The association of isolated mild fetal hydronephrosis with postnatal vesicoureteral reflux.

OBJECTIVE: We evaluated the incidence of vesicoureteral reflux in fetuses with prenatally detected isolated mild fetal hydronephrosis. METHODS: Fetuses with isolated mild fetal hydronephrosis (defined as a fetal renal pelvis anteroposterior diameter of > or = 4 and < 10 mm before 24 weeks' gestational age) were prospectively evaluated with postnatal renal ultrasound and voiding cystourethrography within the first few weeks after delivery. Infants were evaluated regardless of whether or not renal pelvic dilatation was seen on postnatal ultrasound examination. RESULTS: Forty cases of mild fetal hydronephrosis were identified from the 5,432 patients cared for at our institution from February 1996 to December 1998 (overall incidence: 1/136). Cases involving aneuploidy (n = 1) and inadequate follow-up (n = 5) were excluded from the investigation. One fetus with documented mild hydronephrosis early in gestation had spontaneous resolution and did not undergo postnatal evaluation. Of the remaining 33 infants, 32 underwent postnatal renal ultrasound examination and all had voiding cystourethrography. Vesicoureteral reflux was identified in five (15%) of the neonates. Eighty per cent (four out of five) of these infants were male. Resolution of vesicoureteral reflux occurred in 75% (three out of four) of the infants available for follow-up within 2 years of birth. CONCLUSIONS: Isolated mild fetal hydronephrosis is associated with vesicoureteral reflux on postnatal voiding cystourethrography.

Risk factors for deep vein thrombosis and pulmonary embolism during pregnancy or post partum: a population-based, case-control study.

OBJECTIVE: We sought to determine risk factors for deep vein thrombosis and pulmonary embolism during pregnancy or post partum. STUDY DESIGN: We performed a population-based case-control study. All Olmsted County, Minnesota, residents with a first lifetime deep vein thrombosis or pulmonary embolism during pregnancy or post partum from 1966 to 1990 were identified (N = 90). Where possible, a resident without deep vein thrombosis or pulmonary embolism was matched to each patient by date of the first live birth after the patient's child. The medical records of all remaining patients and all control subjects were reviewed for >25 baseline characteristics, which were tested as risk factors for deep vein thrombosis or pulmonary embolism. RESULTS: In multivariate analysis smoking (odds ratio, 2.4) and prior superficial vein thrombosis (odds ratio, 9.4) were independent risk factors for deep vein thrombosis or pulmonary thrombosis during pregnancy or post partum. CONCLUSION: Venous thromboembolism prophylaxis may be warranted for pregnant women with prior superficial vein thrombosis. Smoking cessation should be recommended, especially during pregnancy and the postpartum period.

Malignant pleural mesothelioma in pregnancy.

A 37-year-old pregnant woman presented at 18 weeks' gestation with unrelenting chest and shoulder pain, massive pleural effusion, and a large thoracic mass. Biopsy revealed an undifferentiated sarcomatous pleural mesothelioma. Malignant mesothelioma is a rare thoracic malignancy, which has not been described in pregnancy and appears to be minimally affected by the pregnant state.

Universal versus selective gestational diabetes screening: application of 1997 American Diabetes Association recommendations.

OBJECTIVE: We sought to evaluate the impact of the 1997 American Diabetes Association gestational diabetes mellitus screening guidelines applied to a universally screened population. STUDY DESIGN: A retrospective analysis of 18,504 women universally screened for gestational diabetes mellitus at Mayo Clinic, Rochester, between January 1, 1986, and December 31, 1997, was performed. Diabetic screening consisted of plasma glucose determination 1 hour after a 50-g oral glucose challenge. Diagnosis of gestational diabetes mellitus was based on National Diabetes Data Group criteria. RESULTS: Of 564 cases of gestational diabetes mellitus diagnosed during the study period, 17 (3.0%) would have been missed under the 1997 American Diabetes Association selective screening guidelines while exempting only 10% of this predominantly white population from screening. Screening only women >/=25 years old would have detected 90.4% of gestational diabetes mellitus cases, whereas the addition of the remaining 3 screening criteria combined would have detected only an additional 6.6% of cases. CONCLUSIONS: The proportion of patients with gestational diabetes mellitus that would remain undiagnosed under the 1997 American Diabetes Association screening guidelines would be relatively small in our population. However, implementation of these guidelines would decrease the number of screens by only 10% while adding significant complexity to the screening process. Youth appears to be the most significant protective factor for gestational diabetes mellitus in our population.

Sequelae of unrecognized gestational diabetes.

OBJECTIVE: Prior studies have suggested that macrosomia is the only morbid condition associated with gestational diabetes and that this association is the result of confounding by maternal obesity rather than a result of gestational diabetes itself. We sought to determine whether unrecognized gestational diabetes is an independent predictor of macrosomia and other perinatal morbid conditions after controlling for confounding variables. STUDY DESIGN: A retrospective analysis of 472 consecutive cases of gestational diabetes diagnosed between 24 and 30 weeks' gestation was undertaken including 16 prospectively identified but clinically unrecognized cases, 297 cases treated with diet alone, and 76 treated with diet plus insulin. Unrecognized cases were matched to 64 nondiabetic controls for race, age, body mass index, parity, pregnancy weight gain, and gestational age at delivery. RESULTS: In the unrecognized gestational diabetes group versus the nondiabetic control versus gestational diabetes diet groups rates of large for gestational age infants (44% vs 5% vs 9%, p < 0.0005), macrosomia (44% vs 8% vs 15%, p < 0.01), shoulder dystocia (19% vs 3% vs 3%, p < 0.05), and birth trauma (25% vs 0% vs 0.3%, p < 0.001) were all significantly increased. These differences remained significant after controlling for maternal age, race, parity, body mass index, pregnancy weight gain, and gestational age at delivery. CONCLUSIONS: This study suggests that unrecognized gestational diabetes increases risks of large for gestational age infants, macrosomia, shoulder dystocia, and birth trauma independent of maternal obesity and other confounding variables. Clinical recognition and dietary control of gestational diabetes are associated with a reduction in these perinatal morbid conditions.

Positional effects on maternal cardiac output during labor with epidural analgesia.

OBJECTIVE: Our purpose was to test the hypothesis that the supine versus the lateral position is associated with a greater decrement in cardiac output after epidural analgesia in labor. STUDY DESIGN: Twenty-one normal term subjects were randomized to the left lateral or supine position in early labor. Cardiac output measured by the acetylene rebreathing method, stroke volume, heart rate, mean arterial pressure, and systemic vascular resistance were obtained at 5-minute intervals, beginning before a 500 ml intravenous fluid bolus (baseline) and ending 45 minutes after epidural injection. RESULTS: Mean baseline supine versus lateral group differences were significant for 21% lower cardiac output, 21% lower stroke volume, 19% higher mean arterial pressure, 50% higher systemic vascular resistance, and equivalent heart rate. In the supine group fluid bolus resulted in significantly increased cardiac output and stroke volume, decreased mean arterial pressure and systemic vascular resistance, and unchanged heart rate. In the supine group cardiac output and stroke volume decreased significantly after epidural injection. The lateral position group exhibited no hemodynamic alterations after fluid bolus or epidural. CONCLUSIONS: In contrast to the lateral position, the supine position is associated with a significant postepidural decrement in cardiac output, not identified by a change in heart rate. This likely reflects an inability to maintain stable preload volume in the supine position.