Shlomit Riskin-Mashiah

First-Trimester Fasting Hyperglycemia and Adverse Pregnancy Outcomes

OBJECTIVE The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study found strong associations between higher levels of maternal glucose at 24–32 weeks, within what is currently considered normoglycemia and adverse pregnancy outcomes. Our aim was to evaluate the associations between first-trimester fasting plasma glucose level and adverse pregnancy outcomes. RESEARCH DESIGN AND METHODS Charts of all patients who delivered at our hospital between June 2001 and June 2006 were reviewed. Only subjects with singleton pregnancy and a recorded first-trimester fasting glucose level were included. Women with pregestational diabetes, fasting glucose level >105 mg/dl, or delivery <24 weeks were excluded. Fasting glucose levels were analyzed in seven categories, similar to the HAPO study. The main outcomes were development of gestational diabetes mellitus (GDM), large-for-gestational-age (LGA) neonates and/or macrosomia, and primary cesarean section. Multivariate logistic regression analysis was used; significance was <0.05. RESULTS A total of 6,129 women had a fasting glucose test at median of 9.5 weeks. There were strong, graded associations between fasting glucose level and primary outcomes. The frequency of GDM development increased from 1.0% in the lowest glucose category to 11.7% in the highest (adjusted odds ratio 11.92 [95% CI 5.39–26.37]). The frequency of LGA neonates and/or macrosomia increased from 7.9 to 19.4% (2.82 [1.67–4.76]). Primary cesarean section rate increased from 12.7 to 20.0% (1.94 [1.11–3.41]). CONCLUSIONS Higher first-trimester fasting glucose levels, within what is currently considered a nondiabetic range, increase the risk of adverse pregnancy outcomes. Early detection and treatment of women at high risk for these complications might improve pregnancy outcome.

The relationship between delivery mode and mortality in very low birthweight singleton vertex-presenting infants

Objective  To investigate the factors associated with caesarean delivery and the relationship between mode of delivery and mortality in singleton vertex‐presenting very low birthweight (≤1500 g) live born infants.

Delivery Mode and Severe Intraventricular Hemorrhage in Single, Very Low Birth Weight, Vertex Infants

OBJECTIVE: To investigate the association between delivery mode and grade 3–4 intraventricular hemorrhage in singleton, vertex presenting, very low birth weight (VLBW) (1,500 g or less) liveborn infants. METHODS: The Israel National VLBW Infant Database includes perinatal and neonatal data on greater than 99% of all VLBW newborns. A total of 4,658 singleton vertex-presenting infants born at 24–34 weeks were included (1995–2004). Infants with lethal congenital malformations, delivery room deaths, and home deliveries were excluded. Our population-based observational study evaluated the effect of delivery mode and confounding variables on severe intraventricular hemorrhage using univariable and multivariable logistic regression analyses. RESULTS: The rate of severe intraventricular hemorrhage was 10.4%. Cesarean delivery rate was 54.3%. The rate of severe intraventricular hemorrhage was 7.7% for infants delivered by cesarean compared with 13.6% in vaginal delivery (P<.001). However, analysis according to gestational age showed that the rate of severe intraventricular hemorrhage was similar in cesarean and vaginal delivery in all gestational age groups. In the multivariable model, cesarean delivery had no effect on the odds for severe intraventricular hemorrhage (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.77–1.24). Other factors independently associated with severe intraventricular hemorrhage included gestational age (OR 0.71, 95% CI 0.68–0.75 for each week increase), maternal hypertensive disorder (OR 0.43, 95% CI 0.30–0.61), no antenatal steroids (OR 2.70, 95% CI 2.12–3.45), 1-minute Apgar score 0–3 (OR 1.72, 95% CI 1.33–2.21), delivery room resuscitation (OR 2.16, 95% CI 1.65–2.83), and non-Jewish ethnicity (OR 1.28, 95% CI 1.03–1.59). CONCLUSION: In this population-based study, the odds for severe intraventricular hemorrhage were not influenced by mode of delivery in vertex-presenting singleton VLBW infants after controlling for gestational age. LEVEL OF EVIDENCE: II

Autonomic Imbalance in Preeclampsia: Evidence for Increased Sympathetic Tone in Response to the Supine-Pressor Test

Objective To examine whether an increase in sympathetic nervous tone contributes to the augmented response to cardiovascular reflex testing in preeclamptic women. Methods Maternal electrocardiograms were recorded from 11 nonpregnant women and 25 normotensive and 15 preeclamptic nulliparous women at term, during periods of quiet respiration in the left-lateral position and after shifting to the supine position. Power spectral analysis was applied to epochs of 512 consecutive beat-to-beat intervals to determine the contribution of sympathetic tone, parasympathetic tone, and respiratory sinus arrhythmia to heart rate variability. Results Both normotensive and preeclamptic pregnant women showed a significant decrease in respiratory sinus arrhythmia and an increase in sympathetic tone compared with nonpregnant women. In nonpregnant and in normotensive pregnant women, shifting from the left-lateral to the supine position did not cause any change in autonomic characteristics. In contrast, preeclamptic women demonstrated a marked increase in power within the very lowfrequency range representing sympathetic tone, from 288 ± 214 to 556 ± 322 second2/Hz, in response to the same challenge (P < .05). Conclusion Third-trimester pregnancy is characterized by sympathetic overactivity. When complicated by preeclampsia, sympathetic overreactivity to cardiovascular reflex testing is observed. Our data support the notion that the pathophysiologic phenomena that characterize preeclampsia are mediated not only by circulating or locally acting vasoactive substances, but also, at least in part, by an increase in sympathetic nervous tone.

Cerebrovascular reactivity in normal pregnancy and preeclampsia

OBJECTIVE To compare cerebrovascular reactivity in normotensive and preeclamptic pregnant women. METHODS Transcranial Doppler ultrasound was used to measure peak, end‐diastolic, and mean velocities in the middle cerebral arteries of 45 normotensive and 36 pre‐eclamptic women in the third trimester. All measurements were done in the left lateral position at baseline, during 5% carbon dioxide (CO2) inhalation, and during an isometric hand‐grip test. Blood pressure (BP), heart rate, oxygen (O2) saturation, and end‐tidal partial pressure of carbon dioxide (pCO2) were recorded with each Doppler measurement. The mean pulsatility index (PI), resistance index (RI), and cerebral perfusion pressure at each time was compared using two‐way repeated measures analysis of variance. Cerebrovascular reactivity, calculated as the percentage change in response to each maneuver, was also compared using analysis of covariance. A post hoc power analysis was performed to evaluate the primary measures of the study (middle cerebral artery PI and RI). Using alpha error of 5%, the statistical power to identify a difference in PI and RI in women with preeclampsia compared with normotensive women was 90% and 67%, respectively. The statistical power to identify a difference in PI and RI in response to the two maneuvers was 69% and 53%, respectively. Statistical significance was set at P < .05. RESULTS Preeclamptic women had higher baseline cerebral perfusion pressure (90.4 compared with 61.9 mmHg, P < .05) and lower PI (0.64 compared with 0.76, P < .05) and RI (0.46 compared with 0.51, P < .05) than normotensive pregnant women. In normotensive patients, both 5% CO2 inhalation and isometric hand‐grip test caused a significant decrease in PI (−9.5% and −6.1%, respectively) and RI (−6.5% and −4.2%, respectively). In contrast, in preeclamptic patients there was no change in any of the middle cerebral artery parameters in response to either maneuver. CONCLUSION Normotensive pregnant women had normal middle cerebral artery responses to both 5% CO2 inhalation and isometric hand‐grip test. Preeclamptic patients had elevated baseline cerebral perfusion pressure and reduced vasodilatory responses to both tests. These findings are consistent with a state of vasoconstriction in preeclamptic women that is unresponsive to stimuli that under normal circumstances result in vasodilation.

In utero diagnosis of intrapericardial teratoma: a case for in utero open fetal surgery

We present a case of intrapericardial teratoma diagnosed by ultrasound at 26 weeks of gestation presenting as a large tumour mass and rapid development of hydrops fetalis. The fetus died in utero one day before scheduled open fetal surgery. Copyright

Normal fasting plasma glucose levels during pregnancy: a hospital-based study

Abstract Objective: Recently, the International Association of Diabetes and Pregnancy Study Groups have suggested new criteria for the diagnosis of gestational diabetes including a fasting glucose level of ≥92 mg/dL. We determined reference levels for normal fasting plasma glucose levels throughout pregnancy and evaluated the new normal cut-off for fasting glucose level. Methods: Charts of patients who delivered in our hospital between June 2001 and June 2006 were reviewed. Women with pregestational diabetes, fasting glucose level >105mg/dL or delivery at <24 weeks were excluded. Fasting glucose levels were assessed in 11 time categories between three months prior and four months postpartum in 7946 women. Results: Compared to preconception levels, fasting glucose levels decreased by a median of 3 mg/dL in the first trimester (81–78 mg/dL). During the third trimester a slight further glucose reduction was observed (median 76 mg/dL). After delivery fasting glucose levels increased sharply (84 mg/dL in the puerperium and 81 mg/dL by three months postpartum). Throughout pregnancy 5.2–9.0% of pregnant women had a fasting glucose level of ≥92 mg/dL ;ibcompared to 8.2% in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study]. Conclusion: Fasting glucose levels decrease early in pregnancy with only slight further decrease later on. It seems that the same fasting glucose cut-off can be used throughout pregnancy for the diagnosis of gestational diabetes mellitus.

Preeclampsia is associated with global cerebral hemodynamic changes

Objective: To compare blood flow-velocity parameters in the anterior and posterior cerebral arteries between normotensive and preeclamptic pregnant women. Methods: Transcranial Doppler ultrasound was used to measure peak, end-diastolic, and mean velocities in the anterior cerebral artery (ACA) and posterior cerebral artery (PCA) of 22 normotensive and 12 preeclamptic women in the third trimester. All measurements were performed with the subject in the left lateral position. Blood pressure and heart rate were recorded with each Doppler measurement. The mean pulsatility index (PI), resistance index (RI), and cerebral perfusion pressurefor each artery was averaged and compared. Statistical sigmnficance was set at P <.05. Results: Preeclamptic women had higher cerebral perfusion pressure in both ACA and PCA (64.7 ± 5.9 and 78.1 ± 7.6 compared with 42.4 ± 2.6 and 54.1 ± 4.1 mmHg, P <. 05), lower PI (0.83 ± 0.05 and 0. 71 ± 0.04 compared with 0.96 ± 0.04 and 0. 84 ± 0.02, P <. 05), and lower RI (0.55 ± 0.02 and 0.49 ± 0.02 compared with 0. 60 ± 0.02 and 0.55 ± 0. 01, P <. 05) than normotensive pregnant women. Conclusion: Preeclamptic patients have globally elevated cerebral perfusion pressure and lower resistance in the cerebral circulation than normotensive pregnant women.

Assisted Reproductive Technologies: Medical Safety Issues in the Older Woman

Abstract Previous study has shown that in the United States, most maternal deaths and severe obstetric complications due to chronic disease are potentially preventable through improved medical care before conception. Many women who need assisted reproductive technology (ART) because of infertility are older than the average pregnant woman. Risks for such chronic diseases as obesity, diabetes mellitus, chronic hypertension, cardiovascular disease (CVD), and malignancy greatly increase with maternal age. Chronic illness increases the risk of the in vitro fertilization (IVF) procedure and is also associated with increased obstetric risk and even death. The objective of this review is to outline the potential risks for older women who undergo ART procedures and pregnancy and to characterize guidelines for evaluation before enrollment in ART programs. A PubMed search revealed that very few studies have related to pre-ART medical evaluation. Therefore, we suggest a pre-ART medical assessment, comparable to the recommendations of the American Heart Association before noncompetitive physical activity and the American Society of Anesthesiologists before elective surgery. This assessment should include a thorough medical questionnaire and medical examination. Further evaluation and treatment should follow to ensure the safety of ART procedures and of ensuing pregnancies.

Cerebrovascular hemodynamics in pregnant women with mild chronic hypertension.

OBJECTIVE: To evaluate and compare the cerebrovascular autoregulation in pregnant normotensive and mild chronic hypertensive patients without preeclampsia. METHODS: Transcranial Doppler ultrasound was used to measure peak, end-diastolic, and mean velocities in the middle cerebral arteries of 34 normotensive and 17 mild chronic hypertensive women in the third trimester of pregnancy. Measurements were performed in the left lateral position at baseline, during 5% CO2 inhalation, and during an isometric handgrip test. Mean pulsatility index, resistance index, and cerebral perfusion pressure at each time were compared using 2-way repeated measures analysis of variance. Using an alpha error of 5%, the statistical power to identify differences in middle cerebral artery indices in response to the two maneuvers was at least 90% and 50% in comparison between the two groups. Significance was P < .05. RESULTS: Pregnant women with mild chronic hypertension had higher baseline mean blood pressure but similar pulsatility index (0.73 versus 0.75), resistance index (0.50 versus 0.50), and cerebral perfusion pressure (59.9 versus 61.8 mm Hg) compared with normotensive pregnant women. Both maneuvers caused a significant reduction in pulsatility index and resistance index and higher cerebral perfusion pressure. No significant differences were noted in the response to either 5% CO2 inhalation or isometric handgrip test between the two groups. CONCLUSION: Pregnant women with mild chronic hypertension show normal cerebral vasomotor reactivity to CO2 breathing and isometric handgrip. This suggests that the abnormal cerebrovascular autoregulation in preeclampsia is not directly linked to the elevated blood pressure but rather is determined by a separate pathophysiologic pathway. LEVEL OF EVIDENCE: II-2