Karen B. Lesser

The use of transvaginal ultrasonography in the diagnosis of ectopic pregnancy

Despite advances in diagnosis made by the introduction of serum beta-subunit of human chorionic gonadotropin determinations and transabdominal ultrasonography, ectopic gestations still present a major diagnostic challenge. The increased resolution of the transvaginally introduced high-frequency ultrasound transducer probes seems to solve this diagnostic problem. In this study 145 patients were referred for ultrasonographic workup because of a suspected ectopic gestation. In 38 patients a diagnosis could be made with classical transabdominal scanning. One hundred seventeen patients required additional transvaginal scanning with a 5.0 and a 6.5 MHz probe. In 98 patients a diagnosis was made during the first transvaginal scan; nine patients were rescanned within 3 days for the final diagnosis. In 56 patients, ectopic pregnancy was successfully ruled out by transvaginal scanning. Thirty-nine ectopic pregnancies were diagnosed. Only one false-positive identification was made. The sensitivity of diagnosing ectopic pregnancy by high-frequency transvaginal sonography was 100%; the specificity was 98.2%. The positive predictive value of this method was 98%, and the negative predictive value was 100%. The rate of the beating fetal heart was seen in the tube (23%). The high number of unruptured tubal pregnancies in this series (66%) suggests the possibility of an early diagnosis that may have therapeutic implications. The use of higher-frequency transvaginal transducer probes improves the diagnosis of the ectopic gestation.

Transabdominal Cerclage: A Laparoscopic Approach

Background The placement of a transabdominal cervical cerclage has been regarded as considerably more morbid than a transvaginal cerclage, in part due to the need for two laparotomies. We describe a technique for the laparoscopic placement and removal of a transabdominal cerclage. Cases Two cases of women with insufficient cervical tissue to place a transvaginal cerclage were managed with a transabdominal cerclage. In one case, the cerclage was placed laparoscopically; in the other, the band was removed, facilitating uterine evacuation following the diagnosis of a missed abortion. In both cases a laparotomy was avoided. Conclusion Laparoscopic placement and removal of a transabdominal cerclage are promising options in the treatment of an incompetent cervix.

Adolescence and very low birth weight infants: A disproportionate association

Objective To examine the incidence of very low birth weight (VLBW) neonates, defined as those weighing less than 1500 g, delivered by adolescents compared with the general obstetric population. Methods A retrospective observational study of 16,857 women delivering live-born infants from January 1,1989, to June 30, 1993, was conducted at the University of Arizona Health Sciences Center. Adolescents were defined as those having a maternal age of 18 years or less at the time of delivery. The rate of VLBW infants delivered to adolescent mothers was compared with the general obstetric population (women at least 19 years old) using χ2 analysis, multiple analysis of variance, and multiple linear regression. Results During the study period, 204 VLBW infants were delivered, yielding an overall VLBW delivery rate of 1.2%. Adolescents had a VLBW delivery rate that was considerably higher than the general obstetrical population: 35 of 1758 (2.0%) versus 169 of 15,099 (1.1%) (P = .002). Whereas adolescents accounted for 10.6% of the total deliveries during the study period, they delivered 17% of the VLBW neonates. The relative risk of an adolescent delivering a VLBW infant was 1.7 (95% confidence interval 1.2-2.2). Conclusion Preterm birth is one of the major unresolved problems in modern obstetrics. Although the association between adolescence and preterm birth has been reported previously, specific attention has not been focused on the VLBW neonate. We conclude that adolescents deliver a disproportionate number of VLBW infants.

Exercise Fails to Improve Postprandial Glycemic Excursion in Women with Gestational Diabetes

The effect of an acute period of moderate intensity exercise on maternal glycemic excursion following a mixed nutrient meal was studied. Five normal (NL) and six gestational diabetic (GDM) subjects were enrolled. A randomized crossover design was used to compare fasting glucose and insulin levels, peak glucose and insulin levels and incremental area of the glycemic and insulin curves following a mixed nutrient meal with or without an exercise stress that took place 14 h earlier. Exercise consisted of upright stationary cycling for 30 min at a heart rate consistent with 60% VO2max. The clinical characteristics of normal and gestational diabetic subjects were comparable. Mean values (+/-SEM) with, versus without, exercise for fasting glucose (NL: 78.9 +/- 2.6 vs. 80.0 +/- 2.6 mg/dl; GDM: 86.4 +/- 2.0 vs. 82.1 +/- 3.5 mg/ dl), peak glucose (NL: 132.3 +/- 10.4 vs. 139.1 +/- 15.6 mg/dl; GDM: 165.8 +/- 5.5 vs. 160.3 +/- 7.8 mg/dl), the area under the glycemic curve (NL: 5758 +/- 1038 vs. 6393 +/- 1281 mg/dl.min; GDM: 8,178 +/- 890 vs. 8,331 +/- 563 mg/dl.min) did not differ. Similarly, plasma insulin levels did not differ between protocols for either group of subjects. Exercise has been proposed as a treatment to reduce glycemia in gestational diabetes. Results from this study indicate a single bout of exercise did not blunt the glycemic response observed following a mixed nutrient meal.

Association Between Polycystic Ovary Syndrome and Glucose Intolerance During Pregnancy

The purpose of our study was to determine if women with polycystic ovary syndrome are more likely than other women with infertility to develop gestational diabetes. All women who were successfully treated for infertility in the reproductive endocrinology clinic at the University of Arizona Health Sciences Center from January 1, 1990, to January 1, 1995, were identified. A retrospective cohort study was performed comparing the incidence of gestational diabetes and abnormal diabetic screening tests among subjects with polycystic ovary syndrome (N = 24) and a general infertility control group (N = 44). The incidence of gestational diabetes diagnosed in subjects with a history of polycystic ovary disease was similar to the incidence of gestational diabetes in subjects with infertility not ascribed to polycystic ovary disease (four subjects, 16.7% v. three subjects, 6.7%; relative risk [RR] 2.05, 95% confidence interval [CI] 0.31-13.57). A greater number of subjects with polycystic ovary syndrome had a positive diabetic screening test compared to the control group (13 subjects, 54% v. 10 subjects, 23%; RR 2.44, 95% CI 1.26-4.71). Our study suggests that women with polycystic ovary syndrome are more likely to have a positive diabetic screening test, but no more likely to have gestational diabetes than other women with infertility.

Elevated zinc protoporphyrin/heme ratios in umbilical cord blood after diabetic pregnancy.

Objective:Offspring of diabetes patients may suffer from tissue iron deficiency. Erythrocyte zinc protoporphyrin/heme (ZnPP/H) ratios measure impaired iron status. The aim of the study was to examine whether cord ZnPP/H ratios were associated with pregnancy glycemic control.Methods:ZnPP/H was measured in cord blood from 31 pregnancies with insulin-treated diabetes (diabetes group) and compared to population normal values. Maternal glycemic control was assessed by daily glucose log, glycosylated hemoglobin and birth weight.Results:Median cord ZnPP/H was higher in the diabetes group than the population normal values (106 (65.2 to 146.8) μ M/M vs 68.2 (37.6 to 98.8) μ M/M, P<0.0001). Ratios were directly correlated to surrogates of control (glycosylated hemoglobin, P=0.05, and birth weight, P<0.04). Cord ZnPP/H ratios from pregnancies with pre-existing and gestational diabetes were similar.Conclusion:Because cord ZnPP/H was higher in large offspring of diabetic pregnancy, it might identify greater iron utilization for fetal erythropoiesis.

Borderline Amniotic Fluid Index and Its Relation to Fetal Intolerance of Labor A 2-Center Retrospective Cohort Study

To determine whether a borderline amniotic fluid index (AFI) in the third trimester is associated with an increased rate of cesarean delivery for fetal intolerance of labor, meconium‐stained amniotic fluid, and intrauterine growth restriction, among other adverse perinatal outcomes.