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91 Affinity Chromatography: Excellent Correlation with Hgba1c
spa Abstracts
Volume 166 Number 1, Part 2
89
GESTATIONAL DIABETES AND INFECTION: AN INFANT AND NOT MATERNAL COMPUCATION, O. Langer, M. Berkus, A. Samueloff, E. Xenakis,' N. Field,' Dept. OB/GYN, University of Texas Health Science Center at San Antonio, Texas.
91 AFFINllY
CHROMATOGRAPHY: EXCELLENT x CORRELATION WITH HghAl.. RO Jelsema , MP Dombrowski, and SF Bottoms. Wayne State Univ., Hutzel Hospital, Detroit, ML Counseling diabetics for risk of fetal anomalies is based exclusively on studies using older techniques such as ion exchange column HgbAle (intra- and inter-assay variation 4% and 6%). Newer affinity chromatography (AC) methodology has the following advantages: 1) greater precision (intra- and inter-assay variation < 3%), 2) measures all glycated Hgb, not just glycated A or Ale, 3) does not measure nonglycated Hgb variants S,C,F, and 4) is faster and less expensive. Correlation of these two methods in pregnant diabetics has not been reported. We prospectively performed both tests on blood samples from 83 pregnant diabetics over a period of 6 months. Using only the first determined level for each patient, and excluding all patients with hemoglobinopathies, 78 samples remained. The mean gestational age (GA) was 21 weeks, with 11 samples from the 1st trimester. Stepwise regression analysis was performed with HgbA1e as dependent, and GA and AC as independent variables. AC was highly correlated with HgbA1e (r = 0.92), regardless of GA, which had no significant effect. The regression equation was: HgbA1e = 0.66 x AC + 2.7, Using this formula, Ylinen's critical HgbA1c of 10% corresponds to an AC of 11 %. Based on these results and the other advantages of AC outlined above, we recommend its use in diabetic pregnancy.
Diabetes in non pregnant women (characterized by severe
glucose abnormality) has been associated with a high inciaence of Infection and resultIng morbidity. In contrast, there is a dearth of information regarding gestational diabetes (GDM) represented by milder glucose abnormality and infection. Therefore, we sought to Investigate thea relationship between GDM and infection. 1740 consecutive gestational diabetic women and 24500 nondiabetic controls were landomly .selected from our data base. The 2 groups were comparable In infection·related factors such as maternal age, parity, duration of labor, time from rupture of membranes to aeilvery and incidence of internal FHR monitoring. To control for method of delivery, each of the 2 groups was stratified into vaginal (VAG), instrumental (lNSTR) and cesarean section (CIS) and measured for infection variables. DIABETIC (n - 1740)
VAG INSTR
CIS
NON· DIABETIC (n - 24500)
VAG
INSTR
CIS
84 4.0 7.2 10.0 Neonatal infect 4.0 12.3 3.7 23 6* 2.1 4.0 32.3 Maternal infect 2.5 2.4 3.7 190* 2.0 4.6 26.8 Endometritis 0.1 0.2 5.5 Wound infect 0.1 0 46 2.5 3.8 11 2.3 4.8 Chorioamnionitis 1.5 7.9 9.4 9.3 8.3 8.6 13 5* Pylonephritis *Significant (p< .01) between the groups for a given category; a II others N.s The study further revealed: 1) when augmentatIon subjects were comparea to s!,ontaneous vaginal deliveries, a 3·fold liigher risk for maternal infection was found in both groups; 2) the incidence of fetal distress, 5·min Apgar score < 7, neonatal death and pneumonia were significantly higher in diabetic fetuses with Infection when compared to non·aiabetic fetuses; and 3) within each group, fetal morbidity and mortality was SignIficantly higher in the infection population. Pregnant diabetics are not at higher risk to develop infection in comparison with the general population. In contrasththe maternal disease may be the catalyst for fetal infection and t e resultant morbidity.
90
PLATELET AGGREGABILIlY IN PREGNANT DIABETICS IS CORRELATED WITH GLYCEMIC CONTROL BUT NOT DURATION OF DISEASE. RO Jelsema" MC Eustice" SF Bottoms, and EF Mammen'. Wayne State Univ./Hutzcl Hosp., Detroit, MI Platelet hyperaggregability among non-pregnant diabetics has been demonstrated using whole blood aggregometry. This could be due to vasculopathy, but we have recently reported evidence suggesting glycemic control may be responsible. To clarify the roles of vasculopathy and glycemic control, we studied 14 non-diabetic pregnant controls, 7 insulin dependent gestational diabetics (GOM), and 24 diabetics with disease predating pregnancy (100M, mean duration 9.1 years). Platelet aggregability and ATP release in whole blood in response to AOP, collage,!! and arachidonic acid were measured using a Chronolog Lumi-aggregometer. Glycated hemoglobin was measured and glycemic control was categorized as good, intermediate, or poor based on fasting blood sugar. The GOM and 100M groups had higher platelet aggregability than pregnant controls (MANOVA, p<0.(05). There was no difference in aggregability between GOM and 100M, and no significant relationship to the duration of diabetes, Among diabetics, canonical correlation of glycated hemoglobin and glycemic control to ATP release in response to AOP and collagen accounted for 34% of total variance (p<0,005). These findings are consistent with a prior study demonstrating increased platelet clumping in whole blood with the addition of glucose that was inhibited by apyrase, an AOP removing enzyme. We conclude that platelet hyperaggregability among pregnant diabetics is related primarily to glycemic control rather than duration of diabetes, which is in turn related to vascular disease.
92
EFFECT OF SUBSTANCE ABUSE REPORTING LAWS ON COCAINE USE IN SUBSEQUENT PREGNANCIES LuQO YR , and Kapernick, P.S .• Hennepin County Medical Center, Minneapolis, Minnesota Since 1987, all women at Hennepin County Medical Center delivering babies exposed to cocaine during pregnancy have been reported to lhe county Child Protective Services, for assessment, intervention and optional chemical dependency therapy. In 1988 and 1989, 176 women or their babies tested positive for cocaine at delivery. When lhese women presented for prenatal care in a subsequent pregnancy, they were prospectively identified and followed by social services and obstetrics for evidence of continued substance abuse. As of August 15, 1991, 431176 women had completed another pregnancy at our institution. Maternal charts were reviewed and demographic data as well as pregnancy outcome were recorded. 3/45 women (7%) had no known substance abuse in pregnancy. 23/45 (51%) again tested positive at delivery for cocaine. 15/45 (33%) lested negative for cocaine at delivery but had documented use in pregnancy and 4/45 women (9%) had no evidence of cocaine use in the subsequent pregnancy but had documentation of heavy alcohol use. Of the 42 non-sober women, 15/42 (36%) delivered babies weighing <2500 grams, 15/42 (36%) delivered prior to 37 completed weeks gestation, 6/42 (14%) had no prenatal care and 31/42 (74%) had <7 prenatal visits. 10/23 (43%) pos~ive at delivery had participated in some form of voluntary chemical dependency treatment since their previous delivery. 4115 women who had used cocaine in pregnancy but were negative at the time of delivery were active in treatment programs at the time of delivery. We regretfully conclude that notification of child protective services and offering optional chemical dependency treatment does not appreciably a~er substance abuse in future pregnancies. States considering implementation of mandatory substance abuse reporting laws such as the 1989 Minnesota law should consider this information. A more intensive program of child protective intervention including use of court-ordered chemical dependency treatment is now being implemented and its impact on recidivism must be assessed.
305
Volume 166 Number 1, Part 2
89
GESTATIONAL DIABETES AND INFECTION: AN INFANT AND NOT MATERNAL COMPUCATION, O. Langer, M. Berkus, A. Samueloff, E. Xenakis,' N. Field,' Dept. OB/GYN, University of Texas Health Science Center at San Antonio, Texas.
91 AFFINllY
CHROMATOGRAPHY: EXCELLENT x CORRELATION WITH HghAl.. RO Jelsema , MP Dombrowski, and SF Bottoms. Wayne State Univ., Hutzel Hospital, Detroit, ML Counseling diabetics for risk of fetal anomalies is based exclusively on studies using older techniques such as ion exchange column HgbAle (intra- and inter-assay variation 4% and 6%). Newer affinity chromatography (AC) methodology has the following advantages: 1) greater precision (intra- and inter-assay variation < 3%), 2) measures all glycated Hgb, not just glycated A or Ale, 3) does not measure nonglycated Hgb variants S,C,F, and 4) is faster and less expensive. Correlation of these two methods in pregnant diabetics has not been reported. We prospectively performed both tests on blood samples from 83 pregnant diabetics over a period of 6 months. Using only the first determined level for each patient, and excluding all patients with hemoglobinopathies, 78 samples remained. The mean gestational age (GA) was 21 weeks, with 11 samples from the 1st trimester. Stepwise regression analysis was performed with HgbA1e as dependent, and GA and AC as independent variables. AC was highly correlated with HgbA1e (r = 0.92), regardless of GA, which had no significant effect. The regression equation was: HgbA1e = 0.66 x AC + 2.7, Using this formula, Ylinen's critical HgbA1c of 10% corresponds to an AC of 11 %. Based on these results and the other advantages of AC outlined above, we recommend its use in diabetic pregnancy.
Diabetes in non pregnant women (characterized by severe
glucose abnormality) has been associated with a high inciaence of Infection and resultIng morbidity. In contrast, there is a dearth of information regarding gestational diabetes (GDM) represented by milder glucose abnormality and infection. Therefore, we sought to Investigate thea relationship between GDM and infection. 1740 consecutive gestational diabetic women and 24500 nondiabetic controls were landomly .selected from our data base. The 2 groups were comparable In infection·related factors such as maternal age, parity, duration of labor, time from rupture of membranes to aeilvery and incidence of internal FHR monitoring. To control for method of delivery, each of the 2 groups was stratified into vaginal (VAG), instrumental (lNSTR) and cesarean section (CIS) and measured for infection variables. DIABETIC (n - 1740)
VAG INSTR
CIS
NON· DIABETIC (n - 24500)
VAG
INSTR
CIS
84 4.0 7.2 10.0 Neonatal infect 4.0 12.3 3.7 23 6* 2.1 4.0 32.3 Maternal infect 2.5 2.4 3.7 190* 2.0 4.6 26.8 Endometritis 0.1 0.2 5.5 Wound infect 0.1 0 46 2.5 3.8 11 2.3 4.8 Chorioamnionitis 1.5 7.9 9.4 9.3 8.3 8.6 13 5* Pylonephritis *Significant (p< .01) between the groups for a given category; a II others N.s The study further revealed: 1) when augmentatIon subjects were comparea to s!,ontaneous vaginal deliveries, a 3·fold liigher risk for maternal infection was found in both groups; 2) the incidence of fetal distress, 5·min Apgar score < 7, neonatal death and pneumonia were significantly higher in diabetic fetuses with Infection when compared to non·aiabetic fetuses; and 3) within each group, fetal morbidity and mortality was SignIficantly higher in the infection population. Pregnant diabetics are not at higher risk to develop infection in comparison with the general population. In contrasththe maternal disease may be the catalyst for fetal infection and t e resultant morbidity.
90
PLATELET AGGREGABILIlY IN PREGNANT DIABETICS IS CORRELATED WITH GLYCEMIC CONTROL BUT NOT DURATION OF DISEASE. RO Jelsema" MC Eustice" SF Bottoms, and EF Mammen'. Wayne State Univ./Hutzcl Hosp., Detroit, MI Platelet hyperaggregability among non-pregnant diabetics has been demonstrated using whole blood aggregometry. This could be due to vasculopathy, but we have recently reported evidence suggesting glycemic control may be responsible. To clarify the roles of vasculopathy and glycemic control, we studied 14 non-diabetic pregnant controls, 7 insulin dependent gestational diabetics (GOM), and 24 diabetics with disease predating pregnancy (100M, mean duration 9.1 years). Platelet aggregability and ATP release in whole blood in response to AOP, collage,!! and arachidonic acid were measured using a Chronolog Lumi-aggregometer. Glycated hemoglobin was measured and glycemic control was categorized as good, intermediate, or poor based on fasting blood sugar. The GOM and 100M groups had higher platelet aggregability than pregnant controls (MANOVA, p<0.(05). There was no difference in aggregability between GOM and 100M, and no significant relationship to the duration of diabetes, Among diabetics, canonical correlation of glycated hemoglobin and glycemic control to ATP release in response to AOP and collagen accounted for 34% of total variance (p<0,005). These findings are consistent with a prior study demonstrating increased platelet clumping in whole blood with the addition of glucose that was inhibited by apyrase, an AOP removing enzyme. We conclude that platelet hyperaggregability among pregnant diabetics is related primarily to glycemic control rather than duration of diabetes, which is in turn related to vascular disease.
92
EFFECT OF SUBSTANCE ABUSE REPORTING LAWS ON COCAINE USE IN SUBSEQUENT PREGNANCIES LuQO YR , and Kapernick, P.S .• Hennepin County Medical Center, Minneapolis, Minnesota Since 1987, all women at Hennepin County Medical Center delivering babies exposed to cocaine during pregnancy have been reported to lhe county Child Protective Services, for assessment, intervention and optional chemical dependency therapy. In 1988 and 1989, 176 women or their babies tested positive for cocaine at delivery. When lhese women presented for prenatal care in a subsequent pregnancy, they were prospectively identified and followed by social services and obstetrics for evidence of continued substance abuse. As of August 15, 1991, 431176 women had completed another pregnancy at our institution. Maternal charts were reviewed and demographic data as well as pregnancy outcome were recorded. 3/45 women (7%) had no known substance abuse in pregnancy. 23/45 (51%) again tested positive at delivery for cocaine. 15/45 (33%) lested negative for cocaine at delivery but had documented use in pregnancy and 4/45 women (9%) had no evidence of cocaine use in the subsequent pregnancy but had documentation of heavy alcohol use. Of the 42 non-sober women, 15/42 (36%) delivered babies weighing <2500 grams, 15/42 (36%) delivered prior to 37 completed weeks gestation, 6/42 (14%) had no prenatal care and 31/42 (74%) had <7 prenatal visits. 10/23 (43%) pos~ive at delivery had participated in some form of voluntary chemical dependency treatment since their previous delivery. 4115 women who had used cocaine in pregnancy but were negative at the time of delivery were active in treatment programs at the time of delivery. We regretfully conclude that notification of child protective services and offering optional chemical dependency treatment does not appreciably a~er substance abuse in future pregnancies. States considering implementation of mandatory substance abuse reporting laws such as the 1989 Minnesota law should consider this information. A more intensive program of child protective intervention including use of court-ordered chemical dependency treatment is now being implemented and its impact on recidivism must be assessed.
305