Valerie J. Rappaport

Metformin Compared With Glyburide in Gestational Diabetes: A Randomized Controlled Trial

OBJECTIVE: To compare the efficacy of metformin with glyburide for glycemic control in gestational diabetes. METHODS: Patients with gestational diabetes who did not achieve glycemic control on diet were randomly assigned to metformin (n=75) or glyburide (n=74) as single agents. The primary outcome was glycemic control. Secondary outcomes were drug failure rate and neonatal and obstetric complications. RESULTS: In the patients who achieved adequate glycemic control, the mean fasting and 2-hour postprandial blood glucose levels were not statistically different between the two groups. However, 26 patients in the metformin group (34.7%) and 12 patients in the glyburide group (16.2%) did not achieve adequate glycemic control and required insulin therapy (P=.01). CONCLUSION: In this study, the failure rate of metformin was 2.1 times higher than the failure rate of glyburide when used in the management of gestational diabetes (95% confidence interval 1.2–3.9). CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00965991. LEVEL OF EVIDENCE: I

Utility of fetal echocardiography in postnatal management of infants with prenatally diagnosed congenital heart disease.

Congenital heart disease (CHD) remains a significant cause of neonatal morbidity and mortality. This study evaluates the success of fetal echocardiography (FECHO) in guiding delivery management in pregnancies complicated by CHD.

Menopausal status associated with increased inhibition of blood coagulation

Postmenopausal women receiving estrogen replacement therapy (ERT) are not as prone to inappropriate venous and arterial thrombosis as are younger women taking oral contraceptives. To establish whether menopausal status per se has any effect on the coagulation-fibrinolytic system normal premenopausal women (mean age 29 years) were compared with younger (mean age 23) and older (mean age 51) surgically menopausal women and a group of naturally postmenopausal women (mean age 53). The results show that in postmenopausal women, irrespective of age or type, the shift is away from clot formatiuon and toward clot inhibition and fibrinolysis as determined by static in vitro analysis. This was characterized by statistically significant increases in antithrombin III antigen, alpha 1-antitrypsin antigen, and plasminogen activity. These changes may help to explain in part why ERT does not appear to cause increased thrombosis in older women.

Prenatal Diagnosis and Genetic Screening—Integration into Prenatal Care

In the last 3 decades, perinatal medicine has made tremendous advances in scientific knowledge and in the successful application of this knowledge toward understanding the fetal aspects of pregnancy. Evaluation of the health of the fetus and screening for birth defects has become an important part of prenatal care. This article provides an overview of birth defects and the various screening methods for diagnosing birth defects before birth. It also discusses the role of preconception genetic screening.

New mesomelic dysplasia with absent fibulae and triangular tibiae.

We report on two unrelated, sporadic cases of a mesomelic dysplasia characterized by absence of fibulae and severely hypoplastic, triangular-shaped tibiae. Moderate mesomelic shortness was present in the upper limbs with proximal widening of the ulnae. There was also axial skeletal involvement in both cases, characterized radiographically by an abnormal pelvis and marked bilateral glenoid hypoplasia. These cases appear to represent a new form of mesomelic dysplasia distinct from those previously delineated.

Pica in Pregnancy: An Unusual Presentation

BACKGROUND Pica is common in pregnancy and is often felt to be benign. The following case of severe pica presenting without anemia is unusual in its presentation, laboratory findings, and treatment. CASE A 31-year-old multiparous woman at 37 0/7 weeks of gestation presented with esophagitis and gastritis secondary to laundry detergent consumption. She had borderline anemia (hemoglobin of 11 g/dL and hematocrit of 37%, mean corpuscular volume 80%) but was severely iron-deficient (serum ferritin 7 micrograms/dL). Parenteral iron infusion was associated with dramatic resolution of her cravings within 36 hours of treatment. CONCLUSION Pica may be related to deficient iron stores in the absence of anemia and can result in serious morbidity. Parenteral iron may be associated with rapid pica resolution in symptomatic pregnant patients.

Comparison of induced versus spontaneous labor in twins

Objective: To compare intrapartum outcomes of women with twin gestations undergoing an induction of labor versus spontaneous labor. Study design: This retrospective investigation included women with twin gestations undergoing a trial of labor between January 1995 and June 200. Only diamniotic twins with twin A presenting as a vertex at 24–40 weeks of gestation and women with an unscarred uterus were included. Statistical analysis was done using McNemar’s test, paired t test, and Wilcoxon signed rank test for paired samples. Results: A total of 121 patients underwent a trial of labor that was either induced (n = 40) or spontaneous (n = 81). No differences between groups were observed for maternal age, race, parity, and gestational age. Labor that was spontaneous eventually required augmentation in all cases. Labor that was induced, rather than spontaneous with augmentation, required a higher maximum dose (17.3 versus 7.3 mU/min, P <0.01) and a longer duration (688 versus 239 minutes, P <0.01) of oxytocin. Interruption of oxytocin infusion was uncommon when labor was either induced or later augmented (15% versus 13%). A greater need for cesarean delivery of twin A was found in the induced labor group (30.0% versus 9.8%, P <0.05). Conclusion: Labor in twin gestations that was induced, rather than spontaneous, required more time and was associated with a higher cesarean delivery rate.