)and newborns small for gestational age (11.5 vs 5.8%) were similar in anti-Ro/SSA positive and negative SLE mothers; findings were similar in non-SLE women. Two cases of congenital heart block were observed out of 100 anti-Ro/SSA positive women. In conclusion, anti-Ro/SSA antibodies are responsible for congenital heart block but do not affect other pregnancy outcomes, both in SLE and in non-SLE women. The general outcome of these pregnancies is now very good, ifprospectively followed by multidisciplinary teams with ample experience in this field.

Early neonatal complications after elective preterm delivery in hypertensive pregnancies.

We evaluated the rates of short-term neonatal complications, neonatal brain damage or mortality in a group of 96 singleton pregnancies complicated by hypertension and electively delivered before 36 weeks gestation. The neonatal outcome of these pregnancies was compared with that of a matched control group of 192 uneventful pregnancies delivered because of spontaneous preterm labor or premature rupture of membranes. Although the rates of acidosis, apneoic crises, bradycardia and ventilatory support were higher among cases than controls, the risk of intraventricular hemorrhage, severe brain damage (grade III-IV intraventricular hemorrhage or periventricular leucomalacia) or neonatal mortality were comparable between the two groups. Neonatal complications were more frequent among infants born to mothers with severe hypertension or severe proteinuria. In conclusion, this study has shown that short term neonatal complications after elective preterm delivery in hypertensive pregnancies are increased in comparison with low risk controls. However, these complications, which were well managed in our intensive care nursery, did not affected neonatal mortality or severe brain damage.

Factors associated with abruptio placentae in preterm deliveries.

OBJECTIVE: To evaluate risk factors associated with occurrence of abruptio placentae in preterm deliveries. METHODS: Risk factors were evaluated in 55 consecutive index cases of abruptio placentae and 726 control patients delivered between 24-36 weeks' gestation. RESULTS: In logistic regression analysis abruptio placentae was associated with a low number of antenatal visits, smoking in pregnancy, hypertension, intravenous drug abuse and a history of recent abdominal trauma. Among hypertensive disorders of pregnancy, preeclampsia superimposed on chronic hypertension was associated with the highest risk of premature placental separation. Finally, there was a significant trend relating duration of premature rupture of membranes with abruptio placentae (chi-square for trend = 3.93, p = 0.047). CONCLUSIONS: Several risk factors seem strongly associated with abruptio placentae in preterm deliveries; the presence of these risk factors should dictate intensive surveillance.