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Diabetes & the LGA fetus
Synopsis: Identification of chromosome patterns in patients has become an integral part of obstetric practice. These authors have evaluated early amniocentesis and compared the results to chorionic villus sampling (CVS). They randomly assigned 116 women to two groups: One group had amniocentesis performed at 1 l-l 3 weeks’ gestation, and the other underwent CVS at 10 -12 weeks’ gestation. The amniocentesis group included 581 patients and the CVS group 579. Their only finding was an increased incidence of talipes equinovarus in the amniocentesis group. . . .
Commentaxyz Adequate karyotyping in early pregnancy allows the patient sufficient time to make her decision regarding termination of the pregnancy or planning for the infant. As a result, karyotyping is being performed earlier and earlier in pregnancy. In this study, the two major procedures were compared in early pregnancy. Although the study is small, the finding of talipes equinovarus is significant and must be considered. On the other hand, the significance of the failure or repeat rate for CVS also must be weighed. This study needs to be repeated on a larger scale and the results carefully reviewed before practices change. Even the suspicion of an association between talipes equinovarus and amniocentesis would be included in informed consent.
Mode of Delivery for BreechPresentation Lindqvist A, Nordtn-Lindeberg S, Hanson U. Perinatal mortahty and route of delivery in term breech presentations. Br J Obstet Gynaecol 1997;104:1288-91.
Synopsis: Using the Swedish Medical Birth Registry, the authors reviewed 6542 singleton breech deliveries from 1991 to 1992. Their objective was to compare mortality rates of infants > 34 weeks’ gestation when delivered vaginally or by cesarean section. 4
l
ACOG
CLINICAL
REVIEW
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May/June
The neonatal mortality rate was 0.09% (two of 2248) in the vaginal delivery group and 0.05% (two of 4029) in the cesarean delivery group. This difference was not statistically significant.
. . . Commentary: By a retrospective chart review, this investigation has shown that there is no difference in mortality rates between singleton breeches delivered vaginally and those delivered by cesarean section. This is in contrast to other studies in Europe. A major deficit in this study is the failure to identify the position of the breech and the status of the fetal heart. Simply stating that the presentation is breech is inadequate. Another concern is morbidity. The major complaint about vaginal breech delivery is the incidence and risk of neurologic impairment. Few obstetricians expect neonatal death to be an outcome when deciding the method of delivery. They do worry about the potential for neurologic impairment, and this concern has been a primary reason for US obstetricians to select cesarean delivery.
Diabetes & the LGA Fetus Casey BM, Lucas MJ, Mcintire DD, Leveno KJ. Pregnancy outcomes in women with gestationaI diabetes compared with the general obstetric population. Obstet Gynecol1997; 90:869-73.
Synopsis: These authors reviewed deliveries from January 1, 1991, to December 31, 1995, in a retrospective cohort study. They identified 6 1,209 nondiabetic women and 874 diagnosed as class A, (class A, was diagnosed if two abnormal sugars other than fasting were found in a 100-g 3-hour glucose tolerance test). The pregnancy outcome of these women was evaluated and compared with that of women in the nondiabetic cohort using matched controls. The authors concluded that the main consequences of class A, gestational diabetes are excessive fetal size and its associated complications. Pregnancy-induced hypertension also 1998
was diagnosed significantly ten (17% versus 12%).
more of-
Commentary: Although this was a retrospective study, the authors have established a concern that class A, gestational diabetes results in larger infants and an increased risk of problems for mother and baby. What is needed is a prospective study to evaluate the authors’ opinion that specific treatment could lower the risk of a large for gestational age fetus.
Cerebral Palsy linked to Gestational Age at Birth Spinillo A, Fazzi E, Capuzzo E, Stronati M, Piazzi G, Ferrari A. Meconium-stained amniotic fluid and risk for cerebral palsy in preterm infants. Obstet Gynecol 1997;90: 519-23.
Synopsis: The authors reviewed the deliveries of 440 consecutive preterm infants of 24-33 weeks’ gestation to estimate the relationship of meconium in the amniotic fluid with the subsequent development of cerebral palsy by the age of 2 years. There were 40 infants of 345 survivors who developed cerebral palsy (11.6%). When those with meconiurn-stained fluid were segregated, seven of those 17 had cerebral palsy (4 1.2%). After analysis of the findings, the authors concluded that the presence of meconium is a gestational age-dependent risk factor among preterm infants.
Commentary: This article, like the other reviewed in this issue, reports the incidence of cerebral palsy associated with a specific finding, meconium-stained amniotic fluid, in preterm infants. Why meconium was present in these infants is not determined. We are left to speculate about the causative factors of this finding. Again, we have accumulated more information but we have not expanded knowledge. Cerebral palsy is a devastating 801998by the AmetlcanCollegeof Obstetriciansand Gynecologists Pi&shed bv Elsew ScienceInc. 1085~686219865.50
Commentaxyz Adequate karyotyping in early pregnancy allows the patient sufficient time to make her decision regarding termination of the pregnancy or planning for the infant. As a result, karyotyping is being performed earlier and earlier in pregnancy. In this study, the two major procedures were compared in early pregnancy. Although the study is small, the finding of talipes equinovarus is significant and must be considered. On the other hand, the significance of the failure or repeat rate for CVS also must be weighed. This study needs to be repeated on a larger scale and the results carefully reviewed before practices change. Even the suspicion of an association between talipes equinovarus and amniocentesis would be included in informed consent.
Mode of Delivery for BreechPresentation Lindqvist A, Nordtn-Lindeberg S, Hanson U. Perinatal mortahty and route of delivery in term breech presentations. Br J Obstet Gynaecol 1997;104:1288-91.
Synopsis: Using the Swedish Medical Birth Registry, the authors reviewed 6542 singleton breech deliveries from 1991 to 1992. Their objective was to compare mortality rates of infants > 34 weeks’ gestation when delivered vaginally or by cesarean section. 4
l
ACOG
CLINICAL
REVIEW
l
May/June
The neonatal mortality rate was 0.09% (two of 2248) in the vaginal delivery group and 0.05% (two of 4029) in the cesarean delivery group. This difference was not statistically significant.
. . . Commentary: By a retrospective chart review, this investigation has shown that there is no difference in mortality rates between singleton breeches delivered vaginally and those delivered by cesarean section. This is in contrast to other studies in Europe. A major deficit in this study is the failure to identify the position of the breech and the status of the fetal heart. Simply stating that the presentation is breech is inadequate. Another concern is morbidity. The major complaint about vaginal breech delivery is the incidence and risk of neurologic impairment. Few obstetricians expect neonatal death to be an outcome when deciding the method of delivery. They do worry about the potential for neurologic impairment, and this concern has been a primary reason for US obstetricians to select cesarean delivery.
Diabetes & the LGA Fetus Casey BM, Lucas MJ, Mcintire DD, Leveno KJ. Pregnancy outcomes in women with gestationaI diabetes compared with the general obstetric population. Obstet Gynecol1997; 90:869-73.
Synopsis: These authors reviewed deliveries from January 1, 1991, to December 31, 1995, in a retrospective cohort study. They identified 6 1,209 nondiabetic women and 874 diagnosed as class A, (class A, was diagnosed if two abnormal sugars other than fasting were found in a 100-g 3-hour glucose tolerance test). The pregnancy outcome of these women was evaluated and compared with that of women in the nondiabetic cohort using matched controls. The authors concluded that the main consequences of class A, gestational diabetes are excessive fetal size and its associated complications. Pregnancy-induced hypertension also 1998
was diagnosed significantly ten (17% versus 12%).
more of-
Commentary: Although this was a retrospective study, the authors have established a concern that class A, gestational diabetes results in larger infants and an increased risk of problems for mother and baby. What is needed is a prospective study to evaluate the authors’ opinion that specific treatment could lower the risk of a large for gestational age fetus.
Cerebral Palsy linked to Gestational Age at Birth Spinillo A, Fazzi E, Capuzzo E, Stronati M, Piazzi G, Ferrari A. Meconium-stained amniotic fluid and risk for cerebral palsy in preterm infants. Obstet Gynecol 1997;90: 519-23.
Synopsis: The authors reviewed the deliveries of 440 consecutive preterm infants of 24-33 weeks’ gestation to estimate the relationship of meconium in the amniotic fluid with the subsequent development of cerebral palsy by the age of 2 years. There were 40 infants of 345 survivors who developed cerebral palsy (11.6%). When those with meconiurn-stained fluid were segregated, seven of those 17 had cerebral palsy (4 1.2%). After analysis of the findings, the authors concluded that the presence of meconium is a gestational age-dependent risk factor among preterm infants.
Commentary: This article, like the other reviewed in this issue, reports the incidence of cerebral palsy associated with a specific finding, meconium-stained amniotic fluid, in preterm infants. Why meconium was present in these infants is not determined. We are left to speculate about the causative factors of this finding. Again, we have accumulated more information but we have not expanded knowledge. Cerebral palsy is a devastating 801998by the AmetlcanCollegeof Obstetriciansand Gynecologists Pi&shed bv Elsew ScienceInc. 1085~686219865.50