Nestor Demianczuk

Gestational diabetes mellitus: prevalence, risk factors, maternal and infant outcomes

Objectives: To study prevalence, risk factors, and maternal and infant outcomes of women with gestational diabetes mellitus (GDM). Methods: A retrospective cohort study was performed based on 111 563 pregnancies delivered between 1991 through 1997 in 39 hospitals in northern and central Alberta, Canada. Multivariate logistic regression was used to estimate the odds ratios with 95% confidence intervals, and to control for confounding variables. Results: The prevalence of GDM was 2.5%. Risk factors for GDM included age >35 years, obesity, history of prior neonatal death, and prior cesarean section. Teenage mothers and women who drank alcohol were less likely to have GDM. Mothers with GDM were at increased risk of presenting with pre‐eclampsia, premature rupture of membranes, cesarean section, and preterm delivery. Infants born to mothers with GDM were at higher risk of being macrosomic or large‐for‐gestational‐age. Conclusions: Specific conditions predispose to GDM which itself is associated with a significantly increased risk of maternal and fetal morbidity.

Impact of pregnancy-induced hypertension on fetal growth

OBJECTIVE The purpose of this study was to evaluate the effect of different types of pregnancy-induced hypertension on fetal growth. STUDY DESIGN A retrospective cohort study was conducted on the basis of 16,936 births from January 1, 1989, through December 31, 1990, by means of data from a population-based perinatal database in Suzhou, China. Pregnancy-induced hypertension was classified as gestational hypertension, preeclampsia, or severe preeclampsia-eclampsia. Univariate and multivariate regression analyses were performed to examine the effect of the various types of pregnancy-induced hypertension on gestational age, preterm birth, birth weight, low birth weight, and intrauterine growth restriction. RESULTS Gestation was 0.6 week shorter in women with severe preeclampsia than in normotensive women (P <.01). However, the risk of preterm birth was not increased with any classification of pregnancy-induced hypertension (for severe preeclampsia: adjusted odds ratio 1.75; 95% confidence interval, 0.88-3.47). After adjustment for duration of gestation and other confounders, preeclampsia and severe preeclampsia increased the risk of intrauterine growth restriction and low birth weight. The adjusted odds ratios of low birth weight were 2.65 (1.73-4.39) for preeclampsia and 2.53 (1.19-4.93) for severe preeclampsia. However, the risk of low birth weight was not increased significantly for gestational hypertension (adjusted odds ratio 1.56 [1.00-2.41]). CONCLUSION Preeclampsia increases the risk of intrauterine growth restriction and low birth weight.

An international trial of antioxidants in the prevention of preeclampsia (INTAPP).

OBJECTIVE We sought to investigate whether prenatal vitamin C and E supplementation reduces the incidence of gestational hypertension (GH) and its adverse conditions among high- and low-risk women. STUDY DESIGN In a multicenter randomized controlled trial, women were stratified by the risk status and assigned to daily treatment (1 g vitamin C and 400 IU vitamin E) or placebo. The primary outcome was GH and its adverse conditions. RESULTS Of the 2647 women randomized, 2363 were included in the analysis. There was no difference in the risk of GH and its adverse conditions between groups (relative risk, 0.99; 95% confidence interval, 0.78-1.26). However, vitamins C and E increased the risk of fetal loss or perinatal death (nonprespecified) as well as preterm prelabor rupture of membranes. CONCLUSION Vitamin C and E supplementation did not reduce the rate of preeclampsia or GH, but increased the risk of fetal loss or perinatal death and preterm prelabor rupture of membranes.

The Use of First Trimester Ultrasound

OBJECTIVE To review the clinical indications for first trimester ultrasound. OUTCOME Proven clinical benefit from first trimester ultrasound. EVIDENCE MEDLINE search and bibliography reviews in relevant literature. VALUES Content and recommendations reviewed by the principal authors and the Diagnostic Imaging Committee of the Society of Obstetricians and Gynaecologists of Canada. Levels of evidence were judged as outlined by the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS 1. First trimester ultrasound is recommended for assessment of threatened abortion to document fetal viability (II-2B) or for incomplete abortion to identify retained products of conception (II-2B). 2. First trimester ultrasound is not recommended to diagnose pregnancy, to date pregnancy when last normal menstrual period and physical examination are concordant, or to investigate an inevitable abortion (II-2B). First trimester ultrasound is indicated when last menstrual period date is uncertain (I-A). 3. First trimester ultrasound is recommended prior to pregnancy termination. (II-2B) 4. First trimester ultrasound is recommended during diagnostic or therapeutic procedures requiring visual guidance (e.g., chorionic villus sampling, amniocentesis) and prior to cervical cerclage placement. (I-A) 5. First trimester ultrasound is recommended for suspected multiple gestation to allow for reliable determination of chorionicity or amnionicity. (II-2A) 6. First trimester ultrasound is recommended for suspected ectopic pregnancy, molar pregnancy, and suspected pelvic masses. (II-1A) 7. First trimester ultrasound is recommended for early assessment of anatomic development in situations of increased risk for major fetal congenital malformations. (II-3C) 8. Nuchal translucency screening should only be offered as part of a comprehensive prenatal screening and counselling program by experienced operators with appropriate quality assurance processes in place (II-2A).

Effect of Older Maternal Age on the Risk of Spontaneous Preterm Labor: A Population-Based Study

To determine if older maternal age (35 years and older) at first birth was an independent risk factor for spontaneous preterm labor, we conducted a retrospective population-based cohort study. Using provincial perinatal data, we developed separate risk models for low- and high-risk women using multivariate logistic regression. We found that older maternal age exerted a direct and independent effect on spontaneous preterm labor for both nulliparous women with no preexisting chronic illnesses or pregnancy complications (low-risk) and nulliparous women who did not have any preexisting chronic illnesses, but developed one or more pregnancy complications (high-risk).

Surgical Site Infection Following Elective Caesarean Section: A Case-Control Study of Postdischarge Surveillance

OBJECTIVES To ascertain the incidence of postoperative surgical site infection (SSI) following elective Caesarean section (CS) and to compare demographic characteristics and antibiotic administration between infected cases and noninfected control subjects. METHODS We conducted a retrospective case-control study of patients undergoing elective CS between 1996 and 2002 at a tertiary centre. Infection-control personnel attempted to contact by telephone all women who had had Caesarean sections, 1 month after their surgery. The women they reached were asked to complete a questionnaire based on CDC-validated criteria for infection to determine whether SSI had occurred. Control subjects without SSI were matched on the basis of having had an elective CS and by date of surgery. We then reviewed the hospital records of both groups. RESULTS Over the study period, 1250 elective Caesarean sections were performed and 124 infected cases were identified, giving an overall SSI incidence of 9.9%. Of the 342 women reviewed (124 cases, 218 control subjects), 23% received prophylactic intraoperative antibiotics. Cases and control subjects differed significantly in terms of estimated blood loss, with fewer control subjects having excessive blood loss (P = 0.04). Among those women receiving postoperative antibiotics, case subjects received a significantly higher number of doses than did control subjects (P = 0.003). The groups did not differ significantly in terms of overall antibiotic administration or other demographic variables. CONCLUSIONS The incidence of SSI following elective CS according to postdischarge surveillance was 9.9%, which is higher than expected for a low-risk procedure. Because follow-up was not possible for all cases, this incidence may be an underestimate. Underuse of antimicrobial prophylaxis may also be a contributing factor, because prophylactic antibiotics were administered in less than 25% of cases.

Where and to what extent is prevention of low birth weight possible

Low birth weight (LBW), due to shortened gestation and/or inadequate fetal growth, is the major determinant of infant mortality and morbidity. Despite improvements in infant mortality, there has been no reduction in LBW rates. The authors examined the relationship between 33 maternal characteristics and the increased risks of preterm (PT) delivery or small-for-gestational-age (SGA) births in 76,444 Alberta women 1994-1997. PT was associated with preexisting medical conditions, obstetrical history, and pregnancy complications. Modifiable factors such as advanced maternal age contributed only 11% to the overall PT risk. SGA births were associated with several modifiable factors, including low prepregnancy weight, maternal age, smoking, drinking, and drug dependency. These contributed to 29% and 31% of PT and term SGA births. Smoking remains an important target for intervention, having contributed to 8% of PT births and about 24% of SGA births. SGA appears to be more amenable to prevention than PT delivery.

Modifiable Risk Factors for Term Large for Gestational Age Births

To determine modifiable and nonmodifiable risk factors for term large for gestational age (T-LGA) births in Northern and Central Alberta and their public health importance, a retrospective cohort study (n = 115,198) of singleton live births (1996–2003) was conducted using maternal and newborn data from a provincial perinatal database. After adjusting for potential confounders, predictors of T-LGA births included prepregnancy weight 91 kg or greater, multiparity, and previous LGA birth. The strongest modifiable predictor was prepregnancy weight 91 kg or greater (OR = 2.52; CI 2.39, 2.65). The population-attributable risk percentage for prepregnancy weight 91 kg or greater was 10%.

Twin-to-twin transfusion syndrome: a review of 27 cases and the relationship between gestational age at diagnosis and serial amniocentesis on outcome

Abstract Objective: To review outcomes of twin-to-twin syndrome (TTTS) cases and to examine the relationship between gestational age at diagnosis and serial amniocentesis drainage on these outcomes. Methods: Charts were reviewed from a 5-year period. Charts with a diagnosis of TTTS and multiples with discordant growth, polyhydramnios, oligohydramnios, or intrauterine growth restriction were reviewed. Diagnosis of TTTS was confirmed by ultrasound and pathological examination. Cases with placental insufficiency or chromosomal, cardiac, or urinary tract abnormalities were excluded. Outcomes were: survival rates, gestational age at delivery, and birth weight. Results were analyzed using the χ 2 and t tests. Results: Overall survival rate was 71%. Mean gestational age at delivery was 27.8 weeks, and mean birth weight was 1,141 g. If diagnosis was made before 24 weeks of gestation, the survival rate was 50%; if it was made after 24 weeks of gestation, survival was 100%. If drainage was required, survival rate was 56%. If no drainage was required, survival was 100%. Conclusions: TTTS still is associated with significant morbidity and mortality. Other treatments, such as laser ablation, need to be investigated, particularly for the patients who present in the second trimester. Studies of long-term morbidity also are needed.

Infants at Psychosocial Risk and their Caregivers: Selection for Early Intervention - Results of the Pilot Study

Healthy term infants whose home and social environments are insufficiently supportive or nurturing may be disadvantaged. This pilot study evaluates the recruitment and testing protocol for a planned longitudinal trial on the comparison of two community-based early interventions to improve psychosocial outcomes for these infants and their low resource mothers. Psychosocial risk for 33 mothers included: first-time inexperienced primary or sole caregiver, age 16-34 years with uneventful postpartum recovery;