The lung profile

Association of Maternal Preeclampsia with Neonatal Respiratory Distress Syndrome in Very-Low-Birth-Weight Infants

Preeclampsia is a common cause of preterm birth and neonatal morbidity, but its relationship with neonatal respiratory distress syndrome (RDS) remains controversial. We conducted a retrospective cohort study with data from very-low-birth-weight (VLBW) infants born in 1997–2014 from the database of the Premature Baby Foundation of Taiwan to evaluate the relationship between maternal preeclampsia and neonatal RDS. In total, 13,490 VLBW infants were enrolled, including 2200 (16.3%) infants born to preeclamptic mothers. The mean (standard deviation) gestational ages were 30.7 (2.5) weeks in the preeclamptic group and 28.6 (2.9) weeks in the control (non-preeclamptic) group. Severe RDS was defined according to the surfactant therapy requirement. The incidence of severe RDS was lower in infants exposed to maternal preeclampsia than in controls [28.9% vs. 44%; odds ratio (OR), 0.52; 95% confidence interval (CI), 0.47–0.57]. However, after adjustment for confounders, the OR for severe RDS development in the preeclampsia group was 1.16 (95% CI, 1.02–1.31). Other factors, such as gestational age, birth weight, female sex, and antenatal receipt of two or more steroid doses were significantly protective against RDS in multivariate regression analysis. This study revealed that maternal preeclampsia slightly increases the risk of severe RDS in VLBW infants.

Administration of steroids after 34 weeks of gestation enhances fetal lung maturity profiles

OBJECTIVE

To estimate the effect of antenatal glucocorticoid administration on fetal lung maturity in pregnancies with known fetal lung immaturity between the 34th and 37th weeks of gestation.

STUDY DESIGN

Pregnancies between 34(0/7) and 36(6/7) weeks undergoing amniocentesis to determine fetal lung maturity were targeted. Women with negative results (TDx-FLM-II <45 mg/g) were randomly assigned to intramuscular glucocorticoid injection or no treatment. A repeat TDx-FLM-II test was obtained 1 week after enrollment.

RESULTS

Thirty-two women who met inclusion criteria were randomly assigned. Seven women delivered within a week of testing for fetal lung maturity, and were excluded from the analysis. Ten received glucocorticoid and 15 did not. Women assigned to glucocorticoids had a mean increase TDx-FLM-II in 1 week of 28.37 mg/g. Women assigned to no-treatment had an increase of 9.76 mg/g (P < .002).

CONCLUSION

A single course of intramuscular glucocorticoids after 34 weeks in pregnancies with documented fetal lung immaturity significantly increases TDx- FLM-II.

No short-term benefits of antenatal corticosteroid treatment in severely preterm growth restricted fetuses: a case-control study

BACKGROUND

Antenatal corticosteroid administration to premature, growth restricted fetuses may not be beneficial and even have adverse effects on neonatal outcome.

AIMS

To determine if preterm growth restricted fetuses benefit from antenatal corticosteroids.

STUDY DESIGN

Retrospective cohort study.

METHODS

All singleton pregnancies with growth restricted fetuses delivered at our department before 34 weeks' gestation or weighing less than 1500 g, between January 2001 and December 2005, were retrospectively reviewed. Neonatal outcome was compared between growth restricted fetuses (defined as abnormal flow patterns in umbilical and middle cerebral arteries) that received antenatal CST (CST group) and those who did not receive antenatal CST (no CST group). The administration of CST appeared to be quasi randomized.

RESULTS

A total of 88 pregnancies fulfilled the inclusion criteria (CST group, n=54; no CST group, n=34). The incidence of neonatal respiratory distress syndrome in the CST and no CST group was 42% (22/54) and 50% (17/34), respectively (p=0.44). Neonatal mortality in the CST and no CST group was 9% (5/54) and 12% (4/34), respectively (p=0.73). The prevalence of adverse neonatal outcome (neonatal mortality, major neonatal morbidity or severe cerebral lesions) in the CST and no CST group was 28% (15/54) versus 24% (8/34), (p=0.62).

CONCLUSIONS

Administration of CST to growth restricted preterm fetuses does not appear to be beneficial with respect to short term neonatal outcome.

Fetal lung maturity

Respiratory distress syndrome of the newborn infant caused by immaturity of the fetal lung continues to be a clinical problem. Measurement of pulmonary surfactant production is the most effective way to evaluate pulmonary maturity. Since the first fetal lung maturity test was described more than two decades ago, advances in methodology have produced diagnostically sensitive tests that are both rapid and precise. Unfortunately, currently available tests continue to demonstrate low diagnostic specificity and remain poor predictors of fetal lung immaturity. We review the background, methodology, pre-analytical and analytical concerns, and clinical performance of various fetal lung maturity assays, and discuss the appropriate use and interpretation of these tests.

Fetal lung development in pregnancies of diabetic women assessed by quantitative ultrasonic tissue characterization

OBJECTIVES

This study was performed to compare quantitative ultrasonic tissue characterization of the fetal lung at different gestational ages in uncontrolled diabetic patients with that in normal uncomplicated pregnancies.

METHODS

A total of 44 women at 24-37 weeks' gestation with the diagnosis of diabetes in pregnancy were enrolled. Data were compared to those of the control group, which consisted of 140 women with uncomplicated pregnancies of the same gestational age. Longitudinal and transverse sections of the fetal thorax and upper abdomen were examined. A region of interest of constant size was defined and the tissue-specific gray scale was determined by using interactive software.

RESULTS

Compared with normal pregnancies, fetal lungs of diabetic pregnancies have a higher echogenicity between 28 and 37 weeks of gestation. The lung mean gray values (MGV) only differed significantly between 30 and 31 weeks of gestation in the group with diabetes (P = 0.033) compared to the control group. The MGV of the liver in diabetic and normal pregnancies is similar during pregnancy, significant differences being found only at 30-31 weeks of gestation (P = 0.038). The lung-to-liver ratio in the control group showed a significant increase from 24 to 31 weeks and a slight non-significant decrease after 31 weeks. The ratio in the group with diabetes increased slightly up to week 33 and decreased slightly afterwards.

CONCLUSION

Fetal lung MGV in uncontrolled diabetic pregnancies compared to that in uncomplicated pregnancies differs significantly only between 30 and 31 weeks of gestation.

Comparisons of mortality and pre-discharge respiratory outcomes in small-for-gestational-age and appropriate-for-gestational-age premature infants

Background

There are differences in the literature regarding outcomes of premature small-for-gestational-age (SGA) and appropriate-for gestational-age (AGA) infants, possibly due to failure to take into account gestational age at birth.

Objective

To compare mortality and respiratory morbidity of SGA and AGA premature newborn infants.

Design/Methods

A retrospective study was done of the 2,487 infants born without congenital anomalies at ≤36 weeks of gestation and admitted to the neonatal intensive care unit (NICU) at John Dempsey Hospital, between Jan. 1992 and Dec. 1999. Recent (1994–96) U.S. birth weight percentiles for gestational age (GA), race and gender were used to classify neonates as SGA (<10th percentile for GA) or AGA (10^th–90th percentile for GA). Using multivariate logistic regression and survival analyses to control for GA, SGA and AGA infants were compared for mortality and respiratory morbidity.

Results

Controlling for GA, premature SGA infants were at a higher risk for mortality (Odds ratio 3.1, P = 0.001) and at lower risk of respiratory distress syndrome (OR = 0.71, p = 0.02) than AGA infants. However multivariate logistic regression modeling found that the odds of having respiratory distress syndrome (RDS) varied between SGA and AGA infants by GA. There was no change in RDS risk in SGA infants at GA ≤ 32 wk (OR = 1.27, 95% CI 0.32 – 1.98) but significantly decreased risk for RDS at GA > 32 wk (OR = 0.41, 95% CI 0.27 – 0.63; p < 0.01). After controlling for GA, SGA infants were observed to be at a significantly higher risk for developing chronic lung disease as compared to AGA infants (OR = 2.2, 95% CI = 1.2 – 3.9, P = 0.01). There was no significant difference between SGA and AGA infants in total days on ventilator. Among infants who survived, mean length of hospital stay was significantly higher in SGA infants born between 26–36 wks GA than AGA infants.

Conclusions

Premature SGA infants have significantly higher mortality, significantly higher risk of developing chronic lung disease and longer hospital stay as compared to premature AGA infants. Even the reduced risk of RDS in infants born at ≥32 wk GA, (conferred possibly by intra-uterine stress leading to accelerated lung maturation) appears to be of transient effect and is counterbalanced by adverse effects of poor intrauterine growth on long term pulmonary outcomes such as chronic lung disease.

Preliminary report on a new and noninvasive method for the assessment of fetal lung maturity

OBJECT

Several patterns of fetal breathing movements (FBMs), i.e. abdominal wall movements (AWm), thoracic wall movements (TWm) and nasal fluid flow velocity waveforms (NFFVW), were investigated by ultrasound (US) technology and related to fetal pulmonary maturity and immaturity, i.e. fetal lung maturity (FLM) tests, in order to validate the hypothesis that they may indicate whether the fetal lung is mature or immature, regardless of gender, weight and gestational age.

MATERIAL AND METHODS

We prospectively enrolled 143 high-risk pregnancies in which a complete US study of FBMs and FLM tests was performed. Among them 43 women satisfied the inclusion criteria. US-FLM was defined as the presence of regular NFFVW detected by pulsed Doppler and spectral analysis, or irregular NF-FVW synchronous with TWm detected by M-mode. An US guided amniocentesis was performed in order to collect amniotic fluid (AF) and FLM was evaluated by L/S (lecithin/sphingomyelin) determination, presence of phosphatidylglycerol (PG) and lamellar bodies (LBs) count. At the end of the study the diagnostic accuracy of US-FLM was compared to that of FLM tests.

RESULTS

Diagnostic accuracy for US evaluation of FLM was as follows: sensitivity: 89.6%; specificity: 85.7%; PPV: 92.8%; NPV: 80%. Diagnostic accuracy of FLM tests was as follows: sensitivity: 100%; specificity: 51.7%; PPV: 100%; NPV: 50%. L/S determination predicted lung maturity with a sensitivity of 100%; specificity of 93.1%; PPV of 100%; NPV of 87.5%.

CONCLUSION

Presence of regular NFFVW or irregular NFFVW and TWm correlate accurately with conventional FLM tests. We suggest that this noninvasive procedure may be helpful for assessing FLM, particularly under certain circumstances, e.g., oligo-anhydramnios, laboratory logistic equipment difficulties or heavily stained AF samples, amniocentesis refusal, religious concerns.

Testing for fetal lung maturation: a biochemical "window" to the developing fetus

Fetal lung maturity testing represents a major milestone in perinatology. This article critically evaluates specific controversies regarding the methodologies used to measure pulmonary surfactant in AF and how well each of these techniques performs both in principle and application. The clinical utility of fetal lung maturity testing as it applies to particularly difficult complications of pregnancy is discussed. These technical and clinical issues are framed by the scientific and empiric evidence that is used as the rationale for such testing and its implementation in the effective management of preterm delivery.

The controversy surrounding fetal lung maturity in diabetes in pregnancy: a re-evaluation

It is beyond the scope of this article to discuss the biochemical markers of fetal lung maturity and their pathophysiological characteristics. This information can be found in several textbooks and review articles. Instead, this article addresses controversial issues that confront the obstetrician in daily clinical practice related to the role of diabetes (glucose) as the teratogen for lung morbidity, and the association between lung maturity testing results and actual lung morbidity.

Optimal thresholds of the lecithin/sphingomyelin ratio and lamellar body count for the prediction of the presence of phosphatidyl glycerol in diabetic women

OBJECTIVE

To assess the optimal thresholds of the lecithin/sphingomyelin (L/S) ratio and lamellar body count for the prediction of the presence of phosphatidyl glycerol (PG) in diabetic pregnant women.

METHODS

We accessed a database of clear amniotic fluid specimens obtained by transabdominal amniocentesis in diabetic women with singleton non-malformed fetuses. PG results were classified as 'absent' or 'present'. Receiver operating characteristic (ROC) curve analysis was constructed of different L/S ratios and lamellar body counts to identify the optimal threshold for prediction of the presence of PG. Sensitivity was defined as the rate of L/S ratio and lamellar body count above specific thresholds among cases with present PG. The false-positive rate was that of L/S ratios or lamellar body counts above specific thresholds among cases with absent PG. Statistical analysis included one-way analysis of variance with post-hoc analysis, with p < 0.05 considered significant.

RESULTS

A total of 76 consecutive women were included in the analysis, 74% (n = 56) using insulin and the remainder treated by diet alone. L/S and PG results were both available in 72 women. PG was reported as 'present' in 70% (51/73) of specimens. As expected, there was a significant relationship between L/S ratios and presence of PG (area under the curve = 0.932, p < 0.001). An L/S ratio of > or = 3.0 represented the optimal trade-off between sensitivity (68%) and false-positive rate (6%) in the prediction of present PG. Similarly, there was a significant relationship between lamellar body count values and presence of PG (area under the curve = 0.976, p < 0.001). A lamellar body count of > or = 50 000 represented the optimal trade-off between sensitivity (92%) and false-positive rate (0%) in the prediction of present PG.

CONCLUSION

In diabetic pregnant patients, the presence of PG in the amniotic fluid more closely corresponded to an L/S ratio of > or = 3.0 or to a lamellar body count of > or = 50,000.

Lung maturation in diabetes in pregnancy: if and when to test

Poorly controlled maternal diabetes in pregnancy may delay fetal pulmonary maturation. However, diabetic women with good glycemic control have fetal lung maturation at the same gestational age as nondiabetic women. With modern ultrasound technology, gestational dates can be accurately assessed in the first or early second trimester. Respiratory distress syndrome is rare in nondiabetic and well-controlled diabetic pregnancies confirmed by early ultrasound to be at or beyond 37 weeks. Early confirmation of dates thus eliminates the need for amniotic fluid assessment of fetal lung maturity prior to elective delivery at or beyond 38 weeks in well-controlled diabetic and nondiabetic women. Poorly controlled diabetic women and pregnancies without early ultrasound verified dates may require amniotic fluid analysis for lung maturity prior to elective delivery.

[Criteria of pregnancy termination in women with preeclampsia]

Preeclampsia remains an important cause of maternal and neonatal mortality and morbidity. Delivery is always the appropriate therapy for the mother but may be responsible for neonatal adverse outcomes, particularly when it occurs at less than < 34 weeks' gestation. In women with severe preeclampsia at < 34 weeks expectant management to improve neonatal mortality and morbidity may be performed under close monitoring of both the mother and the fetus. Any severe condition of the mother (HELLP syndrome, abruptio placentae, eclampsia) or the fetus (abnormal fetal heart rate) should lead to prompt delivery. In women with mild preeclampsia, expectant management should be performed until 38 weeks gestation.

A comparison of amniotic fluid fetal pulmonary phospholipids in normal and diabetic pregnancy

OBJECTIVE

Our purpose was to determine whether there are differences in the timing of the appearance of various amniotic fluid fetal pulmonary phospholipids in normal and diabetic pregnancy.

STUDY DESIGN

A case-control study of 295 subjects with diabetes and 590 control subjects was performed by use of gestational age-matched amniocentesis specimens analyzed for lecithin/sphingomyelin (L/S) ratio, phosphatidylinositol (PI), and phosphatidylglycerol (PG) composition. Diabetic subjects were stratified according to type of diabetes, degree of blood glucose control, and birth percentile of the neonate.

RESULTS

There was no difference in L/S ratios over gestational age by type of diabetes or quality of glycemic control. Women with preexisting diabetes had significantly higher PI levels at 33 to 35 weeks' gestation, which became similar to levels of control subjects after 36 weeks, whereas patients with gestational diabetes mellitus and control subjects had similar PI levels throughout. In diabetic subjects, the onset of production of PG was delayed from 35.9 +/- 1.1 weeks (controls) to 38.7 +/- 0.9 weeks (overt diabetics) and 37.3 +/- 1.0 weeks for gestational diabetes mellitus (P <.001). The delay in PG synthesis was not related to infant sex, level of maternal glucose control, or fetal macrosomia.

CONCLUSIONS

Fetal pulmonary maturation, as evidenced by the onset of PG production in the amniotic fluid, is delayed in diabetic pregnancy by 1 to 1.5 weeks. This delay appears to be associated with an early and sustained elevation in amniotic fluid PI levels at 32 to 34 weeks.

Effects of intrauterine IL-6 and IL-8 on the expression of surfactant apoprotein mRNAs in the fetal rat lung

OBJECTIVE

The purpose of this study was to investigate the effect of interleukin-6 (IL-6) and interleukin-8 (IL-8), whose concentrations are elevated with chorioamnionitis, on the expression of surfactant apoprotein mRNAs in fetal rat lung.

STUDY DESIGN

We employed an animal model in which we were able to administer substances continuously into the cavity between the fetal membranes and endometrium using a miniosmotic pump. Lipopolysaccharide (LPS), IL-6, or IL-8 was administered to timed pregnant rats for 3 days (day 16-19), and fetal lung expression of surfactant apoprotein mRNAs for SP (surfactant apoprotein)-A, SP-B, and SP-C was evaluated by Northern blot hybridization.

RESULTS

Continuous administration of LPS increased the expression of each surfactant apoprotein mRNA, but the expression of mRNAs was not dose-dependent. On the other hand, continuous IL-6 or IL-8 administration increased the expression of each surfactant apoprotein mRNA in a dose-dependent manner.

CONCLUSION

Fetal lung maturation may be promoted by either IL-6 or IL-8 produced in response to chorioamnionitis.

Neonatal outcome in small for gestational age infants: do they really better?

BACKGROUND

There still is a controversy as to the neonatal outcome of small for gestational age (SGA) infants compared to a appropriate for gestational age (AGA) preterm infants. As a part of a randomized multicenter trial on timing of bovine surfactant therapy, we aimed at investigating short-term outcome variables in SGA-infants compared with AGA-infants.

METHODS

SGA-infants were classified weighing below the 10th percentile at birth and were compared to AGA-infants in terms of prenatal and neonatal characteristics and neonatal outcome.

RESULTS

A total of 317 infants were enrolled, 59 SGA- and 258 AGA-infants. Both groups did not differ in gestational age, however, SGA-infants had a lower birth weight. Preterm premature rupture of fetal membranes was observed more frequently in AGA-, preeclampsia in SGA-infants. The rate of intubation, severity of RDS, rate of surfactant administration, pulmonary airleaks and days on the ventilator did not differ between both groups. However prolonged nasal CPAP, supplemental oxygen therapy and chronic lung disease at 28 days and 36 weeks was diagnosed more often in SGA-infants. Furthermore mortality was significantly higher in SGA-infants as well as total NICU and total hospital days.

CONCLUSION

As SGA-infants have an increased mortality rate and an increased risk for developing chronic lung disease, further studies should focus on prevention of intrauterine growth restriction and its complications.

Effects of diabetic pregnancy on the fetus and newborn

Diabetes in pregnancy is unique because of the diversity of problems that can affect the embryo/fetus beginning with conception. Considerable effort has been devoted to understanding the basic developmental biology from observing young embryos in vitro or in vivo. Maternal glucose control has been identified as an important event. The preponderance of evidence indicates that rigid glucose control will minimize the incidence of anomalies incurred before 9 weeks of pregnancy. Later events are related to fetal hyperinsulinemia. These include fetal macrosomia, respiratory distress syndrome, neonatal hypoglycemia, neonatal hypocalcemia, and neonatal hypomagnesemia. Control of maternal metabolism can have a significant impact on each of the above. Finally, the long-term effects of maternal diabetes are as diverse as the pathogenetic events during pregnancy. Surprisingly, there is a significant transmission rate of 2% of type I diabetes if the mother has insulin-dependent diabetic mother, whereas the rate is 6% for the father. The Diabetes in Early Pregnancy Study showed that good maternal control was associated with normal neurodevelopmental outcome.

Fetal lung maturity in pregnancies complicated by insulin-dependent and gestational diabetes: a matched cohort study

OBJECTIVE

To study fetal lung maturity (FLM) as determined by amniotic fluid (AF) tests in diabetic pregnancies (DP) under euglycemic metabolic control, in comparison with matched controls (C).

PATIENTS AND METHODS

From 514 consecutive pregnancies where amniocentesis was performed for FLM assessment, we selected 45 glycemic controlled DP. Nineteen DP were Type I (IDDM) and 26 pregnancies were diagnosed Type III (GDM). Cases were matched to C by therapy with corticosteroids, gestational age at amniocentesis, pregnancy complications other than diabetes and gender. FLM was determined by the shake test and lamellar bodies (LB) count, lecithin/sphingomyelin (L/S) ratio (planimetric and stechiometric) and phosphatidylglycerol presence (PG). DP were further sub-divided according to gestational age period at amniocentesis, type of diabetes, associated therapy and fetal malformations.

RESULTS

RDS (n=2) and neonatal wet lung (n=5) were diagnosed in neonates from diabetic mothers. We found no statistical difference when comparing FLM indices between DP and C groups: shake test 3.1:1+/-1.2 vs. 2.7:1+/-1.2, P<0.40; planimetric L/S 3.4+/-1.4 vs. 3.1+/-2.0, P<0.27; stechiometric L/S 8.2+/-7.4 vs. 7.1+/-6.1, P<0.54; percentage of PG positivity 57% vs. 46%, P<0.13; lamellar bodies count (X10(3)/microl) 42.8+/-36.9 vs. 41.5+/-30.4, P<0.72. No differences were found between DP and controls for subgroups according to gestational age, type of Diabetes (IDDM or GDM), congenital lesions and associated therapy.

CONCLUSIONS

In euglycemic, metabolically controlled diabetic patients FLM is not delayed, however an increased risk for neonatal wet lung should be considered.

Respiratory distress syndrome in infants with impaired intrauterine growth

The recently introduced intrauterine growth curve, based on ultrasonically estimated foetal weights, was retrospectively applied to an inborn population of 883 infants born before 33 gestational weeks at the University Hospital of Lund, during 1985-94. The estimation of birthweight deviation resulted in 630 (71.3%) infants with a birthweight appropriate for gestational age (AGA), 244 (27.6%) infants with a birthweight small for gestational age (SGA) and 9 (1.1%) infants with a birthweight large for gestational age. Birthweight deviation was associated with an increased mortality [odds ratio (OR) adjusted for gestational age 1.29 per SD (12%) change in birthweight for gestational age, 95% CI: 1.10-1.50; p = 0.002]. At gestational age 25-28 weeks, SGA-infants had an increased incidence of respiratory distress syndrome (RDS) as compared to AGA-infants (OR adjusted for gestational age: 1.98, 95% CI: 1.12-3.52; p = 0.019). At gestational age 29-32 weeks, SGA-infants had a lower incidence of RDS as compared to AGA-infants (OR adjusted for gestational age: OR 0.52, 95% CI: 0.34-0.80; p = 0.003). After adjustment for confounding variables, infants born at gestational age 25-28 weeks from mothers with pre-eclampsia, appeared to be a high-risk group for RDS, whereas at the age of 29-32 gestational weeks, negative birthweight deviation had a protective effect against RDS. Antenatal corticosteroid administration appeared to have a less beneficial effect on mortality, RDS and cerebral haemorrhage in infants born SGA vs in those born AGA.

Standards of laboratory practice: evaluation of fetal lung maturity

In this standard of laboratory practice I recommend guidelines for fetal lung maturity (FLM) testing. If possible, obtain a 10-mL uncontaminated sample by amniocentesis. Keep the amniotic fluid at 4 °C and mix well before testing. If centrifugation is required, strictly adhere to the protocol. Most laboratories should offer a rapid test, such as fluorescence polarization, phosphatidylglycerol, or foam stability index, daily on both a routine and emergency basis. Requests for lecithin/sphingomyelin ratio may be referred to a reference laboratory. Communicate immediately the results of any FLM test to the ordering location. The report should contain the result, sample contamination, and reference information. Separate reference intervals for diabetic patients are not recommended.

Management of gestational diabetes mellitus

This article addresses management of gestational diabetes in a two part fashion. It discusses the pathophysiology and pathogenesis of diabetes and outlines the contemporary management approach for gestational diabetes in the 1990s.

Diabetes

There is now strengthening evidence that meticulous control of maternal carbohydrate and fat metabolism before and during pregnancy in women with diabetes mellitus had positive benefits for the offspring, not only by reducing the incidence of congenital malformations, but also by diminishing fetal loss, reducing immediate neonatal complications and, in the long term, reducing unnecessary obesity, improving neuropsychological development and reducing the emergence of diabetes in the offspring at a relatively early age. Women who develop GDM are at a significant risk of developing NIDDM, and prevention of obesity, consumption of a high-fibre diet and possibly prophylactic hypoglycaemic therapy may reduce this otherwise inevitable progression, which will affect at least 50%.

Neonatal outcome after preterm delivery for preeclampsia

OBJECTIVE

Our purpose was to determine whether maternal preeclampsia per se has a beneficial effect on neonatal outcome after delivery before 35 weeks.

STUDY DESIGN

A matched cohort study design was used. Two hundred twenty-three infants of strictly defined preeclamptic women were matched for gestational age, race, gender, and mode of delivery with infants of normotensive women with preterm labor and delivery. Pregnancies with multiple gestation, premature rupture of membranes, known fetal anomalies, diabetes, or maternal medical disease were excluded. Information was obtained by review of maternal and neonatal charts. Paired categoric and continuous data were compared by McNemar's test and the Wilcoxon signed-rank test, respectively.

RESULTS

There was no difference in the incidence of neonatal death (4.5% vs 4.5%, p = 0.82), respiratory distress syndrome (22.0% vs 22.0%, p = 0.88), grades 3 and 4 intraventricular hemorrhage (2.2% vs 2.2%, p = 0.72), grades 2 and 3 necrotizing enterocolitis (5.8% vs 4.0%, p = 0.48), and culture-proved sepsis (9.0% vs 9.0%, p = 0.85). Results were similar when analysis was limited to infants born at < or = 32 weeks, infants born to mothers with severe preeclampsia, and infants with intrauterine growth restriction.

CONCLUSION

Maternal preeclampsia per se does not have a beneficial effect on the postnatal course of infants born at 24 to 35 weeks' gestation.

Influence of metabolic control of pregnant diabetics on fetal lung maturity

We studied the relationship between the metabolic control of pregnant diabetics and fetal lung maturity. In 31 diabetic and 20 normal pregnancies we analysed phospholipids in amniotic fluid and glycaemic control parameters. There were no differences in amniotic fluid lecithin/sphingomyelin (L/S) and phosphatidylinositol/sphingomyelin (PI/S) ratios between pregnant diabetics with strict metabolic control and the control group. Pregnant diabetics with poor metabolic control had significantly different L/S and PI/S ratios than the normal pregnant women. Six women in this group of poorly controlled diabetics had mature surfactant in amniotic fluid (L/S > or = 2.7 and presence of phosphatidylglycerol) at 32-34 weeks of amenorrhea; the difference was significant (p < 0.05) with respect to the control group. These six women had recurrent hypoglycaemic episodes (6.4 +/- 1.3 episodes/week) at 14-27 weeks of amenorrhea. Our findings suggest that hypoglycaemic stress on the fetus could disturb fetal synthesis of pulmonary phospholipids.

Fetal lung maturity is not accelerated in preeclamptic pregnancies

OBJECTIVE

Our purpose was to determine whether there is an increased incidence of pulmonary maturity in premature fetuses of preeclamptic women compared with fetuses of matched controls.

STUDY DESIGN

A matched cohort study design was used. One hundred twenty-seven strictly defined preeclamptic women who had undergone amniocentesis for pulmonary maturity assessment were matched for gestational age, race, and infant gender to nonhypertensive women with preterm labor who had undergone the same procedure. Patients with multiple gestation, ruptured membranes, diabetes, or prior glucocorticoid treatment were excluded. Lung maturity was assessed with the Lumadex foam stability index test, the lecithin/sphingomyelin ratio, and the TDx fetal lung maturity assay. In addition, the occurrence of respiratory distress syndrome was assessed in 69 of the 127 matched pairs who were also matched for mode of delivery and amniocentesis-to-delivery interval.

RESULTS

There was no significant difference in the incidence of an immature result between the preeclamptic and matched control groups (39.4% vs 38.6%). Likewise, women with mild (n = 63) and severe (n = 64) preeclampsia or with small-for-gestational-age (n = 26) and appropriate-for-gestational-age (n = 101) infants, when analyzed separately, showed no differences in comparison with their matched controls. When analyzed by gestational age subgroups, no specific gestational age range was associated with accelerated maturity. The incidence of respiratory distress syndrome in the 69 matched pairs was slightly, but not significantly, higher in the preeclampsia group (relative risk 1.43, 95% confidence interval 0.94 to 2.37).

CONCLUSION

This study does not support the contention that fetuses of preeclamptic women exhibit accelerated lung maturation.

Is lung maturation related to fetal growth in diabetic or hypertensive pregnancies?

The purpose of this study was to determine whether infants sufficiently affected by maternal diabetes or hypertension to exhibit abnormal growth (macrosomia, growth retardation) would also display significant alteration in timing of pulmonary maturity (delay or acceleration, respectively). We studied 874 consecutive women with fetal pulmonary maturity testing prior to delivery. Patients were stratified by birth weight into fetal size categories (small for gestational age [SGA], appropriate for gestational age [AGA], large for gestational age [LGA]). Cases were compared based on maternal disease, fetal size categories and pulmonary maturity testing results. Pulmonary maturity rates based on both phosphatidylglycerol (PG) and lecithin/sphingomyelin ratio (L/S) did not differ between term LGA infants of diabetic mothers (97%) and term LGA (80%) or AGA (97%) infants of non-diabetic, non-hypertensive mothers. When compared based on PG alone, there was no difference between the rate of positive PG in term AGA infants of non-hypertensive, non-diabetic mothers (75%) and that seen in the other pregnancy groups (33-80%). Breakdown by gestational age revealed no significant differences in maturity rates between the study groups. Macrosomic diabetic infants and growth-retarded hypertensive infants are no different from controls in their timing of fetal pulmonary maturation.

Association between pulmonary and gastric inflammatory cells on the first day of life in preterm infants

It has been shown that inflammatory cells in the newborn lung are fetal in origin, whereas those in the amniotic fluid are maternal. In order to explore the relationship between fetal amnionitis and neonatal pneumonitis, we collected paired samples of gastric aspirate within 2 hours of birth, and bronchoalveolar lavage fluid within 24 hours of birth from intubated preterm infants. Leukocyte counts in bronchoalveolar lavage fluid correlated with the duration of membrane rupture (r = 0.68, P = 0.0001). There was a high degree of correlation between leukocyte counts in the two fluids (r = 0.86, P = 0.0001). The factors responsible for this association are unknown.

Does maternal diabetes delay fetal pulmonary maturity?

OBJECTIVE

The purpose of our study was to determine whether a relationship exists between diabetic glucose control and the immaturity rate of fetal pulmonary maturity test results.

STUDY DESIGN

One thousand consecutive women who had fetal pulmonary maturity testing before delivery were studied. Diabetic patients were categorized according to whether their diabetes was well controlled or poorly controlled, then compared to the nondiabetic population on the basis of amniocentesis results.

RESULTS

Pregnant women with poorly controlled diabetes had a significantly higher risk of immature fetal lung profiles at amniocentesis than did pregnant women without diabetes. Pregnant women with well-controlled diabetes were not significantly different from the nondiabetic population. There was no difference between gestational and pregestational diabetic pregnancies.

CONCLUSIONS

Timing of fetal pulmonary maturation is linked to the level of maternal glucose control in diabetic pregnancies. Adequate glucose control may lower the risk of fetal pulmonary immaturity to that seen in the nondiabetic population.

Prediction of respiratory distress syndrome by a new colorimetric assay

OBJECTIVE

The purpose of this study was to evaluate the clinical performance of a new, simple, and rapid colorimetric assay for predicting respiratory distress syndrome.

STUDY DESIGN

Ninety-four specimens obtained within 3 days of delivery were assayed with the new test. For 78 of these specimens, the lecithin/sphingomyelin ratio was also determined. Significant differences were calculated with chi 2 analysis. Cutoff points were selected by maximizing the corresponding sums of sensitivity and specificity and from receiver-operator-characteristic curves.

RESULTS

The specificity of the new colorimetric test was better than 89%, and it yielded more than 86% correct diagnoses. Furthermore, the test had a significantly (p less than 0.05) lower percentage of false-immature results than that obtained with the lecithin/sphingomyelin ratio. Moreover, the new test performed relatively well in analyses of patients between 27 weeks and 36 weeks' gestation.

CONCLUSION

We concluded that the new assay is reliable and that it can serve as a useful alternative to current methods for predicting respiratory distress syndrome.

Analysis of phospholipids in human amniotic fluid by 31P NMR

A recently described solvent-reagent system for obtaining narrow linewidths in 31P NMR spectra of phospholipid extracts was applied to human amniotic fluid. Resolution of the major components was achieved by manipulating the solvent composition, and assignments were made by spiking samples with standard compounds. Spin-lattice relaxation times were determined and used to optimize data acquisition. NMR estimates of the phosphatidylcholine to sphingomyelin ratio for 33 patients were compared to those obtained by TLC densitometry, a common clinical assay for fetal pulmonary maturity. Estimates of the levels of phosphatidylglycerol and phosphatidylinositol could also be obtained from 31P NMR. High-resolution 31P NMR in this solvent-reagent system provides a relatively straightforward and reliable alternative method for assessing fetal pulmonary status by phospholipid quantitation in human amniotic fluid. The 31P NMR method has the advantage that it is sensitive to total, and not just unsaturated, phosphatidylcholine.

Obstetrical management of patients with diabetes in pregnancy

The management of the woman with diabetes diagnosed before the onset of pregnancy, or who develops it during pregnancy, requires a team approach involving the woman and her partner, the diabetes nurse educator, the dietitian, the endocrinologist, the obstetrician, the ultrasonologist and the paediatrician. It should start before pregnancy so that normoglycaemia is achieved before conception and maintained throughout gestation and labour. Fetoplacental surveillance commences with an early ultrasound to confirm fetal viability, repeated around 20 weeks to exclude major fetal malformations and then later in the third trimester to monitor fetal growth. CTG and biophysical profile assessment are major adjuncts to ensuring fetal well-being. The pregnancy should be allowed to go to full term when maternal blood glucose control has been satisfactory, fetal growth is within the normal range and other obstetrical complications, e.g. pre-eclampsia, are absent. Such an approach will ensure that the caesarean section rate can be minimized. During labour, the progress of labour and fetal well-being should be closely monitored. The woman who has microvascular complications of her diabetes (including proliferative retinopathy and nephropathy) requires even closer surveillance and premature delivery is more likely to be needed. The principles of management of the woman who develops gestational diabetes are similar, with even greater emphasis being placed on not inducing labour before full term unless complications dictate otherwise.

Surfactant abnormalities and adult respiratory failure

Surfactant abnormalities have been implicated in the development of the acute respiratory distress syndrome in adults. Experimental studies show that surfactant inhibition by protein-leak into the alveolar space is of major importance under these circumstances. Fibrin(ogen)-surfactant-interaction appears to contribute to disturbances of surfactant function with subsequent alveolar instability and ventilation-perfusion-mismatch. In a prospective study in severely injured patients, the surfactant in serially obtained bronchoalveolar lavage fluids was investigated. An early leakage of plasma proteins into the alveolar space was noted in those patients, who developed severe ARDS. Moreover, deterioration of surfactant function was markedly more pronounced in those patients than in trauma victims who developed only mild pulmonary dysfunction. In addition to the protein-leakage, a progressive decrease of the surfactant-specific dipalmitoyl-phosphatidylcholine was noted, significantly correlated with the deterioration of surfactant function and the severity of respiratory failure. In conclusion, experimental and clinical studies show surfactant abnormalities in the adult respiratory distress syndrome. Plasma protein-leakage and progressive alteration of alveolar type II surfactant secretion appear to be of major importance.

Is indicated or spontaneous preterm delivery more advantageous for the fetus?

We performed a case-control study to determine whether fetuses delivered prematurely because of pregnancy complications (primarily pregnancy-associated hypertensive disease) had a different neonatal course than that of those born after either spontaneous preterm labor or after premature rupture of the membranes. Two case-control populations were matched by gestational age at delivery, fetal sex, and race. There was no perinatal survival advantage in babies delivered from "stressed" pregnancies. Selected neonatal morbidities were generally similar, but there was an increased incidence of necrotizing enterocolitis in babies born after preterm labor and a higher incidence of both necrotizing enterocolitis and neonatal sepsis after premature rupture of the membranes. We conclude that a "stressed" pregnancy confers a negligible survival advantage to the fetus.

Absence of evidence of pulmonary maturity at amniocentesis in term infants of diabetic mothers

A total of 153 patients' charts were reviewed over a 6-year period to assess the results of the practice of amniocentesis for diabetic mothers at term (greater than or equal to 37 weeks' gestation) before elective induction/delivery. The number of cases with absent phosphatidylglycerol were determined at each specific gestational age at or near term. Phosphatidylglycerol was present in 130, and phosphatidylglycerol was absent in 23 at first amniocentesis sampling. A significant proportion (approximately 21%) of those with gestational diabetes were phosphatidylglycerol-negative as late as 38 weeks' gestation. A similar proportion of overt diabetic patients were phosphatidylglycerol-negative as late as 39 weeks' gestation. These figures give the clinician some estimate of the likelihood of the absence of phosphatidylglycerol at or near term if amniocentesis is used before elective delivery in these patients.

Prevalence and etiology of respiratory distress in infants of diabetic mothers: predictive value of fetal lung maturation tests

The purpose of this study was to investigate the prevalence of respiratory distress syndrome attributable to surfactant deficiency in infants of diabetic mothers tested for fetal lung maturation. Three tests were assessed: (1) lecithin/sphingomyelin ratio, (2) phosphatidylglycerol concentration, and (3) optical density at 650 nm. From January 1987 through June 1989, 526 diabetic gestations were delivered within 5 days of fetal lung maturation testing. Surfactant-deficient respiratory distress syndrome was present in five infants (0.95%); all were less than 34 weeks' gestational age. Other causes of respiratory distress were transient tachypnea of the newborn (n = 5), hypertrophic cardiomyopathy (n = 4), pneumonia (n = 2), polycythemia (n = 1), and meconium aspiration syndrome (n = 1). The use of standard maturity values of lecithin/sphingomyelin ratio greater than or equal to 2.0, phosphatidylglycerol greater than 2% to 5%, and optical density at 650 nm greater than or equal to 0.150 were evaluated. Each test had a 100% sensitivity in identifying surfactant-deficient respiratory distress syndrome and a 100% negative predictive value in identifying the absence of disease. All three tests had a low positive predictive value: 15% for lecithin/sphingomyelin ratio, 9% for phosphatidylglycerol, and 3% for optical density at 650 nm. We concluded that most cases of respiratory distress in the infants of diabetic mothers were unrelated to surfactant deficiency. The standard maturity values used in fetal lung maturation tests were valid in the diabetic gestation. The optical density at 650 nm was useful as a first-line test to predict the absence of surfactant-deficient respiratory distress syndrome.

High-performance liquid chromatographic analysis of lung phospholipids and their precursors in the offspring of diabetic rats

Pulmonary phospholipids and their precursors and metabolites were assayed in the offspring of streptozotocin-induced diabetic rats at 19 and 21 days gestation and at 2 days after birth by two unique methods that employ high performance liquid chromatography combined with automated phosphorus analysis. In general, lung phospholipids were not different between offspring of control versus diabetic mothers. Levels of phosphatidylglycerol, however, were decreased in the offspring of diabetics. Lysophosphatidylcholine appears to be increased in the lungs of offspring of diabetic mothers, suggesting that maternal diabetes is associated with alterations in the remodeling of phosphatidylcholine.

Testing for fetal pulmonary maturity: ROC analysis involving covariates, verification bias, and combination testing

The lecithin/sphingomyelin ratio (L/S) and the measured value of saturated phosphatidylcholine (SPC), amniotic fluid determinations obtained to assess fetal pulmonary maturity, were evaluated with receiver operating characteristic (ROC) curve analysis. The effects of covariates on the ROC curves were analyzed with a regression methodology that took into account all the available data when constructing an ROC curve for each subgroup. To correct for verification bias the authors used a logistic regression analysis to model the probability of verification, thereby permitting correction for verification bias of a fully stratified data set in spite of small cell frequencies. They examined combination testing with prediction rules using prospective logistic modeling, including as variables test results and clinical features. The L/S was found to be significantly better than SPC for assessing fetal pulmonary maturity. For older gestational age the L/S and SPC performed better than for younger gestational age. Contamination of the specimen degraded the ROC curves. Correcting for verification bias did not influence the ROC curves significantly but changed the cutoff value of the test variable for any particular operating point. Prediction rules to evaluate combination testing showed that obtaining the SPC level in addition to the L/S ratio added no significant information compared with the L/S only. Including gestational age in the prediction rule of either test improved the prediction.

A methodology for determination of phospholipids

A simple method for the determination of phospholipids in an aqueous dispersion and in amniotic fluid was developed. The procedure is based on the observation that dispersed phospholipids promoted the solubilization of an insoluble dye--detergent complex. The solubilization of the complex between the negatively charged dye, Coomassie brilliant blue (CBB), and a positively charged detergent, cetyltrimethylammonium bromide (CTAB), produced a blue solution having a visible absorbance maximum above 600 nm. A linear increase in absorbance intensity occurs with an increase in phospholipid concentration. An assay using the CBB-CTAB reagent adsorbed on 3-mm glass beads is used to estimate total dispersed phospholipids between 2 and 25 micrograms/ml. Thereby, a two-phase water-methanol-chloroform system is formed. The products of zwitterionic phospholipids (such as phosphatidylcholine and phosphatidylethanolamine) partition to the organic phase while the dye complex solubilized in anionic phospholipids (such as phosphatidylglycerol and phosphatidylinositol) partitions to the aqueous phase. This procedure results in a convenient, sensitive, and rapid method for the simultaneous determination of the total phospholipid, zwitterionic phospholipid, and anionic phospholipid concentrations. Application of the new assay for determination of phospholipids in amniotic fluid is described.

Surfactant proteins in the diagnosis of fetal lung maturity. II. The 35 kd protein and phospholipids in complicated pregnancy

The major surfactant protein with a molecular weight of 35 kd and also saturated phosphatidylcholine and phosphatidylglycerol were analyzed in specimens of amniotic fluid; 68 were from cases of maternal diabetes, 41 from preeclampsia or maternal hypertension, 26 from premature rupture of the fetal membranes, and 45 from normal pregnancies. The relationship between the individual surfactant components was studied after covariance adjustment for the length of gestation. In severe early-onset preeclampsia, the 35 kd surfactant protein/saturated phosphatidylcholine ratio was significantly higher than in the other pregnancies. In diabetic pregnancies (classes B to D without preeclampsia), the phosphatidylglycerol/saturated phosphatidylcholine ratio was lower than in the other pregnancies. Isolated surfactant complex showed similar abnormalities. In severe early-onset preeclampsia and insulin-dependent diabetes without vascular disease, the phosphatidylglycerol/saturated phosphatidylcholine ratio correlated negatively with fetal growth. In four samples of amniotic fluids from cases of severe early-onset preeclampsia, the 35 kd protein falsely predicted lung maturity. All had abnormally high 35 kd protein/saturated phosphatidylcholine ratios (greater than 2 SD of controls). According to the present results, the 35 kd protein may give a false mature test result in severe preeclampsia.

Pulmonary phospholipids in amniotic fluid of pathologic pregnancies: relationship with clinical status of the newborn

We evaluated phospholipids, C-peptide and cortisol levels in amniotic fluid of 203 pathologic pregnancies (63, class A, B and C diabetics; 11 class D, F and H diabetics; 44 preclampsia and 85 Rh-isoimmunization); the control group was 82 normal pregnant women. There was an acceleration of fetal pulmonary maturation in women with preclampsia and severe Rh-isoimmunization in class D, F and H diabetics (at 34 weeks gestation the incidence of mature surfactant (lecithin/sphingomyelin greater than or equal to 2.7 and presence of phosphatidyl-glycerol) in these groups was 30%, 50% and 100%, respectively, while it was zero in the control group). At 37 and 38 weeks only 44.4% of the class A, B and C diabetics had mature surfactant and there was a significant difference with respect to the control group (x2 = 4.9; p less than 0.05); C-peptide levels in these diabetics (class A, B and C) were higher than in controls (p less than 0.001); in pregnant women with accelerated fetal lung maturation they were lower. We demonstrated a close relationship between fetal pulmonary maturity and the type of surfactant in amniotic fluid, which was independent of gestational age.

Current perspectives in assessment of fetal pulmonary surfactant status with amniotic fluid

In recent years, improvements in analytical methodology and clinical management of maternal-fetal diseases have altered the understanding of data from amniotic fluid analysis. Delays in phospholipid production or lung function are not currently reported in maternal diabetes. Fetal lung function following glucocorticoid therapy or premature membrane rupture is uncoupled from amniotic fluid phospholipid concentrations, which do not have the usual significance in these circumstances. Phosphatidylglycerol (PG) is present prior to the usual time it is detected by thin layer chromatography (TLC) methods, which vary in sensitivity for PG. Consequently, the significance of its "absence" is highly varied. These observations are discussed in light of the earlier methods and data, along with new perceptions of the functions of the individual phospholipids and apoproteins, the regulatory mechanism of surfactant production, and the relationship of amniotic fluid components to neonatal lung function.

Pregnancy outcome in maturity onset diabetes at young age (MODY)

Diabetes mellitus is not a single disease, but rather a syndrome comprised of a variety of diseases characterized by hyperglycaemia. Indeed it has a heterogeneous nature. Maturity Onset Diabetes of the Young or MODY is an unusual, mild type of hyperglycaemia, which develops in young women, (below the age of 25), who do not require insulin. This study describes 10 pregnancies in MODY women, who are compared to a group of patients with insulin-dependent diabetes mellitus (IDDM), a group with gestational diabetes, and a control group of normal, healthy pregnant women. Our group of pregnant MODY patients proved to have an intermediate form of diabetes, more severe than gestational diabetes and yet not as severe as insulin-dependent diabetes mellitus. Mean duration of diabetes was shorter and mean daily insulin requirement (during pregnancy) was lower among MODY patients in comparison to IDDM gestants. Moreover the frequency of maternal complications and Caesarean deliveries in MODY patients were lower than in the IDDM group, but higher when compared to the gestational diabetes group.

Actual state in the diagnosis of fetal lung maturity

Four methods of phospholipid analysis in amniotic fluid were compared: miniaturized version of a one-dimensional thin-layer chromatographic determination of the lecithin/sphingomyelin ratio; A one-dimensional thin-layer chromatographic separation of all phospholipid components in amniotic fluid; A completely enzymatic determination of amniotic fluid lecithin concentration; An immunological method for semiquantitative measurement of phosphatidylglycerol. The various phospholipid parameters (L/S ratio, lecithin concentration, phosphatidylglycerol detection either by thin-layer chromatography or immunological methods) show a strong correlation to advancing gestational age. While we were not able to prove a statistically significant correlation between enzymatic lecithin values or L/S ratio values and the occurrence of neonatal RDS cases in this study due to the relatively small number of RDS cases, the L/S ratio values obtained by one-dimensional thin-layer chromatography and the phosphatidylglycerol values, determined either chromatographically or immunologically, showed a clear correlation to the expected development of RDS in the newborn. Thus we can conclude that under the actual methods of amniotic fluid phospholipid evaluation immunological phosphatidylglycerol determination as well as the one-dimensional separation of amniotic fluid phospholipids, which is easier to run than the "lung profile" determination of Kulovich and Gluck provide good information about the exclusion of RDS.

Preconceptional diabetes control in insulin-dependent diabetes mellitus patients with continuous subcutaneous insulin infusion therapy

Preconceptional diabetes management is an important prerequisite for pregnancy planning and its value has been well-documented. Glucose control and the outcome of pregnancy, managed in the preconceptional period, with continuous subcutaneous insulin infusion therapy to those receiving insulin injections are compared. Fifty-two juvenile onset insulin dependent diabetic women contemplating pregnancy were regularly consulted by a diabetology team starting at least two months before conception. Glucose control was achieved by continuous subcutaneous insulin infusion pumps (CSIIP) in 18 patients, and 34 women received intensive insulin therapy (IIT). In both groups, normal glucose levels and normal HbA1 were achieved at conception, maintained during the period of organogenesis and throughout pregnancy. In view of the fact that perinatal results, such as the occurrence of malformations, mean gestational age, mean birth weight and neonatal complications were not significantly different in both groups, we believe that both methods are equally effective. Consequently, the less costly and yet effective IIT may be the method of choice, while the more expensive pump should be used mainly in selected cases.

Effect of maternal-fetal disorders on lung maturation. I. Diabetes mellitus

Amniotic fluid for fetal lung maturity studies was obtained from 287 healthy and 198 diabetic women. Classes of diabetes were as follows: Class A, 111; Class B, 58; Class C, 13; Class D, 11; Class F, 4; and Class R, 1. The regression lines representing the relationship of amniotic fluid lecithin phosphorus concentration to gestational age at amniocentesis in each of the groups of diabetic patients were not statistically different from those of the control subjects. Each of the diabetic patients was then matched with a control subject of the same race, sex of newborn infant, and gestational age at amniocentesis. The regression lines of the nonhypertensive, hypertensive, and all diabetics were not different from those of their respective matched control subjects. Also there was no difference in the proportion of mature lecithin phosphorus concentrations at different weeks between diabetic and normal women. The absence of a significant influence of diabetes on fetal lung maturation is probably due to improvement in diabetic control resulting in normalization of the fetal metabolic environment.

Pregnancy outcome in patients with insulin-dependent diabetes mellitus with preconceptional diabetic control: a comparative study

Forty-four of 75 pregnant women with juvenile-onset insulin-dependent diabetes, who attended a preconceptional clinic, were seen regularly by a diabetologic team. Glycemic control was obtained by intensified insulin therapy and monitored by blood glucose self-monitoring. When these patients were compared with a group of 31 nonattenders of the preconceptional clinic, in the former normoglycemia and normal hemoglobin A1 values were achieved before conception, whereas in the latter good control was reached by the second trimester. This group had also more maternal complications, such as preeclampsia, and higher cesarean section rates. Congenital anomalies were 9.6% among offspring of nonattenders, while none occurred in those with preconceptional counseling. We confirm the evidence accumulated in the recent literature that congenital malformations in pregnancy complicated by diabetes may be linked to disturbances in maternal metabolism during the period of embryogenesis. Consequently we concur with the recommendation that tight diabetic control is required before the patient attempts to conceive.