C. Loghis

Maternal Plasma Leptin Levels and Their Relationship to Insulin and Glucose in Gestational-Onset Diabetes

To investigate the changes in leptin levels and the relationship between this substance and insulin and glucose in pregnant women with gestational-onset diabetes, we measured plasma leptin levels in the maternal peripheral vein of 17 healthy and 17 diabetic women at 29 and 33 weeks of gestation. We also correlated maternal plasma leptin levels in diabetic women with fasting plasma insulin levels and plasma glucose levels obtained 1 h after oral administration of 50 g of glucose. Maternal serum leptin levels in women with gestational diabetes (mean ± SD 16.52 ± 5.07 ng/ml, range 10.84–27.4 ng/ml) were significantly higher (p < 0.001) than those found in uncomplicated pregnancies (10.61 ± 1.47 ng/ml, range 7.28–13.4 ng/ml). A positive correlation was found between maternal serum leptin levels and glycosylated haemoglobin values in diabetic pregnant women (r = 0.94, p < 0.001). A positive correlation was also found between maternal leptin concentrations and fasting serum insulin levels, as well as between leptin concentrations and plasma glucose levels obtained 1 h after the administration of 50 g of glucose in women with gestational diabetes (r = 0.84, p < 0.001, and r = 0.92, p < 0.001, respectively). We conclude that leptin levels are elevated in pregnant women with gestational diabetes, and its metabolism depends on insulin levels and the severity of diabetes.

Computerized analysis of fetal heart rate variability using the matching pursuit technique as an indicator of fetal hypoxia during labor.

Objective. To determine whether the computerized analysis of fetal heart rate variability with the new matching pursuit technique can indicate fetal distress during labor. Study design. Eighty women were studied during the intrapartum period with external cardiotocography. In all cases, cord arterial pH and 5-min Apgar Scores were evaluated. Six cases that presented large segments of missing data were excluded from the study. The remaining 74 women were divided into two groups; 32 women with normal (Group A) and 42 women with non-reassuring FHR tracings (group B). Group B was divided in subgroup BI, including 24 women with pH > 7.20, and BII, including 18 women with pH < 7.20. In order to evaluate the FHR fluctuations, in different frequency ranges, we applied an adaptive time-frequency method, called Matching Pursuit. We estimated the power of the FHR signal in four frequency ranges. Results. The 5-min Apgar Scores were significantly lower in both subgroup BI and subgroup BII (p = 0.003 and p = 0.003 respectively). The Low Low Frequency (LLF) parameter appears to recognize better the cases with lower pH (sensitivity 78.5%, specificity 52.3%) than the cases with non-reassuring FHR (66.6%, 56.2). The sensitivity and specificity of the Very Low Frequency (VLF) parameter were 72.2% and 59% respectively in recognizing the cases with lower pH and 64.2% and 53.1% in recognizing non-reassuring FHR. Conclusion. Fetal hypoxia during labor can be recognized using the MP technique for the analysis of FHR signal power in the VLF and LLF frequency ranges. Since the analysis is feasible in real-time, it can be a useful tool for the intrapartum evaluation of fetal well-being.

Congenital adrenal hyperplasia because of 21-hydroxylase deficiency. A genetic disorder of interest to obstetricians and gynecologists.

Congenital adrenal hyperplasia (CAH) due to deficiency of the enzyme 21-hydroxylase (21-OH), is distinguished in its classical and nonclassical form and is one of the most common autosomal recessive inherited diseases in humans. The classical form appears between 1:5000 and 1:15000 among the live neonates of North America and Europe, whereas the nonclassical form occurs in approximately 0.2% of the general white populations. Three alleles are associated with the 21-OH locus and can be combined in various ways to individuals who are either unaffected, heterozygote carriers, or affected with the classical or nonclassical disease. Variable signs and symptoms of hyperandrogenism are common to both types of the disorder. In women with CAH, hyperandrogenism may be present, extending from virilization of external genitalia and salt-wasting in classical (C)-CAH cases, to menstrual irregularity, obesity, short stature, infertility or subfertility and skin disorders such as hirsutism, in nonclassical (NC)-CAH cases. These clinical characteristics of NC-CAH cases do not differ unmarkedly from those shown in patients with polycystic ovary syndrome, idiopathic hirsutism, or hyperinsulinemia. The significant advances in molecular biology and gene analysis over the past 2 decades have led to the development of novel sensitive methods of DNA analysis and study, including polymerase chain reaction and Southern blot analysis. Thus it has been revealed that the 21-OH gene (CYP21A2) and its nonfunctional pseudogene (CYP21A1P) are located on chromosome 6 (6p21.3), sharing a high homology of about 98%. Inactivating mutations occur as complete gene deletions, large gene conversions and pseudogene-derived mutations. Target Audience: Obstetricians & Gynecologists, Family Physicians Leaning Objectives: After completion of this article, the reader should be able to recall the epidemiology of carrier status for 21-hydroxylase deficiency, identify phenotypic characteristics for classic and non-classic congenital adrenal hyperplasia, and describe the consequences of 21-hydroxylase block with respect to production of other hormones and enzymes.

Sweeping of the Membranes versus Uterine Stimulation by Oxytocin in Nulliparous Women

The aim of this study was to evaluate whether sweeping of the membranes at term could shorten the length of pregnancy and reduce the incidence of postterm pregnancies. We randomly selected 104 nulliparas with uncomplicated pregnancy and gestational age between 281 and 287 days. Our patients were divided into three groups. Group A consisted of 34 women who were subjected to sweeping of the membranes. Uterine stimulation with oxytocin was applied in 35 women (group B), and 35 women (group C) were used as a control group. We had no significant reduction of the time interval from sweeping of the membranes until delivery (1.9 ± 1.2 days), compared to that of group B (2.1 ± 0.8 days) as well as that of the control group (2.5 ± 0.9 days). The incidence of spontaneous labor in patients after sweeping of the membranes was greater (67.6%) when compared with oxytocin-stimulated patients and the control group (p < 0.05). Furthermore, a better Bishop score was noted in patients of group A. No statistically significant difference was noted in the mode of delivery between the groups, but sweeping of the membranes significantly decreased the incidence of postterm pregnancies (p < 0.05). We concluded that sweeping of the membranes is an effective method for initiating labor in women with a gestational age between 40 and 41 weeks, thus reducing the need for induction.

Cervical incompetence: a 24-year review.

Three hundred nineteen cervical cerclages performed in 264 pregnant women were retrospectively studied. The diagnosis of cervical incompetence was established by the obstetrical history, hysterosalpingography, ultrasound screening and vaginal examination. All cervical cerclages were applied between 14 and 17 weeks gestation according to Shirodkars technique except 49 emergency cases between 18 and 26 weeks gestation for which other techniques were chosen. The incidence of preterm deliveries (26–37 weeks gestation) decreased from 39.7% to 14.23% (P < 0.001) and that of full term pregnancies increased from 20.04% to 75.74% (P < 0.001). The number of neonates weighing ⩽2000 g decreased from 44.20% to 11.38% (P < 0.001) and those weighing ⩾2500 g increased from 44.83% to 75.82% (P < 0.001). Perinatal mortality after cerclage declined from 28.21% to 5.52% (P < 0.001). There was no increase in congenital defects. An increased rate of breech presentation (5.32%) and cesarian section (20.38%) was noticed. The repeated cerclage in consequent pregnancies did not seem to influence the duration of gestation. In emergency cases the rate of preterm deliveries was 53.06%, of full term pregnancies 12.25%, of newborns with birthweight ⩽2500 g 31.77% and of those with birthweight ⩾2500 g 19.23%. Perinatal mortality in emergency cases was 42.3%. An increase in aerobic and anaerobic pathological flora was noticed in postoperative cervical cultures.

The effect of early second stage bradycardia on newborn status

In the present study 45 patients with intrapartum cardiotocograms showing prolonged fetal bradycardia during the early second stage of labor were included. Bradycardia persisted for 180 s or more with either rapid or prolonged return to baseline, without loss of variability and rise of baseline fetal heart rate (FHR). The mean duration of bradycardia was 5.0 +/- 1.3 min. In the group with normal FHR tracings the rate of normal delivery (73.3%) was significantly higher than that of the group with fetal bradycardia (26.7%, P < 0.0001). We also noted a significantly higher rate of cesarean section (44.4%) in patients with abnormal FHR tracings, compared to that (11.1%) of parturients with normal FHR tracings (P < 0.001). In all cases blood samples were obtained from the umbilical cord artery, immediately after delivery. Only in two cases with abnormal FHR tracing umbilical cord artery was the pH less than 7.20. We conclude that in most cases, prolonged fetal bradycardia in the early second stage with the characteristics described above is well tolerated by a mature fetus.

Evaluation of Fetal Heart Rate Patterns during the Second Stage of Labor through Fetal Oximetry

The purpose of this study was to assess the feasibility and accuracy of fetal pulse oximetry during the second stage of labor in cases with abnormal fetal heart rate (FHR) patterns with reference to postpartum acid-base status and Apgar scores. Forty-eight parturients with normal and 20 parturients with abnormal FHR tracings during the second stage of labor were monitored by fetal pulse oximetry and postpartum umbilical artery pH, pO2, pCO2 values and 1- and 5-min Apgar scores. The mean SpO2 value was 55.47 ± 9.95% in cases with normal and 52.55 ± 16.42% in cases with abnormal FHR patterns. A significant correlation was noted between fetal SpO2 and umbilical artery pH in cases with normal (r = 0.76, p < 0.05) as well as in cases with abnormal FHR patterns (r = 0.78, p < 0.05). No significant correlation was found between fetal SpO2 and Apgar scores at 1 and 5 min in cases with normal FHR patterns. On the contrary a significant correlation was noted in cases with abnormal FHR patterns. A normal FHR pattern alone is reassuring. In cases with abnormal FHR, fetal pulse oximetry is an objective method for distinguishing a hypoxic fetus.

Umbilical cord blood gas analysis in augmented labour

Labour augmentation with oxytocin may produce an excessive increase in frequency, duration or strength in uterine contractions which may result in fetal stress. Umbilical cord acid-base assessment provides an objective parameter in evaluating the neonatal condition immediately after delivery. We evaluated the neonatal condition in 235 deliveries where oxytocin was used for labour augmentation. The umbilical cord blood acid-base status was correlated with intrapartum cardiotocographic findings and Apgar scores. In two cases we noted umbilical artery pH <7.05 but the BDecF was not higher than 11 mmol/l and the 5-minute Apgar score was 8 in all cases. Our results indicate that the use of oxytocin for labour augmentation had no adverse effects on neonatal condition.

The predictive value of a nonstress test taken 24 h before delivery in high-risk pregnancies.

OBJECTIVES: A series of 180 cases of high risk pregnancies were studied in order to assess if a nonstress test taken 24 h before delivery is of any prognostic significance. METHODS: To assess the predictability of the NST (reactive or nonreactive) in terms of fetal outcome, the following variables were taken into consideration: fetal distress during labor, low Apgar score (< 7) and perinatal mortality rate. RESULTS: A reactive test was found to be a good predictor of the healthy fetus (negative predictive value = 91.2%). Also, specificity of the test was found to be 85.4%. CONCLUSIONS: The nonreactive test could identify a population at risk but it was not helpful as a ‘stand alone’ modality in decision making, because of the low sensitivity and positive predictive value rates (40.9% and 28.1%, respectively).

The influence of vacuum extractor on fetal oxygenation and newborn status

AimThe aim of this study was to determine the effects of vacuum extractor assisted delivery on fetal oxygenation and acid-base balance.MethodsSixty-one women were enrolled in the present study. The subjects were divided into two groups. Group A, consisting of 39 women, had normal vaginal deliveries. Group B, consisting of 22 women, underwent a vacuum extractor assisted vaginal delivery. Fetal arterial oxygen saturation (SpO2) monitoring was used in all women after full cervical dilatation. After delivery, umbilical artery pH, pCO2, pO2 and base deficit (BDecf) levels were determined in all neonates.ResultsThe mean FSpO2 value in Group A was 51.53±5.87% and in Group B 48.03±6.39% (p<0.03). The mean cord pH value in fetuses of Group A was 7.26±0.05, and in Group B 7.17±0.09. There was also a significant difference between the two groups with regards to mean pO2, pCO2 and BDecf values.ConclusionsVacuum assisted vaginal delivery was associated with lower fetal arterial oxygen saturation levels as well as lower cord blood pH values compared to those seen after unassisted vaginal delivery. Although decreased, however, the above parameters remained within normal ranges.