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96 Accelerated Fetal Growth Following Early Growth Delay in Insulin-Dependent Diabetic Pregnancies
306
93
SPO Abstracts
January 1992 Am J Obstet Gynecol
MATERNAL AND PERINATAL OUTCOME OF 18 CASES OF ADULT RESPIRATORY DISTRESS SYNDROME (ARDS) IN PREGNANCY. lLMilli£, J. Barton,x B. Sibai. University of Tennessee, Memphis. There is limited information available regarding maternal and perinatal outcome in pregnancies complicated by ARDS. The purpose of this clinical investigation is to report our experience with ARDS in patients managed in an Obstetric ICU at a tertiary care center. Patients and Methods: The study population consisted of 18 patients who developed ARDS in pregnancy or immediately postpartum in a 6-year period during which there were 47,200 deliveries. R.tlJiJ.u.: The incidence of ARDS was I in 2,662 deliveries. Infection was the most frequent cause of ARDS (11/18, 61%) including pneumonia (4 varicella, influenza A, and pneumococcus), pyelonephritis (n=4), and chorioamnionitis (n=I). Other causes of ARDS were preeclampsiaeclampsia (n=3), massive hemorrhage (n=2), TIP (n=I), and smoke inhalation (n=I). Fifteen of 18 patients required mechanical ventilation (mean 13.5, range 3-54 days). Pneumothorax occurred in 7 patients; mUltiple organ failure developed in 10 patients. Maternal mortality was 39%. There was 1 ectopic pregnancy and 2 spontaneous second trimester abortions. Of 15 pregnancies that reached viability (;;'24 weeks' gestation), 4 fetuses died (fetal distress secondary to maternal shock, trisomy 18, abruptio placenta, and uterine rupture). Of 11 surviving infants, 9 did well and 2 had major morbidity. Outcome of the 15 patients requiring mechanical ventilation is shown in the table
95
PREECLAMPSIA IN HYPOTHYROID PREGNANCIES_ Anna S Leung MD," Martin N Montaro MD," Jorge H Mestman MD.'" University of Southern California, Los Angeles, California. The purpose of this study was to investigate the relationship between hypothyroidism and preeclampsia. A cohort of 97 hypothyroid pregnant patients were evaluated in our medical specialty clinic between 1978-1990. Patients with any other medical complications were excluded. Initial and subsequent thyroid function studies were obtained. Overall, the incidence of preeclampsia was 12.3% (12/97). Comparison was made between the patients with (P) and without preeclampsia (no P). peN = 12) no peN =85) Pvalue age 26.9 29.7 N.S. N.S. 1.6 1.6 parity N.S. 5.7 7.5 initial FT41 24.5 0.0038 initial TSH (mlU/ml) 72.4 10.0 0.0002 FT41 prior to delivery 6.2 0.0000 41.5 5.5 TSH prior to delivery (mIU/mI) 37 N.S. No. positive antimicrosomal antibody N.S. No. positive antithyroglobulin antibody 2 26 N.S. 8 No. positive TSH receptor antibody 0.006 20 No. never euthyroid during pregnancy Preeclampsia was more likely to occur in patients who were more hypothyroid on presentation and remained hypothyroid at delivery. The presence of antimicrosomal, antithyroglobulin, and TSH receptor antibody was not a significant factor. The correction of hypothyroidism is essential in the management of these patients.
96
The most widely used screening test for gestational diabetes is the 50 gr oral glucose load. A threshold value of 140 mg/dl or higher ;s recorrmended for use as a positive test, requiring a 3hour oral glucose tolerance test. However, it remains t.KlClear whether minimal glucose elevation even in this normal range is associated with perinatal clJq)l ications. The purpose of the present prospective study was to determine whether a single glucose challenge test (GeT) resut t, currently considered to be in the normal range is associated with pregnancy C~l ications. MATERIALS All) IETHIIlS: A total nll1ber of 225 consecutive pregnant patients who IXlCterwent 50 gr oral GeT and who had negative test results (plasma glucose level of 139 mg/dl or less at 1 hOUr) were evaluated. All 225 patients were identified based on the following criteria: 1. Plasma glucose determinations performed at 24-28 weeks gestation. 2. Patients had one or no previous del iveries. 3. No previous history of cesarian section or gestational diabetes or any medical disorders. The 225 patients were divided into two groups according to their blood glucose level, Group A (n=221), women with plasma glucose levels less than 120 mg/dL, Group B (n=54), those with plasma glucose level of 120-139 mg/dl. RESULTS: Mean birth weight was not significantly different between the two groups (3,252.410 gr vs. 3,304.382 gr). Patients with elevated GCT, although in the normal range, had a significantly higher rate of cesarean section, preecl~ia or both (12.2% and 31.2% in Group A and 8 respectiveLy) (p
below. Conclusions: ARDS is an uncommon complication of pregnancy with diverse etiologies and substantial morbidity and mortality. Multiple organ failure is associated with poor maternal and perinatal outcome. Multiple Organ Failure Respiratory Failure (n-IO> Oniy(n-Sl Maternal death #(%) I (20) 6 (60) Days ventilation (mean) 6 (range 3-9) 17 (range 3-54) I (20) 2n (29)Perinatal deaths #(%) 2/5 (40) Neonatal morbidity 0 -I ectopic, 2 spontaneous abortions
94
CHALLENGING THE lIDRMAL GLUCOSE CHALLENGE TEST: Zion Hagav", Gil BolotinX , Roni Le~, Vaclav InslerX, E. Albert Reece·, Departments of Ob/Gyn, Kaplan University Hospital, Israel and T"""le University School of Medicine, Philadelphia, PA*
ACCELERATED FETAL GROWTH FOLLOWING EARLY GROWTH DELAY IN INSULIN-DEPENDENT OIABETIC PREGNANCIES. LA..,~, B. Rosenn. J. Khoury: M. Miodovnik, Dept. Ob/Gyn, Univ. ClnClnnatl Med. Ctr., Cincinnati, OH Although macrosomia 15 a Gommon complication in infants of diabetic mothers (rOMs). early fetal growth delay has been observed in insul1n-dependent diabetic (IDD) pregnancies. This prospect; ve 1ongitud1 na 1 study was desi gned to estab 1 i sh fetal growth characteristics of 1DMs compared to normal controls. Twenty-five IDDs and 32 normal, non-diabetic controls were recruited prior to 12 weeks' gestation. Gestational age (GA) was established by menstrual hlstory and first trimester sonogram and confirmed at birth by physical examination. Patients in both groups underwent a complete ultrasound examination of the fetus dunng the first trimester and every 4 weeks from 20 weeks' gestati on l.mt i 1 deli very. Growth curves of the biparietal diameter (BPD) and abdomlnal c1rcumference (AC) were established for fetuses in both groups. A biphasic growth pattern of the BPD was found in the 10M group, described by the cubic equation: BPD = 9.64 - l.Ol GA + 0.05 (GAl' 0.00068244 (GA)~. BPO growth in the control group was descrlbed by a different cubic equation: BPD = 5.769 - 0.5957 GA + 0.03826 (GA)' - 0.000532 (GA)~ Compared to the growth pattern of normal controls, IDMs demonstrated early BPD growth delay followed by accelerated growth starting early 1n the third trimester. The AC growth pattern was 1 inear in both groups, with a steeper slope in the IOMs Thus, despite initial growth delay of AC in the 10M group, catchup with the control group was evident by the middle of the thlrd trimester. Our findlngs support the suggestion that fetal growth in 100 pregnancles lS biphasic, characterized by a phase of early delay followed by acce 1 erated growth; however, the mechani sms under 1yi ng thi s We speculate that the phenomenon are yet to be determined. initial tOX1C effect of hyperglycemia causing stunted growth of the embryo is 1ater followed by the effects of hyperi nsul i ni sm, once the fetal pancreas maturates and becomes metabolically active.
93
SPO Abstracts
January 1992 Am J Obstet Gynecol
MATERNAL AND PERINATAL OUTCOME OF 18 CASES OF ADULT RESPIRATORY DISTRESS SYNDROME (ARDS) IN PREGNANCY. lLMilli£, J. Barton,x B. Sibai. University of Tennessee, Memphis. There is limited information available regarding maternal and perinatal outcome in pregnancies complicated by ARDS. The purpose of this clinical investigation is to report our experience with ARDS in patients managed in an Obstetric ICU at a tertiary care center. Patients and Methods: The study population consisted of 18 patients who developed ARDS in pregnancy or immediately postpartum in a 6-year period during which there were 47,200 deliveries. R.tlJiJ.u.: The incidence of ARDS was I in 2,662 deliveries. Infection was the most frequent cause of ARDS (11/18, 61%) including pneumonia (4 varicella, influenza A, and pneumococcus), pyelonephritis (n=4), and chorioamnionitis (n=I). Other causes of ARDS were preeclampsiaeclampsia (n=3), massive hemorrhage (n=2), TIP (n=I), and smoke inhalation (n=I). Fifteen of 18 patients required mechanical ventilation (mean 13.5, range 3-54 days). Pneumothorax occurred in 7 patients; mUltiple organ failure developed in 10 patients. Maternal mortality was 39%. There was 1 ectopic pregnancy and 2 spontaneous second trimester abortions. Of 15 pregnancies that reached viability (;;'24 weeks' gestation), 4 fetuses died (fetal distress secondary to maternal shock, trisomy 18, abruptio placenta, and uterine rupture). Of 11 surviving infants, 9 did well and 2 had major morbidity. Outcome of the 15 patients requiring mechanical ventilation is shown in the table
95
PREECLAMPSIA IN HYPOTHYROID PREGNANCIES_ Anna S Leung MD," Martin N Montaro MD," Jorge H Mestman MD.'" University of Southern California, Los Angeles, California. The purpose of this study was to investigate the relationship between hypothyroidism and preeclampsia. A cohort of 97 hypothyroid pregnant patients were evaluated in our medical specialty clinic between 1978-1990. Patients with any other medical complications were excluded. Initial and subsequent thyroid function studies were obtained. Overall, the incidence of preeclampsia was 12.3% (12/97). Comparison was made between the patients with (P) and without preeclampsia (no P). peN = 12) no peN =85) Pvalue age 26.9 29.7 N.S. N.S. 1.6 1.6 parity N.S. 5.7 7.5 initial FT41 24.5 0.0038 initial TSH (mlU/ml) 72.4 10.0 0.0002 FT41 prior to delivery 6.2 0.0000 41.5 5.5 TSH prior to delivery (mIU/mI) 37 N.S. No. positive antimicrosomal antibody N.S. No. positive antithyroglobulin antibody 2 26 N.S. 8 No. positive TSH receptor antibody 0.006 20 No. never euthyroid during pregnancy Preeclampsia was more likely to occur in patients who were more hypothyroid on presentation and remained hypothyroid at delivery. The presence of antimicrosomal, antithyroglobulin, and TSH receptor antibody was not a significant factor. The correction of hypothyroidism is essential in the management of these patients.
96
The most widely used screening test for gestational diabetes is the 50 gr oral glucose load. A threshold value of 140 mg/dl or higher ;s recorrmended for use as a positive test, requiring a 3hour oral glucose tolerance test. However, it remains t.KlClear whether minimal glucose elevation even in this normal range is associated with perinatal clJq)l ications. The purpose of the present prospective study was to determine whether a single glucose challenge test (GeT) resut t, currently considered to be in the normal range is associated with pregnancy C~l ications. MATERIALS All) IETHIIlS: A total nll1ber of 225 consecutive pregnant patients who IXlCterwent 50 gr oral GeT and who had negative test results (plasma glucose level of 139 mg/dl or less at 1 hOUr) were evaluated. All 225 patients were identified based on the following criteria: 1. Plasma glucose determinations performed at 24-28 weeks gestation. 2. Patients had one or no previous del iveries. 3. No previous history of cesarian section or gestational diabetes or any medical disorders. The 225 patients were divided into two groups according to their blood glucose level, Group A (n=221), women with plasma glucose levels less than 120 mg/dL, Group B (n=54), those with plasma glucose level of 120-139 mg/dl. RESULTS: Mean birth weight was not significantly different between the two groups (3,252.410 gr vs. 3,304.382 gr). Patients with elevated GCT, although in the normal range, had a significantly higher rate of cesarean section, preecl~ia or both (12.2% and 31.2% in Group A and 8 respectiveLy) (p
below. Conclusions: ARDS is an uncommon complication of pregnancy with diverse etiologies and substantial morbidity and mortality. Multiple organ failure is associated with poor maternal and perinatal outcome. Multiple Organ Failure Respiratory Failure (n-IO> Oniy(n-Sl Maternal death #(%) I (20) 6 (60) Days ventilation (mean) 6 (range 3-9) 17 (range 3-54) I (20) 2n (29)Perinatal deaths #(%) 2/5 (40) Neonatal morbidity 0 -I ectopic, 2 spontaneous abortions
94
CHALLENGING THE lIDRMAL GLUCOSE CHALLENGE TEST: Zion Hagav", Gil BolotinX , Roni Le~, Vaclav InslerX, E. Albert Reece·, Departments of Ob/Gyn, Kaplan University Hospital, Israel and T"""le University School of Medicine, Philadelphia, PA*
ACCELERATED FETAL GROWTH FOLLOWING EARLY GROWTH DELAY IN INSULIN-DEPENDENT OIABETIC PREGNANCIES. LA..,~, B. Rosenn. J. Khoury: M. Miodovnik, Dept. Ob/Gyn, Univ. ClnClnnatl Med. Ctr., Cincinnati, OH Although macrosomia 15 a Gommon complication in infants of diabetic mothers (rOMs). early fetal growth delay has been observed in insul1n-dependent diabetic (IDD) pregnancies. This prospect; ve 1ongitud1 na 1 study was desi gned to estab 1 i sh fetal growth characteristics of 1DMs compared to normal controls. Twenty-five IDDs and 32 normal, non-diabetic controls were recruited prior to 12 weeks' gestation. Gestational age (GA) was established by menstrual hlstory and first trimester sonogram and confirmed at birth by physical examination. Patients in both groups underwent a complete ultrasound examination of the fetus dunng the first trimester and every 4 weeks from 20 weeks' gestati on l.mt i 1 deli very. Growth curves of the biparietal diameter (BPD) and abdomlnal c1rcumference (AC) were established for fetuses in both groups. A biphasic growth pattern of the BPD was found in the 10M group, described by the cubic equation: BPD = 9.64 - l.Ol GA + 0.05 (GAl' 0.00068244 (GA)~. BPO growth in the control group was descrlbed by a different cubic equation: BPD = 5.769 - 0.5957 GA + 0.03826 (GA)' - 0.000532 (GA)~ Compared to the growth pattern of normal controls, IDMs demonstrated early BPD growth delay followed by accelerated growth starting early 1n the third trimester. The AC growth pattern was 1 inear in both groups, with a steeper slope in the IOMs Thus, despite initial growth delay of AC in the 10M group, catchup with the control group was evident by the middle of the thlrd trimester. Our findlngs support the suggestion that fetal growth in 100 pregnancles lS biphasic, characterized by a phase of early delay followed by acce 1 erated growth; however, the mechani sms under 1yi ng thi s We speculate that the phenomenon are yet to be determined. initial tOX1C effect of hyperglycemia causing stunted growth of the embryo is 1ater followed by the effects of hyperi nsul i ni sm, once the fetal pancreas maturates and becomes metabolically active.