Do HbA1c levels and the self-monitoring of blood glucose levels adequately reflect glycaemic control during pregnancy in women with type 1 diabetes mellitus?

AIMS/HYPOTHESIS

Pregnancies of women with type 1 diabetes mellitus are associated with maternal and perinatal complications. These complication rates remain elevated despite achievement of the treatment goals described in the widely used guidelines of the American Diabetes Association (i.e. HbA(1)c level <or=7.0%). Against this background, we sought to answer two questions: (1) are HbA(1)c levels within 1% above normal appropriate in pregnant women with type 1 diabetes or should treatment be aimed at normal HbA(1)c levels; and (2) how many self-monitored blood glucose (SMBG) levels are needed per day to obtain an adequate image of glycaemic control in pregnant women with type 1 diabetes?

MATERIALS AND METHODS

We asked 43 pregnant women with type 1 diabetes to use the Continuous Glucose Monitoring System (CGMS) once in each trimester of pregnancy, while continuing their SMBG measurements. Glucose levels measured with the CGMS were compared between patients with HbA(1)c levels of 4.0-6.0%, 6.0-7.0% and >7.0%. Self-monitored glucose levels and those measured with CGMS were compared between patients with four or five, six to nine and ten or more SMBG determinations daily.

RESULTS

In patients with HbA(1)c levels <or=6.0%, the glucose levels obtained by CGMS were significantly better than in patients with HbA(1)c levels >6.0%. In women with HbA(1)c levels 6.0-7.0% and >7.0%, these levels did not differ. The detection rate of hyper- and hypoglycaemic episodes was significantly higher in patients with ten or more SMBG determinations daily than in patients with fewer than ten.

CONCLUSIONS/INTERPRETATION

Treatment of diabetes in pregnant women should be aimed at achieving HbA(1)c levels within the normal range, i.e. <or=6.0%. A minimum of ten SMBG determinations daily is necessary to obtain adequate information of all daily glucose fluctuations.

Ontogeny of hippocampal corticosteroid receptors: Effects of antenatal glucocorticoids in human and mouse

Women at risk for preterm delivery are treated with synthetic glucocorticoids (GCs) to enhance fetal lung maturation. GCs can bind to two intracellular receptors, the glucocorticoid receptor (GR) and the mineralocorticoid receptor (MR), which function as transcription factors. Both are highly expressed in the hippocampus. Several studies have focused on adverse side effects of antenatal GC treatment. However, relatively little is known about the ontogeny of GR and MR, especially in human. Therefore, we studied the ontogeny of both receptors in the human and mouse hippocampus and investigated the effects of antenatal dexamethasone (dex) treatment, a synthetic glucocorticoid, on MR and GR mRNA levels during hippocampal development. The results demonstrate that MR mRNA was first expressed in mouse hippocampus at embryonic day (E)15.5, at the timepoint when dex was administered. In contrast, GR mRNA expression was first observed after birth at postnatal day (P)5. However, in the human hippocampus both receptors are expressed at 24 weeks of gestation, when antenatal GCs are administered in clinical practice. Quantitative in situ hybridization demonstrated that MR mRNA levels were reduced only shortly after dex treatment at E16, but were unaffected from E18 onwards. These findings indicate that a single antenatal dex administration at E15.5 transiently affects MR mRNA levels in the mouse hippocampus. No effect of antenatal dex treatment was found on the human hippocampus at the third trimester of pregnancy. These data on the prenatal ontogeny of both corticosteroid receptors in the human hippocampus is important for understanding the significance of fetal glucocorticoid or stress exposure and its potential effects on health and disease.

Lipoprotein (a) in pregnancy: a critical review of the literature

In this article the literature on lipoprotein (a) during normal pregnancy and pregnancy complicated by preeclampsia or intrauterine growth restriction is reviewed. MEDLINE, from January 1966 to May 2003, was searched to locate relevant articles in English. Additional publications were identified by reviewing references in selected articles. Studies were reviewed by predefined and strict criteria. It appeared that methodology and results of studies on lipoprotein (a) during normal and complicated pregnancy were very diverse. Lipoprotein (a) increased with advancing gestation or remained unaltered during normal pregnancy. Women with preeclampsia had higher, unaltered or lower lipoprotein (a) concentrations as compared to normal pregnant controls. Only few studies were in agreement with most of the review criteria. In conclusion, published studies on lipoprotein (a) in pregnancy differ substantially in the used methods to measure lipoprotein (a), sample size, study design and ethnicity of the study population. Therefore, these studies yielded conflicting results and no unequivocal view on the role of lipoprotein (a) in normal and complicated pregnancy. Recommendations for future studies are amongst others: the use of an apo(a) independent method for measuring Lp(a), inclusion of sufficient numbers of patients, the use of a longitudinal study design when the objective is to study the changes of Lp(a) during pregnancy and selection of a study population that is ethnically representative for the general population.

The umbilical coiling index, a review of the literature

Our aim was to review the literature on umbilical cord coiling. Relevant articles in English published between 1966 and 2003 were retrieved by a Medline search and cross-referencing. The normal umbilical cord coiling index (UCI) is 0.17 (+/- 0.009) spirals completed per cm. Abnormal cord coiling, i.e. UCI <10th centile (<0.07) or >90th centile (>0.30) is associated with adverse pregnancy outcome. Hypocoiling of the cord is associated with increased incidence of fetal demise, intrapartum fetal heart rate decelerations, operative delivery for fetal distress, anatomic-karyotypic abnormalities and chorio-amnionitis. Hypercoiling of the cord is associated with increased incidence of fetal growth restriction, intrapartum fetal heart rate decelerations, vascular thrombosis and cord stenosis. It is not clear whether abnormal coiling is actually a cause of pathology, or merely one of the sequelae, or both. We discuss the theories involving the cause of cord coiling, and the consequences of the degree of cord coiling on blood flow through the umbilical vessels. In the future ultrasonographic evaluation of the umbilical cord and the UCI may become an integral part of fetal assessment in high-risk pregnancies.

[Breech presentation: infant versus mother]

The increase in incidence of Caesarean sections in the Netherlands has resulted in improved infant outcomes in breech infants. About two hundred extra caesarean sections are needed to 'save' one baby. However, maternal outcome is impaired, with increased risks of uterine rupture, placenta praevia and placenta increta in subsequent pregnancies. Data from the Netherlands indicate that for every infant saved by a caesarean section, one woman will experience a uterine rupture during a subsequent pregnancy. These factors have to be taken into account when counselling women. Future reproductive considerations and the motivation of the woman and the gynaecologist for a vaginal breech delivery should be discussed during counselling.

Validation of the Continuous Glucose Monitoring System (CGMS) by the use of two CGMS simultaneously in pregnant women with type 1 diabetes mellitus

BACKGROUND

In pregnant women with type 1 diabetes tight glycemic control reduces perinatal complications. Intensive observation of glucose profiles is essential in the achievement of tight glycemic control. The recent availability of the Continuous Glucose Monitoring System (CGMS, Minimed, Sylmar, CA) creates the opportunity to obtain more complete glucose profiles. This study was aimed at evaluating the accuracy of the CGMS in pregnant women with type 1 diabetes.

METHODS

Five pregnant women with type 1 diabetes were asked to use two CGMS devices simultaneously. The simultaneously measured glucose levels were analyzed using the Pearson correlation, the mean absolute difference, and Bland-Altman analysis. Second, the percentage of concordance of paired data in the hypoglycemic, normoglycemic, or hyperglycemic range was calculated.

RESULTS

The correlation coefficient between simultaneously measured data was 0.94 (P < 0.001). The mean absolute difference was 1.1 +/- 0.8 mmol/L. Bland-Altman analysis shows that 95% of the data pairs have a difference < or = 1.74 mmol/L. Almost 80% of the data pairs could be classified in the same glucose range. In 81% of the non-concordant pairs, one glucose value was classified in the hypoglycemic range and one in the normoglycemic range.

CONCLUSIONS

This study shows that the reproducibility of the CGMS in pregnant women with type 1 diabetes is adequate. This indicates that the CGMS is a useful tool in the management of type 1 diabetes in pregnant women. However, the CGMS should only be used as a supplementary method of daily glucose level measurement as a small degree of error, mainly in the hypoglycemic range, is present.

Sibling birthweight as a predictor of macrosomia in women with type 1 diabetes

AIMS/HYPOTHESIS

The aim of this study was to establish the value of maternal HbA1c levels and older sibling birthweight as predictors of birthweight and macrosomia in the offspring of women with type 1 diabetes.

SUBJECTS AND METHODS

A total of 214 pregnancies of 107 women with type 1 diabetes were studied. Regression analysis was performed to test the predictive value of the birthweight of the first-born infant, HbA(1)c levels, maternal BMI, maternal age and time between subsequent births on the birthweight of the second-born infant. Birthweights were corrected for sex and gestational age. The percentages of first- and second-born infants with macrosomia (weight >90th centile) were calculated and compared.

RESULTS

Only the birthweight of earlier born infants was significantly related to that of second-born infants (p<0.001) and 40-50% of the variation in the birthweight of second-born infants could be explained by the birthweight of the first-born infants. About 85% of the mothers who gave birth to a macrosomic infant had a macrosomic infant in a subsequent pregnancy.

CONCLUSIONS/INTERPRETATION

Although it is clear that glycaemic control contributes to birthweight in women with type 1 diabetes, the birthweight of an earlier born infant appears to be a much better predictor of the birthweight of a subsequent infant than HbA1c levels during pregnancy. It may, therefore, be used to identify patients at risk of giving birth to a macrosomic infant. Daily home monitoring of glucose levels, rather than HbA1c levels, should be used for assessment of maternal glycaemia during pregnancy.

Emergency peripartum hysterectomy: A prospective study in The Netherlands

OBJECTIVE

To determine the incidence, indication, association with caesarean section (CS) and outcome of emergency peripartum hysterectomy (EPH) in The Netherlands.

STUDY DESIGN

All 100 Dutch obstetric departments were asked to participate in a prospective nationwide registration of EPH between 1 April 2002 and 1 April 2003. For every case, a form with questions about obstetrical history, current pregnancy and delivery, maternal and neonatal outcome was completed.

RESULTS

Eighty-nine (89%) hospitals participated and registered in total 48 EPH. The estimated incidence of EPH is 0.33/1000 births. The main indication for EPH was placenta accreta (50%), followed by uterine atony (27%). There were two maternal deaths (4%). Severe maternal morbidity included: urinary tract injury 15%, relaparotomy 25%, transfusion >10 units red blood cells 67%, intensive care admission 77%. Both previous CS and CS in the index pregnancy were associated with a significant increased risk of EPH. The number of previous CS was related to an increased risk of placenta accreta, from 0.19% for one previous CS to 9.1% for four or more previous CS.

CONCLUSION

Emergency peripartum hysterectomy is associated with a high incidence of maternal morbidity and a case fatality rate of 4%. It is significantly related to CS in index or previous pregnancy. Placenta accreta is the most common indication to perform a peripartum hysterectomy.

Transient loss of the diurnal rhythms of fetal movements, heart rate, and its variation after maternal betamethasone administration

Antenatal betamethasone administration to enhance fetal lung maturation is associated with transient reductions in fetal heart rate (FHR) variation, breathing, and body movements 2 d after the first dose (d 2). This study examines whether steroid administration affects the natural diurnal rhythms of fetal variables. Sixteen women at 27-32 wk of gestation received two doses of betamethasone 24 h apart. One-hour recordings of FHR, breathing, and body movements were made in the morning, afternoon, and evening of d 2, and again in the morning of d 3. Repeat recordings were obtained at 4-6 d later from 9/16 women. Maternal blood samples were obtained with each recording to determine ACTH and cortisol. No diurnal rhythm was present for FHR, FHR variation, breathing, and body movements on d 2. This resulted from suppression of the expected natural rise in body and breathing movements, and heart rate variation in the course of the day. Suppression of the diurnal rhythm of body movements depended on gestation (R = -0.89; p < 0.01). All variables showed diurnal rhythms 4-6 d later. Maternal ACTH and cortisol diurnal rhythms were completely suppressed on d 2. Four to six days later, the normal diurnal pattern was resumed, although absolute levels of ACTH and cortisol were still suppressed. We conclude that maternal betamethasone administration transiently abolishes the fetal diurnal rhythms of heart rate and its variation, breathing, and body movements.

Concomitant anomalies in 100 children with unilateral multicystic kidney

OBJECTIVES

To determine the incidence and type of associated urogenital anomalies in children with a unilateral multicystic kidney and to assess in children with nephrectomy the additional diagnostic value of cystoscopy and, in girls, of colposcopy.

METHODS

This was a follow-up study of 100 fetuses with antenatally detected unilateral multicystic kidneys. After ultrasound confirmation of the diagnosis within a few days after birth voiding cystourethrography and isotope scan were performed in 83 of the surviving children to exclude vesicoureteral reflux and to establish renal function. Eighty-one children underwent nephrectomy and, prior to surgery, all underwent cystoscopy and girls also underwent colposcopy.

RESULTS

Seventy-five children had one or more additional urogenital anomalies: 39 had anomalies of the contralateral kidney, 40 had anomalies of the ipsilateral kidney and 30 had one or more anomalies of the lower urogenital tract. With cystoscopy 54 anomalies of the genitourinary tract were detected in 48 children and with colposcopy three anomalies were detected in 35 girls. Eighty-one children had a nephrectomy or heminephrectomy and 33 of them needed other urological intervention. Thirteen fetuses died (mostly from agenesis of the contralateral kidney) and six infants had no surgery at all.

CONCLUSION

Children with a unilateral multicystic kidney are at considerable risk of having other urogenital anomalies. When cystoscopy and colposcopy are added to routine investigations the rate of detection of anomalies is 75%, twice that reported in the literature.

Fetal scalp pH and ST analysis of the fetal ECG as an adjunct to CTG. A multi-center, observational study

OBJECTIVE

To evaluate the relationships between scalp-pH and CTG plus ST waveform analysis of the fetal ECG (STAN) clinical guidelines as indicators of intrapartum hypoxia in term fetuses born with cord artery acidemia.

STUDY DESIGN

Data from 6999 term deliveries monitored by the STAN (R) S 21 as part of an EU multi-center study on clinical implementation of the STAN methodology for intrapartum fetal surveillance were analyzed. We identified 911 cases where a scalp-pH was obtained, including 53 cases with cord artery acidemia (pH < 7.06). Lag times between ST events and scalp-pH and time to delivery were related to cord artery metabolic and respiratory acidosis and neonatal outcome.

RESULTS

43 fetuses were identified by CTG plus ST as being in need of intervention 31 (25-46) minutes before delivery (median, 95% Cl). In five, no indications were given and in another five there were inadequate data. Fifteen cases with metabolic acidosis required special neonatal care, all 14 cases adequately monitored on STAN had indications to intervene for 19 minutes or more. In 30 adequately recorded cases, fetal blood sampling (FBS) was obtained within the last hour of labor. In 22 cases, FBS was obtained 13 (7-24) minutes after STAN guidelines had indicated abnormality and in eight no ST changes had occurred at time of FBS. The corresponding FBS data were pH 7.10 (7.01-7.15) and pH 7.21 (7.08-7.31), respectively, P = 0.01. In cases of metabolic acidosis, scalp-pH fell 0.01 units per minute after a baseline T/QRS rise was recorded during the second stage of labor. Apart from one newborn that died at 2 h from E. Coli septicemia, none of the neonates were affected neurologically.

CONCLUSION

Cardiotocography plus ST analysis provides accurate information about intrapartum hypoxia similar to that obtained by scalp-pH.

Severe umbilical cord acidemia and neurological outcome in preterm and full-term neonates

BACKGROUND

Severe intrauterine hypoxia-ischemia and acidemia may lead to a disturbed neurodevelopment.

OBJECTIVES

To study the effects of acidemia at birth on neurodevelopment in preterm and full-term neonates.

SUBJECTS AND METHODS

Short- and long-term outcome were studied retrospectively in 44 inborn preterms and 95 full-terms with severe acidemia at birth defined as a pH of the umbilical artery <7.00. Outcome was compared with 67 preterm and 90 full-term non-acidemic neonates (pH>7.15). Intraventricular hemorrhage (preterms) or seizures (both preterms and full-terms) were considered an adverse short-term outcome. Neonatal death, cerebral palsy or neurodevelopmental delay were considered an adverse long-term outcome.

RESULTS

Severe intraventricular hemorrhage (IVH) occurred in 5 of the 44 (11%) acidemic preterms and in none of the 67 (0%) non-acidemic preterms (p<0.01). Seizures were observed in 9 of the 44 (20%) and 11 of the 95 (12%) acidemic preterms and full-terms, respectively, and in none of the 67 (0%) and 1 of the 90 (1%) non-acidemic preterms and full-terms, respectively (p<0.001 for preterms, p<0.01 for full-terms). Nine preterms (6 acidemic, 3 non-acidemic) and 2 full-terms (both acidemic) died in the neonatal period. Adverse long-term outcome occurred in 32% of the acidemic preterms, in 21% of the non-acidemic preterms, in 7% of the acidemic full-terms and in 7% of the non-acidemic full-terms.

CONCLUSIONS

Acidemia at birth increased the occurrence of severe IVH in preterm neonates and seizures in both preterm and full-term neonates. However, no significant effect of acidemia on long-term outcome could be demonstrated.

The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in The Netherlands: an analysis of 35,453 term breech infants

OBJECTIVE

To examine the effects of the Term Breech Trial on the medical behaviour of Dutch obstetricians and on neonatal outcomes.

DESIGN

Retrospective observational study.

SETTING

The Netherlands.

POPULATION

Infants born at term in breech presentation in the Netherlands between 1998 and 2002, with birthweights < or =4000 g (n= 33,024) and >4000 g (n= 2429), respectively. Multiple pregnancies, antenatal death and major congenital malformations were excluded.

METHODS

Data derived from the Dutch Perinatal Database were used to compare modes of delivery and neonatal outcome of infants born in breech position in the 33 months preceding publication of the Term Breech Trial and in the 25 months thereafter.

MAIN OUTCOME MEASURES

Incidence of planned and emergency caesarean section, vaginal breech delivery, perinatal death, 5-minute Apgar score and birth trauma.

RESULTS

Within two months after publication of the Term Breech Trial, the overall caesarean rate increased from 50% to 80% and has remained stable thereafter. In the group of infants < or =4000 g, this was associated with a significant decrease of perinatal mortality from 0.35% to 0.18%, a decrease of the incidence of a 5-minute Apgar score <7 from 2.4% to 1.1% and a decrease of birth trauma from 0.29% to 0.08%. In the (small) group of infants >4000 g, a similar trend was observed.

CONCLUSIONS

The Term Breech Trial has resulted in an exceptionally rapid change in medical behaviour by Dutch obstetricians. This change was followed by improved neonatal outcome.

Transient Non-Autoimmune Fetal Heart Block

OBJECTIVES

Fetal heart block is a rare and irreversible condition associated with structural heart defects or maternal autoantibodies (SS-A/Ro and SS-B/La) resulting in permanent damage of the atrioventricular (AV) node. This is the first report of 4 cases with a transient fetal heart block in structurally normal hearts without maternal autoantibodies.

METHODS

A report on 4 patients seen within a 14-year period at one center with fetal heart block without intracardiac abnormalities or maternal autoantibodies.

RESULTS

Three patients were referred to our center with a fetal bradycardia (heart rate 70-85 bpm), between 20 and 33 weeks' gestational age, and 1 for a 'triple' test at 16 weeks' gestational age. Echocardiography showed a complete heart block in 2 fetuses, and a second-degree AV block in the other 2. Heart block had completely resolved at all following visits. Postnatal ECG recordings showed normal sinus rhythm in all patients. Echocardiographic evaluation at presentation and follow-up showed normal cardiac anatomy, without signs of hydrops or cardiac decompensation in all patients. All mothers tested negative on SS-A/Ro and SS-B/La autoantibodies.

CONCLUSIONS

Fetal heart block can occur in the absence of structural heart defects and maternal autoantibodies to SS-A/Ro and SS-B/La. The origin of such heart block is unknown, but its course seems benign: none of the patients ever showed ventricular heart rates <55 bpm, signs of congestive heart failure or fetal hydrops. Heart block resolved spontaneously in all patients.

Congenital renal tract anomalies: outcome and follow-up of 402 cases detected antenatally between 1986 and 2001

OBJECTIVE

To determine the long-term prognosis of antenatally detected renal tract anomalies in order to optimize parental counseling.

METHODS

This was a follow-up study of all renal tract abnormalities detected antenatally in a Level 3 ultrasound department between 1986 and 2001. Follow-up data (median age, 8 years) were retrieved from the records of the Paediatric Urology Department or the attending pediatrician.

RESULTS

A urinary tract anomaly was detected in 408 fetuses. There were four false-positive diagnoses. From two children follow-up data were incomplete, leaving 402 cases for analysis. A chromosomal abnormality was present in 7/81 (8.6%) fetuses that had karyotyping. Termination of pregnancy was performed in 55 (13.7%) cases and a further 66 (16.4%) children died during the perinatal period and up to 1 year of age. In 106/121 (26.4% of all fetuses) deceased children the cause of death was directly related to the renal tract anomaly. In the 281 surviving children a total of 545 renal tract anomalies were diagnosed postnatally, requiring a total of 381 surgical interventions in 156 infants. Outcome in survivors was generally good, with impaired renal function in nine infants and hypertension in three (4% of the survivors).

CONCLUSIONS

Congenital renal tract anomalies are associated with a high mortality rate, especially when they are structural developmental anomalies of the kidneys. Survivors require multiple operations, but the outcome is generally favorable. Ultrasound diagnosis, especially when made early, of non-lethal urinary tract anomalies may prevent additional renal damage by timing of delivery and early postnatal treatment.

The effects of prenatal stress on temperament and problem behavior of 27-month-old toddlers

AIM

To examine, in a prospective study, the influence of prenatal stress on infant temperament and problem behavior.

METHOD

Self-report data on stress and anxiety, and levels of cortisol in saliva were collected from nulli-parous women during pregnancy. Temperament of the child was measured at 27 months by parent report on the Infant Characteristics Questionnaire. Behavior of the child was assessed by direct observation during the administration of the Bayley Scales of Development 2-30, and by parent report on the Child Behavior Checklist 2-3.

RESULTS

Complete data were available for 103 healthy toddlers. Logistic regression analyses were performed and results were adjusted for possible prenatal, perinatal and postnatal confounders. Perceived stress during pregnancy was a predictor of lower levels of restless/disruptive temperament (OR=0.77), more total behavioral problems (OR=1.17), and more externalizing behavioral problems (OR=1.12) in 2-year-olds. Fear of bearing a handicapped child was a predictor of higher levels of restless/disruptive temperament (OR=1.39) and more attention regulation problems in toddlers (OR=1.46).

CONCLUSIONS

Increased levels of maternal prenatal stress appear to be associated with temperamental and behavioral problems in toddlers.

Effect of breast milk of diabetic mothers on bodyweight of the offspring in the first year of life

OBJECTIVE

There is increasing evidence that in healthy populations, breast-fed infants are leaner than formula-fed infants. It is of interest to know the effects of breast-feeding on infant weight in case of maternal diabetes, given the high incidence of fetal macrosomia and risk of childhood obesity in this population.

DESIGN AND SUBJECTS

As part of a nation-wide study in the Netherlands on diabetes and pregnancy, 229 women with Type 1 diabetes were sent a questionnaire on weight and height of their infant, the type of nutrition given during the first 6 weeks of life, the duration of lactation and intercurrent diseases during the first year of life.

RESULTS AND CONCLUSION

Our data show no significant difference between breast-,formula-, and mixed-fed infants in weight and body mass index (BMI) at 1 y of age, which is not in accordance with the findings in nondiabetic populations.

[Diabetes and pregnancy; the prevention of hypoglycaemia]

In women with type-1 diabetes, the prevalence of maternal and fetal complications is high despite the overall adequate blood glucose control (HbA1c < 7%). Further improvements are hampered by the high incidence of maternal hypoglycaemia, including coma, especially during the first trimester of pregnancy. The reasons for this include the intensified insulin treatment, the decrease in hypoglycaemia awareness and the increase in glucose fluctuations. A further improvement of glucose control would provisionally seem possible only by using short-acting insulin analogues. These agents are currently under investigation. Continuous subcutaneous glucose measurements early in pregnancy show considerable glucose fluctuations despite almost normal HbA1c values. Moreover, they often reveal a hypoglycaemic event that the pregnant woman has not recognised. It is possible that these glucose fluctuations, rather than the too high average blood glucose levels, are responsible for congenital malformations and fetal macrosomia. Neonatal hypoglycaemia is associated with poor psychoneurological development. This relationship has not been established for maternal hypoglycaemia during pregnancy.

Psychological consequences of termination of pregnancy for fetal anomaly: similarities and differences between partners

OBJECTIVE

We examined the psychological responses to termination of pregnancy (TOP) for fetal anomaly from both men and women. The aim was to find risk factors for poor psychological outcome both for the individuals and for the couple.

METHODS

A cross-sectional study was performed in 151 couples 2-7 years after TOP. We used standardized and validated questionnaires to investigate grief, symptoms of posttraumatic stress, somatic complaints, anxiety, and depression.

RESULTS

Most couples adapted well to their loss, although several patients had pathological scores on posttraumatic stress symptoms and depression. Differences between men and women were slight. Higher education, good partner support, earlier gestational age, and life-incompatibility of the disorder positively influenced the outcomes, more for women than for men. Men and women with pathological scores rarely had such scores simultaneously.

CONCLUSION

We emphasize the importance of equally involving both parents in the counselling because the outcomes of grief and posttraumatic stress symptoms between men and women only moderately differ and post-TOP psychopathology occurs in men as well. Good adjustment to TOP in women seems dependent on the level of support that they perceive from their partners. The intracouple results of the study suggest a mutual influence in the process of grieving between the partners.

The role of lipoprotein (a) in pregnancies complicated by pre-eclampsia

Endothelial cell dysfunction is a key feature of the pathogenesis of pre-eclampsia. The cause of the endothelial cell injury is probably multifactorial, but poor placenta perfusion plays a major role. In pre-eclampsia, characteristic pathological lesions in the placenta are fibrin deposits, acute atherosis and thrombosis. The similarity between the lesions of pre-eclampsia and atherosclerosis has led to speculations of a common pathophysiological pathway. An abnormal lipid profile is known to be strongly associated with atherosclerotic cardiovascular disease and has a direct effect on endothelial function. Abnormal lipid metabolism seems important in the pathogenesis of pre-eclampsia too. An elevated plasma lipoprotein (a) concentration is a known risk factor for atherosclerotic cardiovascular disease. In this paper, we discuss three hypotheses about the mechanisms by which lipoprotein (a) may be associated with pre-eclampsia: 1. Lp(a), as an acute-phase reactant, transporting cholesterol to sites of endothelial damage for reparation, temporarily increases during pregnancy and increases more during a pregnancy complicated by mild to moderate pre-eclampsia as compared to an uncomplicated pregnancy, in response to a greater extend of endothelial injury in pre-eclampsia. After delivery, pre-eclampsia subsides and Lp(a) concentrations return to baseline levels. 2. In cases of severe pre-eclampsia, there is even more extensive endothelial damage and consequently a higher consumption of Lp(a) in reparation of this vascular damage. These women will have lower concentrations of Lp(a). 3. High baseline concentrations of Lp(a), which are genetically determined, may induce or contribute to the development of pre-eclampsia by promoting endothelial dysfunction. In this line of reasoning one would expect to find higher concentrations of Lp(a) in women at risk for developing pre-eclampsia in a future pregnancy or with a history of pre-eclampsia. As discussed above, these women are also at increased risk for future cardiovascular disease as compared to women with a history of normal pregnancy. The pathophysiologic changes associated with cardiovascular disease may also be responsible for the increased incidence of pre-eclampsia in these women.

Long-term psychological consequences of pregnancy termination for fetal abnormality: a cross-sectional study

OBJECTIVE

We examined women's long-term psychological well-being after termination of pregnancy (TOP) for fetal anomaly in order to identify risk factors for psychological morbidity.

METHODS

A cross-sectional study was performed in 254 women, 2 to 7 years after TOP for fetal anomaly before 24 weeks of gestation. We used standardised questionnaires to investigate grief, posttraumatic symptoms, and psychological and somatic complaints.

RESULTS

Women generally adapted well to grief. However, a substantial number of the participants (17.3%) showed pathological scores for posttraumatic stress. Low-educated women and women who had experienced little support from their partners had the most unfavourable psychological outcome. Advanced gestational age at TOP was associated with higher levels of grief, and posttraumatic stress symptoms and long-term psychological morbidity was rare in TOP before 14 completed weeks of gestation. Higher levels of grief and doubt were found if the fetal anomaly was presumably compatible with life.

CONCLUSION

Termination of pregnancy for fetal anomaly is associated with long-lasting consequences for a substantial number of women. Clinically relevant determinants are gestational age, perceived partner support, and educational level.

Variability in dilatation of the fetal renal pelvis during a bladder filling cycle

OBJECTIVE

To investigate the variation in the dimensions of the fetal renal pelvis in relation to the degree of bladder filling in fetuses with mild pyelectasis.

METHODS

Eighteen third-trimester pregnant women with mild uni- or bilateral fetal pyelectasis, defined as an anteroposterior (A-P) diameter of the renal pelvis between 5 and 10 mm, were recruited for the study. The women were examined for 2-3 h by ultrasound. The A-P and transverse dilatation of the renal pelvis and the bladder dimensions (to calculate fetal bladder volume) were measured at 2-3-min intervals. Postnatally, all infants were investigated by ultrasound at 3-4 months.

RESULTS

In 6/18 fetuses a consistent relationship between the size of the renal pelvis and bladder filling was found, with a mean difference in renal pelvic diameter before and after voiding of 6.7 mm and a largest observed difference of 14.3 mm. In 12/18 fetuses no such relationship was found. Postnatally, five infants were referred to a pediatric urologist. The investigations in these five infants could not confirm the hypothesis that variation in renal pelvic size in relation to bladder size may predict prenatal vesicoureteric reflux (VUR).

CONCLUSIONS

In mild pyelectasis the size of the renal pelvis is highly variable in one-third of cases. The association with bladder volume and micturition suggests evidence of VUR, but this could not be proven. If cut-off values are used to differentiate between normal and abnormal renal pelvic size then not only gestational age but also the degree of bladder filling at the time of measurement should be taken into account. Caution should be expressed when the diagnosis of a possible urological anomaly is based on a single measurement during just one investigation.

Day-to-day glucose variability during pregnancy in women with Type 1 diabetes mellitus: glucose profiles measured with the Continuous Glucose Monitoring System

OBJECTIVE

To observe day-to-day variability in glucose levels in pregnant women with Type 1 diabetes using the Continuous Glucose Monitoring System (CGMS) and to assess the usefulness of continuous glucose measurements for adjustment of insulin treatment.

DESIGN

A prospective observational study.

SETTING

The obstetrical outpatient clinic of the University Medical Centre Utrecht.

POPULATION

Pregnant women with Type 1 diabetes mellitus.

METHODS

Thirty-one pregnant women with Type 1 diabetes used the CGMS for two consecutive days. Patients were classified in two groups (high vs low day-to-day variability) based on visual inspection of the glucose excursions. The relationship between day-to-day variability and the variables HbA(1c), maternal age and body mass index (BMI), duration of diabetes, number of self-monitored blood glucose levels, number of insulin injections, gestational age, nutrition, physical activity, White classification, living with children and method of insulin administration was determined. The two days of the first 20 CGMS measurements were separated and four physicians were asked to give recommendations on treatment adjustment for each separate day.

MAIN OUTCOME MEASURES

Mean absolute difference (MAD) was calculated for each patient as measure of day-to-day variability.

RESULTS

Seventeen patients (55%) were classified as having low (MAD 0.92-2.33 mmol/L) and 14 (45%) as having high day-to-day variability (MAD 2.41-6.12 mmol/L). Of the variables measured, only the relation between MAD and HbA(1c) was significant (r= 0.58, P= 0.001). The difference in recommendation on treatment adjustment between the days of the CGMS measurement ranged from 29% to 48%. This percentage was significantly higher in the high day-to-day variability group (48 vs 33%, P= 0.01).

CONCLUSION

Day-to-day glucose variability is high and the treatment of pregnant women with Type 1 diabetes is a problem. Fine-tuning of insulin regimens based on two-day measurements with the CGMS is not advisable.

The Continuous Glucose Monitoring System during pregnancy of women with type 1 diabetes mellitus: accuracy assessment

BACKGROUND

The Continuous Glucose Monitoring System (CGMS, Medtronic MiniMed, Northridge, CA) allows close monitoring of glucose patterns and might be helpful in explaining the persistence of high complication rates in pregnancies of women with type 1 diabetes. It was the aim of this study to determine whether the CGMS accurately reflects glucose levels in pregnant women with type 1 diabetes mellitus.

METHODS

Fifteen pregnant women with type 1 diabetes used the CGMS and were asked to determine at least seven fingerstick blood glucose levels each day, of which four were used for calibration. The patients were asked to keep a diary of the non-calibration blood glucose values. The accuracy of the CGMS was studied by comparing the non-calibration blood glucose values with simultaneously measured sensor glucose values using the Pearson correlation coefficient, the mean of absolute differences, and the Clarke error grid analysis.

RESULTS

A total of 239 non-calibration blood glucose values were analyzed. The correlation coefficient between non-calibration blood glucose and sensor glucose value was 0.94 (P < 0.001). The mean of the absolute difference was 0.74 mmol/L. Of the non-calibration data 93.8% fell in the clinically acceptable zone of the Clarke error grid analysis.

CONCLUSIONS

The CGMS is an accurate tool for additional glucose monitoring in pregnant women with type 1 diabetes mellitus.

Treatment of fetal heart block with maternal steroid therapy: case report and review of the literature

The presence of maternal autoantibodies to SS-A/Ro and/or SS-B/La is associated with the development of fetal heart block. There are data suggesting that maternal treatment with steroids might reverse heart block. We report on a pregnancy in a mother with secondary Sjögren syndrome and systemic lupus erythematosus with presence of autoantibodies to SS-A/Ro and SS-B/La, which was complicated by the development of incomplete fetal heart block. Oral dexamethasone treatment could not prevent progression to complete heart block and was associated with a number of complications.A review of the literature revealed 19 studies (including ours) in which 93 cases of fetal heart block were treated with maternal steroid therapy. Complete heart block proved irreversible in all cases; and of 13 fetuses with incomplete heart block which received maternal steroid therapy, three had a reduction in their degree of block and one reverted to sinus rhythm. Maternal steroid therapy, initiated early in pregnancy and potentially preventing the onset of heart block, did not decrease the incidence of heart block in nine studies with 43 cases. Furthermore, the literature review revealed numerous serious side effects of maternal steroid administration during pregnancy. Data on these potential side effects are lacking in the 28 studies discussed in this review. Maternal dexamethasone therapy to prevent or treat fetal heart block remains, in our opinion, a questionable intervention and can as yet not be recommended in the clinical situation.

Is pregnancy anxiety a distinctive syndrome?

OBJECTIVE

Assessment of general anxiety during pregnancy may underestimate anxiety specifically related to pregnancy. Pregnancy anxiety rather than general anxiety has been shown to predict birth outcome and neuroendocrine changes during pregnancy. Therefore, a questionnaire on pregnancy anxieties was used to test their structure, and to examine their associations with general anxiety and depression.

METHOD

Nulliparous pregnant women with a normal risk status (N=230) filled in a 34-item questionnaire on pregnancy-related anxiety and other questionnaires covering general anxiety and depression. These questionnaires were filled in at 15-17, 27-28, and 37-38 weeks of gestation.

RESULTS

A three-factor model of pregnancy anxiety was found by means of confirmatory factor analysis, reflecting 'fear of giving birth', 'fear of bearing a handicapped child' and 'concern about one's appearance'. General anxiety and depression measures explain only a small part of the variance of these fears.

CONCLUSION

Pregnancy anxiety should be regarded as a relatively distinctive syndrome. Its measurement enables researchers and clinicians to address issues of prediction, identification and risk reduction more precisely and perhaps more effectively in the future.

Neurological outcome of children who were treated for fetal tachycardia complicated by hydrops

OBJECTIVE

Fetal tachycardia is a condition associated with congestive heart failure and development of fetal hydrops, which may result in neurological morbidity and mortality. The aim of this study was to investigate the long-term outcome of hydropic fetuses.

METHODS

This was a retrospective study on cognitive and neurological functioning of 11 infants, aged 6 months to 12 years, who experienced fetal tachycardia complicated by hydrops.

RESULTS

Seven fetuses had supraventricular tachycardia (SVT), three had atrial flutter (AF) and one had ventricular tachycardia (VT). Nine fetuses converted to sinus rhythm within a mean time of 8.2 days of presentation; resolution of hydrops was achieved in six of these patients in a mean time of 8.8 days. Mean gestational age (GA) at birth was 35 + 4 weeks. Neonatal cranial ultrasound was normal in seven infants and all but one of these were normal at follow-up: one infant who initially had no abnormalities developed multiple cerebral lesions as a result of a malignant long QT syndrome (LQTS) and died at the age of 2 years. Three infants had periventricular echogenicity (PVE) on neonatal cranial ultrasound, associated with a pseudocyst in one infant. The remaining infant showed a parenchymal hemorrhage of antenatal onset, seen as a porencephalic cyst at birth. One of these infants was normal at follow-up, one died 2 days after birth and two infants had neurological abnormalities at follow-up, consisting of mild hemiplegia with normal cognitive function in one, and a cognitive developmental delay in the other.

CONCLUSIONS

In this study, neurological outcome was good in eight out of 11 infants. Initiation of therapy should not be withheld or delayed on the assumption of poor neurological outcome.

Effects of antenatal betamethasone administration on fetal heart rate and behavior in twin pregnancy

The efficacy of antenatal corticosteroid therapy in reducing the incidence of respiratory distress syndrome in twin pregnancy is controversial. The corticosteroid levels achieved with the current regimen might not be high enough to reach both siblings. In singleton fetuses, maternal betamethasone administration causes transient reductions in fetal heart rate (FHR), FHR variability, and body and breathing movements. We performed a prospective study to determine whether there are similar effects of betamethasone on FHR and behavior in preterm twin pregnancy and whether the effects occur similarly in both twin members. Eighteen women who were carrying twins received optimal corticosteroid treatment. Simultaneous recordings were made on twins before (day 0), during (days 1-2), and after (days 3-4) corticosteroid therapy using separate cardiotocography and ultrasound machines. Betamethasone administration was associated with significant transient decreases in basal FHR (day 1), FHR variability (days 2 and 3), and body and breathing movements (day 2). The overall changes in twins were similar to those previously found in singleton pregnancies. There was a high degree of association of response to betamethasone among individual members of twin pairs. The betamethasone-induced effects were unrelated to fetal sex, positioning, chorionicity, and discordance in size, but there was an effect of gestation on FHR. We conclude that the current regimen of antenatal corticosteroids used in preterm twin pregnancies results in observable physiologic and behavioral changes in twin pairs irrespective of their composition. This provides evidence that the achieved betamethasone levels are high enough to reach the compartment of either twin member.

The effects of intrapartum hypoxia on the fetal QT interval

BACKGROUND

The morphology of the fetal ECG complex provides information on the fetal condition during labour, such as the ST segment and T-wave configuration. We hypothesised that the intrapartum fetal QT interval may provide additional information on the condition of the fetus, as it is known that the QT interval reacts to situations of stress and exercise.

DESIGN

Retrospective study.

SETTING

Data were substracted from a European community multicentre trial.

METHODS

The intrapartum QT interval was measured in 68 fetuses who were acidemic at birth (pH <7.05 and BD (ecf) >12 mmol/L) and in a control group of similar size. All of these cases were monitored by STAN S21. Measurements were performed at the start of the recording at baseline heart rate, during variable decelerations and at the end of the recording. The QTc was calculated using Bazett's formula: QT/ radical RR. The intervals were compared using the Wilcoxon signed ranks test.

MAIN OUTCOME MEASURES

Fetal QT interval, and the corrected QT interval: QTc.

RESULTS

In the acidemic fetuses, there was a significant shortening of the QTc interval at the end of the recording compared with the start of the recording (397 ms at the end vs 359.3 ms at start; P < 0.001), in association with a significantly lowered heart rate (136.3 vs 110.9 bpm, P < 0.001). Measurements of QT and QTc during variable decelerations at the start and end of the recording also showed a shortening of the QT interval (301.9 vs 273.3 ms, P< or = 0.001) and QTc interval (381.6 vs 340.3, P < 0.001), and this was not dependent on heart rate. In the control cases, no differences in FHR, QT and QTc intervals were present.

CONCLUSIONS

In intrapartum hypoxia, resulting in metabolic acidosis, a significant shortening of the fetal QT and QTc is present, irrespective of changes in heart rate. In control cases, this shortening does not occur. The intrapartum fetal QT interval may therefore provide additional information on the condition of the fetus.

Distribution of Glutamate Transporters in the Human Placenta

Glutamate metabolism is known to be important for growth and development of the human fetus. The glutamate transporters EAAT1, EAAT2 and EAAT3 are key components of the glutamate-glutamine cycle and responsible for active transport of glutamate over the cell membrane. The placenta is thought to regulate glutamate transport during fetal development. Glutamate transporters have been found in placentae of rats, but their distribution in the human placenta is unknown. Therefore, the distribution of glutamate transporters EAAT1, EAAT2 and EAAT3 were analysed in the human placenta during normal pregnancies ending between 8 and 40 weeks of gestation and in placentae of intrauterine growth restricted infants with gestational ages between 28 and 35 weeks of pregnancy. Using immunohistochemistry, EAAT1 expression was found in the syncytiotrophoblast layer, while EAAT2 was detected in the syncytiotrophoblast layer and in endothelial cells of about 5 per cent of all fetal blood vessels. EAAT3 was observed in the endothelium of the fetal blood vessels in all placentae examined. However, expression was also found in the syncytio- and the cytotrophoblast layer of the fetal villi at 8 weeks of gestational age. The expression patterns of EAAT1, EAAT2 and EAAT3 suggest involvement in active transport of glutamate between the fetal and maternal blood circulation. No differences were found in the distribution of the glutamate transporters between control and IUGR placentae. Our data show specific localization of EAAT1, EAAT2 and EAAT3 in the human placenta during development.

Effect of antenatal glucocorticoid therapy on arterial and venous blood flow velocity waveforms in severely growth-restricted fetuses

OBJECTIVE

To study the effects of antenatal glucocorticoid (betamethasone) therapy on blood flow velocity waveform patterns in the umbilical artery (UA), middle cerebral artery (MCA) and ductus venosus (DV) in severely intrauterine growth-restricted (IUGR) fetuses.

METHODS

Fifty-five severely IUGR fetuses at 24-34 weeks of gestation were included in the study. The effect of antenatal glucocorticoid administration on Doppler findings in the UA, MCA and DV was studied using two statistical approaches, namely paired sample analysis and multilevel analysis.

RESULTS

There were no effects of betamethasone on the pulsatility index (PI) of the vessels studied. The only changes noticed during the 14 days of observation were a gradual decrease of PI in the MCA, an increase in the UA-PI/MCA-PI ratio and an increase in the DV-PI. These changes with time may be explained by a progressive and gradual deterioration of the fetal condition.

CONCLUSION

Antenatal glucocorticoids (betamethasone) do not affect fetal Doppler waveform patterns of the UA, MCA and DV in severely IUGR fetuses.

Risk of complications of pregnancy in women with type 1 diabetes: nationwide prospective study in the Netherlands

OBJECTIVE

To investigate maternal, perinatal, and neonatal outcomes of pregnancies in women with type 1 diabetes in the Netherlands.

DESIGN

Nationwide prospective cohort study.

SETTING

All 118 hospitals in the Netherlands.

PARTICIPANTS

323 women with type 1 diabetes who became pregnant between 1 April 1999 and 1 April 2000.

MAIN OUTCOME MEASURES

Maternal, perinatal, and neonatal outcomes of pregnancy.

RESULTS

84% (n = 271) of the pregnancies were planned. Glycaemic control early in pregnancy was good in most women (HbA(1c) < or = 7.0% in 75% (n = 212) of the population), and folic acid supplementation was adequate in 70% (n = 226). 314 pregnancies that went beyond 24 weeks' gestation resulted in 324 infants. The rates of pre-eclampsia (40; 12.7%), preterm delivery (101; 32.2%), caesarean section (139; 44.3%), maternal mortality (2; 0.6%), congenital malformations (29; 8.8%), perinatal mortality (9; 2.8%), and macrosomia (146; 45.1%) were considerably higher than in the general population. Neonatal morbidity (one or more complications) was extremely high (260; 80.2%). The incidence of major congenital malformations was significantly lower in planned pregnancies than in unplanned pregnancies (4.2% (n = 11) v 12.2% (n = 6); relative risk 0.34, 95% confidence interval 0.13 to 0.88).

CONCLUSION

Despite a high frequency of planned pregnancies, resulting in overall good glycaemic control (early) in pregnancy and a high rate of adequate use of folic acid, maternal and perinatal complications were still increased in women with type 1 diabetes. Neonatal morbidity, especially hypoglycaemia, was also extremely high. Near optimal maternal glycaemic control (HbA1c < or = 7.0%) apparently is not good enough.

Caesarean section on request: a survey in The Netherlands

OBJECTIVE

To determine the opinion of Dutch gynaecologists and registrars on caesarean section (CS) on request.

STUDY DESIGN

Anonymous postal survey.

METHODS

A structured survey was send to all 900 gynaecologists and registrars in The Netherlands. They were asked to what extent they were willing to accept a request for an elective caesarean section, without evident medical reason. The survey contained eight simulated cases in which the reason for this request differed (obstetrical history and course of the present pregnancy). In two cases, there was no medical indication at all to perform a caesarean section; and in a third case caesarean section was due to excessive maternal weight relatively contraindicated.

RESULTS

The response rate was 65%. Willingness to perform an elective caesarean section ranged from 17 to 81% between the cases. Main reasons to perform a caesarean section were: (a). autonomy; (b). an unfavourable course of delivery in the absence of motivation for a natural childbirth; (c). litigation. The main reasons to refuse a request for a caesarean section were: (a). higher maternal morbidity and mortality; (b). no indication for caesarean section. A logistic regression analysis on personal characteristics showed that an experienced doctor is more willing to perform an elective caesarean section then a consultant or registrar with limited experience. The sex of the doctor was of no influence and the same held for the University at which they had been trained. Furthermore, it seems that doctors are more willing to accept the request if it is based upon unfounded, but understandable fear.

CONCLUSION

In The Netherlands, a woman can always find a gynaecologist willing to perform a caesarean section for non medical reasons. This willingness increases with the age of the doctor. There is a need for guidelines when handling these cases.

Relationship between monitoring parameters and perinatal outcome in severe, early intrauterine growth restriction

OBJECTIVE

To investigate whether pathological changes in the umbilical artery (UA), ductus venosus (DV) and short-term fetal heart variation are related to perinatal outcome in severe, early intrauterine growth restriction (IUGR).

METHODS

This multicenter, prospective, longitudinal, observational study was carried out in the Departments of Fetal Medicine and Obstetrics in Hamburg, Amsterdam, Utrecht and London. In 70 singleton pregnancies with IUGR fetuses, delivered at 26-33 weeks of gestation because of antepartum fetal distress, short-term variation (STV) of fetal heart rate, pulsatility index of the fetal UA (UA PI) and DV pulsatility index for veins (DV PIV) were assessed at least weekly. The final measurement was performed within 24 h of delivery. Standard cut-off levels (2 SD or 3 SD, absent flow or reversed flow) were used and new cut-off levels were calculated by means of receiver-operating characteristics analysis. Adverse outcome was defined as perinatal death, cerebral hemorrhage (> or = Grade II) or bronchopulmonary dysplasia before discharge. The predictive value for adverse outcome was calculated for different cut-off levels of the monitoring parameters, adjusted for gestational age (GA), by multivariate logistic regression analysis. Data were analyzed separately for three different time blocks, namely 8-14, 2-7 and 0-1 days before delivery.

RESULTS

Adverse perinatal outcome occurred in 18/70 (26%) infants. During the last 24 h before delivery DV PIV and UA PI were significantly higher and STV lower in the adverse outcome group, while 2-7 days before delivery only DV PIV was significantly higher. Adverse perinatal outcome could be predicted at 0-1 days before delivery by DV PIV at a cut-off of three multiples of the SD (odds ratio (OR) 11.3; 95% CI 2.3-57) and GA (OR 0.4; 95% CI 0.3-0.8), at 2-7 days by DV PIV at 2 SD (OR 3.0; 95% CI 0.8-12) and GA (OR 0.5; 95% CI 0.3-0.8) and at 8-14 days by DV PIV at 2 SD (OR 3.9; 95% CI 0.8-20) and GA (OR 0.5; 95% CI 0.3-0.8). Other parameters did not contribute to the multivariate model.

CONCLUSIONS

DV PIV measurement is the best predictor of perinatal outcome. This measurement may be useful in timing the delivery of early IUGR fetuses and in improving perinatal outcome, even when delivery may be indicated at an earlier GA. However, as GA was also an important factor influencing outcome, with poorer outcome at earlier gestation at delivery, this hypothesis needs to be tested in a multicenter, prospective, randomized trial.

Fibrinogen and high molecular weight fibrinogen during and after normal pregnancy

INTRODUCTION

Pregnancy has recently been described as a generalized intravascular inflammatory response to the conceptus. Total fibrinogen concentrations increase during pregnancy. The percentage high molecular weight fibrinogen (HMW-Fg) of the concentration total fibrinogen is known to increase during acute-phase conditions like inflammation. Therefore, we investigated whether the percentage high molecular weight fibrinogen increases during normal pregnancy.

MATERIALS AND METHODS

Eighteen healthy nulliparous women with uncomplicated pregnancies with normal course and outcome participated in this study. Five blood samples were drawn from every woman in the gestational age periods 9 to 16, 17 to 24, 25 to 33 and 34 to 42 weeks and at 12 to 20 weeks after delivery. Total fibrinogen concentrations were determined according to Clauss and the percentage high molecular weight fibrinogen was assessed by SDS-electrophoresis and densitometry after isolation of fibrinogen by precipitation. One-way analysis of variance (ANOVA) was used to evaluate differences between gestational age periods and correlation coefficients were calculated by Pearson's method.

RESULTS

Total fibrinogen concentrations increased with advancing gestational age and decreased after delivery. The percentage high molecular weight fibrinogen of the total fibrinogen remained unaltered during and after pregnancy.

CONCLUSIONS

During normal pregnancy, there is an increase of total fibrinogen concentrations with advancing gestational age, without a rise in percentage high molecular weight fibrinogen. After delivery, the total fibrinogen returns to baseline concentrations.

The effects of antenatal betamethasone administration on fetal heart rate and behaviour depend on gestational age

OBJECTIVE

We previously reported decreases in fetal heart rate (FHR) variability and body and breathing movements after maternal betamethasone administration. We now test the hypothesis that fetal responsiveness to betamethasone depends on the gestational age at which glucocorticoid therapy is started.

DESIGN OF THE STUDY

1-h recordings of FHR (n=350) and fetal movements (n=310) made during a 5-day period (days 0-4) were available for analysis. The recordings had been obtained from 63 pregnant women at high risk for preterm delivery who received betamethasone (two doses of 12 mg 24 h apart) between 26 and 34 weeks' gestational age (wGA). The response to betamethasone, i.e. the direction and magnitude of change in FHR and movement parameters compared with baseline (day 0), was studied in relation to gestational age at drug administration.

RESULTS

Fetuses exposed to betamethasone at 29-34 wGA showed a decrease in FHR on day 1 (indicative of baroreceptor reflex), and reduced breathing activity and prolonged episodes of quiescence with a concomitant decrease in body movements on days 1 and 2. However, these changes were not observed if betamethasone administration occurred at 26-28 wGA. Betamethasone-induced reductions in FHR variability were similar in young and older fetuses.

CONCLUSIONS

Age-related differential responsiveness to betamethasone was found for all studied fetal processes (body and breathing movements, FHR, and quiescence), except FHR variability. Our results suggest ontogenic changes in the mechanisms presumed to underlie these processes (glucocorticoid receptor (GR) maturation, cardiovascular and neuro-endocrine development).

Stress during pregnancy is associated with developmental outcome in infancy

BACKGROUND

Animal studies show that prenatal maternal stress may be related to cognitive impairments in offspring. Therefore, we examined whether psychological and endocrinologic measures of stress during human pregnancy predicted developmental outcome of the infant at 3 and 8 months.

METHOD

Self-report data about daily hassles and pregnancy-specific anxiety and salivary cortisol levels were collected in 170 nulliparous women in early, mid- and late pregnancy in a prospective design, in which healthy infants born at term were followed up after birth.

RESULTS

High levels of pregnancy-specific anxiety in mid-pregnancy predicted lower mental and motor developmental scores at 8 months (p < .05). High amounts of daily hassles in early pregnancy were associated with lower mental developmental scores at 8 months (p < .05). Early morning values of cortisol in late pregnancy were negatively related to both mental and motor development at 3 months (p < .05 and p < .005, respectively) and motor development at 8 months (p < .01). On average a decline of 8 points on the mental and motor development scale was found. All results were adjusted for a large number of covariates.

CONCLUSION

Stress during pregnancy appears to be one of the determinants of delay in motor and mental development in infants of 8 months of age and may be a risk factor for later developmental problems. Further systematic follow-up of the present sample is needed to determine whether these delays are transient, persistent or even progressive.

Placental pathology in women with type 1 diabetes and in a control group with normal and large-for-gestational-age infants

Unexplained intra-uterine fetal death is still a problem in diabetic pregnancies, especially in those with an LGA-infant. We hypothesized that in these pregnancies impaired placental function, in terms of abnormal placental weight and/or abnormal placental histology, may account for this phenomenon. To test this hypothesis, we assessed the relative placental weight and scored several histological abnormalities in 34 AGA- and 24 LGA-placentae of type 1 diabetic women and in 22 AGA- and 16 LGA-placentae of control women. Relative placental weight was comparable in the LGA-diabetic cases and in the control groups, but was significantly higher in the AGA-diabetic subgroup. Histological abnormalities such as the presence of nucleated fetal red blood cells, fibrinoid necrosis, villous immaturity and chorangiosis were observed more often in the diabetic placentae compared with the control placentae. These differences in histology were particularly observed when we compared both AGA-groups. LGA-control placentae showed a high incidence of histological abnormalities, almost comparable to the diabetic placentae. Only fibrinoid necrosis was significantly more common in the LGA-diabetic placentae. Three of the four cases of perinatal death/asphyxia in the diabetic group concerned an LGA-infant with a relative low placental weight. In conclusion, placentae of women with type 1 diabetes showed several abnormalities that can be associated with impaired functioning. The difference between AGA- and LGA-diabetic placentae was related to relative placental weight and our data suggest that an increase in relative weight may protect the fetus from asphyxia. Placentae from LGA-non-diabetic women showed several similarities to those of women with diabetes.

Treatment of fetal tachycardia with sotalol: transplacental pharmacokinetics and pharmacodynamics

OBJECTIVES

The aim of this study was to investigate the pharmacokinetics and pharmacodynamics of sotalol in the treatment of fetal tachycardia.

BACKGROUND

Maternally administered, intrauterine therapy of fetal tachycardia is dependent on the transplacental passage of the antiarrhythmic agent.

METHODS

In a prospective study of patients treated for fetal tachycardia with sotalol, concentrations of sotalol were determined in maternal and umbilical blood and in amniotic fluid, and the relationship between these concentrations and the occurrence of conversion to sinus rhythm was investigated.

RESULTS

Eighteen fetal patients were studied, nine with atrial flutter and nine with supraventricular tachycardia. Fourteen were treated with sotalol; 13 converted to sinus rhythm, of whom 2 relapsed. There was one intrauterine death. Four patients were treated with sotalol and digoxin, of whom two were treated successfully. Mean birth weight was 3,266 g. The daily maternal sotalol dose was linearly related to the maternal plasma concentration. The mean fetal/maternal sotalol plasma concentration was 1.1 (range 0.67 to 2.87, SD 0.63), and the mean amniotic fluid/fetal blood ratio of sotalol was 3.2 (range 1.28 to 5.8, SD 1.4). The effectiveness of sotalol therapy could not be extrapolated from maternal blood levels.

CONCLUSIONS

Sotalol is a potent antiarrhythmic agent in the treatment of fetal tachycardia. The placental transfer is excellent. Sotalol accumulates in amniotic fluid but not in the fetus itself. Therefore it seems that renal excretion in the fetus is efficient and greater than the oral absorption by fetal swallowing. The maternal blood level is not a reliable predictor of the chances of success of therapy. Sotalol is not associated with fetal growth restriction.

Fetal behaviour does not differ between boys and girls

INTRODUCTION

Little is known about sex differences in human fetal heart and behaviour.

PATIENTS AND METHODS

One hundred twenty-three nulliparous healthy women carrying a male (n=56) or female (n=67) fetus participated in this study. All pregnancies remained uncomplicated and delivery was uneventful. Ultrasound observation of fetal general movements (GM) was performed for 1 h at 15-17 (T1) and 27-28 (T2) weeks of gestation and for 2 h at 37-39 weeks (T3). Fetal heart rate (FHR) monitoring occurred simultaneously with fetal ultrasound observations at T2 and T3. The incidence of GM (percentage of time), FHR and its variability, and the incidences of fetal heart rate patterns (HRP) A-D and behavioural states 1F-4F were compared between boys and girls.

RESULTS

There were no significant differences between males and females in the distribution of HRP A-D, overall behavioural state distribution, and basal FHR, FHR variability or the presence of GM during quiet and active sleep (or during HRP A and HRP B, respectively). A TimeXSex interaction effect for GM assessed for total record length and a higher %GM in male fetuses at term age were the only significant findings. However, these observations lost statistical significance after adjustment for the effects of fetal wakefulness, which occurred to a higher extent in male than in female fetuses.

CONCLUSION

Our data do not provide evidence for a difference in fetal functional development or maturation between the two sexes.

Life before birth: effects of cortisol on future cardiovascular and metabolic function

The concept of fetal programming is an area that is now under rigorous investigation in many laboratories throughout the world. We need to engender a fascination in all segments of society, not just pregnant women, about life in the womb.

CONCLUSION

Everyone needs to understand that improving the condition of the fetus will have personal, social and economic benefits. The time has come to realize that, in a sense, it is not just women who are pregnant but it is the family and the whole of society.

Term breech presentation in The Netherlands from 1995 to 1999: mortality and morbidity in relation to the mode of delivery of 33824 infants

OBJECTIVE

To analyse neonatal mortality and morbidity in term infants born in breech presentation in relation to the mode of delivery (planned caesarean section, emergency caesarean section or vaginal delivery) and to compare these findings with those of the Term Breech Trial Collaborative Group [Hannah et al. Lancet 2000; October].

DESIGN

Retrospective observational study.

SETTING

The Netherlands.

POPULATION

Infants (n = 33824) born at term in breech presentation in the Netherlands between 1995 and 1999. Multiple pregnancies, antenatal death and major congenital malformations were excluded.

METHODS

Data derived from the Dutch Perinatal Database were used to compare neonatal outcome of infants born in breech presentation in relation to the different modes of delivery (i.e. planned caesarean section, emergency caesarean section and vaginal delivery). Correction was made for differences in parity, duration of gestation and birthweight, using logistic regression.

MAIN OUTCOME MEASURES

Intrapartum and first-week neonatal death, 5 minute Apgar score and birth trauma. Vaginal delivery and emergency caesarean section resulted in a sevenfold increase in low Apgar score, a threefold increase in birth trauma and a twofold increase in perinatal mortality when compared with the results of planned caesarean section.

CONCLUSIONS

This study confirms the data found by Hannah et al. on an increase in early neonatal morbidity and mortality, following a trial of labour in cases of term breech presentation. These data require carefully weighed consideration against increased maternal (long term) risks due to a rise in caesarean sections.

Prenatal stress and cognitive development and temperament in infants

Studies in rodents and nonhuman primates indicate that maternal stress during pregnancy can influence the developing fetus, resulting in delay of motor and cognitive development and impaired adaptation to stressful situations. These effects may be mediated by the hypothalamic-pituitary-adrenal (HPA) axis. We examined whether stress during pregnancy predicted developmental outcome of human infants in a prospective design. Self-report data about daily hassles and pregnancy-specific anxiety and salivary cortisol levels were collected in nulliparous pregnant women. Dependent measures were scores on the Bayley Scales of Infant Development and on temperamental questionnaires at 3 and 8 months. Pregnancy-specific anxiety in mid pregnancy predicted lower mental and motor developmental scores at 8 months. Early morning values of cortisol in late pregnancy were negatively related to both mental and motor development at 3 months and motor development at 8 months. Pregnancy-specific anxiety explained 7% of the variance of test-affectivity and goal-directedness at 8 months. Increased maternal stress during pregnancy seems to be one of the determinants of temperamental variation and delay of development of infants and may be a risk factor for developing psychopathology later in life.

Poor glucose control in women with type 1 diabetes mellitus and 'safe' hemoglobin A1c values in the first trimester of pregnancy

OBJECTIVE

To observe glycemic excursions, measured continuously over 24 h, in relation to hemoglobin A1c values in the first trimester of pregnancy of women with type 1 diabetes mellitus.

METHODS

The MiniMed Continuous Glucose Monitoring System (CGMS) was used to obtain glucose values every 5 min during 24 h. Hemoglobin A1c was determined at the end of the continuous glucose recording and 6-12 weeks after the continuous glucose recording.

RESULTS

Continuous glucose recordings were obtained in 13 women between 7 and 15 weeks of gestation. Nine patients had hemoglobin A1c levels of < or = 7.0% (< 1% above the upper limit of normal range) while up to 41.3% of the readings had values of < 3.9 mmol/l (70 mg/dl) and up to 52.8% of the readings had values of > 7.8 mmol/l (140 mg/dl).

CONCLUSIONS

Hemoglobin A1c does not reflect the complexities of glycemic control in women with type 1 diabetes who are considered to have accomplished tight glycemic control in the first trimester of pregnancy.

Early neonatal antioxidant capacity after preexisting impaired placental function

Plasma antioxidant capacity in very preterm infants (n=17), measured as the ferric-reducing ability of plasma (FRAP), increased significantly until day 2 postpartum and decreased thereafter until day 7. Within this period, the FRAP values in matched infants, born after impaired placental function (IPF, n=17), did not change. Their FRAP values were lower and the incidence of oxidative stress-related diseases was significantly higher in these infants.

Altered fetal circulation in type-1 diabetic pregnancies

OBJECTIVE

Type-I diabetic pregnancies are associated with congenital cardiac malformations, fetal cardiomyopathy, venous thrombosis and altered placental vascularization, even with tight maternal glucose control. The aim of this study was to investigate if, with good glucose control achieved with continuous subcutaneous insulin infusion, normal blood flow within the fetal heart can be achieved.

METHODS

Seventeen fetuses of women with well-controlled type-I diabetes were studied longitudinally to evaluate effects on the fetal circulation. Doppler frequency shift tracings, valve diameters and intercept angles were measured at right and left atrioventricular valve orifices at 4-week intervals starting at 15 weeks' gestation. Atrioventricular valve flow was calculated and compared to normal fetal data obtained in previous studies.

RESULTS

Maximum and mean temporal velocities across the atrioventricular valves increased in both groups during gestation but significantly more in fetuses of type-I diabetic pregnancies. Combined ventricular output, both absolute and per kg estimated fetal weight, were also greater in these fetuses. In the normal group the ratio of the right/left ventricular output decreased significantly during gestation (from 1.34 +/- 0.28 to 1.08 +/- 0.28 standard deviations), but in type-I diabetic pregnancies this decrease did not occur (1.2 +/- 0.26 to 1.25 +/- 0.29 standard deviations)[corrected].

CONCLUSIONS

These data indicate that there are significant differences in the fetal circulation between normal pregnancy and well-controlled type-I diabetic pregnancy, suggesting the existence of a compensatory mechanism which increases fetal cardiac output and causes cardiac hypertrophy.

Persistent junctional reciprocating tachycardia in the fetus

BACKGROUND

Persistent junctional reciprocating tachycardia (PJRT) tends to be a persistent arrhythmia and requires aggressive therapeutic management. Diagnosis and management of this infrequently occurring tachycardia in the fetus at an early stage is of importance for the prevention of congestive heart failure (CHF).

METHODS

A retrospective study of four fetuses with supraventricular tachycardia (SVT) of the PJRT type was performed.

RESULTS

All had sustained SVT (mean of 228 beats/min) at a mean gestational age of 34 + 5 weeks, with CHF present in two. Three fetuses had prenatal characteristics of PJRT on M-mode echocardiography with a ventriculoatrial (VA)/atrioventricular ratio of > 1 on M-mode echocardiography suggesting a slow conducting accessory pathway. All four fetuses had postnatal confirmation of the diagnosis. Transplacental treatment with flecainide was effective in one patient; sotalol as a single drug or in combination with digoxin was partially effective in the remaining three. Two developed sinus rhythm, with short intermittent periods of tachycardia and decreasing signs of CHF; one case showed a minimal decrease in heart rate. Oral propranolol therapy converted two patients postnatally; in the remaining two patients radiofrequency ablation was performed at the age of 5 months and 6 years.

CONCLUSIONS

The characteristics of our prenatal PJRT cases included a sustained heart rate not exceeding 240 beats/min with a long VA interval, the presence of CHF and therapy resistance. Transplacental treatment should be initiated, possibly with a combination of sotalol and digoxin in non-hydropic cases, or flecainide, especially in case of fetal hydrops. Pharmacological therapy is to be preferred postnatally, but radiofrequency ablation seems to be indicated in therapy-resistant cases with CHF, even in the first months of life.