Celeste Durnwald

Second trimester cervical length and risk of preterm birth in women with twin gestations treated with 17-α hydroxyprogesterone caproate

Objective. To compare rates of preterm birth before 35 weeks based on cervical length measurement at 16–20 weeks in women with twin gestations who received 17-α hydroxyprogesterone caproate (17OHPC) or placebo. Methods. This is a secondary analysis of a randomised, double-blind, placebo-controlled trial of twin gestations exposed to 17OHPC or placebo. Baseline transvaginal ultrasound evaluation of cervical length was performed prior to treatment assignment at 16–20 weeks. Cervical length measurements were categorised according to the 10th, 25th, 50th and 75th percentiles in the women studied. The effect of 17OHPC administration in women with a short (25th percentile) and long (75th percentile) cervix was evaluated. Results. Of 661 twin gestations studied, 221 (33.4%) women enrolled at 11 centers underwent cervical length measurement. The 10th, 25th, 50th, 75th percentiles for cervical length at 16–20 weeks were 32, 36, 40 and 44 mm, respectively. The risk of preterm birth <35 weeks was increased in women with a cervical length <25th percentile (55.8 vs. 36.9%, p = 0.02). However, a cervical length >75th percentile at this gestational age interval was not protective for preterm birth (36.5 vs. 42.9%, p = 0.42). Administration of 17OHPC did not reduce preterm birth before 35 weeks among those with either a short or a long cervix (64.3 vs. 45.8%, p = 0.18 and 38.1 vs. 35.5%, p = 0.85, respectively). Conclusion. Women with twin gestations and a cervical length below the 25th percentile at 16–20 weeks had higher rates of preterm birth. In this subgroup of women, 17 OHPC did not prevent preterm birth before 35 weeks gestation. A cervical length above the 75th percentile at 16–20 weeks did not significantly reduce the risk of preterm birth in this high risk population.

A comparison of lispro and regular insulin for the management of type 1 and type 2 diabetes in pregnancy.

Objective. To describe perinatal outcomes of women with pregestational diabetes treated with short-acting, regular insulin and the short-acting insulin analogue, lispro. Study design. This was a prospective observational study of women with pregestational diabetes maintained on short-acting insulin regimens over a 3-year period. Clinical characteristics, aspects of diabetic therapy, and perinatal/neonatal outcomes were collected. Results. Of 107 women, 49 were maintained on regular insulin and 58 utilized the insulin analogue, lispro. Frequency of type 1 diabetes, maternal age, overweight/obese pregravid body mass index (≥25 kg/m2), preexisting hypertension, and presence of vascular disease were similar between groups. Women treated with lispro had a longer duration of diabetes (11.4 vs. 8.3 years, p = 0.04). Glycemic control was improved in women managed with lispro compared to regular insulin (HgbA1c 5.9 vs. 6.7, p = 0.009). Total insulin requirements were lower in the lispro group in the first (0.58 vs. 0.79 units/kg, p = 0.02), second (0.75 vs. 1.10 units/kg, p = 0.002), and third (0.98 vs. 1.25 units/kg, p = 0.03) trimesters of pregnancy. Mean infant birth weight was greater in the lispro group, whereas the rate of large for gestational age infants and ponderal indices were similar between groups. Malformation rate, gestational age at delivery, neonatal intensive care unit admission, neonatal length of stay, rates of respiratory distress syndrome, and hypoglycemia were similar. Conclusions. Women treated with lispro demonstrated improved glycemic control and lower total insulin requirements during pregnancy compared to those receiving regular insulin. Perinatal outcomes were similar between women treated with both types of insulin.

The effect of treatment with 17 alpha-hydroxyprogesterone caproate on changes in cervical length over time

OBJECTIVE The purpose of this study was to examine whether women who were treated with 17 alpha-hydroxyprogesterone caproate (17-OHPC) to prevent recurrent preterm birth experienced a change in cervical shortening over time, compared with women who were not treated. STUDY DESIGN We conducted a retrospective exposure cohort study of women who were enrolled in a prematurity prevention clinic from 1999-2008 with a singleton pregnancy with > or =1 previous spontaneous preterm births (<37 weeks of gestation) who underwent > or =2 cervical length measurements by endovaginal ultrasound. RESULTS Of 200 women, 105 women received treatment with 17-OHPC; 95 women did not. Women who were treated with 17-OHPC were more likely to have experienced a previous preterm birth (26.0 vs 27.8 weeks; P = .01) than those who were not treated with 17-OHPC. There was no difference in the average weekly change in cervical length among women treated with 17-OHPC, compared with those who were not, after adjustment for covariates (0.79 mm/week; 95% confidence interval, -1.18 to 2.76). CONCLUSION There was no difference in the average weekly change in cervical length measurements over time in women who underwent 17-OHPC treatment, compared with those who were not treated.

Insulin Analogues in the Management of the Pregnancy Complicated by Diabetes Mellitus

Since their introduction, insulin analogues are the preferred choice for short-acting insulin due to their superior pharmacologic profiles, leading to greater flexibility and convenience of dosing and, thus, greater patient satisfaction and improved quality of life. Over the past few years, clinical experience with insulin analogues in pregnancy has increased. The most studied, insulin lispro, has been shown to be a safe and clinically effective option in the treatment of the diabetic gravida. Studies of the other insulin analogues are limited, but promising. Further research is warranted to evaluate safety and efficacy of these analogues.

Myometrial thickness according to uterine site, gestational age and prior cesarean delivery

Objective. To evaluate the myometrial thickness (MT) of multiple uterine sites during all three trimesters of pregnancy in an attempt to identify anticipated myometrial thickness in each trimester for these sites. Methods. In this prospective cross sectional study, MT was evaluated by ultrasound in women with viable singleton pregnancies. Women with suspected abruption, accreta, previa, fibroids, uterine and fetal anomalies, abnormal fluid volume, labor were excluded. MT was measured at the fundus, anterior wall (AW), posterior wall (PW), right and left side walls, lower uterine segment (LUS) and under the placenta. The cohort was divided to determine differences in MT at each site in each trimester (TRI). Differences in MT between sites were assessed. Results. One hundred and seventy five women underwent ultrasound by a single observer. There were 25 1st, 100 2nd and 50 3rd TRI scans at mean (SD) gestations of 11.0 (1.9), 21.5 (3.6) and 34.1 (3.0) weeks, respectively. Women were 37% African American, 72% government insured, 39.4% nulliparous. A total of 13% of women had a prior cesarean. MT of the fundus was less than AW, PW, right and left side walls (p < 0.05 each). For all sites, MT was less in 2nd compared with 1st TRI (p < 0.0001 each). This was most evident with fundal and LUS MT (35% less each). There was no difference in MT between 2nd and 3rd TRI. Fundal, AW, left side wall, subplacental and LUS MT were greater in parous women (p < 0.05 each). With anterior placentation, AW MT was less than when the placenta was implanted elsewhere (6.6 vs 7.4 mm, p = 0.008). This was not found with fundal or posterior placentas. The LUS MT was not less with prior cesarean (6.1 vs 6.0 mm, p = 0.84). Conclusion. Myometrial thickness of all uterine sites is less in 2nd and 3rd trimesters compared with the 1st trimester. Fundal MT is less than other upper segment MT in the 2nd and 3rd trimesters. LUS MT is not less with prior cesarean.

Influence of maternal body mass index and gestational age on accuracy of first trimester gender assignment

Objective. To determine the influence of maternal body mass index (BMI) and gestational age on the accuracy of image acquisition, first trimester fetal gender determination, and correct assignment. Methods. Women presenting for first trimester aneuploidy risk assessment at 110 to 136 weeks were prospectively enrolled. A mid-sagittal view of the fetus including the genital tubercle was obtained. The angle of the genital tubercle was measured with male assigned for angle >30°, female <10°, and indeterminate if 10–30°. This was compared with gender at birth. The influence of maternal and pregnancy characteristics on both image acquisition and correct gender assignment were evaluated. Results. A total of 256 women with 260 fetuses undergoing first trimester risk assessment were enrolled. The genital tubercle was identified in 247/260 (95%) of cases. Image acquisition was negatively influenced by increasing maternal BMI and early gestational age (34.8 ± 7.7 vs. 27.0 ± 6.1 kg/m2, p < 0.0001 and 12.3 ± 0.5 vs. 12.6 ± 0.5 weeks, p = 0.02). Gender was assigned in 93.1% and correctly matched in 85.8% of fetuses. Positive predictive value (PPV) for male and female fetuses were 88.9% and 79.8%, respectively. Correct gender assignment was more likely in male compared with female fetuses (91.4 vs. 80.5%, p = 0.02). Conclusion. Increasing maternal BMI negatively influences image acquisition during the first trimester for gender determination, but does not decrease the accuracy of correct gender assignment if the image is obtained.