Steven G. Gabbe

Neonatal morbidity in pregnancy complicated by diabetes mellitus: Predictive value of maternal glycemic profiles

The relationship between glycemic control and perinatal outcome was assessed in a relatively uniform population of 75 White Class B through D pregnant diabetic women. All patients used glucose reflectance meter self-monitoring and performed a minimum of four determinations daily. Mean capillary blood glucose was calculated from a minimum of 16 weeks of determinations. Regression analysis confirmed a correlation between these values and third-trimester hemoglobin A1 (p less than 0.001). The study population was divided into two groups on the basis of mean capillary blood glucose values: group I, mean capillary blood glucose less than 110 mg/dl (43 patients) (mean = 96.8 +/- 7.1); group II, mean capillary blood glucose greater than 110 mg/dl (32 patients) (mean = 126 +/- 9.0). Of the 32 patients in group II, eight had mean capillary blood glucose greater than or equal to 130 mg/dl. The degree of maternal glycemic control appeared to affect perinatal outcome. At least one form of infant morbidity was present in 33% of group I infants compared with 53% of group II. Significant differences were observed for the incidence of hypoglycemia (p less than 0.05), macrosomia (p less than 0.05), and respiratory distress syndrome (p less than 0.01). One of six group I infants delivered at 35 to 36 weeks developed respiratory distress syndrome, compared with four of seven group II patients. The appearance of phosphatidylglycerol in amniotic fluid appeared delayed in group II patients at term. These data suggest that maintaining mean capillary blood glucose values less than 110 mg/dl may serve to reduce several major forms of morbidity in the infant of the diabetic mother. This information is helpful in establishing objectives for glycemic control in pregnant women using self-monitoring techniques.

Risk scoring for preterm labor: Where do we go from here?

Risk scoring systems based on traditional demographic, social, and medical factors have limited use, especially in certain populations. Newer approaches, including frequent cervical examinations, periodic outpatient monitoring for contractions, extensive daily monitoring at home for contractions in very high-risk persons, and identification and reduction of modifiable behavioral risks, offer promise.

Macular edema and pregnancy in insulin-dependent diabetes

Seven women with insulin-dependent diabetes (mean age, 26 years; mean duration of diabetes, 15.4 years) had minimal or no retinopathy before becoming pregnant but developed severe macular edema associated with preproliferative or proliferative retinopathy during the course of their pregnancies. The edema was associated with significant macular capillary nonperfusion, and often with significant proteinuria and mild hypertension. Although proliferation was controlled with panretinal photocoagulation, the macular edema continued to worsen until delivery in all cases and was often aggravated by the photocoagulation. Macular edema and retinopathy both regressed after delivery in some patients but persisted in others, causing significant visual loss. Pregnant women with retinopathy, nephropathy, or hypertension should undergo ophthalmoscopy at least once a month. If proliferative retinopathy develops, panretinal photocoagulation should be applied even if the macular edema is aggravated.

Abnormalities in platelet antiglobulin tests in preeclamptic mothers and their neonates

We prospectively studied 40 women with preeclampsia and 26 women with normal pregnancy for the presence of platelet-bound and circulating platelet-bindable immunoglobulin and complement. Although only 12 patients with preeclampsia had a platelet count less than 150,000/mm3, 36 of 40 demonstrated an abnormal direct antiglobulin test, compared with only three of 26 control subjects (p less than 10(-8]. An abnormal indirect test was also detected in 30 of 40 patients with preeclampsia compared with five of 26 healthy pregnant control women (p = 9.3 X 10(-6]. Abnormal antiglobulin tests persisted for 2 to 6 weeks after delivery. Although each neonate had a platelet count greater than 200,000/mm3 at the time of delivery, 10 of 18 had an abnormal direct antiglobulin test compared with one of 14 control subjects (p = 0.0049). The high frequency of abnormal platelet antiglobulin tests in women with preeclampsia and their neonates may indicate an immune cause of certain aspects of the syndrome or may reflect the extent of platelet activation.

Human Fetal Weight and Placental Weight Growth Curves

A mathematical analysis of human fetal and placental growth curves was made on data collected prospectively from a population at sea level. Both the fetal and placental growth curves can best be described by a form of the logistic equation inhibited growth model. The fetal growth rate reaches its maximum approximately 4 weeks after the placental growth rate has reached its maximum. Growth rate constants were calculated for several populations at various altitudes.

Fetal heart rate monitoring in premature infants weighing 1,500 grams or less

Continuous monitoring tracings of fetal heart rate in 61 infants with birth weights of 1,500 grams or less were analyzed and related to newborn outcome. Reassuring heart rate patterns or good baseline variability correlated well with a normal unbilical artery pH. Fetal heart rate patterns and baseline variability were not related in a predictive way to central nervous system hemorrhage, respiratory distress syndrome, or neonatal death. Early intervention and operative delivery in cases demonstrating abnormal fetal heart rate patterns may have influenced the outcome in these infants. Fetal heart rate patterns can play an important role in the intrapartum assessment of the condition of the very-low-birth-weight infant and may be used to select those infants requiring prompt operative intervention and vigorous neonatal resuscitation.

The effect of oral ritodrine therapy on glucose tolerance in pregnancy

Intravenous ritodrine therapy can cause significant deterioration of maternal glucose homeostasis. We investigated the effect of full maintenance oral ritodrine therapy (120 mg/day) on glucose tolerance in the early third trimester with the use of 50 gm 1-hour screens followed by 100 gm 3-hour oral glucose tolerance tests if the screen level was greater than or equal to 140 mg/dl. Four hundred ninety-one patients were studied, 42 of whom were receiving oral ritodrine therapy. Twenty-one percent of the ritodrine-treated women had an abnormal 1-hour screen, which was not different from the 20% observed in women not receiving therapy. None of the treated group and 13% of the untreated group who had abnormal screens had abnormal oral glucose tolerance tests. The probability of an abnormal test after an abnormal 1-hour screen was also determined.

Prenatal sonographic diagnosis of a vesico-allantoic abdominal wall defect.

The differential diagnosis of fetal ventral wall defects includes omphalocele, gastroschisis, body stalk anom ~ aly, omphalomesenteric duct cyst, and extrophy of the bladder or cloaca. These have all been identified antenatally.•-t Whereas allantoic cyst remnants confined to the umbilical cord have also been prenatally diag ~ nosed,5•6 prenatal detection of a vesica-allantoic abdom· ina) wall defect, is not a common occurence. Of particular importance in this case is that the vesico ~ allantoic cyst prolapsed inward on itself late in gestation and would have been misdiagnosed as a simple umbilical hernia at birth had it not been for early ultrasound evaluation.

The origin of increased serum iron in pregnancy‐induced hypertension

Serum iron was measured in 30 patients with pregnancy-induced hypertension and 24 normal pregnant women. The mean iron concentration was significantly higher in the group with pregnancy-induced hypertension (111 +/- 26 micrograms/ml) than in the controls (69 +/- 17 micrograms/ml) (p less than 0.0001). Readily available laboratory variables were used to determine whether the increased serum iron was the result of (1) hemolysis, (2) hepatocellular injury, or (3) intravascular volume contraction leading to hemoconcentration. It appears that a clinically silent, ongoing hemolytic reaction is responsible for the increase in serum iron seen in patients with pregnancy-induced hypertension.