Antepartum Testing Research Articles

Borderline Amniotic Fluid Index and Its Relation to Fetal Intolerance of Labor

To determine whether a borderline amniotic fluid index (AFI) in the third trimester is associated with an increased rate of cesarean delivery for fetal intolerance of labor, meconium-stained amniotic fluid, and intrauterine growth restriction, among other adverse perinatal outcomes. Patients with a diagnosis of a borderline AFI between January 2008 and August 2012 were identified. Antepartum, delivery, and neonatal data were collected and compared to a cohort with a normal AFI. We enrolled 739 patients, including 177 with a borderline AFI (>5 and <10 cm) and 562 with a normal AFI (≥ 10-24 cm); 360 patients delivered at University of Arizona Medical Center, and 379 delivered at St Joseph's Hospital. Combined and individual analyses of each center revealed no significant difference in fetal intolerance of labor (P = .19) or cesarean delivery for fetal intolerance (P = .074) between cohorts. In both settings, patients with a borderline AFI were more likely than those with a normal AFI to undergo antepartum testing (P < .001). A statistically significant increase in intrauterine growth restriction in the borderline AFI group was noted, with a calculated risk ratio of 13.76 (P < .001). There was no difference between groups for meconium-stained amniotic fluid (P = .23), neonatal intensive care unit admission (P = .054), preterm delivery (P = .31), or operative vaginal delivery (P = .45). The findings of this study suggest that there is no difference in the rate of fetal intolerance of labor in pregnancies with a borderline AFI and those with a normal AFI. Pregnancies complicated by a borderline AFI are more likely to undergo antepartum testing, yet the benefit is unclear. Significantly more patients with a borderline AFI had underlying growth restriction, which may provide a useful tool for risk stratification in the management of a borderline AFI.

Maternal Hemodynamics by Thoracic Impedance Cardiography for Normal Pregnancy and the Postpartum Period

To establish normative impedance cardiography values for the second half of pregnancy and up to 48 hours postpartum after either vaginal or cesarean delivery. A single-center prospective observational institutional review board-approved study of normotensive women (n=168) using thoracic impedance cardiography performed at specific times during gestation. Antepartum testing was performed at three time periods: 20-27 weeks, 28-33 weeks, and 34-40 weeks of gestation. Postpartum testing was undertaken after the immediate puerperium at 6-23 hours and 24-48 hours after vaginal or cesarean delivery. Data analysis was performed using STATA software; data are expressed as mean±standard deviation. All seven of the patient groups studied were comparable with regard to demographic features; 80% of the study participants were African American. Group means obtained between 20 and 40 weeks of gestation and postpartum after vaginal and cesarean delivery fell within the "normal range" of the hemodynamic graph that was developed to associate mean arterial pressure and systemic vascular resistance. The thoracic fluid content group means in both vaginal and cesarean delivery groups were higher than the antepartum patient groups. The thoracic fluid content mean after cesarean delivery at 48 hours is significantly higher than the mean value recorded between 20 and 27 weeks of gestation (P<.05). The systemic vascular resistance systemic vascular resistance means in each of the postpartum groups were significantly higher than the late second-trimester group means recorded at 20-27 weeks of gestation (P<.05). The normative values reported in this investigation can be used to interpret and assess similarly tested patients with hypertensive or otherwise complicated pregnancy. III.

Demographic and Management Trends Among HIV-Positive Pregnant Women Over 10 Years at One Canadian Urban Hospital

ObjectiveThere is limited information about changing trends in the management of HIV-positive pregnancies in Canada as Canadian and international guidelines are updated. We reviewed the experience over a 10-year period of one Canadian urban hospital with regard to trends in the demographics and management of HIV-positive pregnant women. MethodsWe performed a retrospective chart review of all HIV-positive pregnant women delivering between March 2000 and March 2010. Demographic, pregnancy, and intrapartum data were collected and analyzed. ResultsDuring the study period, there were 141 singleton pregnancies in HIV-positive women. The mean age of the cohort was 30.4 years. The number of women seen increased significantly over time (P < 0.001), with 63% of cases in care from 2007 to 2010. Most women were of African descent and had recently immigrated to Canada. There was a statistically significant trend towards increasing numbers of Afro-Caribbean women over the study period (P=0.03). Only 4% reported illicit drug use in their current pregnancy. Although the majority of women had a known diagnosis of HIV before pregnancy, 30 (22.4%) had the diagnosis made on antepartum testing. Most women were compliant with their highly active antiretroviral therapy (94.3%) and had undetectable viral loads documented at the time of delivery (76.4%). A significant shift towards increased use of protease inhibitor antiretovirals in pregnancy was noted over time (P < 0.001). All neonates received zidovudine after delivery. There were no cases of vertical HIV transmission. ConclusionOur review documented increasing numbers of HIV-positive pregnant women over the past 10 years. The majority of these women were healthy with well-managed disease, and had favourable pregnancy outcomes. There were no infected children born during the study period.

Discrepancy between Non-stress Test Result and Umbilical Artery Doppler Study in a Pregnancy Complicated by Diabetes; A Case Report

Pregestational diabetes is a well-known risk factor for perinatal mortality, and regarded as an important cause of stillbirth. Unfortunately, more than half of stillbirths remain unexplained. Nevertheless, there is no consensus regarding the optimal timing and content of antepartum testing in pregnancies complicated by diabetes. A 32-year-old primigravida presented with diabetes diagnosed during pregnancy. Antenatal fetal surveillance tests including nonstress test, biophysical profile, and Doppler waveforms of umbilical arteries were performed twice weekly, beginning at 32 weeks gestation. At 37 +4 weeks’ gestation, a discrepancy in the surveillance test results arose when reversed end-diastolic flow in the umbilical arteries was seen, despite a reactive nonstress test. A male baby was delivered by cesarean section. The umbilical arterial pH at delivery was 7.171. Antenatal fetal surveillance in pregnancies complicated by diabetes should include evaluation of Doppler waveforms in the umbilical vessels, regardless of the presence or absence of maternal vasculopathy.

The Effect of Abused Substances on Antenatal and Intrapartum Fetal Testing and Well-Being

Recognition that use and abuse of substances by pregnant patients perpetuates, despite ongoing efforts to educate the public, necessitates clinicians to integrate understanding of potential effects on antepartum and intrapartum fetal testing into their interpretation and implementation of clinical findings. This includes acknowledging some anticipated alterations in results and selecting the appropriate type and frequency of testing methods and interventions. Certain substances are well documented in terms of expected variations in test results; others are not as clearly defined. An overview of information that may be helpful to the clinician is presented to promote understanding of fetal evaluation performed through common tests such as contraction stress test, the nonstress test, the biophysical profile, the modified biophysical profile, fetal movement counting, and Doppler velocimetry. What evidence is available should be used to assist in defining the actual status of the fetus as best as possible, even when the effects of substances may be unknown or have obscure results.

Strip of the Month: February 2013

Strip of the Month: February 2013

A prospective study of doppler velocimetry in pregnancy-induced hypertension in a rural population of a developing country

Background: Pregnancy-induced hypertension (PIH) remains a great challenge to obstetricians. Doppler velocimetry can detect fetal compromise much before other antepartum tests. Aim: The aim of this study is to detect the changes of uterine artery, umbilical artery and middle cerebral artery in PIH by Doppler velocimetry. Subjects and Methods: This prospective study was conducted on hundred subjects with PIH. Doppler studies were carried, and parameters recorded in uterine, umbilical and middle cerebral artery (MCA) were Systolic/Diastolic ratio, Resistance Index, Cerebro-Placental Index (CPI). Fetal outcomes were monitored. Statistical analysis was performed using Epi Info TM software (Version 3.5.1, CDC, Atlanta). Test for significance was done with student's t -test and Chi-square where applicable. A P- value of Results: Among the 100 subjects, 76 (76%) of fetuses had abnormal and 24% normal umbilical artery Doppler velocimetry; 62% had abnormal and 38% normal MCA Doppler velocimetry; 64% fetuses had abnormal and 36% normal CPI. In 95% of subjects having abnormal umbilical Doppler studies, caesarean section had to be done for acute fetal distress. Incidence of caesarean section was 61% in abnormal MCA group and 63% in abnormal CPI group. Among 14 patients who had abnormal uterine artery Doppler, four developed pre-eclampsia, 2 IUGR. In patients with notches in uterine artery Doppler, 38% developed pre-eclampsia, 38% had IUGR, 13% babies were still born and 25% of newborns required NICU admission. In umbilical artery Doppler, when S/D ratio was abnormal, 60% developed pre-eclampsia, 40% had IUGR and 40% of newborns had to be admitted in NICU. Conclusion: Doppler study for fetal surveillance in pregnancy-induced hypertension is a very useful device and abnormal umbilical artery and uterine artery velocimetry seems to have worse pregnancy outcomes in the present study. Notch as a single parameter is the best indicator with highest sensitivity and positive predicative values. However, combination of parameters is the best indicator.

549: Routine antepartum testing in women of advanced maternal age

of advanced maternal age Rachel Pilliod, Sarah Little, Aaron Caughey, Chloe Zera Brigham & Women’s Hospital, Obstetrics & Gynecology, Boston, MA, Brigham & Women’s Hospital, Obstetrics & Gynecology, Division of Maternal Fetal Medicine, Boston, MA, Oregon Health & Science University, Obstetrics & Gynecology, Portland, OR OBJECTIVE: Women of advanced maternal age (AMA) are at higher risk of poor obstetrical outcomes, including stillbirth and increased risk of cesarean section. Our study investigates the outcomes and costs of weekly antepartum testing for these women. STUDY DESIGN: A cost effectiveness model was created to compare routine antepartum testing starting at 36-40 weeks of gestation to expectant management in a hypothetical study population of women with advanced maternal age (AMA) who were otherwise low risk nulliparas with vertex, singleton gestations stratified by age groups of 35-39 and 40. Women not delivered by 41 weeks of gestation were induced. We accounted for an increased likelihood of cesarean delivery amongst AMA women. Baseline assumptions included a weekly IUFD risk of 0.068% with a relative risk of 1.73 and 2.33 for women 35-39 and 40 respectively. We assumed that antepartum testing was 70% sensitive and 90% specific. The cost-effectiveness threshold was set to $100,000 per QALY. Base-case and one-way sensitivity analysis of model parameters were performed. RESULTS: For AMA women between 35-39 and AMA women 40, weekly antepartum testing beginning at 36 weeks of gestation was cost-effective at $16,103 and $11,692 per quality-adjusted life-year (QALY) as compared to no antenatal testing. Two hundred and one women between 35-39 and 150 women 40 would need to be treated to prevent one stillbirth leading to 40 and 30 additional inductions of labor respectively. CONCLUSION: In our decision analytic model, we find that routine antepartum testing for AMA, but otherwise low risk women beginning at 36 weeks of gestation is cost-effective and leads to improved clinical outcomes. 550 Prenatal detection of structural cardiac defects and presence of associated anomalies: a prospective study of 1244 fetal echocardiograms Sinead Farrell, Aoife McTiernan, Colin Walsh, Colin McMahon, David Coleman, Orla Franklin, Cecilia Mulcahy, Shane Higgins, Peter McParland, Rhona Mahony, Stephen Carroll, Fionnuala McAuliffe University College Dublin, Dept of Obstetrics and Gynaecology, School of Medicine and Medical Science, Dublin, Ireland, National Maternity Hospital, Department of Fetal Medicine, Dublin, Ireland, Our Lady’s Children’s Hospital Crumlin, Department of Cardiology, Dublin, Ireland OBJECTIVE: To document detection of fetal cardiac defects in relation to (i) the indication for referral for fetal echocardiography, (ii) presence of associated extra-cardiac anomalies and (iii) karyotypic abnormalities. STUDY DESIGN: This is a prospective study from 2007-2011 inclusive. Data were recorded for fetal echocardiography and analysed for referral indication, the presence of extra-cardiac anomalies and invasive testing. RESULTS: During the five year period 1244 echocardiographs were recorded, 242 (19.5%) of which had a structural cardiac defect, table 1. The most common defects were AVSD (n 36), VSD (n 26), transpositions (n 15), tetralogy (n 15), hypoplastic left heart (n 27), coarctation (n 6) and valvular defects (n 30). Abnormal anatomy scan was the best indicator for detecting the presence of cardiac defects, compared to all other indications (p 0.0001). Invasive testing was performed for 44% of those identified with a cardiac anomaly, of which 54 (51%) were abnormal karyotypes including 48 trisomies, 5 microdeletions and one triploidy. Thirty-seven percent (n 89) of those with a cardiac anomaly also had an extra-cardiac defect, including ventriculomegaly, omphalocele, duodenal atresia, and cleft lip/ palate. In addition these fetuses were significantly more likely to have a karyotypic abnormality when compared with those with an isolated cardiac anomaly (p 0.0001). CONCLUSION: This study suggests most congenital cardiac defects occur in a low risk population, highlighting the importance of the 20week anomaly scan for detection of cardiac and other defects prenatally. Significant numbers of chromosomal and extra-cardiac defects in this study emphasize the importance of thorough evaluation of any fetus identified with a cardiac defect.

Isolated low-normal amniotic fluid volume in the early third trimester: association with adverse perinatal outcomesa

To test if an isolated finding of low-normal amniotic fluid index (AFI) in the early third trimester in low-risk patients is associated with adverse perinatal outcomes. Retrospective cohort study with uncomplicated singleton pregnancies that had ultrasound studies between 28.0 and 31.9 weeks' gestation. Two cohorts with AFI 8.0-11.9 cm (low-normal, LN) and AFI 12.0-19.9 cm (mid-normal, MN) were compared. Patients with LN-AFI (n=99) were more likely to have early (<34 weeks) and late (<37 weeks) preterm birth (PTB) (relative risk 4.2 and 2.4, respectively) and a small for gestational age (SGA) infant (relative risk 1.8) than MN-AFI (n=834), corresponding to a higher NICU admission rate (relative risk 2.5). The risk of "spontaneous" PTB (preterm labor and rupture of membranes) did not differ between the cohorts, whereas the risk of "indicated" PTB (maternal or fetal indications) was significantly increased in LN-AFI. The incidence of abnormal antepartum testing, stillbirth, preeclampsia, placental abruption, fetal intolerance to labor, emergency cesarean delivery, umbilical artery pH <7.0, Apgar scores <7 at 5 min, and neonatal death was not increased in patients with LN-AFI. Low-normal AFI in the early third trimester increases the risk for subsequent delivery of an SGA infant and indicated PTB.

PP171. Hospitalized preterm mild preeclamptics: Is there a difference in outcomes between isolated or superimposed disease?

Currently the standard of care is to admit and monitor patients with preterm mild preeclampsia. This is particularly important if the disease is superimposed in patients with chpt or with isolated disease if proteinuria is over 500mg in 24hours. Despite the common nature of this disease process little is known about the outcomes of these two groups. The objective of this project is to compare the maternal and neonatal outcomes of patients hospitalized with isolated mild preterm preeclampsia to those with preterm superimposed preeclampsia. All patients admitted between 1/2008 and 12/2011 that were expectantly managed with either mild isolated preterm preeclampsia or chpt with mild superimposed preeclampsia at our tertiary center were evaluated for inclusion in this retrospective cohort study. This study was IRB approved. To be included in the study a patient must have singleton gestation, no overt diabetes, no major chronic medical conditions, no major obstetrical complications, no congenital anomaly, or planned delivery before 37weeks. Patients with the following maternal complications were excluded: lupus, renal disease, and cardiac disease. Patients with the following obstetrical complications were excluded: multiple gestations, preterm labor, placenta previa, and preterm PROM. Mild preeclampsia and chpt were diagnosed using ACOG criteria. Patients were not included if they had severe disease being treated expectantly. Patients that met inclusion criteria were divided into two groups based on the presence of chpt. All patients were admitted to labor and delivery, treated with corticosteroids if indicated and were managed as inpatients until delivery. All patients had an ultrasound on admission, frequent laboratory evaluations, and daily antepartum testing. Outcomes of interest included latency period in days, incidence of IUGR, incidence of abruption, indication for delivery, maternal complications as well as neonatal morbidity and mortality. To date, we have identified 115 patients that met inclusion criteria and were included in this ongoing study. Fifty nine had isolated mild preeclampsia and 56 patients had chronic hypertension with superimposed preeclampsia. The following table compares the results of the two groups. Differences between the groups included age (24 vs. 30yrs, p<0.01), race with more whites having preeclampsia and more blacks having superimposed disease, days in hospital were longer in the superimposed group (9 vs. 13days, p<0.01) despite there being no significant difference in the latency period (6 vs. 9days, p=0.35). More superimposed patients developed pulmonary edema, (0% vs. 7%, p=0.05). A trend for increased abruptions was seen in the isolated group (9% vs. 0%, p=0.06). Vaginal delivery was more common in the preeclamptic group and repeat section more common in the superimposed group. No differences in neonatal outcomes were seen. Patients with preeclampsia were more likely younger, white and delivered vaginally when compared to patients with superimposed disease. While the superimposed patients were more likely older, black, had more pulmonary edema, were more likely treated with antihypertensives both antenatally and postpartum and were delivered by repeat section than patients with isolated disease. Neonatal outcomes were similar between the groups.

ACR Appropriateness Criteria® Multiple Gestations

Multiple gestations are high-risk compared with singleton pregnancies. Prematurity and intrauterine growth restrictions are the major sources of morbidity and mortality common to all twin gestations. Monochorionic twins are at a higher risk for twin-twin transfusion, fetal growth restriction, congenital anomalies, vasa previa, velamentous insertion of the umbilical cord and fetal death. Therefore, determination of multiple gestation, amnionicity and chorionicity in the first trimester is important. Follow up examinations to evaluate fetal well-being include assessment of fetal growth and amniotic fluid volume, umbilical artery Doppler, nonstress test and biophysical profile. To date, there is a paucity of literature regarding imaging schedules for follow-up. At the very least, antepartum testing in multiple gestations is recommended in all situations in which surveillance would ordinarily be performed in a singleton pregnancy.The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed biennially by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging.

692: Improved perinatal outcomes with fetal monitoring in Ghana

692 Improved perinatal outcomes with fetal monitoring in Ghana Frank Anderson, Joseph Seffah, Jocelynn Owusu, Mark Chames, Jerry Coleman University of Michigan, Obstetrics and Gynecology, Ann Arbor, MI, University of Ghana, OBGYN, Accra, University of Michigan Medical Center, Obstetrics and Gynecology, Division of MaternalFetal Medicine, Ann Arbor, MI, University of Ghana, Obstetrics and Gynecology, Accra, Ghana OBJECTIVE: To evaluate the effects of NST on perinatal outcomes in hypertensive disease in Ghana, where electronic fetal monitoring is not routine. STUDY DESIGN: A modified fetal assessment center was established at a major teaching hospital in June 2010. From May 2010 to July 2011, 316 women with preeclampsia or PIH were followed from admission to delivery. PIH was defined as Systolic blood pressure (SBP) 140 mmHg or diastolic blood pressure (DBP) 90 mmHg; preeclampsia included the presence of proteinuria 0.3 grams. Exposure to NST and fetal outcomes were recorded. Prevalence of of Apgar5 7, unexpected stillbirth, and early neonatal mortality were compared for the monitored an unmonitored group. An unexpected stillbirth was defined as a fetus admitted to the hospital live but died in utero. RESULTS: Patients in the unmonitored group received routine care which consisted of ausculation of the fetal heart rate in the antepartum and intrapartum period. Monitored patients received antepartum monitoring. Intrapartum monitoring was per routine. Preliminary results are from 164 unmonitored and 154 monitored patients. There was no significant differences in in gravidity (3.07 / 2.20 vs. 3.16 / 1.85), Parity (1.46 / 1.57 vs. 1.49 / 1.50), SBP (156 / 22 vs. 153 / 21), DBP(101 / 18 vs. 98 / 15). Age (30 / 6.0 vs. 32.8 / 5.6) and gestational age (36.9 / 3.7 vs. 35.6 / 3.3) were statistically different between the two groups (p 0.01). PIH cases had no difference in apgar5 7 (5.7% vs. 4.5%; p 0.54); while 21.6% of infants of unmonitored preeclamptic mothers had Apgar5 7, cf 5.1% in the monitored group (p 0.01). Unexpected stillbirth occurred in 9.2% of unmonitored preeclamptic cases and 3.6% of monitored cases (p 0.11). Perinatal death occurred in 10% of the unmonitored preeclamptic group and 2.5% of the monitored preeclamptic group (p 0.05). CONCLUSION: The introduction of antepartum testing for women with Preeclampsia might significantly reduce perinatal mortaliy in low resource settings and should be adapted to low resource settings to decrease mortality.

391: Maternal and fetal Doppler pulsatility indices predict adverse pregnancy outcome in uncomplicated pregnancies with borderline-low amniotic fluid index in the early third trimester

indices predict adverse pregnancy outcome in uncomplicated pregnancies with borderline-low amniotic fluid index in the early third trimester Kazumasa Hashimoto, Tania Kasdaglis, Sheveta Jain, Ozhan Turan, Kristin Atkins, Jerome Kopelman, Chris Harman, Ahmet Baschat University of Maryland School of Medicine, Obstetrics, Gynecology and Reproductive Sciences, Baltimore, MD, University of Maryland School of Medicine, Obstetrics & Gynecology and Reproductive Sciences, Baltimore, MD OBJECTIVE: We have reported borderline-low (BL) amniotic fluid index (AFI) in the early third trimester in uncomplicated pregnancy associated with adverse outcome. The aim of this study is to test if maternal and/or fetal Doppler indices can stratify risks of adverse perinatal outcome. STUDY DESIGN: Nested case-control study in cohort of uncomplicated pregnancy with BL-AFI (8.0-11.9) at 28.0-31.9 weeks gestation (20062010, N 173). Frequency of abnormal uterine artery Doppler pulsatility index (UtA PI), umbilical artery (UA PI) and middle cerebral artery (MCA PI) were compared between controls and those with adverse outcome, defined in categories: Antepartum (abnormal antepartum testing, stillbirth, placental abruption, preeclampsia, N 9), Delivery (emergency and/or fetal-indicated Cesarean delivery, preterm birth, N 52), Neonatal (birth weight 1.645 (90th centile) for UA PI and UtA PI, and Z-score 1.645 (10th centile) for MCA PI, defined abnormal values. RESULTS: Abnormal UtA, UA, and MCA-PI were significantly more common in all categories of adverse outcome, compared to controls. When any Doppler index is abnormal, prediction of adverse outcome had the following characteristics: Antepartum sensitivity (SN 0.88), specificity (SP 0.80), positive predictive value (PPV 0.26) and negative predictive value (NPV 0.99); Delivery (SN 0.43, SP 0.84, PPV 0.56, NPV 0.76); Neonatal (SN 0.43, SP 0.84, PPV 0.56, NPV 0.76); Composite (SN 0.39, SP 0.85, PPV 0.63, NPV 0.67). While individual Doppler indices had clinically-low predictive ability, combining UtA, UA, and MCA PI increases SN and NPV. CONCLUSION: Using these parameters, maternal and fetal Dopplers can identify cases at high-risk for adverse outcome in uncomplicated patients with borderline AFI. Measurement of all three Doppler indices helps triage such pregnancies.

Cytogenetic analysis of 355 cases of fetal loss in different trimesters

We estimated the success rates of cytogenetic analyses in different tissue samples after intrauterine fetal deaths and analyzed the value of cytogenetic testing for determining the causes. Women with intrauterine fetal deaths (occurring at > 10 weeks of gestation) were offered either invasive testing before medical induction of labor, or solid tissue biopsy diagnosis after delivery. A total cohort of 355 intrauterine fetal deaths was studied. During antepartum examinations, invasive procedures included amniocentesis (AMC), chorionic villus sampling (CVS) and umbilical cord (UBC) sampling. During postpartum examinations, samples were taken from unfixed specimens of fetal skin, placenta and other tissues. Chromosomal abnormalities were observed in 22 fetal deaths for which cytogenetic analyses were successful. Logistic regression analysis identified antepartum invasive sampling [P = 0.000, odds ratio (OR) 31.125, 95% confidence interval (CI) 14.265-67.908] to be associated with a high cytogenetic success rate and older age with fetal deaths (P = 0.104, OR 0.487, 95% CI 0.204-1.160) not to be associated with a high chromosomal abnormality. In the patients with recurrent pregnancy loss, the chromosomal abnormality rate of 18.6% of spontaneous abortions has not been significantly more than that of fetal deaths 11.5% (P = 0.437). Parents should be counseled on all aspects of cytogenetic analysis after fetal death. Antepartum testing after pregnancy loss is recommended.

Neonatal outcomes after demonstrated fetal lung maturity before 39 weeks of gestation.

To compare outcomes among neonates delivered after documentation of fetal lung maturity before 39 weeks and those delivered at 39 or 40 weeks. This was a retrospective cohort study of women with singleton pregnancy delivered at 36 0/7 to 38 6/7 weeks after positive fetal lung maturity testing (based on amniotic fluid lecithin to sphingomyelin ratio) or at 39 0/7 to 40 6/7 weeks (without maturity testing) at our center from 1999 to 2008. Women with fetuses with major congenital anomalies, cord prolapse, nonreassuring antepartum testing, placental abruption, or oligohydramnios were excluded. A primary composite neonatal outcome included death, adverse respiratory outcomes, hypoglycemia, treated hyperbilirubinemia, generalized seizures, necrotizing enterocolitis, hypoxic ischemic encephalopathy, periventricular leukomalacia, and suspected or proven sepsis. There were 459 neonates delivered at 36 to 38 weeks and 13,339 delivered at 39 to 40 weeks; mean birth weight was 3,107±548 g and 3,362±439 g, respectively. The risk of the composite adverse neonatal outcome was 6.1% for the 36- to 38-week group compared with 2.5% for the 39- to 40-week group (relative risk 2.4; confidence interval [CI] 1.7-3.5). After multivariable adjustment, early delivery remained significantly associated with an increased risk of the composite outcome (adjusted odds ratio [OR]1.7; CI 1.1-2.6) as well as several individual outcomes, including respiratory distress syndrome (adjusted OR 7.6; CI 2.2-26.6), treated hyperbilirubinemia (adjusted OR 11.2; CI 3.6-34), and hypoglycemia (adjusted OR 5.8; CI 2.4-14.3). Neonates delivered at 36 to 38 weeks after confirmed fetal lung maturity are at higher risk of adverse outcomes than those delivered at 39 to 40 weeks.

Beta-cell function declines within the first year postpartum in women with recent glucose intolerance in pregnancy.

OBJECTIVEBoth gestational diabetes mellitus (GDM) and mild glucose intolerance in pregnancy identify women at increased risk of future type 2 diabetes. In this context, we queried whether metabolic changes that occur in the 1st year postpartum vary in relation to gestational glucose tolerance status.RESEARCH DESIGN AND METHODSThree-hundred-and-ninety-two women underwent glucose challenge test (GCT) and oral glucose tolerance test (OGTT) in pregnancy followed by repeat OGTT at both 3 months' postpartum and 12 months' postpartum. The antepartum testing defined four gestational glucose tolerance groups: GDM (n = 107); gestational impaired glucose tolerance (GIGT) (n = 75); abnormal GCT with normal glucose tolerance (NGT) on OGTT (abnormal GCT NGT) (n = 137); and normal GCT with NGT on OGTT (normal GCT NGT) (n = 73).RESULTSThe prevalence of dysglycemia progressively increased across the groups from normal GCT NGT to abnormal GCT NGT to GIGT to GDM at both 3 months' postpartum (2.7% to 10.2% to 18.7% to 34.6%, P < 0.0001) and 12 months' postpartum (2.7% to 11.7% to 17.3% to 32.7%, P < 0.0001). Between 3 and 12 months' postpartum, the groups did not differ with respect to changes in waist circumference, weight, or insulin sensitivity. Importantly, however, they exhibited markedly different changes in β-cell function (Insulin Secretion-Sensitivity Index-2 [ISSI-2]) (P = 0.0036), with ISSI-2 declining in both the GDM and GIGT groups. Furthermore, on multiple linear regression analysis, both GDM (t = −3.06, P = 0.0024) and GIGT (t = −2.18, P = 0.03) emerged as independent negative predictors of the change in ISSI-2 between 3 and 12 months' postpartum.CONCLUSIONSWomen with GDM and GIGT exhibit declining β-cell function in the 1st year postpartum that likely contributes to their future diabetic risk.

Glucose intolerance in pregnancy and postpartum risk of metabolic syndrome in young women.

Gestational diabetes mellitus (GDM) and even mild glucose intolerance in pregnancy are both associated with increased risks of developing type 2 diabetes and cardiovascular disease in the future. Because the metabolic syndrome also identifies patients at risk of type 2 diabetes and cardiovascular disease, we hypothesized that gestational dysglycemia may be associated with an unrecognized latent metabolic syndrome. Thus, we sought to evaluate the relationship between gestational glucose tolerance status and postpartum risk of metabolic syndrome. In this prospective cohort study, 487 women underwent oral glucose tolerance testing in pregnancy and cardiometabolic characterization at 3 months postpartum. The antepartum testing defined three gestational glucose tolerance groups: GDM (n = 137); gestational impaired glucose tolerance (GIGT) (n = 91); and normal glucose tolerance (NGT) (n = 259). The primary outcome was the presence of the metabolic syndrome at 3 months postpartum, as defined by International Diabetes Federation (IDF) and American Heart Association/National Heart Lung and Blood Institute (AHA/NHLBI) criteria, respectively. The postpartum prevalence of IDF metabolic syndrome progressively increased from NGT (10.0%) to GIGT (17.6%) to GDM (20.0%) (overall P = 0.016). The same progression was observed for AHA/NHLBI metabolic syndrome (NGT, 8.9%; GIGT, 15.4%; and GDM, 16.8%; overall P = 0.046). On logistic regression analysis, both GDM (odds ratio, 2.05; 95% confidence interval, 1.07-3.94) and GIGT (odds ratio, 2.16; 95% confidence interval, 1.05-4.42) independently predicted postpartum metabolic syndrome. Both GDM and mild glucose intolerance in pregnancy predict an increased likelihood of metabolic syndrome at 3 months postpartum, supporting the concept that women with gestational dysglycemia may have an underlying latent metabolic syndrome.

707: The cost-effectiveness of routine antepartum testing in low risk women

707: The cost-effectiveness of routine antepartum testing in low risk women

Fetal growth restriction: a modern approach

Fetal growth restriction is a complicated perinatal condition, with multiple causes. It shares common pathophysiologies with other important disorders, such as preeclampsia and abruption. As a group, these conditions associated with ischemic placental disease are responsible for a large percentage of indicated preterm births. The ability to accurately predict, diagnose and manage these pregnancies has significant and far-reaching implications, including potential effects on long-term adult health. Placental ischemia is the most common cause of fetal growth restriction. Alterations in placental development are being linked to various angiogenic mediators, which may be of future use in early risk-determination. Until then, the use of ultrasound to accurately diagnose fetal growth restriction and time delivery is the mainstay of management. Research in this area has revealed some commonalities in the deterioration of the growth restricted fetus, but has also indicated that not every affected fetus will follow the same progression in Doppler and other wellbeing parameters. Most importantly, gestational age at delivery is consistently being documented as a critical factor in perinatal morbidity and mortality. Fetal growth restriction is a late manifestation of early abnormal placental development. Once abnormal Doppler velocimetry is present, surveillance and timing of delivery should be based on the antepartum test results and on the gestational age.

Perinatal outcomes of pregnancies wıth borderline amniotic fluid index

Our aim was to determine whether a borderline amniotic fluid index observed during antepartum testing confers a significant risk of adverse perinatal outcome. Between April 2001 and May 2005, uncomplicated gestations with a singleton non-anomalous fetus, who underwent weekly monitoring of amniotic fluid index (AFI) until delivery during the last trimester and who gave birth at our hospital, were identified for our study. Normal amniotic fluid volume and borderline amniotic fluid were defined as AFI of >10 and <24 cm and >5 and <10 cm, respectively. The groups were compared on maternal data, mode of delivery and perinatal outcomes such as fetal distress, intrauterine growth restriction and meconium fluid. A total of 90 cases were identified as borderline amniotic fluid and 277 cases as normal AFI. We observed significant increased incidences of admission to neonatal intensive care unit, intrauterine growth restriction, meconium-stained amniotic fluid, intrapartum fetal distress in the group with borderline amniotic index (P < 0.05). A borderline amniotic fluid index observed in antepartum testing during the last trimester carries an increased risk of adverse perinatal outcomes. These patients should be followed up carefully during the antepartum and intrapartum period.