Kathleen Berkowitz

Congenital malformations in offspring of women with hyperglycemia first detected during pregnancy

OBJECTIVES Our aim was to determine risk factors for congenital malformations in offspring of women with hyperglycemia first detected during pregnancy (i.e., women with gestational diabetes). STUDY DESIGN A total of 3743 pregnancies complicated by gestational diabetes mellitus delivered at > 20 weeks of gestation were reviewed for the presence of congenital malformations diagnosed before hospital discharge. Anomalies were categorized as major, minor, or absent. Pregnancies with genetic syndromes and aneuploidies were excluded. In addition to maternal clinical and historic parameters, diagnostic glycemic parameters (fasting and post-glucose-challenge levels from the diagnostic glucose tolerance test, highest fasting serum glucose level, and hemoglobin A1c level before insulin therapy) were examined by logistic regression for predictive risk of major anomalies. RESULTS One or more major congenital anomalies were present in 108 (2.9%) of the newborns; an additional 91 (2.4%) had only minor anomalies. None of the maternal variables were associated with the risk of minor anomalies. By contrast, parity, a history of gestational diabetes mellitus, and several glycemic parameters were associated with the risk of major anomalies. The highest fasting serum glucose level was the best independent predictor (odds ratio 1.13/10 mg/dl, 95% confidence interval 1.09 to 1.34). The fasting serum glucose level at diagnosis, a parameter that is almost uniformly available to clinicians, gave similar predictive information about the risk of major anomalies (odds ratio 1.13, 95% confidence interval 1.08 to 1.14). Stratification of women into subgroups of fasting serum glucose level at diagnosis revealed the incidence of major anomalies to be as follows: 2.1% with a fasting serum glucose level < 120 mg/dl (2973 pregnancies), 5.2% with a fasting serum glucose level of 121 to 260 mg/dl (747 pregnancies), and 30.4% with a fasting serum glucose level > 260 mg/dl (23 pregnancies). CONCLUSION In a large population of women without a diagnosis of diabetes before pregnancy, the maternal fasting serum glucose concentration at diagnosis was a useful predictor of the risk of major but not minor anomalies. The rate of major anomalies doubled with a fasting glucose level > 120 mg/dl. Thus a fasting glucose level below that of overt diabetes outside of pregnancy carries an important risk of major anomalies that must be considered in the counseling and management of these patients.

Risk factors associated with the increasing prevalence of pneumonia during pregnancy

A retrospective chart review of 1120 antepartum admissions revealed the prevalence of antepartum pneumonia rose to 1 per 367 deliveries. A total of 26 cases in 9560 deliveries were identified with criteria of fever greater than 39 degrees C, productive cough, and radiologic findings of infiltrates or consolidation. Pregnancy-related outcome variables studied were prevalence of preterm labor or birth, birth weight, and trimester of occurrence. Pneumonia characteristics studied were rate and type of organisms recovered, seasonality, and severity of the illness and radiologic findings. Exposure variables relating to the development of pneumonia studied were underlying medical conditions, hematocrit, human immunodeficiency virus status, and drug use. Birth weight, hematocrit, human immunodeficiency virus status, and drug use were compared with a randomly selected sample of women drawn from the general population delivered of infants during the study time period. One patient experienced preterm delivery, which occurred 1 month after cure of pneumonia. Birth weight was significantly lower in the study group (2770 +/- 224 gm versus 3173 +/- 99 gm, p less than 0.01). The most common organism recovered was Streptococcus pneumoniae. A total of 42% of patients had multilobar involvement and two required intubation. Cocaine use (52% in the study group versus 10% in the general population, p less than 0.01) and human immunodeficiency virus positivity (24% in the study group versus 2% in the general population, p less than 0.01) were significant risk factors for antepartum pneumonia.

False-negative syphilis screening: The prozone phenomenon, nonimmune hydrops, and diagnosis of syphilis during pregnancy

The prevalence of congenital syphilis is rapidly rising in several areas of the United States. Efforts to control the disease depend on the effectiveness of established screening strategies and treatment of infected pregnant women. False-negative test results hinder these efforts and leave the fetus at risk for acquiring congenital syphilis. Recently we encountered four cases of false-negative syphilis serologic results in women who gave birth to infants with congenital syphilis. The false-negative results were caused by the prozone phenomenon. The prozone phenomenon, seen during primary and secondary syphilis, occurs because a higher than optimal amount of antibody in the tested sera prevents the flocculation reaction typifying a positive result in reagin tests. Serum dilution is necessary to make the correct diagnosis. We recommend that for any pregnant woman with apparently negative syphilis serologic results in whom fetal compromise of unknown etiology exists, particularly nonimmune hydrops, nontreponemal testing should be repeated using serum dilutions to prevent a missed diagnosis of syphilis. We further recommend serum dilution as a routine procedure for all pregnant women in areas of high syphilis prevalence.

Mitochondrial myopathy and preeclampsia associated with pregnancy.

Mitochondrial myopathy is characterized by weakness, exercise intolerance, and acidosis. Pregnancy has been reported to accelerate the disease process. This report discusses pregnancy and management of labor complicated by mitochondrial myopathy and the therapeutic dilemmas that arise when preeclampsia is diagnosed.

Postpartum osteomyelitis caused by group B streptococcus

Postpartum infections caused by group B streptococci are generally limited in scope. We report a case of vaginal colonization with group B streptococcus that progressed in the postpartum period to osteomyelitis that necessitated total hip replacement. The patient had no risk factors predisposing to streptococcal osteomyelitis. An altered immune status in pregnancy and intrapartum bacteremia may be involved in the pathogenesis of this infection.

FETAL LUNG MATURATION : COMPARISON OF BIOCHEMICAL INDICES IN GESTATIONAL DIABETIC AND NONDIABETIC PREGNANCIES

OBJECTIVE To compare the biochemical maturation of the components of the lung profile according to gestational age between reliably dated gestational diabetic and nondiabetic pregnancies. STUDY DESIGN Lung maturation was compared in reliably dated pregnancies in 501 gestational diabetic women and 561 nondiabetic women. Lecithin/sphingomyelin ratio (L/S) and phosphatidylglycerol (PG) were evaluated by analysis of variance according to the presence or absence of diabetes and weeks of gestational age. The effect of gestational diabetes on fetal lung maturation was determined by analysis of variance. RESULTS The gestational diabetic group had no clinical or statistical differences in L/S ratios as compared to the nondiabetic patients at any gestational age. There were no differences in mean percent PG between the diabetic and nondiabetic groups at any gestational age. By 37 completed weeks, 86% of the L/S ratios and 78% of the PG values were mature in the diabetic group as compared to 80% of the L/S ratios and 78% of the PG values in the control group (P = .33 and .43, respectively). CONCLUSION In reliably dated gestational diabetic pregnancies, biochemical maturation of the fetal lung strongly correlates with gestational age and does not appear to be significantly delayed when compared to a nondiabetic control group.