Randomized trial of diet versus diet plus cardiovascular conditioning on glucose levels in gestational diabetes

390

Citations from the Literature

waveforms. In this group, 12 of 13 patients had normal perinatal outcome, defined by the absence of intrapartum fetal distress or evidence of intrauterine growth retardation. Group 2 consisted of nine subjects with abnormal waveforms. Perinatal morbidity occurred in lad% in this group. We conclude that an abnormal umbilical artery waveform may provide confirmatory evidence of impending fetal compromise when the antenatal sonographic diagnosis of oligohydramnios is made. Ultrasonography versus amniotic fluid spectral analysis: Are they sensitive enough to predict neonatal complications PSSOtinted with isoimmunization?

Reece EA; Cole SW; Romero R; Gabrielli S; O’Connor TZ; Hobbins JC Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, CT 06510; USA Obstetrics and Gynecology/74/3 I (357-360)/1989/ The modern management of pregnancy complicated by erythroblastosis fetalis is based on serial amniocenteses followed by either intrauterine transfusions or early delivery of affected infants, depending on the gestational age. A retrospective study was undertaken involving 92 isoimmunized pregnancies in which ultrasonography and amniotic fluid analyses were used to assess the relative predictive values for neonatal complications. Our data demonstrated that ultrasonography and optical density analyses were comparable in the evaluation of the isoimmunized pregnancy. The combined information from both these modalities did not increase the predictive value over that observed with either one alone. Both instruments were found to have high negative predictive values. However, neither method, used singly or in combination, was highly predictive of neonatal complications. In light of the low positive predictive values, caution should be exercized in using the results of amniotic fluid spectral analyses and/or ultrasound examinations for predicting perinatal complications. Umbilical artery Doppler velocimetry as a predictor of fetal hypoxia and acidosis at birth

Tyrrell S; Obaid AH; Lilford RJ University Department of Obstetrics and Gynecology, St. James’s Hospital, Leeds LS9 7TF; United Kingdom Obstetrics and Gynecology/74/3 I (332-337)/1989/ We studied the relationship between preoperative umbilical artery Doppler waveforms and umbilical vein p0, and pH at elective cesarean section. An absence of end-diastolic velocities had a strong statistical association with hypoxia and acidosis, and was an accurate clinical test for hypoxia (sensitivity 78%, specificity 98%, positive predictive value 88%, and negative predictive value 98%) and acidosis (sensitivity 90%, specificity 92%, positive predictive value 53%, and negative predictive value 100%). It was also a clinically sensitive indicator of perinatal morbidity and mortality. Most fetuses with no end-diastolic velocities were growth-retarded, but the reverse was not true. The absence of end-diastolic velocities also divided both mature and immature fetuses into high- and low-risk groups Int J Gynecol Obstet 31

for hypoxia and acidosis. In the presence of end-diastolic velocities, only very high S/D ratios (above 4.5) have any association with hypoxia. As a noninvasive test of fetal umbilical vein p0, and pH, umbilical artery Doppler performs well. Efficacy and safety of indomethacin

versus ritodrine in the

management of preterm labor; A randomized study

Morales WJ; Smith SC; Angel JL; O’Brien WF; Knuppel RA Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Orlando Regional Medical Center, University of South Florida, Orlando, FL; USA Obstetrics and Gynecology/74/4 (567-572)/1989/ One hundred six patients in preterm labor with intact amniotic membranes and gestational age less than or equal to 32 weeks were randomized to receive either ritodrine hydrochloride or a 48-hour course of indomethacin for tocolysis. The relative efficacy, maternal and neonatal safety, and costs were evaluated to determine which may be the more appropriate first-line pharmacologic agent used to manage preterm labor. Fifty-four patients and 52 patients were randomized to receive ritodrine hydrochloride or indomethacin, respectively. Ritodrine hydrochloride and indomethacin were equally effective in inhibiting uterine contractions and delaying delivery. Delivery was delayed for at least 48 hours in 83 and 94%, and for at least 7 days in 70 and 75% of patients receiving ritodrine or indomethacin, respectively. Tocolysis with indomethacin was associated with no maternal side effects, whereas tocolysis with ritodrine hydrochloride was associated with a 24% incidence of serious cardiovascular and metabolic adverse effects prompting discontinuation of the drug. There were no differences in outcome between the infants exposed to indomethacin versus ritodrine hydrochloride when delivered either remote from therapy or during therapy, except for a statistically high serum glucose in the infants exposed to ritodrine hydrochloride when delivered during tocolytic therapy. There were no cases of premature closure of the ductus arteriosus or pulmonary hypertension. Tocolysis with indomethacin was 17 times less costly than tocolysis with ritodrine hydrochloride. For gestations less than or equal to 32 weeks complicated by preterm labor, indomethatin may be an appropriate alternative as a first-line tocolytic agent. Randomized trial of diet versus diet plus cardiovascular conditioning on glucose levels in gestational diabetes

Jovanovic-Peterson L; Durak EP; Peterson CM Sansum Medical Research Foundation, Santa Barbara, CA 93105; USA American Journal of Obstetrics and Gynecology/l61/2 (415419)/1989/ We studied the impact of a training program on glucose tolerance in gestational diabetes mellitus. Women with gestational diabetes mellitus (N = 19) were randomized into either group I, a B-week diet alone group (24 to 30 kcal/kg/24 hours; 20% protein, 40% carbohydrate, 40% fat), or group II, which followed the same diet plus exercise (20 minutes three times a week for 6 weeks). An arm ergometer was used to maintain heart rate in the training group. Glycemic response was moni-

Citationsfrom the Literature tored by glycosylated hemoglobin, a 50 gm oral glucose challenge with a fasting and l-hour plasma glucose, and blood glucose self-monitoring, fasting and 1 hour after meals. Week 1 glycemic parameters were the same for both groups. Week 6 data (mean + SD) were as follows: group I glycosylated hemoglobin, 4.7% + 0.2% versus group II, 4.2% f 0.2%; p < 0.001. The group I glucose challenge fasting value was 87.6 f 6.2 versus 70.1 -e 6.6 mg/dl, p < 0.001 for group II. The group I l-hour plasma glucose challenge result was 187.5 f 12.9mg/di versus 105.9 f 18.9 mg/dl for group II, P < 0.001. The glycemic levels diverged between the groups at week 4. We conclude that arm ergometer training is feasible in women with gestational diabetes mellitus and results in lower glycosylated hemoglobin, fasting, and l-hour plasma glucose concentrations than diet alone. Arm ergometer training may provide a useful treatment option for women with gestational diabetes mellitus and may obviate insulin treatment. Increasing cesarean section rates in very low-birth infants. Effect on outcome

weight

Malloy MH; Rhoads GG; Schramm W; Land G Prevention Research Program, National Institute of Child Health and Human Development, Bethesda, IUD 20892; USA Journal of the American Medical Association/26211 1 (147% 1478)/1989/ Examination of a linked birth and death certificate file from Missouri revealed a remarkable increase in the use of cesarean section for very low-birth weight infants (500 to 1499) from 24% to 44% in the years 1980-1984. In the same years the rate for 1500-to 2499-g infants went from 21% to 26% and the rate for 2500- to 7000-g infants went from 14% to 18%. We studied first-day death rates in very lowibirth weight infants as an indicator of potential benefit from this increase in cesarean sections. During the S-year period first-day deaths averaged 10% and 22% in the cesarean and vaginal birth groups, respectively. This difference was explained almost entirely by deaths in the 500- to 740-g birth weight group, where the death rates were 33(rloand 59%. respectively. Although this difference remained statistically significant after adjustment for gestational age and other factors that differed between the groups, it was nullified by an excess of deaths in the succeeding 6 days of life. Overall, the odds of death in the first week in these infants weighing 500 to 749 g was 0.85 (95% confidence interval, 0.52 to 1.39) in the cesarean vs vaginal deliveries. We conclude that there is little evidence that the use of cesarean section for the delivery of very low-birth weight infants, independent of maternal or fetal compromise, improves overall survival. We were unable to find reasons to justify the sharp increase in the use of cesarean sections for these small infants. Blood pressure and growth at 6 years of age among offsprings of mothers with hypertension of pregnancy

Palti H; Rothschild E Department of Social Medicine, Hadassah Medical Organization, Jerusalem; Israel Early Human Development119N (263-269)/1989/ The association between hypertension of pregnancy and

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blood pressure (BP) and physical growth of the offspring at 6 years of age has been studied in a historical prospective study. Ninety-four consecutive women who developed hypertension during pregnancy and were hospitalized with a diagnosis of. pre-eclampsia and their children were included. The comparison group consisted of individually-matched normal pregnant women. Each mother-child pair was examined when the child was 6 years of age. The mean systolic BP @BP) of the offspring was 101.3 f 10.2 (SD.) mmHg and that of the controls 99.8 + 9.5 mmHg. The mean diastolic BP (DBP) was significantly higher among the case than among the controls (66.2 f 8.3mmHgand63.9 + 8.0mmHg,P = O.O3).Among the cases, 11 children had a DBP above the 90th centile, whereas only four among the controls. A low, but significant, correlation was found between maternal and child BP for the cases. The DBP of the children with a positive family history of BP was significantly higher than those with a negative history. There were no differences in height, weight or obesity index between cases and controls.

MISCELLANEOUS Dog bite-related fatalities from 1979 through 1988

Sacks JJ; Sattin RW; Bonzo SE Division of Injury Epidemiology and Control, Centers for Disease Control, Atlanta, GA 30333; USA Journal of the American Medical Association/262/ii (14891492)/1989/ By combining data from the National Center for Health Statistics and computerized searching of news stories, we identified 157 dog bite-related fatalities that occurred in the United States from 1979 through 1988. Of the 157 deaths, 70% occurred among children who were less than 10 years of age. The death rate for neonates was almost 370 times that of adults who were 30 to 49 years of age. Pit bull breeds were involved in 42 (41.6%) of 101 deaths where dog breed was reported, almost three times more than German shepherds, the next most commonly reported breed. The proportion of deaths attributable to pit bulls increased from 20% in 1979 and 1980 to 62% in 1987 and 1988. Pit bull attacks were almost twice as likely to be caused by strays as attacks by other breeds. Extrapolated estimates suggest 183 to 204 dog bite-related fatalities from 1979 through 1988. To prevent such deaths, we recommend stronger animal control laws, public education regarding dog bites, and more responsible dog owner-ship. Parents and physicians should be aware that infants left alone with a dog may be at risk of death. A method to limit working hours and reduce sleep deprivation in an obstetrics and gynecology residency program

Carey JC; Fishburne JI Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, OK; USA Obstetrics and Gynecology17414 (669-672)/1989/ We adopted a system in which a team of residents works at night and all other residents work during the day. This system Int J Gynecol Obstet 31