Perinatal Outcomes In Pregnancies Research Articles

Obstetric and perinatal outcomes of pregnancies with COVID 19: a systematic review and meta-analysis

Objective This meta-analysis aimed at comparing obstetric and perinatal outcomes in laboratory-tested pregnant women for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection before delivering. Method We performed a comprehensive systematic review of electronic databases for studies reporting pregnant women with and without SARS-CoV-2 infection, as determined by polymerase chain reaction (PCR) before delivery, during the pandemic period published up to June 25, 2021. Results are reported as mean difference (MD) or odds ratio (OR) and their 95% confidence interval (CI). Results Seventeen observational studies with low to moderate risk of bias, reported on 2,769 pregnant women with a positive SARS-CoV-2 PCR test and 13,807 with a negative test. Pregnant women with a positive PCR test delivered at an earlier gestational age (MD −0.19; 95% CI −0.36 to −0.02 weeks), smoked less (OR 0.75; 95% CI 0.61–0.94) and were associated with higher odds for preeclampsia (OR 1.30; 95% CI 1.09–1.54), NICU admissions (OR 2.37; 95% CI 1.18–4.76), stillbirths (OR 2.70; 95% CI, 1.38–5.29), and perinatal mortality (OR 3.23; 95% CI 1.23–8.52). There were no significant differences between positive and negative tested women in terms of nulliparity, multiple pregnancies, gestational diabetes, route of delivery, labor induction, preterm birth, infant birth weight, 5 min Apgar scores < 7, small-for-gestational-age infants and fetal malformations. Eleven studies included neonatal PCR SARS-CoV-2 testing which was performed on 129 infants, of which 20 were positive. Conclusion Positive SARS-CoV-2 tested pregnant women had higher odds for preeclampsia/hypertensive disorders of pregnancy, NICU admissions, stillbirths and perinatal mortality.

Iatrogenic chorioamniotic separation and septostomy following fetoscopic laser photocoagulation for twin-twin transfusion syndrome.

To compare the perinatal outcomes of pregnancies complicated by chorioamniotic separation (CAS) vs septostomy following fetoscopic laser photocoagulation (FLP) for twin-twin transfusion syndrome (TTTS). This was a retrospective cohort analysis of monochorionic diamniotic twin pregnancies with TTTS that underwent FLP at one of two university-affiliated tertiary medical centers between January 2012 and December 2020. CAS and septostomy were diagnosed either during the procedure or by ultrasonography within 24-48 h after FLP. Data on procedure and postprocedure parameters, pregnancy outcomes and survival were collected from the patients' electronic medical records. Pregnancies were stratified according to the presence of CAS, septostomy or neither. Patients diagnosed with both CAS and septostomy were analyzed separately. Of the 522 women included in the cohort, 38 (7.3%) were diagnosed with CAS, 68 (13.0%) with septostomy and 23 (4.4%) with both CAS and septostomy. The remaining 393 (75.3%) women comprised the control group. Groups did not differ in demographic characteristics. The septostomy group had a lower rate of selective fetal growth restriction than did the CAS and control groups (24.2% vs 36.8% vs 42.7%, respectively; P = 0.017). Moreover, intertwin size discordance was lower in the septostomy group (15.1% vs 23.4% in the CAS group and 25.5% in the control group; P = 0.001). Median gestational age at FLP was significantly lower in the CAS group (19.3 weeks vs 20.4 weeks in controls and 20.9 weeks in the septostomy group; P = 0.049). The rate of delivery prior to 34 weeks was significantly higher in the CAS group (89.2%), followed by the septostomy group (80.9%), compared with the control group (69.0%) (P = 0.006). A secondary analysis demonstrated that patients with both CAS and septostomy presented the highest rates of delivery prior to 34 weeks (100%) and 32 weeks (68.2%). CAS and septostomy following laser surgery for TTTS are independently associated with higher rates of preterm delivery. The presence of these two findings in the same patient enhances the risk of prematurity. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

147. Pregnancy in kidney transplantation: perinatal outcomes and impact on kidney function

Introduction / aims of the study: Pregnancy after kidney transplantation (KT) has a high risk for maternal-fetal complications. This study aims to evaluate maternal and perinatal outcomes in pregnancies after KT and the impact of pregnancy on graft function. Methods: This descriptive and retrospective case-control study included 43 pregnancies in women after KT, followed in our institution, from January 1991 to December 2019. Each pregnancy was considered as an event. The control group included 200 non transplanted pregnants,followed in the same center.

462 Maternal and perinatal outcomes of pregnancies complicated by preeclampsia

Introduction and aim of the study: Preeclampsia occupies a leading place in maternal and perinatal morbidity and mortality. Aim of the study was to analyze the course of pregnancy, perinatal and maternal outcomes in women with pregnancy complicated by preeclampsia. Methods: It was the retrospective evaluation of the pregnancy and labor outcomes, course of early neonatal period of the newborns of 60 women (30 with moderate and 30 with severe preeclampsia). Results: A history of preeclampsia in previous pregnancy has 10 women (16.7%).

Obstetric and Perinatal Outcomes After Assisted Reproductive Technology in Women With Cesarean Scar.

IntroductionAssisted reproductive technology (ART) and previous Cesarean section (CS) are independently associated with the risk of adverse obstetric and perinatal outcomes in general. Few studies have focused on the association between adverse obstetric and perinatal outcomes and ART used in the high-risk population of women with previous CS.Materials and MethodsA retrospective cohort study including 14,099 women with a previous delivery and a subsequent delivery between April 2014 and April 2020 was conducted at our hospital. We assessed the risk of adverse obstetric and perinatal outcomes in pregnancies conceived by ART in women with previous CS, using log-binomial regression models.ResultsIn women with previous CS, ART singleton pregnancies were associated with an increased risk of maternal complications, such as pregnancy complications, placental anomalies of implantation, postpartum hemorrhage, and preterm birth (PTB), as compared to spontaneously conceived pregnancies. The implementation of ART and previous CS interacted in a synergistic manner to increase the likelihood of the placenta accreta spectrum in women with singleton pregnancies [adjusted relative risk (aRR) 5.30, 95% confidence interval (CI) 4.01–7.00; relative risk due to interaction: 1.41, 95%CI 0.07–2.75]. In women with previous CS who underwent ART, women with singletons conceived through intracytoplasmic sperm injection were at increased risk of velamentous placenta (aRR 2.46, 95%CI 1.35–4.48) compared with those with singletons conceived through in vitro fertilization (IVF), whereas women with singletons conceived through cleavage-stage embryo transfer (ET) were at increased risk of gestational diabetes mellitus (GDM) (aRR 1.74, 95%CI 1.16-2.60) than those with singletons conceived through blastocyst–stage ET.ConclusionPregnancies conceived through ART were at increased risk for adverse obstetric and perinatal outcomes in women who had previously delivered by CS, particularly for placental anomalies of implantation. In women with previous CS undergoing ART, IVF and blastocyst–stage ET may be a relatively safe treatment.

Perinatal outcomes of pregnancies with prenatally diagnosed foetal congenital heart disease

We aimed to assess the types of prenatally diagnosed congenital heart disease (CHD) and their association with structural and chromosomal abnormalities and to evaluate the perinatal outcomes according to the type of the heart defect. We retrospectively reviewed 377 pregnancies with prenatally diagnosed CHD. The main outcome measure was to evaluate the pregnancy outcomes of CHD according to the type of the heart defect and associated structural or chromosomal abnormalities. Of 377 foetuses with major structural CHD, 214 (56.8%) were isolated, 49 (13%) had additional cardiac anomalies, 58 (15.4%) had extracardiac malformations with normal karyotype and 56 (14.9%) had chromosomal abnormalities. The most common chromosomal abnormality was trisomy 21 (55.4%). Prenatal detection of CHD allows early workup to identify chromosomal abnormalities and detailed anatomic evaluation of extracardiac malformations. Prognostication of each heart defect at diagnosis and facilitating patients with isolated surgically correctable CHD for targeted postnatal care is essential. IMPACT STATEMENT What is already known on this subject? CHD is the most common structural anomaly and is strongly associated with chromosomal anomalies and genetic syndromes. What do the results of this study add? Survival of the prenatally diagnosed CHD depends on the type and severity of the condition and coexisting extracardiac structural or chromosomal abnormalities. What are the implications of these findings for clinical practice and/or further research? Prenatal detection of CHD allows early workup to identify chromosomal abnormalities, detailed anatomic evaluation of extracardiac malformations and time to refer the parents to tertiary cardiac care centres and prepare for planned delivery, as well as to establish an appropriate perinatal and postnatal therapeutic plan.

Прогнозирование перинатального исхода при преэклампсии на основании доплерометрических показателей

Objective of the Review: To present current literature data on the prediction of perinatal outcomes in pregnant women with preeclampsia and on potential strategies for improving the prediction of outcomes of pregnancy complicated by preeclampsia based on Doppler parameters. Key points. The results of studies devoted to the choice of the most optimal Doppler indicators that can be used to predict perinatal outcome are presented. This review presents an analysis of the accuracy of Doppler parameters (pulsation index in the middle cerebral and umbilical arteries, resistance index, cerebroplacental ratio) in predicting adverse perinatal outcomes in pregnancy complicated by preeclampsia. A review of the current literature on the prediction of perinatal outcomes and management of pregnant women with preeclampsia and potential strategies improving the prediction of outcomes of pregnancy complicated by preeclampsia. Conclusion. Currently, dopplerometry in obstetric practice is a highly accurate prognostic method for determining the perinatal outcome in complicated pregnancy. This method allows to predict the actual risk to the fetus, monitor and evaluate its degree along with other methods of antenatal care, and also allows you to choose the time and method of delivery if the risk of intrauterine death of the fetus is high. Keywords: parameters of fetal cerebral hemodynamics, velocity and pulsation of blood flow in the middle cerebral artery, cerebroplacental ratio, gestational period, Doppler parameters, preeclampsia.

Comparison of maternal and perinatal outcomes of pregnancies with frozen and fresh embryo transfers at term pregnancy

Comparison of maternal and perinatal outcomes of pregnancies with frozen and fresh embryo transfers at term pregnancy

Retraction: Perinatal outcome in pregnancies associated with hypertension: A prospective cohort study in a rural tertiary care teaching hospital of North India.

[This retracts the article on p. 651 in vol. 46, PMID: 35068728.].

Adverse Outcomes in Pregnancy with Chronic Hypertension with and without Superimposed Preeclampsia in Urban South Indian Population: A Prospective Observational Study

Introduction: Pregnant women with chronic hypertension and who developed superimposed Preeclampsia (PE) had a higher rate of adverse maternal and perinatal outcomes. Prospective data on the outcome of pregnancies with chronic hypertension are sparse. Aim: To evaluate the maternal and perinatal outcomes in pregnancies complicated by chronic hypertension with and without superimposed PE in South Indian population. Materials and Methods: A two group, parallel, prospective observational study was carried out in 270 women with singleton pregnancy and chronic hypertension with and without superimposed PE and who received antenatal care and delivered in the Department of Obstetrics and Gynaecology at Fernandez hospital, Hyderabad, Telangana, India from March 2019 to February 2020. A total of 180 women had chronic hypertension without superimposed PE and 90 had superimposed PE (group A, 180 cases; group B, 90 cases). The medical records were reviewed with specific reference to the treatment, development of Foetal Growth Restriction (FGR), maternal and perinatal outcomes. FGR was considered as the primary outcome variable. Secondary variables were stillbirth rate, low birth weight, Neonatal Intensive Care Unit admissions, Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) at 5 minutes, gestational age at delivery, caesarean section rate and maternal complications. Categorical variables were assessed by Pearson’s Chi-square test. Continuous variables were assessed by unpaired student t-test. Results: The mean maternal age in group A was 32±5 years and in group B was 30±4 years. Adverse maternal outcomes like abruption, Haemolysis, Elevated liver enzymes, and Low platelets (HELLP) syndrome, and pulmonary oedema were all low in women without superimposed PE than those with superimposed PE (1.6% vs 12%, p≤0.001). There were no maternal deaths in either group. Compared to group A, group B showed higher FGR rate (15.5%vs 51.1%, p&lt;0.001), preterm deliveries (&lt;37 weeks) (50.5% vs 80% p&lt;0.001), stillbirths (0 vs 13.3%), low APGAR at 5 minutes (1.1% vs 16.6%%, p&lt;0.001), low birth weight (21.2% vs 71.1%, p&lt;0.001), NICU admissions (14.4% vs 43.3%, p&lt;0.001). There was no significant difference in the caeserean section rate between the groups (69.4% vs 74.4%, p=0.39). Conclusion: Maternal and perinatal morbidity was higher in women having chronic hypertension with superimposed PE. They need vigilant maternal and foetal surveillance and should be counseled about all the possible adverse outcomes.

PREGNANCY OUTCOMES IN WOMEN WITH EXTREMELY HIGH SFLT-1/PIGF RATIO: CASE SERIES

Preeclampsia (PE) is a multisystem disorder, usually defined as the development of hypertension and proteinuria after 20 weeks of pregnancy. The sFlt-1/PlGF ratio has been widely studied as a diagnostic and prognostic marker of preeclampsia and other manifestations of placental dysfunction. A sFlt-1/PlGF ratio greater than 85 for early PE, &lt;34 weeks of gestation suggests a high risk of PE requiring close clinical monitoring. Our main aim was to evaluate the maternal and perinatal outcomes of pregnancies with an extremely high sFlt-1/PlGF ratio. The analysis included data on placental growth factor and soluble fms-like tyrosine kinase serum levels, measured during 2017–2020 in 128 pregnant women. Here we present 8 cases of women with a numerical ratio greater than 850. In all 100% of cases, the signs of obstetric angiogenic catastrophe requiring imminent delivery developed soon. We observed a trend for worsening perinatal outcomes in women with an extremely high sFlt-1/PlGF of ≥850.

Evaluation of obstetric and perinatal outcome of pregnancy with bad obstetric history

Background: Adverse perinatal outcome has always been a devastating experience for the mother. Advanced maternal age and other risk factors are independent risk factor for perinatal outcome. Therefore, aim of study is to compare the effect of these factor in different study group. Aims and Objectives: Case–control study has been conducted to evaluate obstetrics outcome, maternal morbidity, and perinatal outcome in patients with bad obstetric history. Materials and Methods: A prospective observational case–control study has been conducted in two groups; GROUP A: BOH group (n = 44) and GROUP B: Controls (n = 88) who fulfilled inclusion criteria in Department of Obstetrics and Gynaecology, GMERS Medical college, Sola during the period of August 2018 to August 2020. Statistical analysis was done by descriptive statistics and qualitative and quantitative method. Results: Incidence of hypertension in Group A was 25%, while in Group B incidence was 6.8%. Incidence of hypertension was 4.5 times higher in Group A than B which was statistically significant (P &lt; 0.05). Incidence of PROM, gestational diabetes mellitus, thyroid dysfunction was higher in Group A than Group B. Higher incidence of preterm delivery found in Group A than in Group B which was statistically significant (P &lt; 0.05). Conclusion: Among all BOH group, cases with previous history of preterm delivery, still birth, recognition of prior learning, and HTD were the major risk factors which could be responsible for adverse obstetric and perinatal outcome.

A cross-sectional evaluation of maternal and perinatal outcomes in pregnancies complicated with COVID-19

Background and Aim Pregnancy is considered a vulnerable period for women regarding increased risk of respiratory tract infections, altered immunity, and metabolic changes in their bodies. COVID-19 pandemic possesses a significant risk on pregnants, but the data on the disease course is insufficient. Therefore, this study aimed to evaluate the maternal and perinatal outcomes in pregnant women diagnosed with COVID-19. Methods This is a cross-sectional study that evaluated the hospital records of pregnant women admitted to the Obstetrics and Gynecology Department of 19 Mayıs University Hospital between 01/04/2020 to 30/12/2021. Outcome measures were gestational week at birth, basal gestational and labor characteristics, delivery complications, and perinatal and maternal COVID-19 outcomes. Results Analyses of the data of 98 patients revealed that median age of the mothers was 30 years; 26.5% were primigravid, 43.9% were nulliparous, and 29.6% were primiparous. Three had twin pregnancies, 52% of the births were preterm, 88% were cephalic presentation, and 95.9% were cesarean deliveries.The most common delivery complications were acute fetal distress (51%), preterm premature rupture of membranes (50%), and neonatal asphyxia (49%). Gestational characteristics were similar between treatment groups for COVID-19, but patients admitted to intensive care unit and applied mechanical ventilation (11.2%) had significantly more preterm births, and perinatal complications including acute fetal distress (p=0.030), PPROM (p&lt;0.001), neonatal asphyxia (p=0.021), and lower APGAR scores (p=0.002). Conclusion COVID-19 is a significant risk factor for pregnant women. This study showed that COVID-19 and pregnancy may induce adverse effects on each other. The data provided here will contribute to the growing body of epidemiological and clinical evidence on the interactions between COVID-19 and pregnancies.

Prevalence and Perinatal Outcomes Following In Utero Exposure to Prehospital Emergency Methoxyflurane: A 17-Year Retrospective Cohort Study.

ObjectiveTo examine the prevalence of exposure and perinatal outcomes associated with in utero exposure to methoxyflurane.Design, Setting and PopulationWhole-population ambulance data in Western Australia (WA) were linked to the statutory perinatal data collection to identify pregnant women transferred by ambulance between 2000 and 2016. The proportion of neonates in WA exposed to methoxyflurane, fentanyl or no analgesia during an ambulance transfer was calculated. Perinatal outcomes of pregnancies exposed to methoxyflurane (n=1579) were compared to those exposed to fentanyl (n=203) or no analgesia (n=10524) using multivariable logistic regression modelling. Perinatal outcomes were considered overall and by trimester of exposure.Main Outcome MeasuresPrimary outcomes were the prevalence of in utero methoxyflurane exposure and Apgar score on the day of delivery.ResultsIn the study period, 0.4% of all neonates born in WA were exposed to methoxyflurane in utero. Methoxyflurane exposure on the day of delivery (n=657) was not associated with an increased likelihood of a low Apgar score at five minutes compared with no analgesia (n=2667) (OR 1.23, 95% CI 0.91-1.67). Whereas fentanyl exposure (n=22) was associated with an increased likelihood of low Apgar score compared with methoxyflurane (OR 3.67, 95% CI 1.18-11.48).ConclusionsMethoxyflurane is commonly used by ambulance services to treat pain in pregnant women in WA. While not recommended for use in pregnancy, pregnancies exposed to methoxyflurane did not have an increased risk of adverse perinatal outcomes in this study.

Is amniopatch an effective treatment for spontaneous previable premature rupture of membranes? Analysis of perinatal outcome.

To characterize the perinatal outcomes of pregnancies complicated by spontaneous previable premature rupture of membranes with a therapeutic intervention in the form of amniopatch (AP) at the 2nd Department of Obstetrics and Gynecology (2008‒2019). The retrospective analysis of perinatal markers and early neonatal morbidity of pregnancies treated with amniopatch. Discussion comparison with the published papers of cases of spontaneous previable rupture of membranes managed expectantly. Out of the total number of pregnancies, 53 met the exclusion criteria, of which 35 were terminated by delivering a live newborn, 3 newborns died during the hospitalization. The following incidence of early complications has been reported in live births: 1) Bronchopulmonary dysplasia (10/35-28.57 %), 2) Newborn respiratory distress syndrome (25/35-71.42 %), 3) Neonatal sepsis (15/35-42.85 %), 4) Intraventricular hemorrhage (14/35-40 %), 5) Periventricular leukomalacia (3/35-8.57 %), 6). Necrotizing enterocolitis (2/35-5.71 %), 7) Retinopathy of prematurity (7/35-20 %) and 8) Foetal compression syndrome (16/35-45.71 %). In a discussion comparison with available publications of expectantly managed pregnancies, we observed a statistically significantly lower incidence of respiratory distress syndrome, retinopathy, and chorioamnionitis in our cohort along with a higher incidence of foetal compression defects. Amniopatch can be a therapeutic method for reducing the neonatal mortality associated with RDS, maternal infectious morbidity, and an alternative in patients, who require an active approach to such a compromised pregnancy (Tab. 12, Fig. 1, Ref. 50).

SİSTEMİK LUPUS ERİTEMATOZUSLU GEBE KADINLARIN MATERNAL VE FETAL SONUÇLARININ DEĞERLENDİRİLMESİ

Aim: To evaluate obstetrical and perinatal outcomes of pregnancies with systemic lupus erythematosus (SLE).&#x0D; Materials and Method: This was a retrospective study evaluating obstetric outcomes of 35 patients with SLE who were followed up between 2010 and 2020. Lupus activity was based on SLE Disease Activity Index (SLEDAI) criteria and pregnancy outcomes were evaluated by grouping as active and inactive SLE.&#x0D; Results: The mean maternal age was 29 (21-39). The rate of antiphospholipid syndrome and active disease was 5% and 40% respectively. There were 30 live births. Two elective abortions were reported, one with major cardiac anomaly and the other with renal agenesis. One spontaneous abortion and 2 stillbirths were observed in the active SLE group. Overall rates of intrauterine growth retardation, preeclampsia, and preterm delivery were 8%, 20%, and 26%, respectively. Fetal loss and preterm delivery were significantly higher in the active SLE group (p=0,018, p=0,023). A higher rate of neonatal intensive care unit (NICU) admission was observed in the active SLE group (p=0,034) but Apgar scores less than 0,05).&#x0D; Conclusion: Despite advances in the medical sciences, an active disease with SLE has an elevated risk of inducing adverse pregnancy outcomes. Close follow-up could helps reduce pregnancy complications, especially preterm deliveries.

Cardiac Disease in Pregnancy: Maternal and Perinatal Outcomes in RSUP Dr. Mohammad Hoesin Palembang

Background: Impaired maternal and uteroplacental perfusion can occur in pregnancy with cardiac disease leading to maternal and perinatal mortality and morbidity due to increased cardiac load and ventricular dysfunction. This research aims to determine maternal and perinatal outcomes of pregnancies with cardiac disease.&#x0D; Method: This research was a descriptive observational study conducted by a total sampling method and a cross-sectional design. This research used medical records of pregnant women with cardiac disease who gave birth in RSUP Dr. Mohammad Hoesin Palembang in January 2018-December 2020 as study samples.&#x0D; Result: Among 68 pregnancies with cardiac disease, there were 4 cases (0.87%) found in 2018, 37 cases (2.47%) found in 2019, and 27 cases (1.48%) found in 2020. The highest distribution of pregnancies with cardiac disease was found at 64.7% in the range of 20-35 years old age group; 57.4% in the multiparity group; 38.2% in the range of ≥34 – &lt;37 weeks gestational age group; 86.8% in the high school educational level group; 66.2% in the high-risk cardiac functional status group; 54.4% in the peripartum cardiomyopathy group; and 36.8% with preeclampsia/eclampsia as a comorbid. In this study, maternal outcomes found were maternal mortality at 11.8%; cardiac failure at 70.6%; arrhythmia at 1.5%; and stroke at 1.5%, while perinatal outcomes found were prematurity at 60.3%; low birth weight at 64.4%; IUGR at 37.0%; IUFD at 1.4%; stillbirth at 6.8%; neonatal death at 9.6%; and perinatal asphyxia at 42.5%.&#x0D; Conclusion: The prevalence rate of pregnancies with cardiac disease in RSUP Dr. Mohammad Hoesin Palembang was 0.87% in 2018, 2.47% in 2019, and 1.48% in 2020. The most common maternal outcome in this study was cardiac failure, with most in the peripartum cardiomyopathy group, while the most common perinatal outcome was low birth weight, with most in the hypertensive heart disease group.

Adverse perinatal outcomes in pregnancies complicated with placental abruption accompanied by hypertensive disorders of pregnancy

Adverse perinatal outcomes in pregnancies complicated with placental abruption accompanied by hypertensive disorders of pregnancy

Association between continuous glucose monitoring metrics and perinatal outcomes in pregnancies complicated by pregestational diabetes

Continuous glucose monitoring (CGM) in diabetic pregnancies improves glycemic control and neonatal outcomes, compared to capillary blood glucose monitoring. Current recommendations for CGM goals are based primarily on expert opinion, and it is not clear which CGM metrics are associated with perinatal outcomes. Our objective was to evaluate the association between CGM metrics and perinatal outcomes and identify evidence-based treatment goals to reduce morbidity.

Effect of fetal sex on perinatal outcome of pregnancies with maternal diabetes- a population-based study

The male sex has been identified as an independent risk factor for many adverse pregnancy outcomes, which implies an evolutionary advantage for the female offspring. However, it is unknown if this advantage translates to fetal responses to maternal diabetes. In this study, we aim to determine the association of fetal sex with perinatal outcomes in pregnancies complicated by pregestational or gestational diabetes.