Prepregnancy Weight in Women with Type I Diabetes Mellitus: Effect on Pregnancy Outcomes.

Objective This study aims to evaluate the association between prepregnancy body mass index (BMI) and adverse pregnancy outcomes in women with type 1 diabetes mellitus (DM). Methods This is a secondary analysis of a cohort of 426 pregnancies in women with type 1 DM recruited before 20 weeks gestation. Women were categorized according to prepregnancy BMI: low BMI (< 20 kg/m2), normal BMI (20 to < 25 kg/m2), and high BMI (≥ 25 kg/m2). The outcomes of interest were: spontaneous abortion (delivery < 20 weeks gestation); preeclampsia; emergent delivery for maternal indications (hypertension or placental abruption); and preterm delivery (< 37 weeks gestation). Analyses included proportional hazards and multiple logistic regression models with covariates: age, age at diagnosis of type 1 DM, previous spontaneous abortion, microvascular disease (nephropathy or retinopathy), and glycohemoglobin A1 concentrations. Results Low BMI was associated with preterm delivery. High BMI was associated with emergent delivery for maternal indications. Glycemic control as measured by glycohemoglobin A1 was associated with increased risk of spontaneous abortion, attenuating the association with low prepregnancy weight. Conclusion Prepregnancy BMI is a risk factor to be considered when caring for women with type 1 DM, in particular for preterm delivery (low BMI) and emergent delivery for maternal indications (high BMI).

Pre-eclampsia and gestational diabetes mellitus: does a correlation exist early in pregnancy?

OBJECTIVE: We investigated whether blood pressure profile early in pregnancy was associated with the development of pre-eclampsia in patients with gestational diabetes mellitus (GDM). METHODS: A retrospective longitudinal database study of 1664 GDM subjects was performed. Systolic and diastolic blood pressure measurements were taken bi-weekly during the first and second trimesters. GDM patients who developed pre-eclampsia were compared to GDM patients who did not. Subjects were further stratified by maternal age, parity, race, prepregnancy body mass index (BMI) and weight gain during pregnancy. Logistic regression was performed to identify the net effect of each factor on the development of pre-eclampsia. RESULTS: Overall, 167/1664 (10%) GDM patients developed pre-eclampsia. GDM patients who developed pre-eclampsia were more obese, gained more weight during pregnancy and had more severe GDM in comparison to GDM patients who did not. Although all mean blood pressure measurements were within the normal range, significantly higher systolic and diastolic values were recorded in the GDM patients who developed pre-eclampsia throughout the first and the second trimesters of pregnancy. Logistic regression revealed that higher parity (p = 0.04), maternal age (p = 0.03) and pre-pregnancy BMI (p = 0.03) were all contributing factors to pre-eclampsia. In contrast, weight gain during pregnancy and race were not related. CONCLUSION: In GDM patients, higher blood pressure readings early in pregnancy, even prior to GDM diagnosis, were associated with the subsequent development of pre-eclampsia.

Fetal weight and progression of diabetic retinopathy.

OBJECTIVE: To test the hypothesis that progression of diabetic retinopathy in pregnancy is associated with reduced fetal growth and related neonatal morbidity. METHODS: Women with type 1 diabetes (n = 205) were enrolled before 14 weeks' gestation in a prospective study of diabetes in pregnancy and treated with intensive insulin therapy. They had serial ophthalmologic evaluations before 20 weeks' gestation and in late gestation or postpartum. Subjects were divided into two groups based on whether retinopathy progressed (progression group) or remained unchanged (no progression group). RESULTS: Retinopathy progressed in 59 of 205 women (29%) and was associated with advanced White classification (P =.001): three (5%) were class B, 14 (23%) class C, 24 (41%) class D, and 18 (30%) class F-RF. Reduced fetal growth was associated with progression of retinopathy. Mean birth weight was lower (P =.02), and more infants were small for gestational age (P =.02) and had low birth weights (P =.02) in the progression group. More large-for-gestational-age infants were noted in the no-progression group (P =.04). Birth weight percentile distributions showed a shift of the curve to the left in the progression group (P =.03). There were no differences in gestational age at delivery, macrosomia, preterm delivery, respiratory distress syndrome, neonatal hypoglycemia, or neonatal death. Small for gestational age was associated with chronic hypertension (odds ratio [OR] 6.4; 95% confidence interval [CI] 1.5, 27.9) and retinopathy progression (OR 4.7; 95% CI 1.2, 23.8). CONCLUSION: Development and progression of diabetic retinopathy during pregnancy were associated with reduced fetal growth manifested as increased rate of small-for-gestational-age and low-birth-weight infants.

Is insulin lispro associated with the development or progression of diabetic retinopathy during pregnancy?

OBJECTIVE: This study was designed to determine whether there is an association between the use of insulin lispro during pregnancy and the development or progression of diabetic retinopathy. STUDY DESIGN: This observational cohort study included women with type 1 diabetes mellitus (n = 12) who were enrolled in our diabetes mellitus in pregnancy program and were treated with insulin lispro during pregnancy. We compared these women with a historical cohort (n = 42) who were treated with regular insulin during pregnancy. All patients underwent ophthalmologic examinations before 24 weeks' gestation and post partum, and retinopathy was graded according to a previously defined scale. RESULTS: Whereas none of the patients in the insulin lispro group showed any change in retinopathy status, 6 patients in the regular insulin group (14%) demonstrated changes in retinopathy status. Mild background retinopathy (change from grade 0 to 1) developed in 3 of these patients, and extensive proliferative retinopathy developed in 1 patient after normal results of the baseline examination (change from grade 0 to 6). Two patients had progression of retinopathy--1 had progression from background retinopathy to mild proliferative retinopathy (change from grade 2 to 4) and 1 had progression from mild proliferative retinopathy to extensive proliferative retinopathy (change from grade 4 to 6). CONCLUSIONS: These preliminary findings provide no evidence that insulin lispro treatment during pregnancy is associated with the development or progression of diabetic retinopathy.

A focused preconceptional and early pregnancy program in women with type 1 diabetes reduces perinatal mortality and malformation rates to general population levels.

OBJECTIVE: To evaluate the impact of a focused preconceptional and early pregnancy program specializing in the care of women with Type 1 diabetes on perinatal mortality and congenital malformations. METHODS: This clinical study included women with Type 1 diabetes in an interdisciplinary Diabetes in Pregnancy Program Project Grant (PPG) funded by the NIH (1978-1993); these women were enrolled preconceptionally or during the first trimester (up to 14 weeks) and had pregnancies continuing beyond 20 weeks gestation. Strict glucose control was implemented and adherence assessed. Antepartum fetal surveillance was started at 32 weeks gestation. All live-born infants and stillbirths were examined. A retrospective comparison analysis of the period before PPG I (1973-1978) and after cessation of funding (1993-1999) was performed, specifically evaluating perinatal mortality and congenital malformation rates. Data were analyzed using analysis of variance, chi2, and Fisher's exact test. RESULTS: Three hundred and six women were enrolled in three 5-year periods: PPG I (1978-1983) n = 111, PPG II (1983-1988) n = 103, and PPG III (1988-1993) n = 92. Entry and interval glycohemoglobin A1 concentrations obtained decreased with each consecutive PPG. An emphasis on preconception care began in 1984, with preconception enrollment reaching 23% for PPG II and increasing in PPG III to 37%. As preconception enrollment increased, perinatal mortality rate decreased from 3% for PPG I and 2% for PPG II, to 0% in PPG III, and the congenital malformation rate decreased to a low 2.2% by PPG III. Comparison data collected for the period before PPG 1 (1973-1978) n = 79 revealed a perinatal mortality rate of 7% and a congenital malformation rate of 14%. Also, a postprogram retrospective analysis of the period 1993-1999 (n = 82) revealed an increase in perinatal mortality, with one death compared to none in PPG III, and a congenital malformation rate of 3.65% compared to 2.2% during PPG III. The preconception enrollment for this period decreased (19.5%). CONCLUSIONS: A program emphasizing preconceptional care, strict glycemic control preconceptionally and throughout gestation, and the use of antepartum fetal surveillance was associated with a significant decrease in the rate of perinatal mortality and congenital malformations in infants of women with Type 1 diabetes. However, ongoing improved outcome appears to depend on the availability of funding for a specialized preconception program.

Glycemic control in the diabetic pregnancy: is tighter always better?

Glucose is the principal nutrient that the mother supplies to the fetus through the placenta by way of concentration-dependent mechanisms. In the presence of maternal hypoglycemia, with limited glucose supply, fetal hypoglycemia and hypoinsulinism ensue. This may be viewed as an adaptive mechanism to increase the chances of fetal survival in the face of limited maternal supply, albeit of a growth-restricted fetus. Fetal nutrient deprivation and the resulting hypoinsulinism may have both short- and long-term consequences. Intrauterine growth failure is associated with higher rates of gestational age-specific neonatal mortality and with long-term cognitive deficits. Furthermore, epidemiologic data suggest that diabetes, coronary artery disease, and hypertension are more common among adults who were small for gestational age at birth. Thus, pancreatic failure in adulthood may be either a response to excessive exposure to glucose as a result of maternal hyperglycemia, or as a result of hypoglycemia where nutrient deprivation leads to fetal growth restriction and reduced islet cell proliferation. Because low mean concentrations of maternal glucose in gestational diabetes are associated with an increased risk of fetal growth restriction, overzealous glycemic control during pregnancy may raise concerns regarding the possible effects on the infant. In the mother with Type 1 diabetes, strict glycemic control is often associated with an increased incidence of severe hypoglycemia. Up to 40% of women report at least one episode of severe hypoglycemia during pregnancy, requiring assistance by another person or professional intervention. It is quite possible that in some patients striving to optimize pregnancy outcome by maintaining the best possible glycemic control jeopardizes the well-being of the mother and the fetus. Thus, with respect to tight glycemic control of pregnant women with diabetes, the question arises: How tight is too tight? Is there a threshold below which the trade-off in terms of maternal morbidity as well as fetal growth restriction and its consequences outweighs the benefits of preventing the effects of maternal hyperglycemia?

Sonographic EFW and macrosomia: is there an optimum formula to predict diabetic fetal macrosomia?

OBJECTIVE: To compare the accuracy of 31 published formulas for estimated fetal weight (EFW) in predicting macrosomia (birthweight 4,000 gm or more) in infants of diabetic mothers. METHODS: The study population comprised 165 women with gestational or pregestational diabetes who had sonograms to estimate fetal weight after 36 weeks of gestation and within 2 weeks of delivery. Three measures of accuracy were compared: 1) area under the receiver operating characteristic (ROC) curve relating EFW to macrosomia, 2) systematic error, and 3) absolute error. For each measure, the 31 formulas were rank-ordered from 1 (best) to 31 (worst). For each formula, the three rank scores were summed to give a total score. The formula with the lowest total score was considered the "best" formula. RESULTS: Macrosomia occurred in 49 cases (30%). Areas under the ROC curves ranged from 0.8361-0.8978. Differences in areas were not significantly different between the 31 formulas. The 1986 formula of Ott et al. had the lowest total score. Using this "best" formula, an EFW of 4,000 gm or more had a sensitivity of 45% to predict macrosomia and a positive predictive value of 81%. To achieve 90% sensitivity with this formula would have required diagnosis of macrosomia with an EFW of 3,535 gm or more, but this would have comprised 46% of the population with a 42% false-positive rate. All 31 formulas were better at predicting macrosomia than predictions based on gestational age alone, and 28 were better than predictions based on abdominal circumference alone. CONCLUSIONS: All 31 formulas for EFW had comparably poor accuracy for prediction of macrosomia. Delivery decisions based on EFW will often be in error. Future studies should determine whether specific sonographic measurements, ratios, or differences are better than EFW or birthweight as predictors of birth trauma.

Medical complications of diabetes mellitus in pregnancy.

Many women with diabetes develop complications of their chronic disease that may have a tremendous impact on their quality of life and their ultimate prognosis. Because Type 1 diabetes often begins at a very early age, it is quite common for women in their child-bearing years to be affected by these complications. As described in this article, diabetic complications and pregnancy may significantly affect each other, but it is not always easy to predict the course of either and to counsel these patients accordingly. Nevertheless, it appears that only in rare occasions should women with diabetes be advised against pregnancy, and that in most situations, with careful and knowledgeable management, a favorable outcome of pregnancy can be expected both for the mother and her infant.

The effect of early discharge after vaginal delivery on neonatal readmission rates.

OBJECTIVE: To determine the effect of a structured program for early neonatal discharge from a tertiary medical center on the risk of neonatal readmission. METHODS: An early-discharge program was instituted at our tertiary medical center in July 1993, with the objective of discharging mothers and infants within 24 hours after vaginal birth. The readmission rate of vaginally delivered infants during the early-discharge period (July 1, 1993, through March 31, 1995) was compared with the rate during a conventional-discharge period (January 1, 1992, through June 30, 1993). Analyses were performed to examine two groups within the early-discharge group: those discharged within 24 hours of vaginal delivery; and those discharged within 1 hospital day of vaginal delivery. RESULTS: During the early-discharge period, 1.24% of neonates were readmitted within 10 days of birth, compared with 1.35% during the conventional-discharge period. In the early-discharge period group, infants born vaginally and discharged within 24 hours of birth had a readmission rate of 1.46% compared with 1.14% for those who stayed longer than 24 hours after delivery. Similarly, the readmission rate was no different for infants who were discharged within 1 hospital day. The primary indications for readmission in both periods were infections and jaundice. CONCLUSION: Implementation of a structured program for early neonatal discharge does not have an association with increased risk of neonatal readmission to the hospital.

Deficient counterregulation: a possible risk factor for excessive fetal growth in IDDM pregnancies.

OBJECTIVE: The rate of macrosomia in infants born to women with IDDM remains high despite intensive insulin therapy and good glycemic control. We hypothesized that one of the factors contributing to this high rate of macrosomia is deficient counterregulatory hormonal responses to hypoglycemia. RESEARCH DESIGN AND METHODS: Hypoglycemia was induced in 17 women with IDDM and 10 normal control subjects at 24-28 and at 32-34 weeks' gestation, using the hypoglycemic clamp technique. Plasma glucose concentrations were decreased to 3.3 mmol/l and maintained at this level for 1 h. Blood samples were drawn every 15 min for measurement of counterregulatory hormone concentrations. RESULTS: All 17 women with IDDM had diminished epinephrine responses to hypoglycemia, compared with control subjects. Eight of the women with IDDM (nonresponders) had minimal or no responses (< 165 pmol/l above baseline) and nine women (responders) had a moderate response (244-764 pmol/l). Of the eight nonresponders, seven had large infants (birth weight in the upper quartile), while only three of the nine responders had large infants (P < 0.05). CONCLUSIONS: Severely impaired counterregulatory epinephrine responses to hypoglycemia in pregnant women with IDDM may be a factor contributing to excessive fetal growth. We speculate that in these women, recurrent episodes of hypoglycemia may result in frequent bouts of increased caloric intake, with repeated episodes of transient hyperglycemia leading to fetal hyperinsulinism and excessive fetal growth.

Hyperreactio luteinalis complicating a normal singleton pregnancy.

Hyperreactio luteinalis is a rare, usually self-limited syndrome with bilaterally enlarged ovaries containing multiple theca lutein cysts. It is usually associated with gestational trophoblastic disease and/or pregnancies that have elevated maternal serum hCG levels. Hyperreactio luteinalis with maternal anasarca was diagnosed at 19 weeks in a spontaneously conceived gestation, in a 16-year-old primigravida. A second trimester termination for maternal respiratory decompensation secondary to pleural effusions and ascites was required. There was no evidence of trophoblastic disease on pathological examination of the products of conception. Hyperreactio luteinalis may be diagnosed prenatally by ultrasound, and intervention may be necessary for maternal indications. Following termination of pregnancy, spontaneous resolution and regression of ovarian size may be expected.

Common clinical manifestations of maternal diabetes in newborn infants: implications for the practicing pediatrician.

Even though perinatal mortality of infants of diabetic mothers has decreased remarkably in recent years and now approaches that of the general population, these infants still face a multitude of potential complications and the propensity for increased morbidity, both in utero and postnatally. Many of these complications are clearly related to the metabolic status of the diabetic mother. Increasing awareness among insulin-dependent diabetic patients and health providers of the need for glycemic control and the ever-growing understanding of the peculiarities of diabetic pregnancies eventually should combine to provide the best possible outcome for these infants.

Does pregnancy increase the risk for development and progression of diabetic nephropathy?

OBJECTIVE: This study was designed to determine whether pregnancy and increasing parity in women with insulin-dependent diabetes mellitus (1) increases the risk for diabetic nephropathy and (2) accelerates the progression of diabetic nephropathy. STUDY DESIGN: The study included women with insulin-dependent diabetes mellitus who enrolled in our diabetes-in-pregnancy trial with a pregnancy that continued beyond 20 weeks' gestation and who were delivered between 1978 and December 31, 1991, to allow for a minimum of 3 years' follow-up. Pregnancy and follow-up information was obtained from the medical records and from our computerized database. For patients followed up elsewhere, information was obtained from their current physicians. Life-table analysis was used to determine (1) the risk for nephropathy developing de novo as a function of duration of disease and the association of this risk with parity and (2) the risk of renal failure developing in women with preexisting nephropathy and its association with parity. RESULTS: The study population included 182 pregnant women with insulin-dependent diabetes mellitus: 46 with overt nephropathy (group F) and 136 without nephropathy (group NF). Pregnancy and increasing parity did not increase the overall risk for nephropathy (44% after 27 years of diabetes). In group NF 10% had nephropathy within 10.1 +/- 4.2 years of the pregnancy. Proteinuria appearing during pregnancy and glycemic control during pregnancy were significantly associated with the subsequent development of nephropathy. In group F 26% had end-stage renal disease after a median period of 6 years from the pregnancy. Pregnancy or increasing parity did not increase the risk for renal failure in women with nephropathy. CONCLUSIONS: Our data support the premise that pregnancy in women with insulin-dependent diabetes mellitus does not increase the risk of subsequent nephropathy and does not accelerate progression of renal disease in women with preexisting nephropathy.

Counterregulatory hormonal responses to hypoglycemia during pregnancy.

OBJECTIVE: To evaluate the counterregulatory responses to insulin-induced hypoglycemia in healthy women and in women with insulin-dependent diabetes during pregnancy and in the nonpregnant state. METHODS: Hypoglycemia was induced using the hypoglycemic clamp technique in 17 women with insulin-dependent diabetes and in ten healthy controls, both in the nonpregnant state (study 1), at 24-28 weeks' gestation (study 2), and at 32-34 weeks' gestation (study 3). Plasma glucose concentrations were decreased to 60 mg/dL and maintained at this level for 1 hour. Blood samples were drawn every 15 minutes to measure epinephrine, glucagon, growth hormone, and cortisol concentrations. Statistical analyses compared counterregulatory responses between women with and without diabetes, and between the pregnant and nonpregnant state. RESULTS: Women with diabetes had significantly diminished peak epinephrine responses to hypoglycemia compared with controls (mean +/- standard error of the mean [SEM]): 52 +/- 11 versus 191 +/- 42 pg/mL in study 1, 30 +/- 9 versus 102 +/- 47 pg/mL in study 2, and 38 +/- 10 versus 148 +/- 38 pg/mL in study 3 (P < .05). Their responses during pregnancy were also diminished compared with their own nonpregnant epinephrine responses. Women with diabetes also had no recognizable cortisol or glucagon responses to hypoglycemia, and in healthy controls the glucagon responses were significantly diminished during pregnancy compared with their own nonpregnant responses. In both groups, growth hormone responses (mean +/- SEM) diminished progressively during pregnancy from study 1 (14.6 +/- 2.5 and 12.5 +/- 5.2 ng/mL) to study 2 (4.4 +/- 1.1 and 7.3 +/- 2.7 ng/mL) to study 3 (2.5 +/- 0.9 and 4.4 +/- 2.3 ng/mL) in women with diabetes and in controls, respectively. CONCLUSION: Counterregulatory epinephrine and growth hormone responses to hypoglycemia are diminished in women with insulin-dependent diabetes during pregnancy. This may be due, in part, to an independent effect of pregnancy, contributing to the increased incidence of hypoglycemia in these patients during pregnancy.

Hypoglycemia: the price of intensive insulin therapy for pregnant women with insulin-dependent diabetes mellitus.

OBJECTIVE: To evaluate the risk of hypoglycemia associated with intensive insulin therapy of type I diabetes during pregnancy. METHODS: Eighty-four women with type I diabetes were recruited before 9 weeks' gestation and received intensive insulin therapy throughout pregnancy. Patients monitored glucose concentrations with memory glucometers, and insulin dosages were adjusted weekly accordingly. A detailed history of clinical hypoglycemic events was obtained at each weekly clinic visit. RESULTS: Clinically significant hypoglycemia requiring assistance from another person occurred in 71% of pregnant patients, with a peak incidence between 10-15 weeks. Severe hypoglycemia during the early weeks of embryogenesis was not associated with an increase in embryopathy. Glycemic control was similar in women with or without recurrent hypoglycemia, but glucose fluctuations were significantly greater in hypoglycemic women. CONCLUSION: Severe hypoglycemia is a significant maternal risk associated with intensive insulin therapy of pregnant women with type I diabetes. In women with recurrent episodes of hypoglycemia, the clear benefits of strict glycemic control must be weighed against the hazards of hypoglycemia.

Interaction of angiotensin II and brain natriuretic peptide in the placentas of normal and diabetic women.

OBJECTIVE: To evaluate the effects of angiotensin II and brain natriuretic peptide on the placental vasculature of diabetic women. METHODS: Term placentas from five diabetic women and five nondiabetic controls were collected. Isolated placental cotyledons were perfused dually with fetal perfusion pressure as an index of vascular response. The effect of angiotensin II (10(-10)-10(-5) mol/L bolus injection) was established in the fetal-placental vasculature of all placentas in the absence or presence of brain natriuretic peptide (10(-8) mol/L final concentration). Data were analyzed using repeated measures analysis of variance and paired t test where appropriate. RESULTS: A significant vasoconstrictor response to angiotensin II was achieved in placentas of both diabetic and nondiabetic women (P < .001); however, the angiotensin II-induced increase in perfusion pressure was significantly greater in the diabetic group (P < .01). Significant attenuation of vasoconstrictor response to angiotensin occurred in the presence of brain natriuretic peptide in placentas of both nondiabetic (P < .0025) and diabetic (P < .025) women, but the effect was more prominent in the diabetic group. CONCLUSION: The in vitro placental vasculature of diabetic women is more sensitive to angiotensin II than is the in vitro placental vasculature of nondiabetic women. The attenuation exerted by brain natriuretic peptide on angiotensin II-induced vasoconstriction is more prominent in placentas from diabetic women compared to those from nondiabetic women.

Normalization of blood glucose in insulin-dependent diabetic pregnancies and the risks of hypoglycemia: a therapeutic dilemma.

Intensive insulin therapy delays the onset and progression of microvascular complications in insulin-dependent diabetes mellitus (IDDM). Such therapy, however, is associated with an increased risk of potentially life-threatening hypoglycemia due to the loss of normal counterregulatory hormonal responses to hypoglycemia and to the syndrome of hypoglycemia unawareness. Current standards for glycemic control during pregnancy in IDDM women require intensive insulin therapy to optimize pregnancy outcome. Therefore, obstetricians and gynecologists providing prenatal care for women with IDDM should be aware that intensive insulin therapy predisposes these patients to the significant risks of severe hypoglycemia. It often becomes necessary to individualize the optimal balance between glycemic control during pregnancy and the risks of hypoglycemia.

Nitric oxide metabolites and preterm pregnancy complications.

OBJECTIVE: Intraamniotic infection may play a significant role in preterm labor and premature rupture of membranes. Synthesis of nitric oxide and its metabolites nitrite and nitrate purportedly are increased in infection. This project was designed to evaluate whether plasma or urine nitrate concentrations are increased in patients with either preterm labor or premature rupture of membranes in comparison with pregnant controls. STUDY DESIGN: A total of 42 patients between 24 and 35 weeks' gestation (20 with preterm labor; 14 with premature rupture of membranes, and 8 with premature rupture of membranes and contractions) and 35 additional patients without preterm labor or premature rupture of membranes (controls) had blood and urine collected for nitrate determination. Nitrate was reduced to nitrite and quantitated with the Griess reagent. RESULTS: The urine nitrate concentrations were significantly higher only in the preterm labor group compared with the control group (1.23 +/- 0.22 vs 0.67 +/- 0.05 mumol/mg creatinine, p < 0.05). The plasma nitrate level, however, was significantly higher in both the preterm labor and the premature rupture of membranes groups compared with the control group (52.47 +/- 10.11 and 40.05 +/- 5.38 mumol/L vs 16.29 +/- 2.89 mumol/L, p < 0.05). However, the concentrations of nitrate in the urine or plasma did not correlate with time from admission to delivery (p > 0.2). Finally, the presence of positive cervical or urine cultures, a clinical examination consistent with chorioamnionitis, or a maternal temperature > 100.4 degrees F was not associated with higher levels of nitrates in this small series of patients. CONCLUSION: Patients with preterm labor or premature rupture of membranes do have increased nitrate concentrations; however, this increased concentration is not predictive of impending delivery but may indicate that a subclinical infectious process is occurring.

Glycemic thresholds for spontaneous abortion and congenital malformations in insulin-dependent diabetes mellitus.

OBJECTIVE: To test the hypothesis that women with insulin-dependent (type I) diabetes have a threshold of glycemic control in early pregnancy for increased risks of spontaneous abortion and congenital malformations. METHODS: Receiver-operating characteristic (ROC) curves were formed for the occurrence of abortion and malformations as a function of the median first-trimester preprandial blood glucose concentration and the first measured glycohemoglobin concentration in pregnant women with type I diabetes. RESULTS: Fifty-two of the 215 women (24%) who enrolled before 9 weeks' gestation had spontaneous abortions. Six percent of the women enrolled before 14 weeks had infants with major congenital malformations. Thresholds for an increased risk of abortion and malformations were a median first-trimester blood glucose concentration of 120-130 mg/dL or an initial glycohemoglobin concentration of 12-13% (6.2-7.5 standard deviations above the normal mean). CONCLUSIONS: Type I diabetic women with initial glycohemoglobin concentrations in pregnancy above 12% or median first-trimester preprandial glucose concentrations above 120 mg/dL have an increased risk of abortion and malformations. Below these glycemic thresholds, the risks are comparable to those in nondiabetic women.

Maternal floor infarction of the placenta: prenatal diagnosis and clinical significance.

OBJECTIVE: To determine whether maternal floor infarction can be diagnosed prenatally. METHODS: We reviewed the charts of 13 patients with maternal floor infarction confirmed histopathologically to determine the frequency of increased placental echogenicity, fetal growth restriction (FGR), and oligohydramnios. Subsequently, we applied these criteria prospectively to diagnose maternal floor infarction in three cases. RESULTS: Twelve of the 13 pregnancies reviewed retrospectively resulted in small for gestational age infants, of which eight were stillbirths. Fetal growth restriction and oligohydramnios were evident on ultrasound in five pregnancies and a placental abnormality was noted in four; two patients exhibited this complete triad of sonographic abnormalities. Three patients were identified prospectively with maternal floor infarction based on sonographic findings and electively delivered live preterm infants. CONCLUSIONS: Maternal floor infarction is a placental condition with profound risk for FGR and stillbirth. Antenatal diagnosis may improve the perinatal outcome with this condition.