Effect of uncomplicated chronic hypertension on the risk of small-for-gestational age birth.

This study assesses the effect of chronic hypertension on fetal growth. A cohort of 1,938 pregnant women attending five prenatal clinics in France between August 1991 and May 1993 were enrolled in a prospective study. Chronic hypertension was defined according to blood pressure at enrollment and past history, and cases complicated by preeclampsia were excluded. Adjusted odds ratios of small-for-gestational age birth were estimated by logistic regression. The independent effect of chronic hypertension on mean birth weight was examined through multiple linear regression analysis adjusting for gestational age at delivery and potential confounders. Uncomplicated chronic hypertension was associated with an increased risk of small-for-gestational age birth. Odds ratios increased with age. In women over age 30 years, the association was strong (adjusted odds ratio = 8.5, 95% confidence interval 2.9-24.5). Multiple linear regression showed that mean birth weight was 161 g (95% confidence interval 66-256 g) less in women with chronic hypertension compared with normotensive women. The authors conclude that mean birth weight is reduced and the risk of small-for-gestational age birth is increased in uncomplicated chronic hypertension compared with normotensive pregnancies. Results further suggest that the magnitude of this association increases with age.

[Calcium channel blockers in pregnancy]. / Antagoniste calcique pendant la grossesse.

Calcium channel blockers are used more and more in pregnancy. No teratogenic effect has been observed in humans despite the lack of adequate studies. The use of calcium channel blockers in premature labor and in arterial hypertension may be recommended. In premature labor, maternal tolerance is better than that of beta adrenergic drugs. In hypertensive disorders of pregnancy, current data indicate that calcium channel blockers may be a good second line medication. Acute lowering of maternal blood pressure (by sublingual or intravenous use) may however induce fetal distress.

[Indication of corticotherapy for fetal pulmonary maturation]. / Indication actuelle de la maturation pulmonaire foetale par corticothérapie.

Corticosteroid administration before anticipated premature delivery is associated with a large reduction in the incidence of early neonatal death, respiratory distress syndrome, intraventricular hemorrhage and necrotizing enterocolitis. Despite scientific evidence, a minority of women delivering prematurely receive antenatal corticosteroid treatment. Randomized control trials show that there is no short term adverse effects for the infant and mother and no long term adverse effects for the child. We conclude that antenatal corticosteroid use is recommended before premature delivery until 34 weeks gestational age.

Predictive value of uterine Doppler waveform during pregnancies complicated by diabetes.

Diabetes, whether or not it is insulin deficient, is frequently associated with vascular complications during pregnancies. It is accepted nowadays that the uterine artery velocity waveform is predictive concerning pregnancy-induced hypertension (PIH) and its complications. It thus seemed interesting to analyse the predictivity of vascular complications of diabetes by using uterine artery velocity waveforms. We have thus explored 37 diabetic patients [group 1: insulin-deficient diabetes (IDD), n = 10; group 2: gestational IDD, n = 6; and gestational non-IDD, n = 21). We have found vascular complications for 10 patients, divided between all 2 groups: 2 pre-eclampsia, 2 fetal suffering before any labour, 2 cases of intra-uterine growth retardation (including a trisomy 18) and 5 PIH. The uterine artery velocimetry measurement has been found to be pathological 5 times, and always in patients who later developed vascular complications. Among this selected population and excluding the trisomy 18, the sensitivity is of 44.5%, the specificity of 100%, the positive predictive value of 100%, and the negative predictive value of 84.3%. If these results are confirmed, this examination could be an excellent marker of the vascular risk and thus would have its place during systematic survey of pregnancies complicated by diabetes.

Predictive value of uterine artery velocity waveforms in pregnancies complicated by systemic lupus erythematosus and the antiphospholipid syndrome.

The objective of this study was to see if determination of uterine artery velocity waveforms between 20 and 30 weeks in lupus pregnancy and the antiphospholipid syndrome (APS) have a good predictive value for later fetal distress before labor, intrauterine growth retardation, and preeclampsia. Uterine and umbilical artery blood flow velocity waveforms were determined in 21 pregnancies complicated by systemic lupus erythematosus (SLE): 12 with antiphospholipid antibodies (aPL), 9 without aPL. We also studied 7 pregnancies with APS. This retrospective study was running from January 1st 1986 to July 31st 1991, at the Port-Royal Maternity, Paris, France. Abnormal uterine artery blood flow velocity waveforms were found in 10 out of 28 pregnancies at the first examination performed between 20 and 30 weeks gestational age. All the later adverse fetal and neonatal events were predicted by an abnormal uterine artery blood flow velocity waveform. From the 7 cases of fetal distress diagnosed during pregnancy, 6 were predicted by abnormal uterine waveforms and all of these pregnancies resulted in induced delivery before 32 weeks of gestational age. Twelve pregnancies with aPL and normal uterine artery waveforms were uncomplicated. Only 1 out of 7 pregnancies with abnormal uterine artery waveform and aPL ended without complication. Determination of uterine artery flow velocity waveform is a good adjunct to the management of pregnancies complicated by SLE or aPL. This determination has a better predictive value than the presence of aPL.

Risk/benefit ratio of changing late obstetrical strategies in the management of insulin-dependent diabetic pregnancies. A comparison between 1971-1977 and 1978-1985 periods in 389 pregnancies.

We compared the results of 166 pregestational insulin dependent diabetic pregnancies in the period 1971-1977 to those of 223 in the period of 1978-1985, after the introduction of self monitoring of blood glucose. During this second study period late obstetrical strategies changed to prolongation of pregnancy up to term, avoidance of final hospitalization and decrease of the rate of cesarean section. Maternal blood glucose control was less optimal in the second period resulting in a higher incidence of fetal macrosomia. Despite this, unexplained stillbirth disappeared, neonatal morbidity did not change significantly and the overall benefit was a reduction of preterm birth and a better quality of life for our patients. We conclude that the final hospitalization from week 32 onward in insulin dependent diabetic pregnancies is no more mandatory.

[Management of gestational diabetes: objectives and results]. / Prise en charge des diabètes gestationnels: objectifs et résultats.

Control of diabetes may easily, in gestational diabetes, avoid possible ketosis in the mother and fetal death. Reduction of fetal macrosomia is much less efficient.

[Obstetric management and delivery in diabetics]. / Surveillance obstétricale et accouchement de la diabétique.

A review of the obstetrical management of diabetic pregnancies is presented. The best way to avoid complications is to achieve the best possible diabetic control. Ultrasonics are able to determine gestational age in the first weeks of pregnancy, to detect fetal malformations and to follow fetal growth. At the end of pregnancy, fetal heart rate monitoring is the golden standard to judge fetal well being. Delivery at term is of paramount importance. The presence of fetal macrosomia is an important parameter of the decision of the mode of delivery.