Eran Hadar

Diabetes and Pregnancy: An Endocrine Society Clinical Practice Guideline

OBJECTIVE Our objective was to formulate a clinical practice guideline for the management of the pregnant woman with diabetes. PARTICIPANTS The Task Force was composed of a chair, selected by the Clinical Guidelines Subcommittee of The Endocrine Society, 5 additional experts, a methodologist, and a medical writer. EVIDENCE This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence. CONSENSUS PROCESS One group meeting, several conference calls, and innumerable e-mail communications enabled consensus for all recommendations save one with a majority decision being employed for this single exception. CONCLUSIONS Using an evidence-based approach, this Diabetes and Pregnancy Clinical Practice Guideline addresses important clinical issues in the contemporary management of women with type 1 or type 2 diabetes preconceptionally, during pregnancy, and in the postpartum setting and in the diagnosis and management of women with gestational diabetes during and after pregnancy.

Expectant management of preterm premature rupture of membranes: is it all about gestational age?

OBJECTIVE We sought to compare neonatal outcome in cases of uncomplicated preterm premature rupture of membranes (PPROM) (ie, no evidence of clinical chorioamnionitis, placental abruption, or fetal distress) with that of spontaneous preterm deliveries (PTDs) and to determine the effect of the latency period. STUDY DESIGN The study group included women with PPROM at gestational age 28⁰(/)⁷-33⁶(/)⁷ weeks (n = 488). Neonatal outcome was compared with a matched control group of women with spontaneous PTD (n = 1464). RESULTS Neonates in the uncomplicated PPROM group were at increased risk for composite adverse outcome (53.7% vs 42.0%; P < .001), mortality (1.6% vs 0.0%; P < .001), respiratory morbidity (32.8% vs 26.4%; P = .006), necrotizing enterocolitis, jaundice, hypoglycemia, hypothermia, and polycythemia. Neonatal adverse outcome was more likely in cases of latency period >7 days, oligohydramnios, male fetus, and nulliparity. CONCLUSION Consultation regarding prematurity-related morbidity in infants exposed to uncomplicated PPROM cannot be extrapolated from PTDs and should be stratified by the duration of the latency period and the other risk factors identified in the current study.

Factors affecting the duration of the latency period in preterm premature rupture of membranes.

Objective. To investigate the natural course of preterm premature rupture of membranes (PPROM) at <34 + 0 weeks and to identify factors that affect the duration of the latency period. Design. A retrospective cohort study of all women diagnosed with PPROM prior to 34 + 0 weeks during 1998–2006. Latency period was defined as the time between onset of PPROM to either spontaneous delivery, labor induction at 34 + 0 weeks, or indicated delivery prior to 34 + 0 weeks because of suspected chorioamnionitis or nonreassuring fetal heart rate. Results. The overall rate of PPROM was 1.4% (905/66,775), of which 46% (417/905) occurred at <34 + 0 weeks. Overall, the latency period exceeded 48 h in about 73.4% of cases (306/471). Women with short latency periods (<48 h) were characterised by higher degree of cervical dilatation and higher gestational age at admission and were more likely to be nulliparous. The duration of the latency period ranged between 0 and 59 days and was inversely related to gestational age at admission (r = −0.63, P < 0.001). Using Cox proportional hazards model, gestational age at admission (HR = 1.29, 95% CI = 1.22–1.37), oligohydroamnios (HR = 1.49, 95% CI = 1.18–1.87), cervical dilatation >1 cm (HR = 0.65, 95% CI = 0.52–0.83), fetal growth restriction (HR = 2.94, 95% CI = 1.24–6.94) and nulliparity (HR = 1.28, 95% CI = 1.12–1.63) were significantly associated with shorter duration of the latency period. Conclusion. In this study, we have identified several predictive factors for the duration of the latency period in cases of PPROM. This information may assist clinicians in risk stratification and in providing consultation for women presenting with PPROM prior to 34 weeks of gestation.

Establishing consensus criteria for the diagnosis of diabetes in pregnancy following the HAPO study

The current diagnostic criteria for gestational diabetes mellitus are controversial because they lack correlation to maternal and perinatal outcome. The results of the hyperglycemia and adverse pregnancy outcome (HAPO) study demonstrate a linear association between increasing levels of fasting, 1‐ and 2‐h plasma glucose post a 75 g oral glucose tolerance test to several significant outcome endpoints, such as birth weight above the 90th percentile, cord blood serum C‐peptide level above the 90th percentile, primary cesarean delivery, clinical neonatal hypoglycemia, premature delivery, shoulder dystocia or birth injury, intensive neonatal care admission, hyperbilirubinemia, and preeclampsia. A consensus report by the IADPSG, based on a vigorous assessment of the HAPO results and other studies, recommended an endorsement of risk‐based, internationally accepted criteria for the diagnosis and classification of diabetes in pregnancy. This review follows the steps from defining the problem to the endpoint of achieving a worldwide policy change.

Towards new diagnostic criteria for diagnosing GDM: the HAPO study.

Abstract Gestational diabetes mellitus (GDM) is defined as a carbohydrate intolerance, with onset or first recognition during pregnancy. The prevalence of GDM, and the occurrence of related complications, depends upon the definition of normal glucose values during gestation. The diagnostic criteria for GDM are controversial mainly because they lack correlation to outcome, be it maternal or perinatal. To date, there are no risk based guidelines to make the diagnosis of GDM and determine practice guidelines that are extrapolated from perinatal and maternal outcome and endpoints. To answer some of the above-mentioned controversies, the hyperglycemia and adverse pregnancy outcome study (HAPO) was planned and executed. This review outlines the results of the HAPO study, which demonstrates that fasting glucose levels and post 75 g OGTT are correlated to maternal, perinatal and neonatal outcomes. It is anticipated that the international recommendation for GDM diagnosis, will be shortly published.

Risk for recurrence of preeclampsia and outcome of subsequent pregnancy in women with preeclampsia in their first pregnancy

Objective: To assess subsequent pregnancy outcome and to identify risk factors for recurrence of preeclampsia (PET) in women with PET in their first pregnancy. Methods: A retrospective cohort study of all nulliparous women diagnosed with PET during the years 1996–2008 (PET group, N = 600). Outcome of subsequent pregnancy was compared with a control group of nulliparous women without PET matched by maternal age in a 3:1 ratio (N = 1800). Results: Subsequent pregnancies in the PET group were characterized by a higher rate of preterm delivery at less than 37 and 34 weeks (15.2% vs. 5.7%, p < 0.001 and 3.8% vs. 0.8%, p < 0.001, respectively), placental abruption (1.7% vs. 0.2%, p = 0.004), IUGR (2.8% vs. 0.9%, p = 0.016), and PET (5.9% vs. 0.8%, p < 0.001). Risk factors for PET and adverse outcome in the subsequent pregnancy included: PET complicated by placental abruption in the index pregnancy (OR = 10.8, 95%-CI = 1.8–34.6), PET requiring delivery prior to 34 weeks in the index pregnancy (OR = 6.5, 95%-CI = 1.6–22.5), chronic hypertension (OR = 5.3, 95%-CI = 1.9–12.7), and maternal age > 35 (OR = 4.3, 95%-CI = 1.2–20.5). Conclusion: PET in the first pregnancy is independently associated with an increased risk for adverse pregnancy outcome and recurrence of PET in the subsequent pregnancy in a manner that is related to the severity of PET in the first pregnancy.

A comparison between electrical uterine monitor, tocodynamometer and intra uterine pressure catheter for uterine activity in labor

Abstract Objective: We aimed to evaluate the performance of a non-invasive EMG electrical uterine monitor (EUM) versus tocodynamometry (TOCO) by comparing both to internal uterine pressure catheter (IUPC). Study design: Prospective observational trial. Uterine activity was recorded continuously and simultaneously, in women during active term labor, with TOCO, EUM and IUPC. Uterine activity tracings were analyzed by three blinded physicians. Results: Overall, 385 tracings from 43 women were analyzed. A similar rate of interpretable tracings between physicians was demonstrated for EUM (87%; 95% CI 80.9–92.7%) and IUPC (94.8%; 95% CI 83.4–96.3%), with a significantly lower rate for TOCO (67.5%; 95% CI 59.4–76.8%, p < 0.001). There is a significant difference in the contraction frequency for EUM versus IUPC (0.77 ± 2.3) compared to TOCO versus IUPC (−3.34 ± 4.97). There is a high variability between the timing of TOCO contractions as compared to IUPC (4.74 ± 10.03 seconds), while a gap of 8.46 ± 4.24 seconds was detected for EUM. The sensitivity, positive predictive value and false positive rate for individual contraction identification by TOCO and EUM are 54.0%, 84.4%, 15.6% and 94.2%, 87.6%, 12.4%, respectively. Conclusion: EUM is efficient as IUPC for uterine activity assessment and both techniques are superior in comparison to external tocodynamometry. Our results support the use of non-invasive EMG technology to monitor uterine activity.

Periconceptional cytomegalovirus infection: pregnancy outcome and rate of vertical transmission

To evaluate pregnancy outcome and rate of vertical transmission in primary maternal periconceptional cytomegalovirus (CMV) infection.

Obstetrical outcome in women with self-prepared birth plan

Objective: To determine whether introducing a pre-prepared birth plan upon labor admission has an impact on obstetrical outcome.Methods: A retrospective study of all women who prepared an ante-partum birth plan, from 2007–2010. Outcome was compared with a control group consisting of women without a birth plan matched by age, parity and gestational week in a 3:1 ratio. Results: 154 women were compared to a matched control group of 462 women. Women preparing a birth plan, were less likely to undergo an intra partum cesarean section (11.7% vs. 20.3%, p = 0.016). First and second degree perineal tears occurred more frequently in women preparing a birth plan (72.1% vs. 25.5%, p < 0.001). The utilization of birth plan was also associated with a higher rate of epidural administration (81.2% vs. 68.8%, p = 0.004) and a lower rate of intravenous analgesics use (1.3% vs. 10.2%, p < 0.001). Conclusion:Women presenting with a birth plan, compared to an age-, parity- and gestational week- matched control group are less likely to undergo a cesarean section, more likely to have first and second degree perineal tears and more likely to use an epidural. The paucity of data and the mis-concepts of medical staff suggest that larger prospective studies are needed.

Precision and accuracy of noninvasive hemoglobin measurements during pregnancy

Introduction: The NBM-200 is a novel device allowing noninvasive hemoglobin measurement. The system is based on occlusion spectroscopy technology in the red/near-infrared range. At the core of this technology is the production of a new bio-physical signal, resulting from temporarily occluding the blood flow in the measurement site. The measurement is performed using an annular, multi-wavelength probe with pneumatically operated cuffs, with which an over-systolic pressure is produced at the finger base. Methods: OrSense NBM200 was tested during the years 2011–2012 in a population of pregnant women. Upon receipt of informed consent, two noninvasive Hemoglobin measurements were performed on the right and left thumbs of each subject. Reference hemoglobin values were obtained from venous blood samples drawn at the same time of the noninvasive measurement. Blood Hemoglobin was evaluated on an LH-750 Beckman Coulter counter, acting as the reference “gold standard.” Results: A total of 126 data pairs were obtained in the trial from 63 women. The mean error (bias) of the NBM200 readings compared to the reference was 0.1 g/dL and the accuracy, defined as the standard deviation of error, was 0.86 g/dL. A Bland–Altman comparison of the NBM200 versus the Coulter device shows that the 95% limits of agreement is −1.59 to 1.79 g/dL. Conclusion: Our study demonstrates a good correlation between reference blood hemoglobin and noninvasive hemoglobin measurements. The NBM-200 can accurately assess hemoglobin levels, in a noninvasive fashion, during pregnancy.