Thaddeus P. Waters

Maternal Weight Gain in Women Who Develop Gestational Diabetes Mellitus

OBJECTIVE: To assess maternal weight gain before 24 weeks in women developing gestational diabetes mellitus (GDM) compared with controls with normal glucose tolerance. METHODS: This was a retrospective cohort study of maternal weight gain. Women developing GDM were matched to three controls by self-reported prepregnancy body mass index (BMI), maternal age, race, and parity. Women without documented pregravid or 22- to 24-week weights and multiple gestations were excluded. The primary outcome was weight gain through 24 weeks of gestation. RESULTS: Six hundred fifty-two women (163 in the GDM group and 489 controls) underwent chart review. There were no significant differences in race (36% compared with 36% African American, P=.99), age (28.7±6.3 years compared with 29.4±6.9 years, P=.26) or prepregnancy BMI (31.7±8.2 compared with 31.8±8.6, P=.88). Maternal weight gain was higher in the GDM group than in the control group (14.8 compared with 11.2 lb, P<.001). When controlling for prepregnancy BMI, overweight (18.6 compared with 12.9 lb, P<.004), and obese (12.6 compared with 8.8 lb, P<.008), GDM participants gained significantly more weight by 24 weeks. Both diet-controlled (A1) and insulin-requiring (A2) GDM had higher weight gain compared with controls (control compared with A1: 11.2 compared with 15.3 lb, P=.029; control compared with A2: 11.2 compared with 14.6 lb, P=.018. No difference was found between A1 and A2 patients (P=.942). CONCLUSION: Women who develop GDM have higher gestational weight gain through 24 weeks. Gestational weight gain is a significant risk factor for GDM in the overweight or obese patient but not in patients who were underweight or had a normal BMI before pregnancy. LEVEL OF EVIDENCE: II

Perinatal Outcomes Associated With the Diagnosis of Gestational Diabetes Made by The International Association of the Diabetes and Pregnancy Study Groups Criteria

OBJECTIVE: To assess perinatal outcomes with Carpenter-Coustan criteria for gestational diabetes mellitus (GDM), those with normal glucose testing, and those who would be added to GDM by The International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria. METHODS: This was a retrospective cohort study of women who underwent screening and diagnostic testing for GDM. Patients were divided into nonoverlapping groups: GDM by Carpenter-Coustan (Carpenter-Coustan), IADPSG GDM criteria but not Carpenter-Coustan (IADPSG), and normal GDM screening or testing (control). Outcomes included newborn birth weight, birth weight z-score, Ponderal Index, and large for gestational age. Data were analyzed with one-way analysis of variance, t tests, or &khgr;2. RESULTS: There were 8,390 women who met inclusion criteria: 338 Carpenter-Coustan; 281 IADPSG; and 7,771 women in the control group. Mean birth weight (3,411 compared with 3,240 g, P<.01), birth weight z-score (0.477 compared with 0.059, P<.01), Ponderal Index (2.79 compared with 2.73 g/cm3, P=.014), and large for gestational age (19.9% compared with 8.8%, relative risk 2.25, 95% confidence interval [CI] 1.76–2.88) were higher in IADPSG compared with women in the control group. The IADPSG group had greater birth weight (3,411 compared with 3,288 g, P<.01) than Carpenter-Coustan neonates with no difference in large for gestational age (19.9% compared with 16.0%, relative risk 1.25 95% CI 0.88–1.75), Ponderal Index (2.78 compared with 2.79 g/cm3, P=1), or birth weight z-score (0.477 compared with 0.330, P=.30). CONCLUSIONS: Newborns of women who would be added to the diagnosis of GDM by IADPSG criteria have greater measures of fetal overgrowth than those in the control group and greater birth weight in comparison with Carpenter-Coustan GDM neonates. LEVEL OF EVIDENCE: II

Effect of 17α-hydroxyprogesterone caproate on glucose intolerance in pregnancy

OBJECTIVE: To estimate whether 17α-hydroxyprogesterone caproate treatment in pregnancy increases the frequency of abnormal glucose screening and gestational diabetes mellitus (GDM). METHODS: This is a retrospective cohort study of women treated with weekly 17α-hydroxyprogesterone caproate. Women with pregestational diabetes and multiple gestations were excluded. 17α-hydroxyprogesterone caproate–exposed women were randomly matched with three unexposed controls by maternal age and prepregnancy body mass index (BMI). The main outcomes were an abnormal 1-hour 50-g glucose screen (at least 135 mg/dL) and GDM (a 1-hour 50-g glucose screen of at least 200 mg/dL or two or more abnormal values on a 3-hour 100-g oral glucose tolerance test). RESULTS: A total of 110 17α-hydroxyprogesterone caproate–exposed women were matched with 330 controls. Maternal race between exposed women and controls was similar (46% compared with 39% African American, 17% compared with 18% Hispanic, 36% compared with 40% white, P=.57). Abnormal 1-hour glucose screens were more frequent in the 17α-hydroxyprogesterone group (23.6% compared with 11.2%, P<.001), as was the diagnosis of GDM (10.9% compared with 3.6%, P=.003). 17α-hydroxyprogesterone caproate remained independently associated with the diagnosis of GDM (odds ratio 3.3, 95% confidence interval 1.3–8.1) in a conditional multiple logistic regression analysis controlling for maternal race, age, BMI, and parity. CONCLUSION: Women receiving weekly intramuscular 17α-hydroxyprogesterone caproate have more frequent abnormal glucose testing and gestational diabetes compared with unexposed controls. These results are consistent with published data regarding the effect of progesterone on insulin resistance. LEVEL OF EVIDENCE: II

Maternal and Neonatal Morbidity for Women Who Would Be Added to the Diagnosis of GDM Using IADPSG Criteria: A Secondary Analysis of the Hyperglycemia and Adverse Pregnancy Outcome Study

OBJECTIVE To assess the frequency of adverse outcomes for women who are diagnosed with gestational diabetes mellitus (GDM) by the International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria using data from the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study. RESEARCH DESIGN AND METHODS This is a secondary analysis from the North American HAPO study centers. Glucose measurements from a 75-g oral glucose tolerance test were used to group participants into three nonoverlapping categories: GDM based on Carpenter-Coustan (CC) criteria (also GDM based on IADPSG criteria), GDM diagnosed based on IADPSG criteria but not CC criteria, and no GDM. Newborn outcomes included birth weight, cord C-peptide, and newborn percentage fat above the 90th percentile; maternal outcomes included primary cesarean delivery and preeclampsia. Outcome frequencies were compared using multiple logistic regression, adjusting for predefined covariates. RESULTS Among 25,505 HAPO study participants, 6,159 blinded participants from North American centers were included. Of these, 81% had normal glucose testing, 4.2% had GDM based on CC criteria, and 14.3% had GDM based on IADPSG criteria but not CC criteria. Compared with women with no GDM, those diagnosed with GDM based on IADPSG criteria had adjusted odds ratios (95% CIs) for birth weight, cord C-peptide, and newborn percentage fat above the 90th percentile, as well as primary cesarean delivery and preeclampsia, of 1.87 (1.50–2.34), 2.00 (1.54–2.58), 1.73 (1.35–2.23), 1.31 (1.07–1.60), and 1.73 (1.32–2.27), respectively. CONCLUSIONS Women diagnosed with GDM based on IADPSG criteria had higher adverse outcome frequencies compared with women with no GDM. These data underscore the need for research to assess the effect of treatment to improve outcomes in such women.

Measures of success: Prediction of successful labor induction

Ideally, all pregnant women would enter labor spontaneously at the safest time to yield the best health outcomes for both themselves and their newborns. Unfortunately, this does not always happen and leaves obstetric providers weighing the maternal and fetal risks of continued expectant management versus labor induction. Several elements have been reported to affect the success rate of an induction, including the Bishop score, maternal parity, body mass index (BMI), age, medical comorbidities, fetal gestational age, and estimated weight, as well as the hospital site and provider practice. Recent data suggest that the decision to induce or continue expectant management in anticipation of labor is an important variable in determining whether a woman has a safe and successful delivery.

Obstetric team simulation program challenges

OBJECTIVE To describe the challenges associated with the development and assessment of an obstetric emergency team simulation program. DESIGN The goal was to develop a hybrid, in-situ and high fidelity obstetric emergency team simulation program that incorporated weekly simulation sessions on the labor and delivery unit, and quarterly, education protected sessions in the simulation center. All simulation sessions were video-recorded and reviewed. SETTING Labor and delivery unit and simulation center. PARTICIPANTS Medical staff covering labor and delivery, anesthesiology and obstetric residents and obstetric nurses. MEASUREMENTS Assessments included an on-line knowledge multiple-choice questionnaire about the simulation scenarios. This was completed prior to the initial in-situ simulation session and repeated 3 months later, the Clinical Teamwork Scale with inter-rater reliability, participant confidence surveys and subjective participant satisfaction. A web-based curriculum comprising modules on communication skills, team challenges, and team obstetric emergency scenarios was also developed. MAIN RESULTS Over 4 months, only 6 labor and delivery unit in-situ sessions out of a possible 14 sessions were carried out. Four high-fidelity sessions were performed in 2 quarterly education protected meetings in the simulation center. Information technology difficulties led to the completion of only 18 pre/post web-based multiple-choice questionnaires. These test results showed no significant improvement in raw score performance from pre-test to post-test (P=.27). During Clinical Teamwork Scale live and video assessment, trained raters and program faculty were in agreement only 31% and 28% of the time, respectively (Kendalls W=.31, P<.001 and W=.28, P<.001). Participant confidence surveys overall revealed confidence significantly increased (P<.05), from pre-scenario briefing to after post-scenario debriefing. CONCLUSION Program feedback indicates a high level of participant satisfaction and improved confidence yet further program refinement is required.

Fetal, neonatal and infant death and their relationship to best gestational age for delivery at term: is 39 weeks best for everyone?

Recent recommendations have stated that ‘non-medically indicated delivery before 39 weeks gestation should be avoided.’ The current work examines much of the published national data used as a foundation for those recommendations, which are based on stated improvements to fetal, neonatal and infant mortality as well as neonatal morbidity. In this work, each of these factors is analyzed, with a specific aim to delineate the role of week of gestation along with other possible confounding variables affecting outcome, and to explain several methodological shortcomings that have characterized the research up to now. The analysis suggests that delaying delivery until 39 weeks would increase fetal deaths and have little or no influence on neonatal and infant deaths. Further, confounding factors that effect both neonatal and maternal morbidity have not been adequately examined. Decisions aimed at optimizing perinatal outcomes require simultaneous consideration of multiple, complex, inter-related dynamic factors and would be highly unlikely to be optimized with a simple recommendation such as ‘avoidance of delivery before 39 weeks.’ It is the aim of this work to encourage current stakeholders to recognize the need to re-examine this issue, with an understanding that an individualized approach to decisions regarding the timing of delivery at term is essential. Proper analysis of current and future data will likely point to a different approach that is clearly away from the same recommendation for all.

Obstetric and Non-Obstetric Indications for Admission in the Antepartum and Postpartum Periods of Pregnancy

Objective: To determine the most common non-obstetric indications for admission during the antepartum and postpartum period of pregnancy. Methods: This is a population-based investigation of the primary diagnoses for admission in the antepartum and postpartum periods of pregnancy. Data was obtained from the Healthcare Cost and Utilization Project’s State Inpatient Database for the state of California for 2005. The frequency of each primary diagnosis was determined. Diagnoses were classified as obstetric or non-obstetric and compared for differences in maternal race, age and insurance provider. Results: 576,846 total maternal admissions were identified with 35,158 antepartum (6.1%), 536,415 intrapartum (93.0%) and 5273 postpartum (0.9%). Overall, 26.6% of admissions were non-obstetric in nature. The most common non-obstetric indication for antenatal admission was urinary tract infections. The most common postpartum non-obstetric indication for admission was psychiatric/substance abuse disorders. Conclusions: Many admissions during pregnancy are non-obstetric in nature and may be amenable to outpatient screening.

Microorganisms Identified in the Maternal Bladder: Discovery of the Maternal Bladder Microbiota

Objective  The objective of this study was to characterize the bladder microbiota in pregnancy. Methods  A prospective observational study of 51 pregnant women, admitted to a tertiary care hospital, who underwent straight catheterization urine collection or transurethral Foley catheter placement. 16S rRNA gene sequencing and enhanced quantitative urine culture assessed the maternal bladder microbiota with comparisons made to standard urine culture results. Results  Enhanced quantitative urine culture and 16S rRNA gene sequencing detected bacteria in the majority of participants. Lactobacillus and Gardnerella were the most commonly detected microbes. In contrast, standard urine culture had a 100% false-negative rate and failed to detect several known or emerging urinary pathogens. Conclusion  There are live bacteria in the bladders of most pregnant women. This challenges the definition of asymptomatic bacteriuria.