81 The Significance of Anticardiolipin Antibodies in Diabetic Pregnancies

spa Abstracts

Volume 166 Number I, Part 2

81 THE SIGNIFICANCE OF ANTICAROIOLIPIN ANTIBODIES IN DIABETIC PREGNANCIES. S Rotmensch EA Reece, M

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Liberati,' J Peipert,' J Garofalo,' M Breitenstein,' JC Hobbins. Depts OBIGYN and Rheumatology, Yale University

Anticardiolipin antibody (ACA) is characteristically found in patients with autoimmune diseases and the primary "antiphospholipid antibody syndrome". Gestational and pregestational diabetes are also associated with increases in a variety of autoantibodies. We determined IgG and IgM ACA concentrations in 41 consecutive pregnant diabetics (Classes A, n = 21; B, n= 13,; C, n=7) using solid phase ELISA (>2SD above mean = positive). Elevated ACA concentrations were found in 32% (13/41; IgM = 2/13; IgG =11/13). No differences were found between ACA positive and negative patients in mean birthweight (3455.±.573 vs 3369 .±. 772gml. gestational age at delivery 39.1 vs 38 wks), mean arterial pressure in all three trimesters (92.6 vs 90.3; 93.3 vs 93.0; 93.0 vs 95.9 mmHg), and platelet count (292,000 vs 287,000 per mm'). No cases of deep vein thrombosis occurred. One patient in each group was delivered preterm due to early onset severe preeclampsia. Statistical power calculations confirmed adequacy of sample sizes for the detection of clinically meaningful differences. Two intrauterine demises occurred in the ACA negative group. Conclusions: Elevated ACA concentrations are frequent in diabetic pregnancies, with an incidence approaching that of patients with systemic lupus erythematosus. However, they are not associated with adverse maternal or fetal outcome.

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INCREASED PLASMA LEVELS OF ENDOTHELIN-I IN GRAVIDAS ABUSING COCAINE I..!~. Steinfeldx, P. Samuels, M. Rhoa x, D.B. Cinesx, and K.R. McCrae x Depts. of Obstetrics & Gynecology, Medicine, and Laboratory Medicine, University of Pennsylvania. Philadelphia. PA

Cocaine abuse during pregnancy is often associated with maternal vascular complications including hypertension and abruption. We

investigated the possibility that these complications may be mediated by the vasoactive peptide, endothelin-I (ET-I). We measured the

plasma concentration of ET -1 in 20 patients with acute cocaine

intoxication, 20 normal gravidas, and 10 nonpregnant individuals.

There were no significant differences in age (p ::::: 0.64), gravidity (p = 0.08) or diastolic blood pressures (p = 0.13) between women using

cocaine and healthy, pregnant controls.

There were, however,

significant differences in the systolic blood pressures (126 ± 18 vs 108 ± 9 mm Hg, p < 0.01), gestational age (31.6 ± 3.4 vs 37.5 ± 2.2 weeks, p < 0.01), and number of women presenting with evidence of abruption (II vs 0, P < 0.01). No patient met clinical or laboratory criteria for preeclampsia. Plasma. concentrations of ET-l were determined in early labor (cervix dilated S 3 em) in both pregnant groups using a commercially available radioimmunoassay kit (Arnersham). The mean (± SD) concentration of ET -I in the gravidas with a positive screening assay for cocaine was 12.8 ± 6.2 fmol/ml compared with 5.8 ± 2.7 fmol/ml in the pregnant control group (p < 0.01) and 3.5 ± 2.2 fmol/ml in nonpregnant women (p < 0.01) The plasma concentration of ET -1 continued to rise in the 5 gravidas with cocaine abuse in whom additional samples were obtained, from a mean of 13.7 ± 6.9 fmol/ml in early labor to 16.2 ± 7.7 fmol/ml at 24 hours after delivery, and remained elevated 48 hours after delivery (13.7 ± 6.6 fmol/ml). In contrast, the concentration of ET-I in 5 normal gravidas did not change significantly after delivery (5.8 ± 2.5 fmol/ml before delivery, 4.3 ± 0.57 fmol/ml and 3.9 ± 1.1 fmol/ml 24 and 48 hours after delivery, respectively). Conclusion: Thirteen of 20 (65%) women who presented with cocaine abuse and pregnancy complications had endothelin-I levels> 2 SD above the mean for normal pregnant controls. The source(s) of this vasoactive peptide and its role in the pathogenesis of the vascular complications of cocaine abuse remain to be identified.

IS FETAL PULMONARY MATURITY RElATED TO SIZE FOR GESTATIONAL AGE IN PREGNANCIES COMPLICATED BY DIABETES OR HYPERTENSION? L_eJ..Q.~!..,x O. langer, Dept. Ob/Gyn. UTHSC, San Antonio, TX Fetal size for gestational age is influenced by maternal diabetes and hypertensive disorders. Alterations in fetal pulmonary maturity have also been attributed to these conditions. Thus, maternal hypertension of sufficient severity to cause fetal growth retardation should also cause the greatest acceleration of pulmonary maturity while the macrosomic infants of diabetic mothers should have the most marked delay of pulmonary maturation when compared to a control population. This hypothesis was tested on all patients undergoing an amniocentesis for maturity studies at this institution Since f986. More than 730 women have been entered thus far in this ongoing study. The associations between birth percentiles, gestational age and lung maturity are summarized below.

SGA AGA lGA

PERCENT WITH AN IMMATURE AMNIOCENTESIS Preterm « 37 weeks) Term (<< 37weeks DM Htn Controls DM Htn Controls 1000/0 38% ~ 39% 330/0 ~ 69% 34% 49% 17% 25% 3% 42% 62% 19% 25% n=82 n=43 n=331 n=147 n=7 n=126

This study reveals 1) infants of hypertensive mothers showed no significant acceleration of maturity when compared to controls, 2) preterm AGA infants of diabetiC mothers had a significantly higher risk of pulmonary immaturity when compareCf to hypertensive mothers (p< .003) and control mothers (p< .01),3) term AGA infants of diabetic mothers were significantly less mature than controls (p< .004) and 4) macrosomic infants of diabetic mothers however, were essentially identical to the lGA infants of women with negative glucose screening. perhaps reflecting a level of glucose intorerance not detected by current screening techniques. In summary, this study showed no effect of hypertension on pulmonary maturity and that the effects of diabetes on fetal size are unrelated to ItS effects on fetal lung maturity.

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DOES MATERNAL DIABETES DElAY FETAL PULMONARY MATU/IITY? JPlper.' O. langer, Dept. Ob!Gyn, UTHSC, San AntOniO, T)C Diabetes In pregnancy has been associated with fetal pulmonary immaturity even at term gestation. Thus, confirmation of maturity has been recommended prior to delivery at :5 39 weeks gestation. We hypothesize that adequate glucose control will prevent the delay in fetal lung maturation as compared to the nondiabetic population. To test this hypothesis, all amniocenteses performed for fetal maturity since 1986 were reviewed and combined with the patients' obstetric data for analysis. To date, 231 diabetic patients and 461 nondiabetic nonFiypertensive patients have been enrolled. Adequate control was aefined as mean blood glucose :5 105 mg. !dlo (self· monitored). Pulmonary maturity was defined as presence of phosphatidyl glycerol (PG) in diaoetics and either presence of PG or lecithinfSphlngomyelin (LIS) ratio« 2/1 in the nondiabetic patients. PERCENT WITH AN IMMATURE AMNIOCENTESIS Diabetics Non· Weeks <34 34·36.9 3737.9 38 38.9 «39

x:5 105 90% 43% 26% 8% 13%

x>105 89% 47% 38% 20% 17%

Total 91% 51% 32% 15% 15%

Diabetics 68% 27% 7%

13%

6% - - - - - - - - - - - - - _.. _ - _ . _ . _ - - - -

The relative maturity for gestational age was not significantly different in the term diaoetic patients than the nondiabetic patients tested. Although there was a trend toward delayed maturity in poorly controlled diabetics beyond 37 weeks, statistical significance was not achieved. In addition, of the 41 diabetic palients delivered within a week of an immature amniocentesis, there were no cases of hyaline membrane disease. In summary, confirmation mfetal lung maturity prior to elective delivery is recommended in all pregnancies prior to 38 weeks. The need for a more aggressive approach to the diabetic patient beyond 38 weeks, cannot be supported by the results of this study

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