Steven H. Golde

The role of nonstress tests, fetal biophysical profile, and contraction stress tests in the outpatient management of insulin-requiring diabetic pregnancies

Antepartum fetal surveillance methods applicable in a home glucose-monitored population of pregnant diabetic women have been evaluated. A testing sequence of nonstress heart rate testing, backed up by either the fetal biophysical profile or contraction stress testing employed at a twice weekly interval, in 107 outpatients was compared with the management of 140 historic control patients by weekly nonstress tests and daily plasma estriols. There were 617 of 672 (91.8%) reactive nonstress tests in outpatients compared to 566 of 626 (90.4%) reactive tests in hospitalized control patients. Of 13 contraction stress tests performed in the outpatient group, only one was positive. Although 2,670 estriol determinations were done on hospitalized control patients, none was used for outpatients. No losses were attributed to unexplained antenatal stillbirth in either group. A fetal biophysical score of 8 was found to be at least as reliable as a reactive nonstress test. Antenatal surveillance in the well-controlled, insulin-requiring diabetic woman can be safely achieved with a testing sequence that consists of twice weekly nonstress tests backed up by the fetal biophysical profile and contraction stress tests.

A blind comparison study of the lung phospholipid profile, fluorescence microviscosimetry, and the lecithin/sphingomyelin ratio

Two hundred thirty-six amniotic fluid samples from 215 patients were analyzed for the acidic phospholipids, phosphatidylglycerol (PG) and phosphophatidylinositol (Pl), using two-dimensional chromatography. One hundred seventy-eight samples were compared for gestational age, 166 were compared with lecithin/sphingomyelin (L/S) ratios, and 56 compared with the FELMA microviscosimeter. Although Pl could be detected by the sixteenth gestational week, PG was not found earlier than the thirty-fifth week. Median L/S ratio in samples not containing PG was 1.94, while PG-positive fluid had a median ratio of 3.72 (p less than 0.001). One hundred twelve infants born within 72 hours were evaluated for outcome. No instance of hyaline membrane disease (HMD) occurred in any neonate with detectable PG regardless of L/S ratio, while 2 of 67 (3%) infants with mature L/S ratios developed HMD. The FELMA technique did not mispredict maturity in any neonate who subsequently developed HMD. Two samples contained PG but the neonates were delivered free of lung disease. The phospholipid lung profile appears to be the most accurate method for the evaluation of fetal lung maturity, while the FELMA technique, although less sensitive, is more rapid.

Unilateral tuboovarian abscess: A distinct entity

In a 30 month interval at the Los Angeles County-University of Southern California Medical Center, 85 patients had tuboovarian abscesses removed that were unrelated to complications of pregnancy. Thirty-seven patients (44 per cent) of the 85 had unilateral abscesses. Twenty patients (54 per cent) of the 37 patients with a unilateral abscess were using an intrauterine contraceptive device (IUD). In 13 (65 per cent) of the 20 women using an IUD, the foreign body was a Dalkon Shield. Unilateral pelvic abscesses can occur with or without the presence of an IUD.

Real-time ultrasound of the placenta in assessment of fetal pulmonic maturity.

The use of ultrasound is a noninvasive method of assessing fetal maturity. However, in order for it to be a substitute for amniocentesis, a high degree of accuracy is required. Static ultrasound examination of placental development has revealed certain patterns of maturity which have suggested to be predictors of fetal pulmonary maturity. This study analyzes 100 patients near term for the accuracy of placental grade in predicting pulmonary maturity when measured by the lecithin/sphingomyelin ratio and by clinical development of the respiratory distress syndrome in the neonate. A mature placental grade (Grade III) determined by real-time sonography corresponded to fetal lung maturity in all cases (n = 15). Placental grade as determined by this methodology appeared to be an accurate predictor of fetal maturity in the population examined.

Antepartum fetal surveillance in diabetic pregnant patients

The antepartum fetal surveillance (biochemical and biophysical) data of 140 pregnant diabetic patients were evaluated. We determined how often intervention occurred on the basis of abnormal tests and correlated each test with neonatal outcome. Fifteen of the total 140 patients had their pregnancies terminated because of abnormal biochemical and/or biophysical tests. An abnormal estriol (E3) value preceded the abnormal antepartum fetal heart rate testing in eight of 10 instances. We conclude that the major benefit of the antepartum fetal surveillance techniques, in this group of patients and under the present scheme, is in determining when not to intervene, thus allowing safe prolongation of pregnancy.

The effect of plasma glucose variability on neonatal outcome in the pregnant diabetic patient

Maternal glucose variability was studied in 154 pregnant diabetic patients hospitalized during the last month of their pregnancies. By means of several statistical analyses of the coefficient of variation for within-day plasma glucose variability, we found as follows. (1) There was a significant association between maternal glucose variability and neonatal outcome. (2) Patients with greater glucose variability had more episodes of hyperglycemia, but not hypoglycemia. (3) There was no correlation between maternal glucose variability and the birth weight of the infant. We are proposing the use of an index for glucose variability to monitor glucose control in pregnancy and predict neonatal outcome. Although absence of glucose variability will not ensure prevention of neonatal complications, there is a clear association between greater glucose variability and neonatal complications.

Insulin requirements during labor: A reappraisal

Continuous insulin infusion has been advocated for strict glucose control during labor in insulin-requiring diabetic patients. We studied 33 insulin-dependent diabetic patients who were at term and undergoing induction of labor with oxytocin. Each patient received a glucose infusion (6 gm/hr), and the blood glucose level was determined hourly. Blood glucose levels did not rise above 100 mg/dl in 16 patients (48.4%) despite continuous intravenous glucose infusion. No differences were found in the following parameters between these patients and those requiring insulin infusion: maternal age, weight, diabetic class, gravidity, and prior insulin requirement. Birth weights and the incidence of neonatal morbidity were similar between groups and occurred despite euglycemia during labor. We found that euglycemia during labor did not prevent infant morbidity irrespective of the use of continuous low-dose insulin infusion. Additionally, 48% of patients did not require any insulin during induction of labor despite large antenatal insulin requirements.

Sympathoadrenal activity in infants of diabetic mothers

We assessed the activity of the sympathoadrenal system in infants of diabetic mothers. Concentrations of metanephrine in the amniotic fluid were correlated to amniotic fluid lung profiles. At the time of delivery, the levels of umbilical artery and vein plasma catecholamines were compared to the incidence of neonatal complications. Mature lung profiles correlated significantly with progressively rising metanephrine concentrations. Infants who had a higher incidence of neonatal complications at delivery had significantly higher plasma catecholamine levels as well. It is concluded that in infants of diabetic mothers there is a higher significant association between the sympathoadrenal activity and lung maturation. The majority of infants of diabetic mothers have excessive sympathoadrenal activity at birth, which could potentially lead toward catecholamine depletion and related complications in the first days of life.

Effect of blood in amniotic fluid on the detection of phosphatidylglycerol

Samples of amniotic fluid were mixed with serum or red blood cells (RBC) in order to determine the effect of blood contamination on the detection of phosphatidylglycerol (PG). Samples of amniotic fluid was obtained from patients in the second trimester of pregnancy and at term, PG standard was added to half of the aliquots of the second-trimester fluid. The samples of fluid were tested before and after the addition of maternal or fetal serum or RBC in concentrations up to 20%. Two-dimensional thin-layer chromatographic procedures were performed to determine the presence or absence of PG. The results obtained showed that serum of RBC contamination of amniotic fluid without PG did not result in the appearance of a PG spot on the chromatographic plate. Neither serum nor RBC contamination interfered with the detection of PG in those fluids in which it was present. Maternal and fetal blood were similar in their failure to affect the detection of PG. These data suggest that PG determination for fetal lung maturity is a reliable test in the presence of bloody amniotic fluid.

The use of ultrasound in the diagnosis of fetal lung maturity.

We have shown that there is a relationship between a BPD of at least 9.2 cm and the presence of lung maturity in the fetus of a nondiabetic pregnancy. The presence of a grade III placenta in the late third trimester appears to be a reliable predictor of maturity, but more data need to be assessed before the utility of this method at any gestational age can be properly evaluated. We have discussed a scheme incorporating ultrasonographic observations and laboratory analysis in reducing the risk of iatrogenic hyaline membrane disease and reducing the need for amniocentesis.