Hugh M. Ehrenberg

The influence of obesity and gestational diabetes mellitus on accretion and the distribution of adipose tissue in pregnancy

OBJECTIVE The purpose of this study was to evaluate the effect of pregravid obesity and gestational diabetes mellitus (GDM) on the longitudinal accretion and distribution of adipose tissue in pregnancy. STUDY DESIGN Women with normal glucose tolerance and GDM were evaluated before conception, early (12-14 weeks) and late (33-36 weeks) in gestation. Fat mass, lean body mass, and percent body fat were assessed longitudinally with hydrodensitometry. Serial biceps, triceps, subscapular, iliac, costal, mid thigh, and lower thigh skinfold measurements quantified the changes in fat mass distribution. Pregravid obesity was defined as >25% body fat. RESULTS Subjects included 19 patients with GDM (5 lean women, 14 obese women), and 33 patients with normal glucose tolerance (controls; 12 lean women, 21 obese women). GDM and control subjects were similar in pregravid percent body fat (29.6% vs 27.9%, P=.47) and fat mass (20.8 kg vs 18.2 kg, P=.37). Values for subjects with GDM and controls were also similar in terms of percent body fat, fat mass, and weight gained (change in percent body fat, -0.7% vs 1.9% [P=.07]; change in fat mass, 3.8 kg vs 5.0 kg [P=.08]; change in weight, 12.0 kg vs 13.2 kg [P=.35]). Lean subjects gained more percent body fat compared with obese subjects (change in percent body fat, 3.3% vs 0.1% [P=.004]) but gained similar amounts of fat mass (change in fat mass, 4.7 kg vs 4.2 kg [P=.58]), lean body mass (7.6 kg vs 8.8 kg [P=.18]), and weight (change in weight, 12.3kg vs 13.0 kg [P=.61]) The distribution of adipose tissue that was accumulated as estimated with skinfold measurements was similar between patients with GDM and glucose tolerance (P>.05 for all changes in skinfolds), but significantly different between lean and obese patients (P<.05 for all changes in skinfolds). Lean women gained a predominance of adipose tissue peripherally over that in obese women. CONCLUSION Lean women accrue significantly more fat mass than obese women, regardless of glucose tolerance. Pregestational obesity rather than GDM influences the distribution of adipose accretion.

Abbreviated postpartum magnesium sulfate therapy for women with mild preeclampsia : A randomized controlled trial

OBJECTIVE: To determine whether women receiving 12-hour and 24-hour postpartum magnesium sulfate (MgSO4) therapy for mild preeclampsia have differing clinical courses. METHODS: Consenting women with suspected mild preeclampsia were randomly assigned to12 hours or 24 hours of MgSO4 postpartum therapy. Treatment was continued after the assigned time period if there was evidence of severe preeclampsia. The frequency of progression to severe disease and other outcomes were compared between study groups using the Fisher exact, &khgr;2, and Student t tests where appropriate. RESULTS: Between January 2001 and August 2004, 200 women were enrolled. The 12-hour and 24-hour groups were similar in age, parity, delivered gestational age, anesthesia, and mode of delivery, as well as for proteinuria and blood pressure. In the 12-hour group, MgSO4 treatment was extended in seven women (6.9%) for progression to severe disease versus one (1.1%) in the 24-hour group (P=.07). Women who developed severe disease had higher blood pressures at the first prenatal visit (140/78 versus 122/69, P≤.02 for systolic and diastolic pressures), at the time of randomization (152/88 versus 135/78, P≤.03 for systolic and diastolic pressures), and were more likely to have insulin-requiring diabetes (27.3% versus 4.4%, P=.03). No 12-hour patients required treatment beyond 24 hours postpartum. There were no seizures, MgSO4 toxicity, or intolerance in either group. CONCLUSION: Twelve hours of postpartum MgSO4 therapy for mild preeclampsia is associated with infrequent disease progression and a clinical course similar to that with 24-hour therapy. Patients with chronic hypertension and insulin-requiring diabetes are at risk for progression to severe disease postpartum. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00344058 LEVEL OF EVIDENCE: I

Endometrial stromal sarcoma: Analysis of recurrence following adjuvant treatment

OBJECTIVE Endometrial stromal sarcoma (ESS) is a rare and indolent form of uterine cancer with ill-defined post-operative treatment guidelines. The goal of this study was to evaluate the rate of recurrence and the effect of various adjuvant treatment modalities. METHODS Patients with ESS at 4 institutions were identified (1986-2007). Patient demographics, pathology, treatment, and follow-up information were collected. Chi-square statistical analysis was performed. RESULTS Forty-three patients with ESS were identified. All patients initially underwent hysterectomy. Twenty-eight (66.7%) had early stage, 12 (28.6%) had advanced stage ESS, and 2 (4.8%) had no staging information. Eight patients received pelvic and or vaginal cuff radiation treatment, with or without chemotherapy. Sixteen of 43 patients experienced a recurrence at an average of 100.5months. Thirty-three patients were treated with progestin therapy alone or followed expectantly. Complete outpatient records were available for 28 of these patients. Sixteen patients (57%) were followed expectantly while 12 (43%) received progestins. Patients receiving progestins vs. expectant management had a lower rate of recurrence in stage 1 (14.3% vs 38.5%, p=0.26) and all stages (33% vs 50%, p=0.38). Twenty-three of 28 (82.1%) patients underwent initial oophorectomy. Eight of 23 (34.8%) had a recurrence, compared to 4 of 5 (80%) in those who retained their ovaries (p=0.06). CONCLUSIONS ESS is a rare cancer that is difficult to study. We found removal of the adnexa and post-operative treatment with progestin therapy decreased recurrence rates. These two treatment strategies should be considered in the treatment of patients with all stages of ESS.

ANTIBIOTICS AND THE MANAGEMENT OF PRETERM PREMATURE RUPTURE OF THE FETAL MEMBRANES

Preterm premature rupture of membranes remains an important cause of preterm birth and neonatal morbidity and mortality. Although the underlying pathophysiology remains largely undefined, subclinical infection has been implicated both in the mechanism of membrane rupture and the resultant neonatal morbidity. The use of maternal systemic antibiotics reduces both neonatal and maternal morbidity in the expectant management of PPROM. Although concern persists over the development of resistant strains of organisms involved with neonatal sepsis, current data support the use of antibiotics in this setting. Further study is needed regarding the risks and benefits of additional tocolytic therapy or antenatal corticosteroids in the management of PPROM, and the predictors of successful and unsuccessful conservative management, and subclinical intrauterine infection. This will be helpful in the ultimate delineation of the optimal management scheme for PPROM.