Socioeconomic factors influence surgical wait times for non-emergent gynecologic surgical procedures: a retrospective analysis

BACKGROUND

In various disciplines, an association between surgical wait times and patient outcomes has been identified. This study is among the first to investigate whether practice setting influences wait times for elective surgeries in benign gynecology.

METHODS

This retrospective study of patients at three New York hospitals from 10/2019-2/2020 compared surgical wait times among patients seen in federally-qualified health centers (FQHC's) and private practice settings. Emergent surgeries, oncology cases, abortions, urogynecology procedures, and cases concurrently booked with another specialty were excluded. Surgical wait time was defined as the time (days) from the decision to operate to the day of the procedure. A multivariable mixed model was used to model surgical wait time by setting of care, adjusting for age, BMI, race, ethnicity, insurance, need for medical clearance, and scheduled block time. A univariable analysis was then utilized to assess surgical wait times by clinical setting for each insurance type.

RESULTS

Five hundred forty patients were identified with a median age of 45.6 years (range 16-87). Average surgical wait time was 27 days (range 1-288 days). In multivariable analysis, longer surgical wait times were associated with being seen preoperatively in a FQHC compared to the private practice setting (102% longer, 59.5 days vs. 22 days, p < 0.0001), and with needing medical clearance (56.4% longer, 45 days vs. 22 days. p = 0.0001).

CONCLUSIONS

These results suggest that in benign gynecology, surgical wait times are significantly influenced by the practice setting in which a patient gets care, with notable delays in care among patients who are seen in a federally qualified health center preoperatively.

Neonatal Birth Weight With Daily Compared With Every-Other-Day Glucose Monitoring in Gestational Diabetes Mellitus: A Randomized Controlled Trial

OBJECTIVE

To assess whether universal use of every-other-day glucose monitoring in patients with gestational diabetes mellitus (GDM) resulted in similar birth weights and medication use and was preferred by the patient compared with traditional daily glucose monitoring.

METHODS

This was a noninferiority randomized controlled trial conducted at a single New York City hospital between April 2021 and May 2022. Patients with singleton pregnancies who were diagnosed with GDM after 20 weeks of gestation and had a minimum of 7 days of previous daily blood glucose testing were randomly assigned to test blood glucose values daily or every other day. The primary outcome was neonatal birth weight. We calculated a total sample size of 196 participants needed for noninferiority to be tested, assuming the mean birth weight in the every-other-day group, compared with the daily group, was no higher than the predefined noninferiority margin of 200 g (80% power and one-sided alpha of 0.05). Postrandomization characteristics, including blood glucose values and medication initiation and timing, were recorded. Satisfaction with treatment group was assessed using the validated Oxford Maternity Diabetes Treatment Satisfaction Questionnaire.

RESULTS

A total of 197 patients were randomized: 98 in the daily group and 99 in the every-other-day group. Baseline characteristics were similar between groups. The mean neonatal birth weight was similar between groups (mean±SD 3,090±418 g among newborns in the daily group compared with 3,181±482 g among newborns in the every-other-day group). For the primary outcome, the every-other-day group was found to be noninferior to the daily group with an upper confidence limit for the mean difference in mean birth weight of 197 g, which was below the noninferiority margin of 200 g (P=.046). Postrandomization, there were no significant differences in the number of patients who required medication, the gestational age at which medication was started, or the type of medication used. Average fasting and postprandial glucose values were similar between groups. There was an increase in adherence to treatment group in those randomized to every-other-day blood sugars, but no difference in patient satisfaction.

CONCLUSION

In patients with GDM, testing blood glucose values every other day was as effective as testing daily, without apparent effects on birth weight, medication initiation, or glucose control. Reduced frequency of blood glucose monitoring might help decrease the emotional, physical, and financial burden experienced by patients with GDM.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT04857073.

Likely Vertical Transmission of Neonatal SARS CoV-2 Infection

Maternal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can affect placental function, but the possibility of intrauterine transmission has been debated. Several authors have published inclusion criteria for vertical transmission, but few reports exist that are able to meet the suggested requirements. Despite the fact that the majority of fetuses born to infected mothers do well, others become critically ill. We present a case of likely intrauterine transmission of a neonate born to a mother who was recently symptomatic with a positive SARS CoV-2 polymerase chain reaction (PCR). The parturient complained of decreased fetal movement and presented at 31 2/7 weeks' gestation with a biophysical profile score of 2/10 and required an emergency cesarean delivery. The neonate went on to develop severe leukopenia with signs of sepsis with a positive SARS CoV-2 PCR on day 4 of life and an otherwise pan-negative workup. Meeting criteria for transplacental transmission requires timely collection of several diagnostic studies that are not standard of care. Further research is needed to support the notion that intrauterine/transplacental infection is possible. Collection swabs should be obtained soon after delivery to help diagnose neonatal infection because early diagnosis is crucial to help identify opportunities for intervention.

Transient elastography and controlled attenuation parameter to evaluate hepatic steatosis and liver stiffness in postpartum patients

INTRODUCTION

Nonalcoholic fatty liver disease (NAFLD) affects 30% of adults in the United States. Transient elastography (TE) (Fibroscan, Echosens, Paris, France) with controlled attenuation parameter (CAP) is a noninvasive way to evaluate liver steatosis and liver stiffness. The primary objective of this study was to assess prevalence of elevated liver stiffness and steatosis immediately postpartum. Furthermore, we sought to evaluate whether there were differences in rates of metabolic disorders of pregnancy (gestational diabetes mellitus (GDM), gestational hypertension, and preeclampsia) and pre-pregnancy conditions (type 2 diabetes mellitus (DM), chronic hypertension, and obesity) in those with elevated postpartum liver steatosis/liver stiffness.

METHODS

IRB approved prospective cross-sectional study in which TE and liver function tests were performed 1-2 days postpartum. CAP ≥300 dB/m was classified as significant steatosis. Increased liver stiffness was defined as ≥7 kPa. Prevalence was determined by proportion of individuals undergoing TE/CAP who met criteria. Chi-square analysis was used to compare differences between groups.

RESULTS

Eighty-nine patients were included: 20 (22%) had GDM, 13 (15%) had gestational hypertension, and 15 (17%) had preeclampsia. Women with kPa ≥7 were more likely to have ALT ≥25, type 2 diabetes, and preeclampsia (p < .05). Pre-gravid BMI, BMI at delivery, and GDM were not associated with increased kPa. Pregravid BMI ≥25 and chronic hypertension were associated with CAP ≥ 300 dB/m (p < .05). GDM, preeclampsia, and gestational hypertension were not associated with CAP ≥300 dB/m.

CONCLUSIONS

Patients with preeclampsia, type 2 diabetes, and elevated ALT were more likely to have elevated postpartum liver stiffness. Pregravid BMI ≥25 and ≥30 were associated with increased liver steatosis, although did not impact liver stiffness. GDM was not associated with increased liver stiffness or steatosis. Consideration should be made for screening pregnant patients with preeclampsia, type 2 DM and overweight or obese BMI for liver disease in the postpartum period with potential for lifestyle intervention.

Barriers to Completion of Expanded Carrier Screening in an Inner City Population

PURPOSE

The American College of Medical Genetics and Genomics emphasizes a "consistent and equitable approach for offering carrier screening". At our academic center, publicly insured prenatal patients underwent universal Expanded Carrier Screening (ECS) to promote equitable care. The aim of the study was to evaluate rates, time, and barriers to complete ECS. This was defined as post-test counseling and partner testing after a patient was found heterozygous for a pathogenic variant.

METHODS

A descriptive retrospective cohort study from 2018-2021. Patients were offered ECS, consisting of 283 recessive and X-linked genes. Heterozygotes were contacted by genetic counselors (</=5 attempts), for education and partner testing. Rates of counseling, partner testing, diagnostic procedures, follow up times, and barriers to completion were assessed.

RESULTS

During this time, 643 women underwent ECS. 462/643 were heterozygotes and 326/462 had counseling. 222/462 partners obtained testing, with a median of 32 days from patient to partner result. 21 couples were heterozygous for the same pathogenic variant. One patient pursued diagnostic testing.

CONCLUSION

ECS offers useful information, however, this study highlights significant barriers to completion. There was suboptimal patient follow up and low partner screening, perhaps from insufficient time to educate and counsel. Future directions include implementing quality measures to ensure optimal completion.

Comparison of an intermittently scanned (flash) continuous glucose monitoring system to standard self-monitoring of capillary blood glucose in gestational diabetes mellitus

Objective Gestational diabetes mellitus (GDM) requires close surveillance of blood glucose to prevent perinatal morbidity. Self-monitoring of capillary blood glucose (BGM) comes with considerable psychosocial burden. Intermittently scanned CGM (isCGM) devices are discreet and could considerably impact the lifestyle of the patient. They are designed to replace BGM testing in nonpregnant patients. Data on this technology in pregnancy is scant. The aim of this study was to assess concordance of BGM with isCGM in GDM. Methods IRB approved prospective single arm study evaluating agreement of isCGM (Freestyle Libre 14 day system) compared to BGM when determining glucose levels fasting and 2 hours postprandial for 14 days. This was documented as percentage of results within Zone A (clinically accurate measurements with no effect on clinical action) or Zone B (values that deviate from reference by >20% but would lead to benign/no treatment) of the Parkes Error Grid (developed for non-pregnant patients with diabetes). Per International Organization for Standardization (ISO) criteria, agreement was defined as >95% within Zone A or B. Analytical agreement was evaluated using mean and median absolute relative difference (ARD), mean and median absolute difference (AD). Results There were 1604 pairs of BGM/isCGM observations for 41 patients. Mean glucose values were 102.0 (SD 20.5) mg/dL and 89.4 (SD 20.1) mg/dL for BGM and isCGM, respectively. Mean and median AD were 15.9 and 13.0 mg/dL, respectively. Mean and median ARD were 15.9% and 12.5%, respectively. Zones A and B contained 76.9% and 22.9% of values, respectively, in the Parkes Error Grid, for a total of 99.8%. Conclusions BGM and isCGM demonstrate clinical agreement. However, glucose values with isCGM trended lower, with greater mean and median ARD than prior studies. Given the strict glycemic control required during pregnancy, physicians should be aware of these differences and their possible clinical implications.

Incidentally Found Midtrimester Shortened Cervical Length: Practice Patterns among American Maternal-Fetal Medicine Specialists

OBJECTIVE

The management of incidentally found short cervical length (CL) without prior spontaneous preterm birth (PTB) can vary. While most agree on starting vaginal progesterone, management after CL shortens <10 mm varies. The purpose of this study was to elucidate current practice patterns amongst maternal-fetal medicine (MFM) specialists.

STUDY DESIGN

We conducted an online survey of MFM attending physicians and fellows in the United States from May 2019 to April 2020. The primary outcome was management of varying CL based on gestational age. Variations in management were assessed descriptively.

RESULTS

There were 236 respondents out of 400 eligible surveyed, with a response rate of 59.2%. Universal CL screening was reported by 93.6% (49.6% abdominal and 44.1% transvaginal). Management of short CL varied based on CL measurement, rather than gestational age at presentation. At CL <10 mm, management included cerclage (17.4-18.7%), vaginal progesterone (41.3-41.7%), or cerclage plus vaginal progesterone (43.4%). Between CL of 10 to 20 mm, the majority (77.4-91.9%) would start vaginal progesterone. At CL 21 to 25 mm, management varied between expectant management (45.5-48.5%) or vaginal progesterone (51.1-52.8%). Suture material used was ethylene terephthalate (47.4%) or polypropelene (31.2). Preoperative antibiotic use was reported by 22.3%, while 45.5% used them only if the amniotic membranes were exposed, and 32.2% reported no antibiotic use. Postoperative tocolytic use varied with 19.3% reporting no use, 32.6% using it always, 8.2% only after significant cervical manipulation, 22.7% after the patient is experiencing symptoms, and 17.6% using it only if the cervix is dilated on exam. After cerclage placement, 44.5% continued CL surveillance.

CONCLUSION

Substantial differences of opinion exist among MFM physicians regarding management of incidentally found short CL in patients without history of PTB. The differences in responses obtained highlight the need for evidence-based guidelines for managing this clinical scenario.

KEY POINTS

· There is lack of consensus on the management of incidentally found shortened CL.. · The purpose of this study was to elucidate current trends in CL screening and management.. · Substantial differences of opinion exist regarding management of incidentally found short CL..

Opening Pandora's box: abnormal genetic carrier screening and need for lifetime follow-up

OBJECTIVE

Expanded carrier screening (ECS) is rising in popularity because of its application in a diverse population, its decreasing cost, and efficiency.¹ However, it has traditionally been used to assess fetal risk. The next generation sequencing ECS panel offered at our academic medical center consists of 283 genes associated with hereditary disorders. Of those, 20 (7.1%) are autosomal recessive conditions, notable for variable expression of the clinical phenotype in heterozygous carriers, which may increase maternal risk for malignancy, bleeding, cardiovascular, or rheumatologic disease. Another 21 (7.4%) are X-linked conditions. We aimed to evaluate the prevalence of variants that have a potential for maternal phenotypic expression and whether identification of specific variants prompted patients to pursue further care in our health system, namely comprehensive genetic counseling and further healthcare consults when recommended.

STUDY DESIGN

An institutional review board-approved descriptive retrospective cohort study was performed in a New York City academic medical center at which reproductive aged women were offered universal ECS from 2018 to 2021 by their provider, inclusive of obstetrician-gynecologists, maternal-fetal medicine physicians, and genetic counselors. Pretest counseling was performed by the ordering provider. Patients found to carry mutations with the potential for maternal phenotypic expression were contacted by genetic counselors regarding their clinical risks. In addition, patients who were carriers for factor XI deficiency, Bernard Soulier syndrome, ataxia telangectesia, fumarase deficiency, Nijmegen breakage syndrome, Duchenne muscular dystrophy, and familial hypercholesterolemia were advised to seek specialized healthcare pertaining to their clinical risk. The genetic counseling summary was placed in the electronic medical records (EMRs) so that the primary provider could view the findings. Through our EMRs, we evaluated the rates of healthcare uptake among these patients for at least 1 year after delivery.

RESULTS

In total, 168 of 1184 (14.2%) patients were identified as carriers of mutations with a potential for maternal phenotypic expression. Of these, 156 (93%) were pregnant and 12 (7%) were preconception. Of those patients, 143 (85%) were carriers of autosomal recessive traits (Figure 1), whereas 22 of 168 (13%) patients were carriers of X-linked conditions (Figure 2) and 3 of 168 (2%) patients carried both autosomal recessive traits and X-linked conditions. Of these carriers, 132 of 168 (78.6%) patients underwent genetic counseling. The most common heterozygous mutations were sickle cell trait (25.6%), thalassemia (alpha and/or beta) trait (14.2%), factor XI deficiency (4.7%), dystrophic epidermolysis bullosa (4.2%), and Alport syndrome (4.1%). Two patients were diagnosed as homozygous carriers of nonclassical congenital adrenal hyperplasia. During the study period, 23 of 168 (13.6%) patients were heterozygous for specific pathogenic variants (inclusive of factor XI, Bernard Soulier syndrome, ataxia telangectesia, fumarase deficiency, Nijmegen breakage syndrome, Duchenne muscular dystrophy, and familial hypercholesterolemia) and were advised to seek specialized healthcare pertaining to these findings. Of these, 20 (87.0%) received genetic counseling with standardized recommendations, however, only 4 of 23 (17%) patients pursued the recommended referrals during our study period.

CONCLUSION

This study described the follow-up rates among patients identified as carriers of conditions with the potential for maternal phenotypic expression using ECS. We observed that 14.2% of patients who underwent ECS were identified as carriers of genetic mutations with the potential for maternal phenotypic expression, and of the 23 who were recommended specific care because a pathogenic variant was identified, only 17.4% of patients followed the recommendations. We believe that as ECS implementation becomes widespread, more maternal carriers with clinical risk to themselves will be identified. Therefore, as we open this Pandora's box, the burden of counseling and follow-up must be addressed.

An Electronic Medical Record Intervention to Increase Early Screening Rates for Gestational Diabetes

OBJECTIVES

 Our objective was to implement an electronic medical record reminder to perform the early gestational diabetes mellitus (GDM) screening test and to evaluate if this intervention increased screening rates.

STUDY DESIGN

 We performed a retrospective chart review of all deliveries at Mount Sinai West in January 2020 to determine the number of patients that met criteria for and actually underwent early GDM screening. A total of 314 patients had complete charts with pregnancy data. The following American College of Obstetricians and Gynecologists (ACOG)-defined risk factors were collected: body mass index greater than 25 (Asians greater than 23), history of GDM, history of macrosomia, hypertension (systolic >140 or diastolic >90), polycystic ovarian syndrome, hemoglobin A1c above 5.7, cardiovascular disease, and family history of diabetes. We used this data to advocate for and design an electronic medical record-based intervention to remind obstetric providers to complete the early glucose challenge test screening for eligible patients at the first prenatal visit.

RESULTS

 Our investigation confirms there is a low adherence rate of 12% at our facility to ACOG's updated early GDM screening guidelines (12 out of 97 patients). Furthermore, nearly one-fifth (16 out of 85) of eligible patients who did not receive screening were eventually diagnosed with GDM by screening at 24 to 28 weeks. After implementing an electronic medical record reminder at the initial prenatal visit, screening rates more than doubled to 28% (33 out of 115 eligible patients). The most common diabetic risk factors were high-risk ethnic background, current hypertension, family history of diabetes, history of polycystic ovarian syndrome, and body mass index of 40 or greater.

CONCLUSION

 Our data suggests that obstetricians could be missing an opportunity to improve maternal and neonatal outcomes by diagnosing GDM earlier in pregnancy, as recommended by ACOG. The adoption of an electronic medical record reminder seems to improve the rate of indicated early GDM screening.

KEY POINTS

· There is a low adherence rate of 16% to ACOG's updated early GDM screening guidelines.. · After implementing an electronic medical record alert at the initial prenatal visit, screening rates nearly doubled.. · Screening rates were higher at prenatal practices with resident physician involvement in patient care..

Resolved but Not Forgotten: The Effect of Resolved Placenta Previa on Labor Management

OBJECTIVES

Placenta previa is diagnosed in up to 15% of pregnancies at the anatomy ultrasound and 0.5% persist to term. There is limited data regarding pregnancy outcomes with resolved previa. We aimed to examine patients with resolved placenta previa to determine if abnormal placentation at any time during pregnancy is associated with adverse events during labor.

STUDY DESIGN

Patients with placenta previa were identified after second trimester ultrasound, included if placenta previa resolved with the placental edge greater than 2 cm from the internal cervical os, and excluded if placenta previa persisted to term, resolution occurred prior to 20 weeks, patients underwent a prior cesarean delivery, or delivered at an outside institution. Time-matched controls were identified among patients with normal placental location. Demographic data and outcomes were collected. Student's t-test, Wilcoxon's rank-sum test, Chi-square, Fisher's exact test, and univariable and multivariable logistic regression were used as appropriate RESULTS:  Overall, 560 patients had placenta previa, 275 had resolved placenta previa, 285 were excluded. Resolved placenta previa patients were significantly older with lower prepregnancy body mass index (BMI), were significantly more likely to be a current smoker, have used assisted reproductive technology, and have had previous uterine surgeries. Overall, 10.2% of patients with resolved placenta previa experienced postpartum hemorrhage, compared with 2.1% in the normal placentation group. Patients with resolved placenta previa were 5.2 times more likely to have a postpartum hemorrhage (odds ratio [OR] = 5.2, 95% confidence interval [CI]: 2.1-12.7; p < 0.01) and 3.4 times more likely to require extra uterotonic medications (OR = 3.4, 95% CI: 1.9-6.2; p < 0.01). There is no difference with regard to rates of operative delivery for fetal distress (OR = 1.2, 95% CI: 0.7-1.9; p = 0.48), or category-II or-III fetal heart tracing around the time of delivery.

CONCLUSION

Patients with resolved placenta previa had a higher rate of postpartum hemorrhage and use of uterotonic agents. This information might have important clinical implications and could be incorporated into the hemorrhage risk assessment during labor.

KEY POINTS

· This study aimed to determine if patients with resolved placenta previa had an increased risk of expedited delivery due to fetal distress during labor.. · Patients age with resolved placenta previa have similar risk factors to those with persistent placenta previa, including older maternal, lower prepregnancy BMI, current smoking status, use of assisted reproductive technology (ART) and history of previous uterine surgeries. They were not at increased risk for operative vaginal delivery or cesarean section due to fetal distress. They did require increased uterotonic use and were at an increased risk for postpartum hemorrhage. · Patients with resolved placenta previa should undergo hemorrhage precautions at the time of admission..

The role of the first trimester screen in the face of normal cell free DNA

OBJECTIVE

There is no consensus for the method of aneuploidy screening in pregnancy. Cell free DNA (cfDNA) is the most sensitive screen for trisomies 21, 13, and 18, however the first trimester screen (FTS) is a marker for other adverse outcomes, such as structural anomalies, growth restriction, and preeclampsia. In 2019, we offered FTS (nuchal translucency (NT) and analytes) with or without cfDNA. The purpose of this study was to assess clinical relevance of abnormal FTS in women with normal cfDNA.

METHODS

We retrospectively reviewed women undergoing screening in our Fetal Evaluation Unit in 2019. Women included had normal cfDNA and abnormal FTS; consisting of NT >95%, PAPP-A < 0.4 MoM, beta-HCG >2.5 MoM, or overall increased risk of trisomies.

RESULTS

195 patients had abnormal FTS and normal cfDNA. 41 (21%) had adverse maternal outcomes including hypertension, abnormal placentation, and placental abruption. 34 (17%) had adverse fetal outcomes including growth restriction, structural anomalies, fetal demise, polyhydramnios, previable PPROM, necrotizing enterocolitis after a preterm birth, and a balanced translocation.

CONCLUSION

Abnormal FTS predicts adverse outcomes in 33% of women with normal cfDNA. Our data suggests that offering universal FTS with cfDNA may have clinical benefit.

Intraoperative coagulopathy during cesarean section as an unsuspected initial presentation of COVID-19: a case report

BACKGROUND

The world's understanding of COVID-19 continues to evolve as the scientific community discovers unique presentations of this disease. This case report depicts an unexpected intraoperative coagulopathy during a cesarean section in an otherwise asymptomatic patient who was later found to have COVID-19. This case suggests that there may be a higher risk for intrapartum bleeding in the pregnant, largely asymptomatic COVID-positive patient with more abnormal COVID laboratory values.

CASE

The case patient displayed D-Dimer elevations beyond what is typically observed among this hospital's COVID-positive peripartum population and displayed significantly more oozing than expected intraoperatively, despite normal prothrombin time, international normalized ratio, fibrinogen, and platelets.

CONCLUSION

There is little published evidence on the association between D-Dimer and coagulopathy among the pregnant population infected with SARS-CoV-2. This case report contributes to the growing body of evidence on the effects of COVID-19 in pregnancy. A clinical picture concerning for intraoperative coagulopathy may be associated with SARS-CoV-2 infection during cesarean sections, and abnormal COVID laboratory tests, particularly D-Dimer, may help identify the patients in which this presentation occurs.

A case report of a pregnant woman diagnosed with intrahepatic cholangiocarcinoma (ICC) complicated by opioid tolerance

Background

Intrahepatic cholangiocarcinoma (ICC) is a rare form of cancer that has a poor prognosis with a 5-year survival rate for localized disease of approximately 15%.

Case presentation

This is a report of a case of cholangiocarcinoma (CC) diagnosed in pregnancy in a patient with an opioid use disorder. The patient is a 37-year-old G7P2042 who presented at 29 weeks of gestation with acute right upper quadrant pain along with jaundince, and changes to her urine and stool. Her workup revealed CC, a rare diagnosis in pregnancy. Approximately 6 months after the diagnosis of ICC the patient died.

Conclusion

Along with the management of this cancer in pregnancy, this case was further complicated by opioid tolerance and the difficulty in controlling the patient’s pain in pregnancy.

The importance of fasting blood glucose in screening for gestational diabetes

OBJECTIVE

To determine how well an isolated abnormal fasting blood glucose (FBG) value on the 1-step, 75-g, 2-hour glucose tolerance test (GTT) indicates significant gestational diabetes (GDM).

METHODS

Retrospective cohort study, January 2011 to May 2012. Patients diagnosed by the 1-step method were assigned by their abnormal results to the isolated fasting (FBG), isolated 1-hour (1HBG), isolated 2-hour (2HBG), or multiple-value (≥2BG) group. Characteristics and outcomes were compared using ANOVA, Kruskal--Wallis, and Chi-squared tests.

RESULTS

324 patients were included. Compared to other groups, the FBG group (N = 23) had the highest incidence of requiring medical therapy (78.26%), mean body mass index (29.40 ± 6.20 kg/m(2)), and percentage of Black plus Hispanic women (60.87%).

CONCLUSIONS

Seven percent of women were diagnosed with GDM by an isolated abnormal fasting BG and have significant disease. This group should not be missed; therefore, fasting BG should be integrated into all GDM screening.

Male-to-female gender ratio in fetuses with increased nuchal translucency

OBJECTIVE

To describe gender distribution in fetuses with increased nuchal translucency (NT) measurements.

METHODS

All fetuses with mild (2.5-2.9 mm) and moderate (3.0-3.5 mm) NT enlargement at 12.0-12.6 weeks gestation were studied. The Z test for proportions was used to compare the gender distribution of this study group to that of all babies born at Roosevelt Hospital in 2008, and to compare the gender distributions of the subgroups.

RESULTS

5109 patients received screening at 12.0-12.6 weeks gestation. 44 fetuses had mild and 28 had moderate enlargement, with a male-to-female ratio of 3.8:1.0, much higher than the 1.06:1.0 ratio among total births at Roosevelt Hospital in 2008 (p < 0.0001). Male-to-female ratio was 7.8:1.0 in fetuses with mild and 1.8:1.0 with moderate NT enlargement (p = 0.03). Among fetuses with mild NT enlargement, 3 males had aneuploidy; among those with moderate enlargement, 6 fetuses had aneuploidy, 3 males and 3 females. Seven pregnancies with aneuploidy were voluntarily terminated. All pregnancies carried to term were healthy.

CONCLUSIONS

More males than females had mild NT enlargement on first-trimester screening, but unless aneuploidy was detected they had normal birth outcomes. A slightly larger NT may be normal in males, while indicating possible fetal abnormalities in females.

Pre-eclampsia and gestational diabetes mellitus: does a correlation exist early in pregnancy?

OBJECTIVE

We investigated whether blood pressure profile early in pregnancy was associated with the development of pre-eclampsia in patients with gestational diabetes mellitus (GDM).

METHODS

A retrospective longitudinal database study of 1664 GDM subjects was performed. Systolic and diastolic blood pressure measurements were taken bi-weekly during the first and second trimesters. GDM patients who developed pre-eclampsia were compared to GDM patients who did not. Subjects were further stratified by maternal age, parity, race, prepregnancy body mass index (BMI) and weight gain during pregnancy. Logistic regression was performed to identify the net effect of each factor on the development of pre-eclampsia.

RESULTS

Overall, 167/1664 (10%) GDM patients developed pre-eclampsia. GDM patients who developed pre-eclampsia were more obese, gained more weight during pregnancy and had more severe GDM in comparison to GDM patients who did not. Although all mean blood pressure measurements were within the normal range, significantly higher systolic and diastolic values were recorded in the GDM patients who developed pre-eclampsia throughout the first and the second trimesters of pregnancy. Logistic regression revealed that higher parity (p = 0.04), maternal age (p = 0.03) and pre-pregnancy BMI (p = 0.03) were all contributing factors to pre-eclampsia. In contrast, weight gain during pregnancy and race were not related.

CONCLUSION

In GDM patients, higher blood pressure readings early in pregnancy, even prior to GDM diagnosis, were associated with the subsequent development of pre-eclampsia.