Eran Hadar

The International Federation of Gynecology and Obstetrics (FIGO) Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and care#

In addition to the authors, t he following people provided important contributions during the creation of the document. Thanks go to international experts: Tao Duan, Huixia Yang, Andre Van Assche, Umberto Simeoni, Tahir Mahmood, Biodun Olagbuji, Eugene Sobngwi, Maicon Falavigna, Rodolfo Martinez, Carlos Ortega, Susana Salzberg, Jorge Alvariñas, Gloria Lopez Steward, Silvia Lapertosa, Roberto Estrade, Cristina Faingold, Silvia García, Argyro Syngelaki, Stephen Colagiuri, Yoel Toledano, Mark Hanson, and Blami Dao. Special thanks, for FIGO guidance and coordination, go to President Sabaratnam Arulkumaran, President Elect CN Purandare, Chief Executive Hamid Rushwan, and Chair of the SMNH Committee, William Stones. The following external groups evaluated the document and support its contents: European Board and College of Obstetrics and Gynaecology (EBCOG), The Society of Obstetricians and Gynaecologists of Canada (SOGC), Chinese Society of Perinatal Medicine, Diabetic Pregnancy Study Group (DPSG), African Federation of Obstetrics and Gynaecology (AFOG), South Asian Federation of Obstetrics and Gynecology (SAFOG), Australian Diabetes in Pregnancy Society (ADIPS), International Association of Diabetes in Pregnancy Study Groups (IADPSG), European Association of Perinatal Medicine (EAPM), Diabetes in Pregnancy Study Group of India (DIPSI), and the Diabetes in Pregnancy Study Group of Latin America. In addition to the FIGO Executive Board, all relevant FIGO Committees and Working Groups contributed to and supported the document. Acknowledgments

Timing and risk factors of maternal complications of cesarean section

ObjectiveTo investigate the timing and risk factors of maternal complications of cesarean section (CS).MethodsReview of the files of all women who underwent CS at a tertiary medical center between September 2007 and December 2008 yielded 100 patients with postpartum complications. Their clinical and surgery-related characteristics were compared with 100 women with uncomplicated CS operated in January 2009. Complications were analyzed by prevalence and time of occurrence.ResultsThe only between-group difference in background factors was a higher rate of obesity (BMIxa0>xa030) in the controls. The complication rate was 5.7%. The most common complication was endomyometritis (3.6%), followed by wound infection (1.8%) and wound hematoma (1.2%). In most cases, endomyometritis was diagnosed on postoperative days 2–3 and wound complications on days 2–5; 7 of the 9 readmissions occurred on postoperative days 5–6. On multivariate analysis, significant independent predictors of postoperative complications were surgeon experience (ORxa0=xa02.4, 95% CI 1.2–4.8) and intra-partum CS (ORxa0=xa02.1, 95% CI 1.1–4.3).ConclusionCesarean section performed by a resident or during active labor is associated with an increased risk of postpartum complications. Medical teams should be alert to morbidity in women at risk, particularly during the first 4xa0days after CS.

Maternal obesity is a major risk factor for large-for-gestational-infants in pregnancies complicated by gestational diabetes

ObjectivesOur aim was to evaluate the relative contribution of maternal weight, GDM severity and glycemic control in women with gestational diabetes (GDM) on the prevalence of LGA infants.MethodsA total of 233 women with GDM were classified according to the fasting and/or postprandial glucose levels as in “good” or “poor” glycemic control. Severity of GDM was categorized using fasting plasma glucose on the 3-h 100xa0g oral glucose tolerance test (OGTT).ResultsThe incidence of LGA infants was significantly higher in obese women than in those with lower BMI. There was no significant correlation between GDM severity or level of glycemic control and birth weight or proportion of LGA infants. On multivariate regression analyses, only maternal weight at delivery and fasting glucose level on OGTT were found to be independently and significantly associated with the birth weight, and only maternal weight at delivery was a significant and independent predictor of LGA infants.ConclusionsBoth the GDM severity and maternal weight are independent predictors of infants’ birth weights. Maternal weight at delivery is a major risk factor for LGA infants.

The preconceptional period as an opportunity for prediction and prevention of noncommunicable disease

Preconceptional care is a set of interventions, aimed to identify and modify medical, behavioral, and social risks to a womans health and her pregnancy outcome, prior to conception. Diagnosing and treating some of the common noncommunicable diseases (NCDs) may have an impact on pregnancy outcome. Ample time should be allowed to properly intervene in some of the following situations: hypertension, diabetes, obesity, systemic lupus erythematosus, thyroid disease, anemia, epilepsy, asthma, and cardiac disease. Diabetes mellitus and obesity are common NCDs, with proven efficacy for preconceptional care, for both maternal and perinatal outcome. These primary components of the metabolic syndrome, if properly treated prior to pregnancy, will prevent long-term hazards for the mother, her children, and the next generations, by providing in utero primary prevention of NCDs.

Pregnancy outcome in pregnancies complicated with gestational diabetes mellitus and late preterm birth

AIMnTo assess pregnancy outcome among women with gestational diabetes mellitus (GDM) delivering at the late preterm period.nnnMETHODSnRetrospective observational cohort of all women with GDM who delivered a singleton fetus at the late preterm birth period (34+0/7 to 36+6/7 weeks of gestation). The study group included all women diagnosed with GDM and were compared to a control group of women delivering at the same gestational age period but without known GDM.nnnRESULTSn1849 women were included in the study, of whom 132 (7.1%) were diagnosed with GDM and 1717 (92.9%) were not. Women with GDM had a lower rate of spontaneous vaginal delivery (45.5% vs. 62.9%, p<0.001) and a higher rate of cesarean delivery (50.8% vs. 31.8%, p<0.001). GDM diagnosis incurs an adjusted ratio of 1.82 for cesarean delivery (95% CI 1.24-2.66, p=0.002). Neonates of mothers with GDM had significant higher mean birth weight and birth weight percentile, including higher rate of large-for-gestational age newborns. There were no differences in mortality or other parameters for neonatal morbidity.nnnCONCLUSIONnaccording to our data, late preterm occurring in women with GDM does not confer an increased risk for neonatal complications.

Sonographic evaluation of kidney parenchymal growth in the fetus

ObjectiveThe aim of the study was to establish a nomogram for renal parenchymal thickness throughout pregnancy.MethodsOne-hundred and twenty-eight healthy women with singleton, well-dated, uncomplicated second- or third-trimester pregnancies were prospectively evaluated for renal parenchymal thickness on routine ultrasound scans. The renal parenchyma was measured in transverse and sagittal sections using predefined criteria.ResultsThere were no differences in anterior or posterior parenchymal measurements in either plane by fetal sex. On sagittal-section analysis, no differences were noted between the right and left kidneys. A nomogram was established on the basis of the findings. The results showed constant linear growth of the fetal parenchyma during pregnancy.ConclusionsThe normal fetal parenchyma grows at a constant, linear rate throughout pregnancy. The nomogram formulated may serve as a basis of future studies of the correlation of parenchymal thickness with postnatal kidney function in fetuses with urinary tract anomalies.

Association between sonographic measurement of fetal head circumference and labor outcome

To evaluate the association between sonographically measured head circumference (HC) and labor outcome.

Pharmacological Management of Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is one of the most common morbidities complicating pregnancy, with short- and long-term consequences to the mothers, fetuses, and newborns. Management and treatment are aimed to achieve best possible glycemic control, while avoiding hypoglycemia and ensuring maternal and fetal safety. It involves behavioral modifications, nutrition and medications, if needed; concurrent with maternal and fetal surveillance for possible adverse outcomes. This review aims to elaborate on the pharmacological options for GDM therapy. We performed an extensive literature review of different available studies, published during the last 50xa0years, concerning pharmacological therapy for GDM, dealing with safety and efficacy, for both fetal and maternal morbidity consequences; as well as failure and success in establishing appropriate metabolic and glucose control. Oral medication therapy is a safe and effective treatment modality for GDM and in some circumstances may serve as first-line therapy when nutritional modifications fail. When oral agents fail to establish glucose control then insulin injections should be added. Determining the best oral therapy in inconclusive, although it seems that metformin is slightly superior to glyburide, in some aspects. As for parenteral therapy, all insulins listed in this article are considered both safe and effective for treatment of hyperglycemia during pregnancy. Importantly, a better safety profile, with similar efficacy is documented for most analogues. As GDM prevalence rises, there is a need for successful monitoring and treatment for patients. Caregivers should know the possible and available therapeutic options.

Obstetric antiphospholipid syndrome and long term arterial thrombosis risk

Antiphospholipid syndrome (APS) is classified as the association of a thrombotic event and/or obstetric morbidity in patients persistently positive for antiphospholipid antibodies and/or lupus anticoagulant. To evaluate the incidence of subsequent thrombosis among women diagnosed with purely obstetric APS. We retrospectively reviewed and collected demographic and clinical data from the computerized charts of all patients with obstetric APS, from 1992 to 2017. Eligibility criteria included all women diagnosed with APS, according to the 2006 revised criteria, for whom the clinical manifestations were purely obstetric. The primary endpoint was the occurrence of subsequent thromboembolic events, following diagnosis of obstetric APS. The study included 115 women diagnosed with obstetric APS. During the study’s follow up period, 12 (10.4%) women developed thrombosis. Of the 12 women who developed thrombosis, 9 (75%) of the thrombotic events were arterial. The site of arterial thrombosis was cerebral in all cases. Venous thrombosis occurred in 3 (25%) women, including one in each of the following sites—pulmonary embolism, ovarian vein thrombosis and proximal leg deep vein thrombosis. Our data suggests that women with obstetric APS are at risk for subsequent long-term thrombosis, especially arterial cerebral events. We did not identify any clinical or laboratory unique features among women with obstetric APS who will eventually develop thrombosis.

Pregnancy Outcome in Women with Decreased Sensation of Fetal Movements at Term According to Parity

BACKGROUNDnDecreased sensation of fetal movements (DFM) is a common maternal complaint. Thus, we aimed to evaluate the association between DFM and pregnancy outcome in singleton gestation at term according to parity.nnnMETHODSnA retrospective cohort study of singleton pregnancies at term between 2008 and 2013. Eligibility was limited to women carrying a fetus with no known structural or chromosomal anomalies, at 37+0/7 to 42+0/7xa0weeks of gestation. Women presenting to the delivery ward with DFM were compared with women without similar complaints.nnnRESULTSnOverall, 12,564 nulliparous women and 25,292 multiparous women gave birth during the study period; of them, 300 nulliparous women (2.4%) and 525 multiparous women (2.1%) complained of DFM. For nulliparous women, after adjusting for potential confounders, DFM was associated with antepartum fetal death (aOR 4.6 [95% CI 1.1-19.8]), cesarean delivery (CD) (aOR 1.3 [95% CI 1.01-1.8]), 1-minute Apgar score less thanxa07 (aOR 2.3 [95% CI 1.5-3.5]) and neonatal seizures (aOR 3.2 [95% CI 1.3-8.2]). For multiparous women, DFM was associated with unscheduled CD (aOR 2.7 [95% CI 1.6-4.6]) and CD indicated by intermediate/abnormal fetal heart rate tracing (aOR 4.8 [95% CI 2.8-8.4]).nnnCONCLUSIONSnDFM carries different outcomes according to parity. Although for nulliparous women, DFM is associated with increased risk of CD and immediate adverse perinatal outcome, for multiparous women it is associated with increased risk for CD, with no immediate increased risk for adverse perinatal outcome.