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

Gestational diabetes mellitus and late preterm birth: outcomes with and without antenatal corticosteroid exposure

BACKGROUND

Unlike pregestational diabetes mellitus, the American College of Obstetricians and Gynecologists recommends antenatal corticosteroids in those with gestational diabetes mellitus at risk for preterm birth. However, this recommendation is based on limited data, only 10.6% of the Antenatal Late Preterm Steroids study sample had gestational diabetes mellitus. There is a paucity of data on the risk of neonatal respiratory and other morbidity in this population.

OBJECTIVE

This study aimed to examine respiratory outcomes in parturients with gestational diabetes mellitus who received antenatal corticosteroids and delivered during the late preterm period vs those who did not.

STUDY DESIGN

This population-based cohort study used the US Vital Statistics dataset between 2016 to 2020. The inclusion criteria were singleton, nonanomalous individuals who delivered between 34.0 to 36.6 weeks with gestational diabetes mellitus and known status of antepartum corticosteroid exposure. The primary outcome, a composite neonatal adverse outcome, included Apgar score <5 at 5 minutes, immediate assisted ventilation, assisted ventilation >6 hours, surfactant use, seizure, or neonatal mortality. The secondary outcome was a composite maternal adverse outcome, including maternal blood transfusion, ruptured uterus, unplanned hysterectomy, and admission to the intensive care unit. Multivariable Poisson regression models were used to estimate adjusted relative risks and 95% confidence intervals. Average annual percent change was calculated to assess changes in rates of corticosteroid exposure over the study period.

RESULTS

Of 19 million births during the study period, 110,197 (0.6%) met the inclusion criteria, and among them, 23,028 (20.9%) individuals with gestational diabetes mellitus received antenatal corticosteroids. The rate of antenatal steroid exposure remained stable over the 5 years (APC=10.7; 95% confidence interval, -5.4 to 29.4). The composite neonatal adverse outcome was significantly higher among those who received corticosteroids than among those who did not (137.1 vs 216.5 per 1000 live births; adjusted relative risk 1.24; 95% confidence interval, 1.20-1.28). Three components of the composite neonatal adverse outcome-immediate assisted ventilation, intubation >6 hours, and surfactant use-were significantly higher with exposure than without. In addition, the composite maternal adverse outcome was significantly higher among those who received corticosteroids (adjusted relative risk, 1.34; 95% confidence interval, 1.18-1.52). Three components of the composite maternal adverse outcome-admission to intensive care unit, blood transfusion, and unplanned hysterectomy-were significantly higher among the exposed group. Subgroup analysis, among large for gestational age, by gestational age, and race and ethnicity, confirm the trend of increased likelihood of adverse outcomes with exposure to corticosteroid.

CONCLUSION

Individuals with gestational diabetes mellitus and antenatal corticosteroid exposure, who delivered in the late preterm, were at higher risk of neonatal and maternal adverse outcomes than those unexposed to corticosteroid.

ANTENATAL FACTORS AFFECTING THE DECISION TO HAVE AN ORAL GLUCOSE TOLERANCE TEST

Aim We aimed to investigate the factors that may affect the pregnant’s decision to have an oral glucose tolerance test (OGTT) between 24-28 gestational weeks. Material and Methods This descriptive and cross-sectional study was conducted prospectively with 307 pregnant women. Demographic characteristics of the pregnant women, pregnancy follow-up findings, antenatal tests, and their decision for having an OGTT were questioned and recorded. All the factors were analyzed that may have a possible effect on the OGTT decision. Results Fifty-three percent of the participants had OGTT during pregnancy. The rate of positive OGTT was found to be 8.5%. Body mass index, gravida, history of abortion, miscarriage risk, weight gain during pregnancy, the rate of using antenatal folic acid and iron supplementation were similar between the groups that had and did not have OGTT (p &gt;0.05). In the univariate model, age, parity, planned pregnancy, regular follow-up, educational status and physical activity were found to have a significant effect on predicting patients who will have OGTT (p &lt;0.05). Also, antenatal screening tests and level 2 obstetrics ultrasonography were shown to have a significant independent effect in predicting patients who will have OGTT (p &lt;0.05). Conclusion By evaluating the factors that may affect the decision of pregnant about OGTT during pregnancy follow-up, we can predict the patients who tend not to have GDM screening and we can increase the screening rate by giving these pregnant women more detailed information. Thus, we have a chance to diagnose and treat more GDM and reduce related mortality and morbidity.

Association of antenatal steroids with surfactant administration in moderate preterm infants born to women with diabetes mellitus and/or hypertension

BACKGROUND

Randomized trials of antenatal steroid administration (ANS) for extreme or moderate preterm pregnancies excluded women with diabetes mellitus (DM) and included few with preeclampsia.

METHODS

Cohort study (n = 1,813) including moderate preterm births [290/7-336/7wks' gestational age GA)] before (Epoch-1) and after (Epoch-2) expansion of ANS administration to women with hypertensive disorders (HTN) and/or DM. We compared surfactant administration in Group-1 (neither HTN nor DM), Group-2a (HTN not DM), Group-2b (DM not HTN) and Group-2c (DM and HTN).

RESULTS

Surfactant administration was less frequent after ANS in Group-1 [adjusted odds ratio (aOR) 0.54, 95% confidence interval (CI) 0.31, 0.93, P = 0.03], Group-2a (aOR 0.36, CI 0.22, 0.58, P < 0.001) and Group-2c (aOR 0.29, CI 0.12, 0.71, P = 0.007) but not Group-2b (P = 0.64).

CONCLUSIONS

ANS administration was independently associated with less surfactant administration in moderately preterm neonates whose mothers had neither HTN nor DM, and those with HTN, but not those with DM without HTN.

Gestational Diabetes Mellitus: The Crosslink among Inflammation, Nitroxidative Stress, Intestinal Microbiota and Alternative Therapies

Gestational diabetes mellitus (GDM) is characterized by a set of metabolic complications arising from adaptive failures to the pregnancy period. Estimates point to a prevalence of 3 to 15% of pregnancies. Its etiology includes intrinsic and extrinsic aspects of the progenitress, which may contribute to the pathophysiogenesis of GDM. Recently, researchers have identified that inflammation, oxidative stress, and the gut microbiota participate in the development of the disease, with potentially harmful effects on the health of the maternal-fetal binomial, in the short and long terms. In this context, alternative therapies were investigated from two perspectives: the modulation of the intestinal microbiota, with probiotics and prebiotics, and the use of natural products with antioxidant and anti-inflammatory properties, which may mitigate the endogenous processes of the GDM, favoring the health of the mother and her offspring, and in a future perspective, alleviating this critical public health problem.

Time Interval From Early-Term Antenatal Corticosteroids Administration to Delivery and the Impact on Neonatal Outcomes

OBJECTIVES

To determine the association between the time interval from antenatal corticosteroids administration to delivery and neonatal complications in diabetic mothers undergoing early term (37+0 to 38+6 weeks) scheduled cesarean section (ETSCS).

STUDY DESIGN

A retrospective cohort study of women with any form of diabetes in pregnancy undergoing ETSCS was included. Cases were stratified into the following groups based on the time interval from the first dose of corticosteroids administration to delivery: <2, 2-7, and >7 days. Women undergoing ETSCS, who did not receive corticosteroids were included as controls. We assessed the association between the time interval and neonatal outcomes in a multivariate regression model that controlled for potential confounders. Primary outcomes were the incidence of respiratory distress syndrome (RDS)/transient tachypnea of the newborn (TTN) and neonatal hypoglycemia.

RESULTS

The study cohort comprised 1,165 neonates. Of those, 159 (13.6%) were delivered within 2 days of maternal corticosteroids administration, 131 (11.2%) were delivered within 2-7 days after maternal corticosteroids administration, and 137 (11.8%) delivered more than 7 days after maternal corticosteroids administration. The remaining 738 (63.3%) were not exposed to corticosteroids. Multivariate analysis demonstrated that delivery within any time of antenatal corticosteroids administration was not associated with decreased risks of RDS/TTN. The risk of neonatal hypoglycemia was highest in the delivery of <2 days group (adjusted odds ratio [aOR]: 2.684, 95% confidence interval [CI]: 1.647-4.374 for control group; aOR: 2.827, 95% CI: 1.250-6.392 for delivery 2-7 days group; aOR:2.975, 95% CI: 1.265-6.996 for delivery >7 days group).

CONCLUSIONS

Corticosteroids treatment for diabetic mothers undergoing ETSCS was not associated with beneficial neonatal respiratory outcomes. In addition, delivery, <2 days after antenatal corticosteroids administration was associated with an increased risk of neonatal hypoglycemia.

Association between maternal diabetes mellitus and allergic diseases in children - A systematic review and meta-analysis

BACKGROUND

Existing knowledge suggests that gestational diabetes mellitus was inconsistently associated with offspring allergic diseases. The aim of this study was to identify the association between maternal diabetes mellitus and the risk of offspring allergic diseases by systematic review.

METHODS

We searched and retrieved three databases (PubMed, Web of Science, and Cochrane Library) for articles on the association between maternal diabetes mellitus and offspring allergic diseases published before December 31, 2019. Stata software version 16.0 was used for statistical analysis.

RESULTS

Eight published studies were included in this meta-analysis. The pooled effect estimates showed the association between maternal diabetes mellitus and allergic outcomes, including asthma (OR: 1.13, 95% CI: 1.01-1.27), wheezing (OR: 1.13, 95% CI: 1.07-1.21), and atopic dermatitis (OR: 1.43, 95% CI: 1.22-1.57). Maternal diabetes mellitus was not associated with the risk of allergic sensitization, with a pooled effect estimate of 1.07 (95% CI: 0.45, 2.58).

CONCLUSION

Maternal diabetes mellitus may increase the risk of allergic diseases in their children. However, this finding should be validated with future large-sample epidemiological studies covering a wider spectrum of allergic diseases.

Molecular Mechanisms of Maternal Diabetes Effects on Fetal and Neonatal Surfactant

Respiratory distress is a significant contributor to newborn morbidity and mortality. An association between infants of diabetic mothers (IDMs) and respiratory distress syndrome (RDS) has been well recognized for decades. As obesity and diabetes prevalence have increased over the past several decades, more women are overweight and diabetic in the first trimester, and many more pregnant women are diagnosed with gestational diabetes. Glycemic control during pregnancy can be challenging due to the maternal need for higher caloric intake and higher insulin resistance. Surfactant is a complex molecule at the alveolar air-liquid interface that reduces surface tension. Impaired surfactant synthesis is the primary etiology of RDS. In vitro cell line studies, in vivo animal studies with diabetic rat offspring, and clinical studies suggest hyperglycemia and hyperinsulinemia can disrupt surfactant lipid and protein synthesis, causing delayed maturation in surfactant in IDMs. A better understanding of the molecular mechanisms responsible for surfactant dysfunction in IDMs may improve clinical strategies to prevent diabetes-related complications and improve neonatal outcomes.

Evaluation of the Effects of Delayed Cord Clamping in Infants of Diabetic Mothers

OBJECTIVE

This study aimed to investigate the effect of delayed cord clamping (DCC) in infants of diabetic mothers.

STUDY DESIGN

Women who had diabetes throughout their pregnancy and gave birth at 37 weeks of gestation or later were included in the study along with their babies. Early cord clamping was performed as soon as possible after birth, while DCC was performed by clamping 60 second after birth. The two groups were compared in terms of venous hematocrit (htc) levels and rates of hypoglycemia, jaundice requiring phototherapy, and respiratory distress.

RESULTS

Venous htc levels at postnatal 6 and 24 hours were significantly higher in the DCC group (p = 0.0001). Polycythemia rates were higher in the DCC group at both 6 and 24 hours, but partial exchange transfusion (PET) was not needed in either group. There were no differences between the groups with regard to the rates of hypoglycemia or jaundice requiring phototherapy. Rate of admission to the neonatal intensive care unit (NICU) was lower in the DCC group.

CONCLUSION

Although DCC increased the rate of polycythemia, it did not result in PET requirement. Moreover, DCC reduced the severity of respiratory distress and the rate of admission to NICU due to respiratory distress.

Could the E/A ratio be included in the cardiological evaluation of the offspring of diabetic mothers? A case-control study in South Sardinia

INTRODUCTION

Diabetes mellitus (DM) is a chronic disease widespread in the world. Sardinia represents, together with Finland, the region with the highest incidence of type 1 DM (DM1), as well as a high prevalence of gestational DM (GDM). Despite the improvement in obstetric surveillance, perinatal and long-term adverse outcomes are still frequent in the offspring of diabetic mothers. During gestations complicated by DM, fetal heart is one of the most affected organ potentially undergoing structural heart defects or several degrees of fetal myocardium hypertrophy and impaired cardiac function.

AIM

The aim of our study was to evaluate, through echocardiographic examination, cardiac features and performance in a South Sardinian population of newborns of diabetic mothers comparing them to a group of control subjects.

CONCLUSIONS

In our sample, the E/A ratio resulted a significant marker of early diastolic dysfunction in asymptomatic neonates born by diabetic mothers, even if such result should be confirmed on larger samples.

Controversies in antenatal corticosteroid treatment

Antenatal corticosteroids are now established as one of the cornerstones of therapy in the prevention of neonatal morbidity and mortality prior to preterm birth. Although this practice is widely accepted, a significant number of controversies exist. This review explores the knowledge gaps regarding the use of antenatal corticosteroids in the preterm, late preterm and term populations. Furthermore, the role of antenatal corticosteroids in special populations, such as diabetes, multiple pregnancies and periviable gestations, where high-quality data from randomized controlled trials are lacking, is also considered.

Hyperglycemia During Pregnancy and Long-Term Offspring Outcomes

PURPOSE OF REVIEW

This review will focus on the long-term outcomes in offspring exposed to in utero hyperglycemia and gestational diabetes (GDM), including obesity, adiposity, glucose metabolism, hypertension, hyperlipidemia, nonalcoholic fatty liver disease, and puberty.

RECENT FINDINGS

There is evidence, mostly from observational studies, that offspring of GDM mothers have increased risk of obesity, increased adiposity, disorders of glucose metabolism (insulin resistance and type 2 diabetes), and hypertension. In contrast, evidence from the two intervention studies of treatment of mild GDM and childhood measures of BMI, adiposity, and glucose tolerance do not demonstrate that GDM treatment significantly reduces adverse childhood metabolic outcomes. Thus, more evidence is needed to understand the impact of maternal GDM on offspring's adiposity, glucose metabolism, lipid metabolism, risk of fatty liver disease, and pubertal onset. Offspring of GDM mothers may have increased risk for metabolic and cardiovascular complications. Targeting this group for intervention studies to prevent obesity and disorders of glucose metabolism is one potential strategy to prevent adverse metabolic health outcomes.

Gestational Diabetes Mellitus

Although it has been accepted for decades that women with gestational diabetes mellitus (GDM) are at high risk for future development of type 2 diabetes, vigorous debate regarding the value of detecting and treating GDM has persisted into the twenty-first century. Although results from 2 randomized trials provide strong evidence that treating GDM reduces adverse perinatal outcomes, it remains to be determined whether treatment impacts long-term offspring outcomes. Insulin is the first-line pharmacologic treatment and is added when glycemic goals are not met with nutritional modifications. Oral agent use is controversial, as data on long-term offspring outcomes are lacking.

Infant of diabetic mother: what one needs to know?

The global incidence of diabetes mellitus, including diabetes in pregnant women, is on the rise. Diabetes mellitus in a pregnant woman jeopardizes not only maternal health but can also have significant implications on the child to be born. Therefore, timely diagnosis and strict glycemic control are of utmost importance in achieving a safe outcome for both the mother and fetus. The treating physician should be aware of the complications that can arise due to poor glycemic control during pregnancy. The objective of this article is to discuss the key concerns in a neonate born to diabetic mother, the underlying pathogenesis, and the screening schedule during pregnancy.

[Insulin treatment of gestational diabetes and respiratory outcome in late-preterm and term babies]

While the incidence of diabetes mellitus (DM) during pregnancy has been steadily increasing in recent years, the link between gestational DM and respiratory outcome in neonates has not been firmly established. To address this gap in understanding, we asked whether DM status and its treatment during pregnancy influence risk of neonatal respiratory distress. We conducted retrospective analysis of a large cohort to determine the relationship between maternal DM status (non-DM, insulin-treated DM [DTI], and non-insulin-treated DM [DTR]) and respiratory distress in term and near-term singletons, born at Robert-Debré Hospital over a 7-year period. Of 18,095 singletons delivered at 34 weeks of gestation or later, 412 (2.3%) were admitted to the NICU for respiratory distress within the first hours of life. The incidence of NICU admissions due to respiratory distress was 2.2% in the non-DM group, 2.1% in the DTR group, and 5.7% in the DTI group. Insulin treatment of DM, together with several other perinatal factors, was associated with an increased risk for severe respiratory distress. In a multivariate model, we found that DTI, but not DTR, was a risk factor independent of gestational age and cesarean section, with an IRR of 1.44 (95% CI, 1.00-2.08). The data indicate that newborns of mothers with DM treated with diet are not at risk for severe respiratory distress. Conversely, newborns of mothers with DM treated with insulin are associated with elevated risk for severe respiratory disease and should therefore be closely monitored.

Insulin treatment of maternal diabetes mellitus and respiratory outcome in late-preterm and term singletons

OBJECTIVES

While the incidence of diabetes mellitus (DM) during pregnancy has been steadily increasing in recent years, the link between gestational DM and respiratory outcome in neonates has not been definitely established. We asked the question whether DM status and its treatment during pregnancy could influence the risk of neonatal respiratory distress.

DESIGN

We studied in a large retrospective cohort the relationship between maternal DM status (non-DM, insulin-treated DM (IT-DM) and non-insulin-treated DM (NIT-DM)), and respiratory distress in term and near-term inborn singletons.

RESULTS

Among 18,095 singletons delivered at 34 weeks of gestation or later, 412 (2.3%) were admitted to the neonatal intensive care unit (NICU) for respiratory distress within the first hours of life. The incidence of NICU admission due to respiratory distress groups was 2.2%, 5.7% and 2.1% in the non-DM, IT-DM and NIT-DM groups, respectively. Insulin treatment of DM, together with several other perinatal factors, was associated with a significant increased risk for respiratory distress. Several markers of the severity of respiratory illness, including durations of mechanical ventilation and supplemental oxygen, and hypertrophic cardiomyopathy were also found increased following IT-DM as compared with NIT-DM. In a multivariate model, we found that IT-DM, but not NIT-DM, was significantly associated with respiratory distress independent of gestational age and caesarean section, with an incidence rate ratio of 1.44 (1.00-2.08).

CONCLUSIONS

This study shows that the treatment of maternal DM with insulin during pregnancy is an independent risk factor for respiratory distress in term and near-term newborns.

Intrafetal glucose infusion alters glucocorticoid signaling and reduces surfactant protein mRNA expression in the lung of the late-gestation sheep fetus

Increased circulating fetal glucose and insulin concentrations are potential inhibitors of fetal lung maturation and may contribute to the pathogenesis of respiratory distress syndrome (RDS) in infants of diabetic mothers. In this study, we examined the effect of intrafetal glucose infusion on mRNA expression of glucose transporters, insulin-like growth factor signaling, glucocorticoid regulatory genes, and surfactant proteins in the lung of the late-gestation sheep fetus. The numerical density of the cells responsible for producing surfactant was determined using immunohistochemistry. Glucose infusion for 10 days did not affect mRNA expression of glucose transporters or IGFs but did decrease IGF-1R expression. There was reduced mRNA expression of the glucocorticoid-converting enzyme HSD11B-1 and the glucocorticoid receptor, potentially reducing glucocorticoid responsiveness in the fetal lung. Furthermore, surfactant protein (SFTP) mRNA expression was reduced in the lung following glucose infusion, while the number of SFTP-B-positive cells remained unchanged. These findings suggest the presence of a glucocorticoid-mediated mechanism regulating delayed maturation of the surfactant system in the sheep fetus following glucose infusion and provide evidence for the link between abnormal glycemic control during pregnancy and the increased risk of RDS in infants of uncontrolled diabetic mothers.

Glycemic targets for the optimal treatment of GDM

Lowering glucose is of pivotal importance in the treatment of diabetes in pregnancy. A spectrum of different glucose thresholds can be established and used appropriately to prevent each complication. This article outlines the concept of normality and what definition of normality should be used to evaluate the relationship between the level of glycemia and perinatal outcome.

Changes in diabetes status between pregnancies and impact on subsequent newborn outcomes

OBJECTIVE

Pregnancies complicated by gestational diabetes mellitus (GDM) or preexisting diabetes mellitus (DM) are at high risk for adverse newborn outcomes. Whether GDM history, recurrence, or transition to DM modifies such risks is unknown.

STUDY DESIGN

Medical record data on 62,013 repeat singleton pregnancies were collected retrospectively from women who delivered at least twice in Utah (2002 through 2010). Poisson regression models with robust variance estimators were used to estimate relative risks (RR) and 95% confidence intervals (CI) associated with GDM/DM status at the previous and/or current pregnancy relative to those without GDM/DM at either. Large for gestational age (LGA), shoulder dystocia, preterm birth (<37 weeks), respiratory distress syndrome, and other neonatal morbidities were examined adjusting for study site, maternal age, race, parity, interpregnancy interval, prepregnancy body mass index, and smoking status.

RESULTS

GDM in the previous pregnancy alone increased the risk of LGA in the current pregnancy (RR, 1.20; 95% CI, 1.05-1.38). Recurrent GDM increased the risks of LGA (RR, 1.76; 95% CI, 1.56-1.98), shoulder dystocia (RR, 1.98; 95% CI, 1.46-2.70), and preterm birth (RR, 1.68; 95% CI, 1.44-1.96) beyond that observed for pregnancies with current GDM alone. Women with GDM in a previous pregnancy that transitioned to DM in the current pregnancy and women with DM prior to the previous pregnancy had increased risks of all above outcomes.

CONCLUSION

GDM in a previous pregnancy alone without recurrence may still confer an increased LGA risk. Pregnancies complicated by GDM that transition to DM and those with DM prior to the previous pregnancy have the highest risks of adverse newborn outcomes.

Fetal lung maturity testing: the end of an era

Respiratory distress syndrome is a major cause of neonatal morbidity and mortality that is most commonly caused by a deficiency in lung surfactant in premature infants. Therefore, laboratory tests were developed to measure the presence and/or concentration of lung surfactant in amniotic fluid in order to estimate maturity of the fetal lung. Although these tests were once widely employed, their utilization by physicians has decreased in recent years. Several studies have shown that demonstration of a mature fetal lung index by antenatal testing does not improve neonatal outcomes. Instead, decreased respiratory and nonrespiratory morbidities are most highly correlated with gestational age of the fetus. Therefore, fetal lung maturity testing may have passed the point of being clinically useful.

Management of diabetes in pregnancy

The link between diabetes and poor pregnancy outcomes is well established. As in the non-pregnant population, pregnant women with diabetes can experience profound effects on multiple maternal organ systems. In the fetus, morbidities arising from exposure to diabetes in utero include not only increased congenital anomalies, fetal overgrowth, and stillbirth, but metabolic abnormalities that appear to carry on into early life, adolescence, and beyond. This article emphasizes the newest guidelines for diabetes screening in pregnancy while reviewing their potential impact on maternal and neonatal complications that arise in the setting of hyperglycemia in pregnancy.

Foetal and neonatal complications in gestational diabetes: perinatal mortality, congenital malformations, macrosomia, shoulder dystocia, birth injuries, neonatal complications

OBJECTIVE

To evaluate the risks of perinatal complications in infants born to mothers with treated or untreated gestational diabetes mellitus (GDM).

METHODS

A search of the PubMed database was performed and recommendations from NICE and the French National Authority for Health were consulted.

RESULTS

Untreated moderate or severe GDM increases the risk of foetal and neonatal complications (EL1). The risk of malformations slightly increases in newborns of mothers with GDM compared to the general population (EL2). This risk is probably associated with the presence of undiagnosed type 2 diabetes among patients with GDM (EL2). There is a linear relationship between maternal blood glucose levels and an increased birth weight (EL2). Treatment for GDM reduces the incidence of macrosomia (EL1). Although the risk of cardiomyopathy in cases of GDM cannot be accurately estimated based on the available data, severe clinical forms are rare. The risks of neonatal asphyxia and perinatal mortality are no higher in infants born to women with GDM (EL2). Birth injuries and brachial plexus injuries are rare, and no more likely to occur in cases of untreated GDM. It is difficult to assess the risk of respiratory distress, regardless of its cause. It is not possible to establish a link between GDM and neonatal respiratory problems due to insufficient data. Although the risk of neonatal hypoglycaemia is difficult to determine due to the variable definitions reported in the literature, the incidence of hypoglycaemia requiring intravenous therapy is low (EL1). The risks of hypocalcaemia (EL4) and hyperbilirubinemia (EL1) are similar to the general population.

CONCLUSION

Serious perinatal complications specifically associated with GDM are rare. Macrosomia has been demonstrated to be the predominant adverse outcome in cases of GDM. It is the main factor linked to reported cases of complications in GDM. Maternal obesity is an additional risk factor for complications, regardless of diabetes status.

Clinical prediction rule for RSV bronchiolitis in healthy newborns: prognostic birth cohort study

OBJECTIVE

Our goal was to determine predictors of respiratory syncytial virus (RSV) lower respiratory tract infection (LRTI) among healthy newborns.

METHODS

In this prospective birth cohort study, 298 healthy term newborns born in 2 large hospitals in the Netherlands were monitored throughout the first year of life. Parents kept daily logs and collected nose/throat swabs during respiratory tract infections. The primary outcome was RSV LRTI, which was defined on the basis of the combination of positive RSV polymerase chain reaction results and acute wheeze or moderate/severe cough.

RESULTS

Of the 298 children, 42 (14%) developed RSV LRTI. Independent predictors for RSV LRTI were day care attendance and/or siblings, high parental education level, birth weight of >4 kg, and birth in April to September. The area under the receiver operating characteristic curve was 0.72 (95% confidence interval: 0.64-0.80). We derived a clinical prediction rule; possible scores ranged from 0 to 5 points. The absolute risk of RSV LRTI was 3% for children with scores of ≤2 (20% of all children) and 32% for children with all 4 factors (scores of 5; 8% of all children). Furthermore, 62% of the children with RSV LRTI experienced wheezing during the first year of life, compared with 36% of the children without RSV LRTI.

CONCLUSIONS

A simple clinical prediction rule identifies healthy newborns at risk of RSV LRTI. Physicians can differentiate between children with high and low risks of RSV LRTI and subsequently can target preventive and monitoring strategies toward children at high risk.

Amniotic lamellar body counts determined with the Sysmex XE-2100 analyzer to predict fetal lung maturity during diabetic and other complicated pregnancies

OBJECTIVE

The detection of amniotic lamellar bodies (LB) has been shown to be a rapid and simple way to assess fetal lung maturity (FLM). The maturity thresholds for LB vary due to different factors, one being the type of particle-count analyser used.

MATERIAL AND METHODS

The Sysmex XE-2100 hematological analyser was evaluated in determination of amniotic LB counts and compared with lecithin/sphingomyelin (L/S) and phosphatidylglycerol (PG) determination. We analysed 132 amniotic samples from a total of 109 mothers (71 diabetic) with 112 infants. Results. The correlation between the LB counts obtained with the Sysmex XE-2100 and our reference thin layer chromatography (TLC) phospholipid method was good. Samples with low L/S ratio (< or = 2.0) and no PG (i.e. premature fetal lung status), had low LB counts (n = 18, mean 8500/L, range 1000-26000), whereas 51 samples with mature fetal lung status had high LB counts (mean 63600/uL, range 20,000-139,000). In all our four cases of respiratory distress syndrome the LB counts were low (range 1000-28000/uL). The reference values for FLM determination were established: < or = 6000/microL for immature, values between 7000 and 35,000/uL for borderline results and >35,000/uL for mature. CONCLUSIONS. The amniotic LB count analysis with Sysmex XE-2100 has many advantages being a repeatable, inexpensive and quantitative method with a very short turn-around time. Consequently, our routine is to perform LB counts initially from all amniotic samples and only borderline LB results are analysed with TLC.

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.

Fatty diabetic lung: altered alveolar structure and surfactant protein expression

Pulmonary dysfunction develops in type 2 diabetes mellitus (T2DM) in direct correlation with glycemia and is exacerbated by obesity; however, the associated structural derangement has not been quantified. We studied lungs from obese diabetic (fa/fa) male Zucker diabetic fatty (ZDF) rats at 4, 12, and 36 wk of age, before and after onset of T2DM, compared with lean nondiabetic (+/+) rats. Surfactant proteins A and C (SP-A and SP-C) immunoexpression in lung tissue was quantified at ages 14 and 18 wk, after the onset of T2DM. In fa/fa animals, lung volume was normal despite obesity. Numerous lipid droplets were visible within alveolar interstitium, lipofibroblasts, and macrophages, particularly in subpleural regions. Total triglyceride content was 136% higher. By 12 wk, septum volume was 21% higher, and alveolar duct volume was 36% lower. Capillary basement membrane was 29% thicker. Volume of lamellar bodies was 45% higher. By age 36 wk, volumes of interstitial collagen fibers, cells, and matrix were respectively 32, 25, and 80% higher, and capillary blood volume was 18% lower. ZDF rats exhibited a strain-specific increase in resistance of the air-blood diffusion barrier with age, which was exaggerated in fa/fa lungs compared with +/+ lungs. In fa/fa lungs, SP-A and SP-C expression were elevated at age 14-18 wk; the normal age-related increase in SP-A expression was accelerated, whereas SP-C expression declined with age. Thus lungs from obese T2DM animals develop many qualitatively similar changes as in type 1 diabetes mellitus but with extensive lipid deposition, altered alveolar type 2 cell ultrastructure, and surfactant protein expression patterns that suggest additive effects of hyperglycemia and lipotoxicity.

The effect of clinical characteristics on the lecithin/sphingomyelin ratio and lamellar body count: a cross-sectional study

OBJECTIVES

To study the changes in the lecithin/sphingomyelin (L/S) ratio and lamellar body count (LBC) during pregnancy and to study the effect of clinical characteristics on these measurements.

METHODS

We reviewed in retrospect the amniotic fluid samples for the assessment of fetal lung maturity of consecutive women between January 1996 and December 2000. We evaluated the effect of antenatal administration of glucocorticoids, the presence of diabetes, fetal growth restriction and the amount of amniotic fluid on the L/S ratio and LBC. We then constructed normal curves, by relating the L/S ratio and LBC to gestational age in the cases without respiratory distress syndrome (RDS). Data from the literature were added to these curves.

RESULTS

From the 334 included women, 64 infants (19%) developed RDS. The LBC was lower in women with polyhydramnios (p = 0.04), and similar in women with oligohydramnios. Administration of glucocorticoids, the presence of maternal diabetes or fetal growth restriction did not affect the L/S ratio or the LBC. The median L/S ratio in cases without RDS showed a constant increase from a gestational age of 28 weeks onwards. The median LBC increased slowly between a gestational age of 28 weeks and 34 weeks, to increase more steeply thereafter.

CONCLUSIONS

The amount of amniotic fluid affects the LBC, but not the L/S ratio. Since the L/S ratio and the LBC increase with gestation, differences in gestational age should be taken into account in the interpretation of these fetal lung maturity tests.

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.

The mean weekly increment of amniotic fluid TDx-FLM II ratio is constant during the latter part of pregnancy

OBJECTIVE

The purpose of this study was to determine the mean weekly increment in amniotic fluid TDx-FLM II ratio during the latter part of pregnancy.

STUDY DESIGN

All women who underwent > 1 amniocentesis for the determination of fetal lung maturity between 1998 and 2004 were identified retrospectively. Clinical information and TDx-FLM II ratios were collected from the participant's chart and analyzed.

RESULTS

The gestational age of all participants at the first TDx-FLM II test was 31.2 to 37.5 weeks (mean, 34.7 +/- 1.4 weeks of gestation). The median interval between the 2 tests was 7 days (range, 5-36 days). We found that the mean weekly increment of TDx-FLM II was 14.4 +/- 9.9 mg/g (surfactant to albumin) and remained constant across the gestational ages.

CONCLUSION

The mean weekly increment of TDx-FLM II is 14.4 +/- 9.9 mg/g and is constant during the latter part of pregnancy. This information, combined with the gestational age, should be useful in treating women with an initial immature test.

Clinical outcomes of near-term infants

OBJECTIVE

To test the hypothesis that near-term infants have more medical problems after birth than full-term infants and that hospital stays might be prolonged and costs increased.

METHODS

Electronic medical record database sorting was conducted of 7474 neonatal records and subset analyses of near-term (n = 120) and full-term (n = 125) neonatal records. Cost information was accessed. Length of hospital stay, Apgar scores, clinical diagnoses (temperature instability, jaundice, hypoglycemia, suspicion of sepsis, apnea and bradycardia, respiratory distress), treatment with an intravenous infusion, delay in discharge to home, and hospital costs were assessed.

RESULTS

Data from 90 near-term and 95 full-term infants were analyzed. Median length of stay was similar for near-term and full-term infants, but wide variations in hospital stay were documented for near-term infants after both vaginal and cesarean deliveries. Near-term and full-term infants had comparable 1- and 5-minute Apgar scores. Nearly all clinical outcomes analyzed differed significantly between near-term and full-term neonates: temperature instability, hypoglycemia, respiratory distress, and jaundice. Near-term infants were evaluated for possible sepsis more frequently than full-term infants (36.7% vs 12.6%; odds ratio: 3.97) and more often received intravenous infusions. Cost analysis revealed a relative increase in total costs for near-term infants of 2.93 (mean) and 1.39 (median), resulting in a cost difference of 2630 dollars (mean) and 429 dollars (median) per near-term infant.

CONCLUSIONS

Near-term infants had significantly more medical problems and increased hospital costs compared with contemporaneous full-term infants. Near-term infants may represent an unrecognized at-risk neonatal population.

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.