Antenatal insulin therapy in gestational diabetes mellitus: validation of the new Brugmann scores

BACKGROUND

Following the adoption of the International Association of Diabetes and Pregnancy Study Group (IADPSG) criteria for gestational diabetes mellitus (GDM) diagnosis by the World Health Organization (WHO) in 2014, many investigators have tried to identify independent risk factors for antenatal insulin therapy (AIT). The purpose of the current study is to build and validate a score that stratifies patients according to their need for AIT.

METHODS

All pregnant women diagnosed with GDM according to the IADPSG definition were included. Group 1 comprised patients of 2018, and group 2 comprised patients of 2019. Each group was divided into two subgroups: subgroup A comprised patients diagnosed according to the 75-g oral glucose tolerance test (OGTT), and subgroup B comprised patients diagnosed according to fasting plasma glucose (FPG).

RESULTS

A total of 1298 patients were included; 19.3% of those diagnosed by OGTT and 40.9% by FPG required AIT. The risk for AIT was stratified as low, moderate, and high. Brugmann FPG score comprised six risk factors and Brugmann OGTT score 12. Higher scores were associated with higher risk for AIT. The use of these scores in the two subgroups of group 2 showed no statistical differences compared to group 1.

CONCLUSIONS

Both Brugmann FPG and OGTT scores may be useful to stratify patients with GDM according to their need for AIT. Future studies should be conducted to prospectively validate these scores, and to examine whether or not using oral anti-hyperglycemic agents in a high-risk group may decrease the need for AIT.

Use of spatiotemporal image correlation at 11-14 weeks' gestation

OBJECTIVE

To assess prospectively the use of four-dimensional (4D) spatiotemporal image correlation (STIC) in the evaluation of the fetal heart at 11-14 weeks' gestation.

METHODS

The study involved offline analysis of 4D-STIC volumes of the fetal heart acquired at 11-14 weeks' gestation in a population at high risk for congenital heart disease (CHD). Regression analysis was used to investigate the effect of gestational age, maternal body mass index, quality of the 4D-STIC volume, use of a transvaginal vs transabdominal probe and use of color Doppler ultrasonography on the ability to visualize separately different heart structures. The accuracy in diagnosing CHD based on early fetal echocardiography (EFE) using 4D-STIC vs conventional two-dimensional (2D) ultrasound was also evaluated.

RESULTS

One hundred and thirty-nine fetuses with a total of 243 STIC volumes were included in this study. Regression analysis showed that the ability to visualize different heart structures was correlated with the quality of the acquired 4D-STIC volumes. Independently, the use of a transvaginal approach improved visualization of the four-chamber view, and the use of Doppler improved visualization of the outflow tracts, aortic arch and interventricular septum. Follow-up was available in 121 of the 139 fetuses, of which 27 had a confirmed CHD. A diagnosis based on EFE using 4D-STIC was possible in 130 (93.5%) of the 139 fetuses. Accuracy in diagnosing CHD using 4D-STIC was 88.7%, and the results of 45% of the cases were fully concordant with those of 2D ultrasound or the final follow-up diagnosis. EFE using 2D ultrasound was possible in all fetuses, and accuracy in diagnosing CHD was 94.2%. Five of the seven false-positive or false-negative cases were minor CHD.

CONCLUSIONS

In fetuses at 11-14 weeks' gestation, the heart can be evaluated offline using 4D-STIC in a large number of cases, and this evaluation is more successful the higher the quality of the acquired volume. 2D ultrasound remains superior to 4D-STIC at 11-14 weeks, unless volumes of good to high quality can be obtained.

Arabin cervical pessary in women at high risk of preterm birth: a magnetic resonance imaging observational follow-up study

OBJECTIVE

To help elucidate the mechanism of action of the Arabin cervical pessary in pregnancies at high risk for preterm delivery.

METHODS

Cervical length and uterocervical angle were evaluated in relation to gestational age in 198 pregnancies not at high risk for preterm birth that underwent clinical fetal magnetic resonance imaging (MRI). Additionally, in 73 singleton pregnancies at high risk for preterm birth, an Arabin cervical pessary was placed at 14-33 weeks' gestation. We performed MRI of the cervix immediately before and after placement and at monthly follow-up until removal of the pessary. In a subgroup of 54 pregnancies with a short cervix and pessary placement at 17-31 weeks' gestation, the uterocervical angle and cervical length at follow-up were compared with the preplacement values.

RESULTS

In pregnancies not at high risk for preterm birth, the uterocervical angle did not vary, but cervical length showed a significant decrease with gestational age (r = -0.15, P < 0.05). Among the high-risk patients, the cervical pessary was successfully placed at first attempt in 60 (82.2%) and by the second attempt in 66 (90.4%), remaining well positioned until removal. In five patients we failed to place the pessary after two attempts, in one patient the pessary dislodged during follow-up and in one case the pessary was partly placed in the external cervical canal and triggered labor the next day. Among the subgroup of 54 patients, the median uterocervical angle immediately after pessary placement was significantly more acute than that prior to placement in the 46 (85.2%) who delivered after 34 weeks (132° vs 146°, P < 0.01), but was unchanged in the eight patients who delivered before 34 weeks (143° vs 152°, P > 0.05).

CONCLUSION

In patients at high risk for preterm delivery, correct placement of the Arabin cervical pessary should be checked immediately; this can be performed quickly and easily using MRI. This study provides some evidence that, in singleton pregnancies with a short cervix, a cervical pessary delays birth through a mechanical effect on the uterocervical angle.

Fetal weight estimation: comparison of two-dimensional US and MR imaging assessments

PURPOSE

To prospectively define fetal density in the second half of pregnancy by using magnetic resonance (MR) imaging and to compare estimates of fetal weight based on ultrasonography (US) and MR imaging with actual birth weight.

MATERIALS AND METHODS

Written informed consent was obtained for this ethics committee-approved study. In this cross-sectional study between March 2011 and May 2012, fetal density was calculated as actual birth weight at delivery divided by fetal body volume at MR imaging in 188 fetuses between 20 weeks and 2 days and 42 weeks and 1 day of gestational age. Regression analysis was used to investigate the effect of variables, including sex, on fetal density. The US estimate of fetal weight was performed according to Hadlock et al, and the MR estimate of fetal weight was calculated based on the equation developed by Baker et al. US and MR estimates of fetal weight were compared with actual birth weights by using regression analysis.

RESULTS

Median fetal density was equal to 1.04 (range, 0.95-1.18). Fetal density was significantly associated with gestational age at delivery but not with fetal sex. In 26.6% of fetuses, the US estimate of fetal weight had a relative error of more than 10%, while a similar relative error for the MR estimate of fetal weight occurred in only 1.1% of fetuses. The limits of agreement were narrower with the MR estimate of fetal weight compared with the US estimate of fetal weight.

CONCLUSION

In the second half of pregnancy, fetal density varies with gestational age. Fetal weight estimates by using fetal MR imaging are better than those by using prenatal US.

Virtual autopsy by computed tomographic angiography of the fetal heart: a feasibility study

OBJECTIVE

To determine the feasibility of postmortem computed tomographic (pm-CT) angiography for fetal heart evaluation.

METHODS

Following termination of pregnancy (TOP) or intrauterine fetal death (IUFD) beyond 18 weeks' gestation, 33 fetuses were examined by pm-CT; in eight contrast medium was injected through the umbilical cord and in 25 contrast medium was injected directly into the heart. Logistic regression analysis was used to investigate the effect on the ability to visualize cardiac structures on pm-CT angiography of gestational age at TOP or delivery following IUFD, the time delay between fetal death and examination, the technique used for contrast-medium injection, the presence of cardiac abnormalities and whether or not there was IUFD. The diagnostic accuracy of pm-CT angiography for the evaluation of fetal cardiac structures was also evaluated.

RESULTS

Cardiac anatomy including heart situs, the four-chamber view and great vessels could be visualized on pm-CT angiography in 29 out of 33 fetuses (87.9%). Logistic regression analysis showed that the ability to visualize cardiac structures on pm-CT angiography was positively correlated only with contrast medium injected directly into the heart. Twenty-five out of the 33 fetuses underwent conventional autopsy. There were five cases with suspected major cardiac abnormality at prenatal ultrasound and one with a minor cardiac abnormality. In one of these cases, severe leakage into the pleural cavity did not allow for visualization of any heart structure on pm-CT angiography and in another invasive autopsy was declined. In two of the remaining four cases, the findings on pm-CT angiography and invasive autopsy were in agreement, while in two a ventricular septal defect was found on invasive autopsy but not on pm-CT. None of the 27 cases with normal hearts was falsely classified as abnormal using pm-CT angiography.

CONCLUSION

Pm-CT angiography by direct injection into the heart seems to be a feasible method for its evaluation. The extent to which such a technique could be used for the evaluation of congenital heart disease as an alternative to classical postmortem autopsy remains to be determined.

Use of a high-frequency linear transducer and MTI filtered color flow mapping in the assessment of fetal heart anatomy at the routine 11 to 13 + 6-week scan: a randomized trial

OBJECTIVE

To prospectively assess the contribution of a high-frequency linear transducer and of moving target indicator (MTI) filtered color flow mapping in the visualization of cardiac fetal anatomy at the routine 11 to 13 + 6-week scan.

METHODS

This was a cross-sectional prospective study, including 300 singleton fetuses at 11 to 13 + 6 weeks' gestation. Patients were randomized into four groups and a detailed fetal cardiac examination was conducted transabdominally using either a conventional curvilinear transducer, a conventional curvilinear transducer and MTI filtered color flow mapping, a high-frequency linear transducer or a high-frequency linear transducer and MTI filtered color flow mapping. Regression analysis was used to investigate the effect on the ability to visualize different cardiac structures of the following parameters: gestational age at ultrasound examination; fetal crown-rump length (CRL); maternal body mass index (BMI); transducer-heart distance; the technique used at ultrasound; and the position of the placenta.

RESULTS

The four-chamber view was visualized in 89.0% of fetuses and regression analysis showed this rate was correlated with CRL and the use of MTI filtered color flow mapping during ultrasonography, and inversely correlated with BMI and transducer-heart distance. Use of a conventional curvilinear transducer and MTI filtered color flow mapping allowed visualization of the four-chamber view in 97.3% of fetuses, while this was only possible in 84.0% of fetuses using a high-frequency linear transducer. The left and right outflow tracts were visualized in 62.3 and 57.7% of fetuses, respectively. Regression analysis showed that the ability to visualize the left or the right outflow tract was correlated with the use of MTI filtered color flow mapping during scanning and was inversely correlated with transducer-heart distance. The use of a conventional curvilinear transducer and MTI filtered color flow mapping allowed visualization of the left and right outflow tracts in 96.0 and 97.3% of fetuses, respectively, while this was only possible in 37.3 and 26.7% of fetuses using a high-frequency linear transducer.

CONCLUSIONS

During the routine 11 to 13 + 6-week scan, the use of MTI filtered color flow mapping but not of a high-frequency linear transducer, improves visualization of cardiac anatomy.

[Prevalence of Aeromonas spp. pediatric gastroenteritis]

A selective medium and biochemical tests were used to search for Aeromonas spp. in the stools of 536 children, more than 90% of whom had "gastroenteritis", seen at Sainte-Justine Hospital, Montreal, in June or July 1986. The organism was found in seven children, six of whom had bloody diarrhea. One of the six, a 6 1/2-year-old boy, required intravenous alimentation and later manifested ulcerative colitis; the other five recovered. The remaining child, a 14-year-old boy, had synovitis of the knee and spondylarthritis. Two of the seven carried other enteric pathogens. The authors discuss the pathogenicity of Aeromonas spp., which is not very marked in temperate climates, in human summer diarrhea and its possible role in the development of ulcerative colitis.

Photoperiod, diet, and method of feeding on reproduction

Effects of two lighting programs and three methods of feeding on semen production of Large White turkey males were investigated. Lighting programs of 14L:10D and 8L:16D were used during the reproduction period. The feeding programs consisted of: 1) a low protein ration (10% FF) containing 3,250 kcal ME/kg fed ad libitum, 2) a high protein ration (15% FF) fed ad libitum, and 3) a restricted intake high protein ration (15% R). The latter two diets contained 3,000 kcal ME/kg. Body weight, semen volume, and semen quality (sperm and seminal plasma protein concentrations) were measured weekly throughout the reproductive cycle from 26 to 52 weeks. There was no significant difference in the rate of weight gain of turkeys kept on 8L:16D and 15% FF from 16 to 52 weeks compared to those on 14L:10D and 15% FF. Decreasing protein from 15 to 10% and increasing energy levels of the diet decreased consumption significantly (P less than .05) from 16 to 52 weeks of age regardless of the light treatment. Mortality was lowest in the 10% FF and highest in the 15% R. Lighting treatment of 14L:10D significantly (P less than .05) increased semen volume and sperm concentration vs. the 8L:16D regimen. All the groups of males given 8L:16D had an endemic yellow semen syndrome (YSS) characterized by a combination of an elevated seminal plasma protein concentration (an average of 12.85 g/100 ml), abnormal spermatozoa, and numerous macrophages. Previous work is confirmed (Cecil, 1981) that low dietary protein can be used as a means of controlling body weight without any adverse effect on semen production or semen quality of Large White turkey breeder males.

Benign familial neonatal convulsions

Benign familial neonatal convulsions are a rare genetic seizure disorder inherited as an autosomal dominant trait. They consist of brief episodes of seizures, recurring during the first few days or weeks of life in otherwise normal babies; their prognosis is good. We report a family in which at least 12 members in three generations presented with this condition; they all had an excellent outcome.

[Trichopoliodystrophy or Menkes disease]

Trichopoliodystrophy (also known as Menkes' kinky or steely hair disease), a recessive sex-linked syndrome, is characterized by severely retarded mental and physical development, convulsions, a particular phenotype and abnormalities of the hair, bones and arteries. Very low levels of copper and ceruloplasmin in the serum confirm the diagnosis. This rare disorder is caused by an inborn error of copper metabolism whose nature is not yet clear. Recent hypotheses favour either an abnormality in the transport of copper across the cell membrane or increased affinity for copper of the intracellular binding protein. Because the metabolic abnormality is expressed autonomously and irregularly in various tissues, the distribution of copper within the body is disordered. Up to now none of the many forms of copper therapy has succeeded in modifying the fatal course of the disease in humans. This article presents a new case, the first in Canada, and a review of the other 69 cases described in the literature. The new case illustrates, in addition to the classic picture, less well known features, such as diverticula of the bladder mucosa and serosa, as well as cortical atrophy and malformed cerebral vessels demonstrated by computer-assisted tomography.