Physiological subtypes of gestational glucose intolerance and risk of adverse pregnancy outcomes

BACKGROUND

Women with gestational glucose intolerance, defined as an abnormal initial gestational diabetes mellitus screening test, are at risk of adverse pregnancy outcomes even if they do not have gestational diabetes mellitus. Previously, we defined the physiological subtypes of gestational diabetes mellitus based on the primary underlying physiology leading to hyperglycemia and found that women with different subtypes had differential risks of adverse outcomes. Physiological subclassification has not yet been applied to women with gestational glucose intolerance.

OBJECTIVE

We defined the physiological subtypes of gestational glucose intolerance based on the presence of insulin resistance, insulin deficiency, or mixed pathophysiology and aimed to determine whether these subtypes are at differential risks of adverse outcomes. We hypothesized that women with the insulin-resistant subtype of gestational glucose intolerance would have the greatest risk of adverse pregnancy outcomes.

STUDY DESIGN

In a hospital-based cohort study, we studied women with gestational glucose intolerance (glucose loading test 1-hour glucose, ≥140 mg/dL; n=236) and normal glucose tolerance (glucose loading test 1-hour glucose, <140 mg/dL; n=1472). We applied homeostasis model assessment to fasting glucose and insulin levels at 16 to 20 weeks' gestation to assess insulin resistance and deficiency and used these measures to classify women with gestational glucose intolerance into subtypes. We compared odds of adverse outcomes (large for gestational age birthweight, neonatal intensive care unit admission, pregnancy-related hypertension, and cesarean delivery) in each subtype to odds in women with normal glucose tolerance using logistic regression with adjustment for age, race and ethnicity, marital status, and body mass index.

RESULTS

Of women with gestational glucose intolerance (12% with gestational diabetes mellitus), 115 (49%) had the insulin-resistant subtype, 70 (27%) had the insulin-deficient subtype, 40 (17%) had the mixed pathophysiology subtype, and 11 (5%) were uncategorized. We found increased odds of large for gestational age birthweight (primary outcome) in women with the insulin-resistant subtype compared with women with normal glucose tolerance (odds ratio, 2.35; 95% confidence interval, 1.43-3.88; P=.001; adjusted odds ratio, 1.74; 95% confidence interval, 1.02-3.48; P=.04). The odds of large for gestational age birthweight in women with the insulin-deficient subtype were increased only after adjustment for covariates (odds ratio, 1.69; 95% confidence interval, 0.84-3.38; P=.14; adjusted odds ratio, 2.05; 95% confidence interval, 1.01-4.19; P=.048). Among secondary outcomes, there was a trend toward increased odds of neonatal intensive care unit admission in the insulin-resistant subtype in an unadjusted model (odds ratio, 2.09; 95% confidence interval, 0.99-4.40; P=.05); this finding was driven by an increased risk of neonatal intensive care unit admission in women with the insulin-resistant subtype and a body mass index of <25 kg/m². Infants of women with other subtypes did not have increased odds of neonatal intensive care unit admission. The odds of pregnancy-related hypertension in women with the insulin-resistant subtype were increased (odds ratio, 2.09; 95% confidence interval, 1.31-3.33; P=.002; adjusted odds ratio, 1.77; 95% confidence interval, 1.07-2.92; P=.03) compared with women with normal glucose tolerance; other subtypes did not have increased odds of pregnancy-related hypertension. There was no difference in cesarean delivery rates in nulliparous women across subtypes.

CONCLUSION

Insulin-resistant gestational glucose intolerance is a high-risk subtype for adverse pregnancy outcomes. Delineating physiological subtypes may provide opportunities for a more personalized approach to gestational glucose intolerance.

Insulin Resistant Gestational Glucose Intolerance Is Associated With Adverse Perinatal Outcomes

Background: Women with gestational diabetes mellitus (GDM) and gestational glucose intolerance (GGI, abnormal initial GDM screening test) and their infants have an increased risk of adverse perinatal outcomes including large for gestational age birth weight (LGA), pregnancy-related hypertension, neonatal intensive care unit (NICU) admission, and cesarean delivery. We expanded a prior analysis defining physiologic subtypes of GGI categorized by insulin resistance, insulin deficiency, or mixed pathophysiology. We aimed to determine if GGI subtypes are at differential risk for adverse outcomes.

Methods: We applied homeostasis model assessment (HOMA2) to fasting glucose and insulin levels at 16–20 weeks’ gestation to assess insulin resistance and deficiency, defined using the 50^th percentile in 220 women with a normal glucose loading test (GLT) at 24–30 weeks’ gestation. We defined GGI as GLT 1-hr glucose ≥140 mg/dL (n=245) and normal glucose tolerance (NGT) as GLT 1-hr glucose <140 mg/dL (n=1538). We classified women with GGI into subtypes according to the presence of insulin resistance and/or deficiency. We compared odds of adverse outcomes in each subtype to odds in women with NGT using logistic regression with adjustment for age, race/ethnicity, marital status, and 1^st trimester BMI, plus infant sex in LGA models.

Results: Of women with GGI, 49.0% had the insulin resistant subtype (IR, n=120), 30.6% had the insulin deficient subtype (ID, n=75), 15.9% had mixed pathophysiology (MP, n=39), and 4.5% had no evidence of IR or ID (n=11). GLT results and GDM diagnosis were similar among GGI subtypes. We found increased odds of LGA (primary outcome) in women with IR compared to women with NGT (OR 1.97 [1.17–3.32], p=0.01) in an unadjusted model; this was attenuated in an adjusted model with BMI (adjusted OR 1.43 [0.82–2.49], p=0.21). There was a trend toward increased odds of LGA in women with ID (adjusted OR 1.87 [0.92–3.80], p=0.09) and no increased odds in women with MP (adjusted OR 1.33 [0.50–3.57], p=0.57) compared to NGT. The odds of pregnancy-related hypertension in the IR subtype were increased (adjusted OR 1.68 [1.02–2.77], p=0.04) compared to women with NGT; women with ID (adjusted OR 0.91 [0.44–1.88], p=0.79) or MP (adjusted OR 1.13 [0.48–2.67], p=0.78) did not have increased odds. Neither infants of women with IR nor ID had increased odds of NICU admission overall, yet among women with BMI <25, infants of those with IR had increased odds of NICU admission compared to those of women with NGT (adjusted OR 3.37 [1.04–10.96], p=0.02); odds of NICU admission were not increased in infants of women with ID and BMI <25 (adjusted OR 0.50 [0.07–3.83], p=0.50). There was no difference in cesarean delivery across subtypes.

Conclusion: Insulin resistant GGI is a high-risk subtype for adverse perinatal outcomes. Using HOMA2 to delineate subtypes may provide opportunities for a personalized approach to GGI/GDM.

Balancing risks: making decisions for maternal treatment without data on fetal safety

Challenges arise when treatment to improve maternal health brings the possibility of risk to fetal health. The coronavirus disease 2019 (COVID-19) vaccine is the most recent, but hardly the only, example. Because pregnant patients are often specifically excluded from trials of new therapies, this is often the dilemma that patients and providers face when considering new treatments. In this study, we used the COVID-19 vaccine as an exemplar to question the broader issue of how society, in general, and obstetricians, in particular, should balance obligations to pregnant women's right of access to new therapeutic agents with the physician's desire to protect the fetus from potential risks. We will argue that in almost all circumstances (with few exceptions, as will also be discussed), maternal benefit and respect for autonomy create the uncertainty that absent safety data bring. Consequently, if pregnant women choose to try new interventions and treatments, such as the COVID-19 vaccination, they should be offered those new regimens and their decision supported. In addition, we will argue that the right solution to avoid the dilemma of absent data is to include pregnant individuals in clinical trials studying new treatments, drugs, and other therapies. We will also discuss the basis for our opinion, which are mainstream obstetrical ethics, precedents in law (supreme court ruling that forbids companies to exclude women from jobs that might pose a risk to the fetus), and historic events (thalidomide). The ethical framework includes the supposition that sacrifice to improve fetal outcome is a virtue and not a mandate. Denying a pregnant patient treatment because of threats to their life can create absurd and paradoxical consequences. Either requiring abortion or premature delivery before proceeding with treatments to optimize maternal health, or risking a patient's own life and ability to parent a child by delaying treatment brings clear and significant risks to fetal and/or neonatal outcomes. With rare exceptions, properly and ethically balancing such consequential actions cannot be undertaken without considering the values and goals of the pregnant patient. Therefore, active participation of both the pregnant patient and their physician in shared decision making is needed.

Diffuse glioneuronal tumour with oligodendroglioma-like features and nuclear clusters (DGONC) - a molecularly defined glioneuronal CNS tumour class displaying recurrent monosomy 14

AIMS

DNA methylation-based central nervous system (CNS) tumour classification has identified numerous molecularly distinct tumour types, and clinically relevant subgroups among known CNS tumour entities that were previously thought to represent homogeneous diseases. Our study aimed at characterizing a novel, molecularly defined variant of glioneuronal CNS tumour.

PATIENTS AND METHODS

DNA methylation profiling was performed using the Infinium MethylationEPIC or 450 k BeadChip arrays (Illumina) and analysed using the 'conumee' package in R computing environment. Additional gene panel sequencing was also performed. Tumour samples were collected at the German Cancer Research Centre (DKFZ) and provided by multinational collaborators. Histological sections were also collected and independently reviewed.

RESULTS

Genome-wide DNA methylation data from >25 000 CNS tumours were screened for clusters separated from established DNA methylation classes, revealing a novel group comprising 31 tumours, mainly found in paediatric patients. This DNA methylation-defined variant of low-grade CNS tumours with glioneuronal differentiation displays recurrent monosomy 14, nuclear clusters within a morphology that is otherwise reminiscent of oligodendroglioma and other established entities with clear cell histology, and a lack of genetic alterations commonly observed in other (paediatric) glioneuronal entities.

CONCLUSIONS

DNA methylation-based tumour classification is an objective method of assessing tumour origins, which may aid in diagnosis, especially for atypical cases. With increasing sample size, methylation analysis allows for the identification of rare, putative new tumour entities, which are currently not recognized by the WHO classification. Our study revealed the existence of a DNA methylation-defined class of low-grade glioneuronal tumours with recurrent monosomy 14, oligodendroglioma-like features and nuclear clusters.

Risk of Preeclampsia and Pregnancy Complications in Women With a History of Acute Kidney Injury

An episode of clinically recovered acute kidney injury (r-AKI) has been identified as a risk factor for future hypertension and cardiovascular disease. Our objective was to assess whether r-AKI was associated with future preeclampsia and other adverse pregnancy outcomes and to identify whether severity of AKI or time interval between AKI and pregnancy was associated with pregnancy complications. We conducted a retrospective cohort study of women who delivered infants between 1998 and 2016 at Massachusetts General Hospital. AKI was defined using the 2012 Kidney Disease Improving Global Outcomes laboratory criteria with subsequent clinical recovery (estimate glomerular filtration rate, >90 mL/min per 1.73 m² before conception). AKI was further classified by severity (Kidney Disease Improving Global Outcomes stages 1-3) and time interval between AKI episode and the start of pregnancy. Women with r-AKI had an increased rate of preeclampsia compared with women without previous r-AKI (22% versus 9%; P<0.001). Infants of women with r-AKI were born earlier (gestational age, 38.2±3.0 versus 39.0±2.2 weeks; P<0.001) and were more likely to be small for gestational age (9% versus 5%; P=0.002). Increasing severity of r-AKI was associated with increased risk of preeclampsia for stages 2 and 3 AKI (adjusted odds ratio, 3.5; 95% confidence interval, 2.1-5.7 and adjusted odds ratio, 6.5; 95% confidence interval, 3.5-12.0, respectively), but not for stage 1 (adjusted odds ratio, 1.7; 95% confidence interval, 0.9-3.2). A history of AKI before pregnancy, despite apparent full recovery, was associated with increased risk of pregnancy complications. Severity and timing of the AKI episode modified the risk.

Metabolic and Hypertensive Complications of Pregnancy in Women with Nephrolithiasis

BACKGROUND AND OBJECTIVES

Kidney stones are associated with future development of hypertension, diabetes, and the metabolic syndrome. Our objective was to assess whether stone formation before pregnancy was associated with metabolic and hypertensive complications in pregnancy. We hypothesized that stone formation is a marker of metabolic disease and would be associated with higher risk for maternal complications in pregnancy.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a retrospective cohort study of women who delivered infants at the Massachusetts General Hospital from 2006 to 2015. Women with abdominal imaging (computed tomography or ultrasound) before pregnancy were included in the analysis. Pregnancy outcomes in women with documented kidney stones on imaging (stone formers, n=166) were compared with those of women without stones on imaging (controls, n=1264). Women with preexisting CKD, hypertension, and diabetes were excluded.

RESULTS

Gestational diabetes and preeclampsia were more common in stone formers than nonstone formers (18% versus 6%, respectively; P<0.001 and 16% versus 8%, respectively; P=0.002). After multivariable adjustment, previous nephrolithiasis was associated with higher risks of gestational diabetes (adjusted odds ratio, 3.1; 95% confidence interval, 1.8 to 5.3) and preeclampsia (adjusted odds ratio, 2.2; 95% confidence interval, 1.3 to 3.6). Infants of stone formers were born earlier (38.7±2.0 versus 39.2±1.7 weeks, respectively; P=0.01); however, rates of small for gestational age offspring and neonatal intensive care admission were similar between groups (8% versus 7%, respectively; P=0.33 and 10% versus 6%, respectively; P=0.08). First trimester body mass index significantly influenced the association between stone disease and hypertensive complications of pregnancy: in a multivariable linear regression model, stone formation acted as an effect modifier of the relationship between maximum systolic BP in the third trimester and body mass index (P interaction <0.001).

CONCLUSIONS

In women without preexisting diabetes, hypertension, and CKD, a history of nephrolithiasis was associated with gestational diabetes and hypertensive disorders of pregnancy, especially in women with high first trimester body mass index.

When Guild Interests and Professional Obligations Collide

Physicians who work in medical organizations are called on to fulfill two roles: guild members who work to advance physician interests (eg, lobbying for tort reform) and professional society members who work to advance patient interests (eg, developing clinical guidelines). Most often, physicians' self-interest and their interest in patient well-being align. When they do not, members of a guild or profession may justify the prioritization of self-interest with a form of motivated reasoning (a process wherein physicians weigh data differently depending on whether it supports their a priori beliefs). This allows physicians to frame self-interest as being in the best interests of their patients (eg, tort reform makes malpractice insurance affordable and allows physicians to continue to serve their patients). When interests conflict, physicians must be cognizant of the forces at play, that is, self-interest or in-group interest on the one hand and obligations to patients on the other. This entails recognition and negation of motivated reasoning. Often the most difficult calculus is evaluating proposed actions that would disadvantage physicians but advantage patients. In such cases, the health care provider must be aware not only of the temptation to oppose the action for financial reasons, but also the equally natural temptation to frame the proposal as a threat to patient well-being. Ultimately recognizing that a central tenet of professionalism is the primacy of patient welfare should help physicians both to maintain their fidelity to patient good and to uphold their reputation for altruism.

Pregnancy Outcomes after Clinical Recovery from AKI

The effect of clinically recovered AKI (r-AKI) on future pregnancy outcomes is unknown. We retrospectively studied all women who delivered infants between 1998 and 2007 at Massachusetts General Hospital to assess whether a previous episode of r-AKI associated with subsequent adverse maternal and fetal outcomes, including preeclampsia. AKI was defined as rise in serum creatinine concentration to 1.5-fold above baseline. We compared pregnancy outcomes in women with r-AKI without history of CKD (eGFR>90 ml/min per 1.73 m² before conception; n=105) with outcomes in women without kidney disease (controls; n=24,640). The r-AKI and control groups had similar prepregnancy serum creatinine measurements (0.70±0.20 versus 0.69±0.10 mg/dl; P=0.36). However, women with r-AKI had increased rates of preeclampsia compared with controls (23% versus 4%; P<0.001). Infants of women with r-AKI were born earlier than infants of controls (37.6±3.6 versus 39.2±2.2 weeks; P<0.001), with increased rates of small for gestational age births (15% versus 8%; P=0.03). After multivariate adjustment, r-AKI associated with increased risk for preeclampsia (adjusted odds ratio [aOR], 5.9; 95% confidence interval [95% CI], 3.6 to 9.7) and adverse fetal outcomes (aOR, 2.4; 95% CI, 1.6 to 3.7). When women with r-AKI and controls were matched 1:2 by age, race, body mass index, diastolic BP, parity, and diabetes status, r-AKI remained associated with preeclampsia (OR, 4.7; 95% CI, 2.1 to 10.1) and adverse fetal outcomes (OR, 2.1; 95% CI, 1.2 to 3.7). Thus, a past episode of AKI, despite return to normal renal function before pregnancy, associated with adverse outcomes in pregnancy.

MENTAL HEALTH DISORDERS SUBSEQUENT TO GESTATIONAL DIABETES MELLITUS DIFFER BY RACE/ETHNICITY

INTRODUCTION

The relationship between gestational diabetes mellitus (GDM) and postpregnancy mental health disorders has been inconsistently reported. Additionally, race/ethnicity data are limited. We sought to elucidate the intersection of these relationships.

METHODS

We analyzed 18,109 women aged 18-40 with self-reported race/ethnicity. Women with (n = 659) and without (n = 14,461) GDM were followed for a median of 4.4 (interquartile range 1.4-6.8) and 4.0 (1.5-6.4) years, respectively, for incident mental health disorders. Multivariable repeated measures analyses were conducted to examine associations between GDM and postpregnancy mental health disorders, race/ethnicity, and the interaction of these factors.

RESULTS

Women with compared to women without GDM were older (mean ± standard deviation, 32 ± 5 vs. 30 ± 5 years; P < .001) and had higher body mass index (29.0 ± 7.2 vs. 25.3 ± 5.2 kg/m(2) ; P < .001). GDM was associated with increased risk for depression and anxiety after adjusting for age and pregnancy complications; however, loss of significance in the fully adjusted model for depression (odds ratio [95% CI]: 1.29 [0.98, 1.70]; P = .064) and anxiety (1.14 [0.83, 1.57], P = .421) suggested that clinical and socioeconomic factors influence this relationship. Hispanic compared to white women had a greater risk for depression (1.40 [1.15, 1.72]; P = .001), even after multivariable adjustment. The interaction between GDM and race was evident in complication-adjusted but not fully adjusted models.

CONCLUSIONS

The incidence of mental health disorders subsequent to GDM was attenuated after adjustment for clinical and socioeconomic factors. Moreover, race/ethnicity influenced this relationship. Further investigation is warranted to clarify potential underlying mechanisms.

Physicians' obligations to patients infected with Ebola: echoes of acquired immune deficiency syndrome

Physicians across the United States are engaged in training in the identification, isolation, and initial care of patients with Ebola. Some will be asked to do more. The issue this viewpoint will address is the moral obligation of physicians to participate in these activities. In order to do so the implicit contract between society and its physicians will be considered, as will many of the arguments that are redolent of those that were litigated 30 years ago when acquired immune deficiency syndrome (AIDS) was raising public fears to similar levels, and some physicians were publically proclaiming their unwillingness to render care to those individuals. We will build the case that if steps are taken to reduce risks-optimal personal protective equipment and training-to what is essentially the lowest possible level then rendering care should be seen as obligatory. If not, as in the AIDS era there will be an unfair distribution of risk, with those who take their obligations seriously having to go beyond their fair measure of exposure. It would also potentially undermine patients' faith in the altruism of physicians and thereby degrade the esteem in which our profession is held and the trust that underpins the therapeutic relationship. Finally there is an implicit contract with society. Society gives tremendously to us; we encumber a debt from all society does and offers, a debt for which recompense is rarely sought. The mosaic of moral, historical, and professional imperatives to render care to the infected all echoes the words of medicine's moral leaders in the AIDS epidemic. Arnold Relman perhaps put it most succinctly, "the risk of contracting the patient's disease is one of the risks that is inherent in the profession of medicine. Physicians who are not willing to accept that risk…ought not be in the practice of medicine."

Supraretinacular endoscopic carpal tunnel release: surgical technique with prospective case series

Current techniques for endoscopic carpal tunnel release use an infraretinacular approach, inserting the endoscope deep to the flexor retinaculum. We present a supraretinacular endoscopic carpal tunnel release technique in which a dissecting endoscope is inserted superficial to the flexor retinaculum, which improves vision and the ability to dissect and manipulate the median nerve and tendons during surgery. The motor branch of the median nerve and connections between the median and ulnar nerve can be identified and dissected. Because the endoscope is inserted superficial to the flexor retinaculum, the median nerve is not compressed before division of the retinaculum and, as a result, we have observed no cases of the transient median nerve deficits that have been reported using infraretinacular endoscopic techniques.

Effect of race/ethnicity on hypertension risk subsequent to gestational diabetes mellitus

Gestational diabetes mellitus (GDM) prevalence is greater in racially/ethnically diverse groups compared with non-Hispanic white populations. Although race has been shown to modify other cardiovascular disease risk factors in postpartum women, the role of race/ethnicity on GDM and subsequent hypertension has yet to be examined. The aim of this study was to evaluate the impact of race/ethnicity in relation to GDM and subsequent hypertension in a retrospective analysis of women who delivered at Massachusetts General Hospital from 1998 to 2007. Multivariate analyses were used to determine the associations between GDM and (1) race/ethnicity, (2) hypertension, and (3) the interaction with hypertension and race/ethnicity. Women were monitored for a median of 3.8 years from the date of delivery. In our population of 4,010 women, GDM was more common in nonwhite participants (p<0.0001). GDM was also associated with hypertension subsequent to delivery after adjusting for age, race, parity, first-trimester systolic blood pressure, body mass index, maternal gestational weight gain, and preeclampsia (hazard ratio [HR] 1.75, 95% confidence interval [CI] 1.28 to 2.37, p=0.0004). Moreover, Hispanic (HR 3.25, 95% CI 1.85 to 5.72, p<0.0001) and white (HR 1.68, 95% CI 1.10 to 2.57, p=0.02) women with GDM had greater hypertension risk relative to their race/ethnicity-specific counterparts without GDM in race-stratified multivariable analyses. In conclusion, Hispanic women compared with white women have an increased risk of hypertension. Hispanic and white women with GDM are at a greater risk for hypertension compared with those without GDM. Because the present study may have had limited power to detect effects among black and Asian women with GDM, further research is warranted to elucidate the need for enhanced hypertension risk surveillance in these young women.

Elective cesarean delivery on maternal request

IMPORTANCE

Some pregnant women prefer cesarean delivery and request it without maternal or fetal indication rather than proceeding with a plan for vaginal delivery.

OBJECTIVE

To review approaches for counseling women who ask for cesarean delivery without maternal or fetal indication (known as cesarean delivery on maternal request [CDMR]).

EVIDENCE REVIEW

An Agency for Healthcare Research and Quality evidence report of studies published after 1990, a 2006 National Institutes of Health state-of-the-science conference report, and published literature were examined.

FINDINGS

The prevalence of CDMR in the United States is not precisely known but probably occurs in less than 3% of all deliveries. Most practicing obstetricians have received requests for CDMR from patients. Compared with a plan for vaginal delivery, CDMR may be associated with lower rates of hemorrhage, maternal incontinence, and rare but serious neonatal outcomes. However, CDMR is associated with a higher risk of neonatal respiratory morbidity. Adverse consequences of CDMR may be manifested only in future pregnancies. Repeated cesarean deliveries have higher rates of operative complications, placental abnormalities such as placenta previa and accreta, and consequent gravid hysterectomy.

CONCLUSIONS AND RELEVANCE

There is no immediate expectation for CDMR to reduce the health risks of mothers or infants. Accordingly, counseling and decisions regarding CDMR should be made after considering a woman's full reproductive plans.

Postnatal outcome of fetuses with the prenatal diagnosis of gastroschisis

OBJECTIVES

The purpose of this study was to assess the postnatal outcome and complications that arise in infants with the prenatal diagnosis of gastroschisis.

METHODS

Prenatal sonograms with the diagnosis of gastroschisis were identified. Maternal age, indication for sonography, gestational age at diagnosis, other sonographic abnormalities, and postnatal outcome were recorded.

RESULTS

Ninety-eight fetuses at 14.3 to 36 weeks' gestation had the diagnosis of gastroschisis on sonography. In 14 cases (14%), other fetal anomalies were identified, including hydronephrosis, hydrocephalus, coarctation of the aorta, and a limb anomaly. Bowel dilatation developed in 72 of 84 cases (86%) followed prenatally with sonography, and bowel wall thickening developed in 40 of 73 cases (55%). On postnatal follow-up, 57 of 68 infants (84%) had postnatal complications, many with multisystem complications, including 6 deaths, 40 with bowel-related complications, 30 with infectious complications, and 32 with anomalies involving other systems (genitourinary, cardiac, and central nervous system). The postnatal outcome did not correlate with the presence of bowel dilatation or bowel wall thickening on prenatal sonography. Only 11 infants (16.2%) had a completely uncomplicated postsurgical course. Hospital stays in survivors (n = 92) ranged from 8 to 307 days (mean, 53 days).

CONCLUSIONS

Although reported survival rates are good for gastroschisis, the postoperative hospital stay is often lengthy, and complications are very common, especially those related to the gastrointestinal tract. Associated anomalies were more common in our study than previously reported.

A reconsideration of home birth in the United States

Home births continue to constitute only a small percentage of all deliveries in the United States, in part because of concerns about their safety. While the literature is decidedly mixed in regard to the degree of risk, there are several studies that report that home birth may at times entail a small absolute increase in perinatal risks in circumstances that cannot always be anticipated prior to the onset of labor. While the definition of "small" will vary between individuals, and publications vary in the level of risk they ascribe to birth at home, studies with the least methodological flaws and with adequate power often cite an excess death rate in the range of one per thousand. Home birth is, in that regard, but one example of patients' choices and plans that sometimes carry increased risk or include alternatives that individual physicians feel uncomfortable supporting or recommending. Our intention in this opinion piece is not to advocate for or against home birth. Rather, we recognize that home birth is but one example of a patient choice that might differ from what a provider feels is in a woman's best interests. In this article we will discuss ethical considerations in such circumstances using home birth as an example. We consider in this article how the ethical principles of respect for autonomy and non-maleficence can be balanced using, among other examples, the choice by some for a home birth. We discuss how absolute rather than relative risk should guide individuals' evaluation of patient choices. We also consider how in some circumstances, the value and safety added by a physician's participation may outweigh a potentially small increment in absolute risk that might result from a patient's decision to deliver at home because of a perceived physician endorsement. We recognize, however, that doctors and midwives participating in choices they have not recommended, or may even believe will lead to or increase risk for adverse outcomes, presents dilemmas and raises important questions. When does respect for patient choice and autonomy become support for poor decision making? When is participation not respectful but enabling? Finally we discuss the role and responsibility of organized medicine in making all births as safe as possible.

Accuracy of sonography to predict estimated weight in fetuses with gastroschisis

OBJECTIVES

The purpose of this study was to determine whether sonographic formulas for estimating fetal weight are as accurate for fetuses affected with gastroschisis as they are for healthy fetuses. We hypothesized that because the most commonly used Hadlock formulas rely on the abdominal circumference as a biometric variable, estimates of birth weight are less reliable in fetuses with gastroschisis than in healthy fetuses.

METHODS

We performed a chart review of all fetuses with a prenatal diagnosis of gastroschisis at 3 tertiary care institutions from 1990 to 2008. Charts were reviewed for clinical and sonographic data. The estimated fetal weight at the prenatal sonogram closest to delivery was compared to the birth weight. Published Hadlock formulas using 4 biometric parameters were used to calculate the estimated fetal weight. Data analysis was performed using the Student t test and χ(2) test for continuous and categorical variables, respectively.

RESULTS

One hundred eleven patients with gastroschisis were identified. Sixty-six patients had a prenatal sonogram with a calculated estimated fetal weight within 7 days of delivery; 88 patients had a sonogram within 14 days. The mean birth weights ± SD were 2292 ± 559 and 2477 ± 531 g in the 0- to 7- and 8- to 14-day groups, respectively. Sonographic biometric measurements underestimated the birth weight by an average of 5.6%. Intrauterine growth restriction was predicted in 72% of all pregnancies but was only present in 52%.

CONCLUSIONS

Our study shows a systematic error of birth weight underestimation when using the Hadlock formulas in fetuses affected with gastroschisis.

Regulatory and electronic alphabet soup: practice improvements and implications for providers

The growth of health information technology, the focus on patient safety and an increased degree of regulatory involvement in the practice of medicine have all transformed the way practitioners provide care. This paper reviews some of the recognized benefits of these advances, while outlining some of the challenges for providers at the bedside, utilizing a case study involving a hypothetical obstetric patient. The way external factors, such as information technology and regulatory requirements, influence the daily practice of medicine, should be carefully considered as the profession evolves.Integration and streamlining processes should remain a guiding principle to ensure patient safety and assist with workflow.

Is a rising cesarean delivery rate inevitable? Trends in industrialized countries, 1987 to 2007

BACKGROUND

 Cesarean delivery rates have been rising rapidly in many countries in the last decade. The objective of this research is to examine cesarean rates in industrialized countries and assess patterns in the trends toward increasing rates.

METHODS

We examined cesarean delivery rates per 1,000 live births from 1987 to 2007 in 22 industrialized countries. To enhance comparability, the inclusion criteria were at least 50,000 births annually and a per capita gross domestic product of at least U.S.$10,000 in 2007. Poisson regression was selected to model the cesarean delivery rates of countries across time.

RESULTS

 We examined overall cesarean delivery rates, absolute changes in these rates, and changes in trend lines for cesarean rates for the period from 1987 to 2007. In 2007, 11 of the 21 countries reported overall cesarean rates of more than 25 percent, led by Italy (39%), Portugal (35%), the United States (32%), and Switzerland (32%). Five countries, the Slovak Republic, Czech Republic, Ireland, Austria, and Hungary more than doubled their cesarean delivery rate between 1992 and 2007. Comparing changes in rates across time periods, 14 countries experienced a greater increase in rates in the period between 1998 and 2002 compared with the period between 1993 and 1997. Comparing trends from 2003-2007 to 1998-2002, eighteen countries experienced a slowing down of rate increases across these two periods.

CONCLUSION

 Although cesarean delivery rates continue to rise, the rate of increase appears to be slowing down in most industrialized countries.

Preeclampsia and the risk of large-for-gestational-age infants

OBJECTIVE

We sought to compare the risk of giving birth to large-for-gestational-age (LGA) infants in women with and without preeclampsia, after adjustment for obesity and glucose intolerance.

STUDY DESIGN

We conducted secondary analysis of a prospective database of pregnant women with and without preeclampsia who delivered infants from 1998 through 2006 at Massachusetts General Hospital (n = 17,465).

RESULTS

The risk of LGA was similar in women with and without preeclampsia (odds ratio, 0.81; 95% confidence interval, 0.59-1.14). After adjustment for body mass index, glucose intolerance, and other factors, the risk of LGA was significantly lower in women with preeclampsia compared to those without preeclampsia (odds ratio, 0.69; 95% confidence interval, 0.49-0.96). Stratified analysis in groups with a higher risk of LGA revealed that preeclampsia has a similar effect on the risk of LGA regardless of maternal obesity, glucose intolerance, parity, and race.

CONCLUSION

Preeclampsia appears to be characterized by reduced, and not increased, fetal growth.

Barriers to follow-up for women with a history of gestational diabetes

Women with gestational diabetes (GDM) are at increased risk for type 2 diabetes (T2DM), but many do not receive recommended follow-up. We sought to identify barriers to follow-up screening. We surveyed primary care providers (PCPs) and obstetric and gynecology care providers (OBCPs) in a large health system. We also assessed documentation of GDM history in the health care system's electronic medical record. Four hundred seventy-eight clinicians were surveyed, among whom 207 responded. Most participants (81.1%) gave an accurate estimate of risk of progression to T2DM. PCPs were less likely than OBCPs to ask patients about history of GDM (odds ratio [OR] 0.43, 95% confidence interval [CI] 0.20 to 0.90), but they were far more likely to indicate that they order glucose screening for women with a known history (OR 4.31, 95% CI 2.01 to 9.26). Providers identified poor communication between OBCPs and PCPs as a major barrier to screening. Fewer than half (45.8%) of 450 women with GDM by glucose tolerance test criteria had that history documented on their electronic problem list. Clinicians are aware that women with GDM are at high risk of developing type 2 diabetes, but they do not routinely assess and screen patients, and communication between OBCPs and PCPs can be improved.

Quality in obstetric care: measuring what matters

Quality measures allow providers, payers, and patients to assess and compare the performance of medical teams. The ideal quality measure is easy to define and observe, important to patients and physicians, and identifies areas ripe for improvement. There are several challenges unique to obstetrics that complicate quality measurement. Nationally available data are flawed and limited. Adverse outcomes are rare and difficult to compare between groups. An appropriate emphasis on teamwork makes assigning outcomes to individuals improper and impractical. We suggest some strategies that address these challenges and may improve obstetric measures: applying measures to teams rather than individuals, using sentinel events for internal root cause analysis rather than comparisons between groups, devising measures that account for alternatives, and developing data-collection fields that address important quality metrics directly. We highlight four measures that meet these criteria: 1) elective delivery before 39 weeks of gestation, 2) prophylactic antibiotic use for cesarean delivery, 3) the Adverse Outcome Index, and 4) the nulliparous term singleton vertex cesarean delivery rate. We suggest that each institution evaluate local priorities, select a measure, then continue to refine measures based on feedback from frontline clinicians.

First trimester vitamin D, vitamin D binding protein, and subsequent preeclampsia

Previous studies report an association between vitamin D deficiency and hypertension, including the pregnancy-specific disorder preeclampsia. Circulating vitamin D is almost entirely bound to vitamin D binding protein, which increases 2-fold during pregnancy and previous studies have not examined vitamin D binding protein or free vitamin D levels. We performed a nested case-control study within the Massachusetts General Hospital Obstetric Maternal Study, measuring first trimester total 25-hydroxyvitamin D (25[OH]D) and vitamin D binding protein and calculating free 25(OH)D levels. We compared these levels from pregnancies complicated by subsequent preeclampsia (cases, n=39) with those from normotensive pregnancies (controls, n=131). First trimester total 25(OH)D levels were similar in cases and controls (27.4±1.9 versus 28.8±0.80 ng/mL; P=0.435). Despite an association between higher first trimester blood pressures and subsequent preeclampsia, first trimester total 25(OH)D was not associated with first trimester systolic (r=0.11; P=0.16) or diastolic blood pressures (r=0.03; P=0.72). Although there was a trend toward increased risk of preeclampsia with 25(OH)D levels <15 ng/mL (odds ratio: 2.5 [95% CI: 0.89 to 6.90]), this was attenuated after adjustment for body mass index and other covariates (odds ratio: 1.35 [95% CI: 0.40 to 4.50]). First trimester vitamin D binding protein and free 25(OH)D levels were similar in cases and controls and were not associated with first trimester blood pressures. These data suggest that first trimester total and free 25(OH)D levels are not independently associated with first trimester blood pressure or subsequent preeclampsia.

First-trimester follistatin-like-3 levels in pregnancies complicated by subsequent gestational diabetes mellitus

OBJECTIVE To determine whether maternal levels of follistatin-like-3 (FSTL3), an inhibitor of activin and myostatin involved in glucose homeostasis, are altered in the first trimester of pregnancies complicated by subsequent gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS This was a nested case-control study of subjects enrolled in a prospective cohort of pregnant women with and without GDM (> or =2 abnormal values on a 100-g glucose tolerance test at approximately 28 weeks of gestation). We measured FSTL3 levels in serum collected during the first trimester of pregnancy. Logistic regression analyses were used to determine the risk of GDM. RESULTS Women who developed GDM (n = 37) had lower first-trimester serum levels of FSTL3 compared with women who did not (n = 127) (median 10,789 [interquartile range 7,013-18,939] vs. 30,670 [18,370-55,484] pg/ml, P < 0.001). When subjects were divided into tertiles based on FSTL3 levels, women with the lowest levels demonstrated a marked increase in risk for developing GDM in univariate (odds ratio 11.2 [95% CI 3.6-35.3]) and multivariate (14.0 [4.1-47.9]) analyses. There was a significant negative correlation between first-trimester FSTL3 levels and approximately 28-week nonfasting glucose levels (r = -0.30, P < 0.001). CONCLUSIONS First-trimester FSTL3 levels are associated with glucose intolerance and GDM later in pregnancy.

Early-pregnancy soluble Fas levels in idiopathic small-for-gestational-age pregnancies

OBJECTIVE

We sought to determine first- and second-trimester serum soluble Fas (sFas) and placental growth factor (PlGF) levels in idiopathic small-for-gestational-age (SGA) pregnancies.

STUDY DESIGN

We measured sFas and PlGF levels in women who delivered SGA infants uncomplicated by preeclampsia and in control subjects. For sFas there were 34 cases and 318 control subjects in the first trimester and 9 cases and 11 control subjects in the second trimester. For PlGF there were 31 cases and 281 control subjects in the first trimester and 8 cases and 11 control subjects in the second trimester.

RESULTS

SGA pregnancies had lower sFas levels than control subjects in the second trimester (3703 + or - 209 pg/mL vs 4562 + or - 241 pg/mL; P = .015), but not in the first trimester (4892 + or - 191 pg/mL vs 4971 + or - 177 pg/mL; P = .68). There was no difference in PlGF levels between SGA and normal pregnancies in both trimesters.

CONCLUSION

Serum sFas levels were lower in idiopathic SGA pregnancies in the second trimester, but not in the first. There was no difference in serum PlGF levels in either trimester.

The cost-effectiveness of prenatal screening for spinal muscular atrophy

OBJECTIVE

We sought to investigate the cost-effectiveness of prenatal screening for spinal muscular atrophy (SMA).

STUDY DESIGN

A decision analytic model was created to compare a policy of universal SMA screening to that of no screening. The primary outcome was incremental cost per maternal quality-adjusted life year. Probabilities, costs, and outcomes were estimated through literature review. Univariate and multivariate sensitivity analyses were performed to test the robustness of our model to changes in baseline assumptions.

RESULTS

Universal screening for SMA is not cost-effective at $4.9 million per quality-adjusted life year. In all, 12,500 women need to be screened to prevent 1 case of SMA, at a cost of $5.0 million per case averted. Our results were most sensitive to the baseline prevalence of disease.

CONCLUSION

Universal prenatal screening for SMA is not cost-effective. For populations at high risk, such as those with a family history, SMA testing may be a cost-effective strategy.

The California octuplets and the duties of reproductive endocrinologists

The recent birth of octuplets unleashed a firestorm of publicity, casting a harsh light on the mother and her presumed inadequacies as a parent. It also raised questions about the role of reproductive endocrinologists. Herein we consider 3 aspects of this question: should reproductive endocrinologists consider the economic interests of society, should they consider parenting abilities, and should the number of embryos transferred be limited? We conclude that the ethical obligation of reproductive endocrinologists does not extend to protection of society's economic interests; that reproductive endocrinologists, although poorly trained and situated to gauge an individual's ability to parent, can in extreme circumstances refuse to provide assisted reproductive technology; and that a firm limit on the number of transferred embryos is ethically and medically appropriate.