Dorothea Mostello

A lifestyle intervention of weight-gain restriction: diet and exercise in obese women with gestational diabetes mellitus.

OBJECTIVE This study assessed whether a weight-gain restriction regimen, with or without exercise, would impact glycemic control, pregnancy outcome, and total pregnancy weight gain in obese subjects with gestational diabetes mellitus (GDM). A total of 96 subjects with GDM met the inclusion criteria and were sequentially recruited, with 39 subjects self-enrolled in the exercise and diet (ED) group, and the remaining 57 subjects self-enrolled in the diet (D) group owing to contraindications or a lack of personal preference to exercise. All patients were provided a eucaloric or hypocaloric consistent carbohydrate meal plan and instructed in the self-monitoring of blood glucose. In addition, all ED subjects were prescribed an exercise routine equivalent to a 60% symptom-limited VO2 max. Subjects were followed at weekly or biweekly office visits. Results showed maternal weight and body mass index (35.2+/-7.2 (ED) vs. 33.5+/-9.2 (D)) at study entry as well as number of weeks into the study (7.7+/-5.7 (ED) vs. 9.4+/-4.7 (D)) were similar in both the ED and D groups. Weight gain per week was significantly lower in the ED group than in the D group (0.1+/-0.4 kg vs. 0.3+/-0.4 kg; p<0.05). Subjects (either ED or D) who gained weight had a higher percentage of macrosomic infants than those subjects who lost weight or had no weight change during pregnancy. Other pregnancy and fetal outcomes such as complications, gestational age at delivery, and rate of cesarean delivery were similar in both groups. Conclusions of this study were that caloric restriction and exercise result in limited weight gain in obese subjects with GDM, less macrosomic neonates, and no adverse pregnancy outcomes. Pregnancy is an ideal time for behaviour modification, and this intervention may also help promote long-term healthy lifestyle changes.

Recurrent preeclampsia: the effect of weight change between pregnancies.

OBJECTIVE: To estimate whether the risk of recurrent preeclampsia is affected by interpregnancy change in body mass index (BMI). METHODS: We conducted a population-based cohort study using Missouri maternally linked birth certificates for 17,773 women whose first pregnancies were complicated by preeclampsia. The women were placed into three groups: those who decreased their BMIs, those who maintained their BMIs, and those who increased their BMIs between their first two pregnancies. The primary outcome was recurrent preeclampsia in the second pregnancy. Adjusted risk ratios and 95% confidence intervals were calculated using Poisson regression analysis. RESULTS: The overall rate of recurrent preeclampsia in women who decreased their BMIs between pregnancies was 12.8% (risk ratio 0.70, confidence interval 0.60–0.81) compared with 14.8% if BMI was maintained and 18.5% in those who increased their BMIs (risk ratio 1.29, confidence interval 1.20–1.38). Within the normal weight, overweight, and obese weight categories, women who decreased BMI between pregnancies were less likely to experience recurrent preeclampsia. Women in all weight categories who increased their BMIs between pregnancies were more likely to experience recurrent preeclampsia. CONCLUSION: Interpregnancy weight reduction decreases the risk of recurrent preeclampsia and should be encouraged in women who experience preeclampsia. LEVEL OF EVIDENCE: II

Abdominal circumference vs. estimated weight to predict large for gestational age birth weight in diabetic pregnancy

Early third trimester fetal abdominal circumference and sonographic fetal weight estimates were compared to predict large for gestational age birth weight in diabetic pregnancy. Both parameters have similar sensitivity, specificity, and predictive values. However, the optimal percentile cutoff values differ. Choice of birth weight standard significantly influences test characteristics. Negative prediction of large birth weight is more accurate than positive prediction. At third trimester sonography with maternal diabetes, the abdominal circumference percentile is potentially useful and should be routinely reported.

Large-for-gestational-age infants of type 1 diabetic mothers: an effect of preprandial hyperglycemia?

Objective. To determine how the frequency, timing and magnitude of hyperglycemia are associated with large-for-gestational-age (LGA) infants in pregnancies complicated by type 1 diabetes. Methods. Charts from pregnant women with type 1 diabetes (n = 70) were reviewed. Indices of maternal glycemic control were determined for seven gestational periods (weeks 7–10, 11–15, 16–19, 20–24, 25–28, 29–32 and 33–38) and compared between women who delivered LGA infants and appropriate-for-gestational-age (AGA) infants. Results. Of the 70 pregnancies, 57% of the infants were LGA (4.3 ± 0.4 kg) and 43% were AGA (3.2 ± 0.4 kg). Total maternal weight gain and rate of weight gain were significantly higher in mothers with LGA infants. The glycemic variables associated with an LGA infant were percentage of preprandial values above target for weeks 11–15, 25–28 and 29–32, and percentage of all values above target for weeks 33–38. For the entire pregnancy, the strongest predictors of an LGA infant were percentage of preprandial blood glucose values above target during weeks 29–32 and maternal weight gain. Conclusions. In pregnant women with type 1 diabetes, frequent episodes of preprandial hyperglycemia in the third trimester significantly impact the development of LGA infants.

Tertiary care improves the chance for vaginal delivery in women with preeclampsia.

OBJECTIVE The purpose of this study was to determine whether the level of hospital care affects cesarean delivery rates for women with preeclampsia. STUDY DESIGN We conducted a population-based cohort study using Missouri birth certificate data for 1993 through 1999. Logistic regression was used to analyze data from 13,646 nulliparous women with preeclampsia who were delivered of singleton live births. RESULTS After adjustment was made for gestational age and birth weight, the data showed that women with preeclampsia at primary and secondary hospitals were more likely to be delivered by cesarean delivery (odds ratio, 1.37; 95% CI, 1.24,1.51; and odds ratio, 1.16; 95% CI, 1.07,1.26, respectively) than at tertiary hospitals. For women who were delivered at >or=37 weeks of gestation, cesarean delivery rates were 38.0%, 33.7%, and 30.0% for primary, secondary, and tertiary hospitals, respectively. Dysfunctional labor, cephalopelvic disproportion, and fetal distress were more commonly noted at primary and secondary hospitals (P<.001). CONCLUSION Levels of expertise and staffing at tertiary hospitals may allow greater attempts and success with vaginal delivery among women with preeclampsia compared with primary or secondary hospitals.

Fetal Parvovirus B19 Infection Doppler Studies Allow Noninvasive Treatment of Ascites

Fetal anemia due to marrow suppression from parvovirus B19 infection may lead to fetal hydrops. In cases of hydrops, outcomes include spontaneous resolution, fetal death without intrauterine fetal transfusion, resolution after transfusion, and fetal death after transfusion. Differentiating those who will have spontaneous resolution from those requiring transfusion is problematic and sometimes based on fetal hematologic parameters measured at funicentesis or somewhat subjective sonographic observations. We report a case in which Doppler sonography was used to obviate funicentesis, fetal transfusion, and their attendant risks. High middle cerebral artery (MCA) peak systolic velocity (PSV) is associated with anemia. In this case, improvement from moderate to mild ascites and normal MCA PSV supported the likelihood of spontaneous resolution in progress.

Metoclopramide and Diphenhydramine: A Randomized Controlled Trial of a Treatment for Headache in Pregnancy when Acetaminophen Alone Is Ineffective (MAD Headache Study)

Objective We investigated whether metoclopramide administered with diphenhydramine (MAD) relieves headache in pregnant women when acetaminophen alone is ineffective, using codeine for comparison. Study Design Normotensive pregnant women in the second or third trimester were randomized to MAD intravenously (10 mg and 25 mg, respectively) or codeine orally (30 mg) for headache after 650 to 1,000 mg of acetaminophen failed to relieve their headaches. Headache severity (pain score 0‐10) was noted at intervals over 24 hours. The primary outcome was reduction in pain score 6 hours after medication administration. A sample size calculation of 35 patients per group was based on estimated reduction in headache pain score by at least two points, with an &agr; of 0.05 and a power of 80%. Results No difference was seen in the primary outcome. MAD pain scores were lower at 30 minutes (3 ± 2.8 versus 5.8 ± 2.3, p < 0.001), 1 hour (2.2 ± 2.3 vs. 4.1 ± 3; p < 0.01), and 12 hours (1.3 ± 2.5 vs. 2.7 ± 3; p < 0.05), but not at 6 hours. Time to perceived headache relief was shorter for MAD than for codeine (20.2 ± 13.4 vs. 62.4 ± 62.2 minutes; p < 0.001). More patients in the MAD group reported full headache relief within 24 hours (76.5 vs. 37.5%; p < 0.01). Conclusion MAD effectively relieves headaches in pregnant women when acetaminophen fails.

Characteristics of Recurrent Large-for-Gestational-Age Infants in Obese Women.

Objective The objective of this study was to identify characteristics associated with recurrent large-for-gestational-age (LGA) infants in obese women and to explore the relationship between interpregnancy weight change and gestational weight gain (GWG) on risk of recurrence. Study Design We conducted a population-based historical cohort study of 1,190 obese women in Missouri who delivered LGA infants in their first pregnancy with two consecutive pregnancies resulting in singleton live births during 1998 to 2005. Adjusted odds ratios (aORs) for recurrent LGA infants were calculated with multiple logistic regression. Population-attributable risk assessed the relative importance of specific characteristics. Results A second LGA infant was delivered by 501 women (42%). Recurrence of LGA infants was associated with GWG (aOR, 1.03 [per pound]; 95% confidence interval [CI], 1.02-1.04), maternal age (aOR, 1.05 [per year]; 95% CI, 1.02-1.08), birth weight of the first LGA infant (aOR, 1.001 [per gram]; 95% CI, 1.000-1.001), being married (aOR, 1.71; 95% CI, 1.02-2.49), diabetes (aOR, 1.79; 95% CI, 1.24-2.59), and pre-pregnancy body mass index (BMI) (aOR, 1.04 [per unit BMI]; 95% CI, 1.02-1.06). Excessive GWG contributed the most to LGA infant recurrence (13%). Interpregnancy weight change was not significantly associated with LGA infant recurrence. Conclusion Lower pre-pregnancy BMI and reduced GWG may mitigate the risk of recurrent LGA infants in obese women.

Association of Depression with Complications of Diabetic Pregnancy: A Retrospective Analysis

The goal of this study was to determine whether an association between histories of depression and adverse pregnancy outcome could be established using a retrospective analysis. Participants were a convenience sample of 152 pregnant diabetic women for whom prior pregnancy data were available. Prior pregnancy outcome, depression history, and other clinical characteristics were determined from chart review and medical history questionnaires. Logistic regression was used to determine which of the measured clinical factors, including history of depression, had a significant association with history of pregnancy complications. Thirty-nine patients (26%) had a past history of depression. Three pregnancy complications (preterm labor, pre-eclampsia, fetal prematurity) were more common in the group having a history of depression as was the proportion of participants requiring Caesarean section p( < .05 for each comparison). A history of depression was associated with prior pregnancy complications independent of the effects of parity, prepregnancy BMI, tobacco use history, diabetes type, and presence of diabetes complications (OR = 3.6; 95% CI = 1.5–9.0, p = .006). These retrospective data indicate that depression is linked to complications of diabetic pregnancy and support the need for prospective studies to clarify the effects of depression and its treatment on diabetic pregnancy.