Universal versus selective gestational diabetes screening: application of 1997 American Diabetes Association recommendations

OBJECTIVE

We sought to evaluate the impact of the 1997 American Diabetes Association gestational diabetes mellitus screening guidelines applied to a universally screened population.

STUDY DESIGN

A retrospective analysis of 18,504 women universally screened for gestational diabetes mellitus at Mayo Clinic, Rochester, between January 1, 1986, and December 31, 1997, was performed. Diabetic screening consisted of plasma glucose determination 1 hour after a 50-g oral glucose challenge. Diagnosis of gestational diabetes mellitus was based on National Diabetes Data Group criteria.

RESULTS

Of 564 cases of gestational diabetes mellitus diagnosed during the study period, 17 (3.0%) would have been missed under the 1997 American Diabetes Association selective screening guidelines while exempting only 10% of this predominantly white population from screening. Screening only women >/=25 years old would have detected 90.4% of gestational diabetes mellitus cases, whereas the addition of the remaining 3 screening criteria combined would have detected only an additional 6.6% of cases.

CONCLUSIONS

The proportion of patients with gestational diabetes mellitus that would remain undiagnosed under the 1997 American Diabetes Association screening guidelines would be relatively small in our population. However, implementation of these guidelines would decrease the number of screens by only 10% while adding significant complexity to the screening process. Youth appears to be the most significant protective factor for gestational diabetes mellitus in our population.

Oral contraceptive use during the perimenopausal years

Few guidelines exist for the use of estrogen, particularly low-dose oral contraceptives, during the perimenopausal years. Use of low-dose oral contraceptive pills in women over 35 years of age provides protection against unwanted pregnancy, maintains a stable hormonal environment and decreases abnormal menstrual bleeding. Other noncontraceptive health benefits of oral contraceptives include a reduction in bone loss and protection against iron deficiency anemia, dysmenorrhea, benign breast disease, endometrial cancer and epithelial ovarian cancer. This article discusses potential risks of oral contraceptive use in this age group, as well as recommendations about when and how to change from contraceptive therapy to postmenopausal hormone replacement therapy.

Chronic appendicitis: does it exist?

The typical presentation of acute appendicitis is well known. A few patients, however, have had an atypical clinical course suggestive of recurrent appendiceal inflammation, which has been confirmed by appendectomy. Therefore, in the evaluation of a patient with abdominal pain, a history of similar episodes should not preclude a diagnosis of appendicitis.

Eclampsia complicating hydatidiform molar pregnancy with a coexisting, viable fetus. A case report

BACKGROUND

Eclampsia is a rare and serious complication of pregnancy. The occurrence of preeclampsia prior to the 20th week of gestation has been associated with concurrent hydatidiform molar pregnancy. We present a case of eclampsia complicating a partial molar pregnancy associated with a viable fetus.

CASE

A 22-year-old white woman, gravida 1, para 0, at 14 weeks' gestation, presented with an excruciating headache associated with hypertension, proteinuria and a viable intrauterine fetus with gastroschisis. Subsequently the patient had a generalized tonic-clonic seizure which resolved with magnesium sulfate therapy. Markedly elevated quantitative human chorionic gonadotropin and a moderately thickened placenta were the sole clinical features suggestive of a molar gestation. Dilation and evacuation was performed revealing unremarkable products of conception. Pathologic and cytogenetic analyses revealed a triploid fetus (69,XXX) consistent with partial molar pregnancy.

CONCLUSION

Development of preeclampsia/eclampsia prior to 20 weeks of gestation should prompt a clinical evaluation to exclude the possibility of an underlying hydatidiform molar pregnancy.

Levonorgestrel contraceptive implants in female patients 14 to 21 years old

OBJECTIVE

To determine which factors are associated with duration of use of a levonorgestrel implant (Norplant) for contraception in adolescents and young adults.

DESIGN

We retrospectively studied 144 young women (14 to 21 years of age) who chose a levonorgestrel contraceptive implant at Mayo Clinic Rochester between April 1990 and December 1993.

MATERIAL AND METHODS

The following information was obtained at the time of insertion of the implant and from any follow-up visits: demographics, prior contraceptive experiences, frequency and management of complications, complications noted at removal of the implant, and subsequent contraceptive choice. The duration of use was examined.

RESULTS

Of the 144 young women who underwent insertion of a Norplant system, 75 telephoned or made a medical appointment because of implant-related side effects. During the follow-up period, 64 patients had the Norplant system removed. The Kaplan-Meier estimate of the probability of the Norplant system remaining in place for at least 12 months was 83 % and for at least 24 months was 63 %. Duration of Norplant use was not found to differ with respect to age, prior contraceptive use, or timing of insertion, but it was significantly shorter among those with a prior pregnancy than in those who had never been pregnant.

CONCLUSION

These findings suggest that a group of young women who are likely to continue use of a contraceptive implant (with or without treatment for side effects) are those who have never been pregnant.

Pregnancy after pancreatic-renal transplantation because of diabetes

In this article, we describe two pregnancies in the same patient after pancreatic-renal transplantation. Severe, labile hypertension necessitated delivery at 35 weeks during the patient's first pregnancy and at 30 weeks (associated with renal graft obstruction) during her second pregnancy. Women with insulin-dependent diabetes mellitus who undergo pancreatic-renal transplantation can have a successful pregnancy if adequate multidisciplinary, specialized medical care is rendered.

Young Moms' Clinic: a multidisciplinary approach to pregnancy education in teens and in young single women

STUDY OBJECTIVE

To study outcome of pregnant adolescents and single young women who attended and those who chose not to attend a nonurban, developmentally appropriate, pilot antenatal clinic called the "Young Moms' Clinic." To study "perceived" outcome among the Young Moms' Clinic participants.

METHODS

A multidisciplinary clinic was established to provide education about pregnancy, childbirth, infant care, contraception, and healthy lifestyles to young mothers with similar backgrounds. Over a 2-year period, all adolescents and single young mothers aged 13-23 years were invited to attend the Young Moms' Clinic after the first trimester. The Clinic group consisted of the first 101 young women who were invited and chose to attend. The nonclinic group consisted of the first 95 young women who were invited but declined to attend. Both groups had the same obstetric care givers, had a similar number of prenatal visits (median number, 12), and delivered in the same hospital. Univariate and multivariate analyses were performed to determine whether participation in the clinic was an independent factor in outcome.

RESULTS

Maternal weight gain and infant birth weight were significantly higher in the Clinic group. Pregnancy complications (preterm labor, intrauterine growth retardation, anemia) were significantly higher in the nonclinic group. Participants in the nonclinic group were almost three times as likely to have cesarean section delivery as those in the Clinic group. Neonatal intensive care unit transfer occurred only in infants of the control group.

CONCLUSIONS

Participation of pregnant adolescent and young adult women from a nonurban community in a developmentally targeted pilot, prenatal program resulted in fewer pregnancy complications and improved outcome in comparison with those who chose not to participate in the program. The results may be subject to bias because of self-selection among participants.

Lung cancer complicating pregnancy: case report and review of literature

Lung cancer during pregnancy is rare. Herein we describe a case of metastatic cancer of the lung in a 36-year-old pregnant patient whose initial complaint was pain in the left thigh. Management of this neoplasm during pregnancy depends on the gestational age of the fetus and the potential operability of the tumor. Surgical, chemotherapeutic, and radiation management considerations are discussed.

Preterm labor and congenital candidiasis. A case report

Intrauterine infection with Candida is a rare complication of pregnancy. We report a case of preterm labor associated with Candida chorioamnionitis and the subsequent delivery of an infant with congenital Candida infection. We also discuss possible factors responsible for the increased invasiveness of this usually benign condition and management considerations once the diagnosis is made.

Vulvar cancer with bulky nodal metastasis in a young woman. A case report

We report a case of vulvar cancer (clinical stage IV, surgical stage III) that occurred in a young woman without identifiable risk factors. The patient underwent radical vulvectomy followed by adjuvant radiotherapy. She remained free of disease two years after diagnosis and treatment. Our case emphasizes the need to biopsy any suspicious vulvar lesions, even those in young patients. Furthermore, histologic evaluation is mandatory prior to ablation of vulvar lesions in any age group.

Identification of acute transplacental hemorrhage in a low-risk patient as a result of daily counting of fetal movements

In this report, we describe a case of acute, massive fetomaternal hemorrhage that was detected during the 32nd week of pregnancy by maternal perception of decreased fetal movement and suggestion of a sinusoidal heart rate pattern. Additional evaluation revealed an abnormal biophysical profile (2 of 10) and intermittent late decelerations. Because of the substantially decreased fetal reserve, cesarean section was emergently performed. A 1,880-g female infant was delivered. She had an initial hemoglobin concentration of 1.9 g/dl and a hematocrit of 5.7% but did well after appropriate transfusion therapy. This case confirms the importance of daily counting of fetal movements in low-risk patients. In addition, it emphasizes that early diagnosis and treatment of massive fetomaternal hemorrhage can improve infant survival.

Colonic cancer during pregnancy: case report and review of the literature

Colonic cancer during pregnancy is rare. Herein we describe a case of adenocarcinoma of the transverse colon in a 29-year-old pregnant patient. Early diagnosis is difficult because the initial symptoms of colorectal cancer, such as abdominal pain, nausea and vomiting, constipation, and abdominal distention, are often attributed to a normal pregnancy. Management of colonic cancer during pregnancy depends on gestational age and operability of the tumor. Medical and surgical management considerations are discussed.

Giant ovarian leiomyoma associated with ascites and polymyositis

BACKGROUND

Primary ovarian leiomyoma is rare. Most cases are asymptomatic; this benign neoplasm is usually found incidentally on routine pelvic examination, at surgery, or at autopsy.

CASE

We present what we believe to be the first case of ovarian leiomyoma associated with ascites and polymyositis, both of which resolved after oophorectomy. This case emphasizes the important fact that preoperative evaluation may be inaccurate.

CONCLUSION

Excision of a pelvic mass with histologic evaluation remains the only reliable way to establish a diagnosis.

Epidural abscess associated with intravenous drug abuse in a pregnant patient

The association between intravenous drug abuse and epidural abscess is well known; however, this association has not previously been reported in a pregnant patient. The classic manifestation of epidural abscess is a febrile patient with back pain that progresses rapidly to radicular pain, spinal cord dysfunction, weakness, and then complete paralysis. Although this condition is rare during pregnancy, these serious complications necessitate prompt diagnosis and intervention. If spinal infection is suspected, magnetic resonance imaging should be performed immediately. After epidural abscess is diagnosed, emergent decompressive laminectomy and appropriate antibiotic coverage are necessary. Herein we describe a 27-year-old pregnant patient with epidural abscess probably related to use of contaminated needles for intravenous administration of drugs and subsequent hematologic spread of staphylococci to the epidural space. The differential diagnosis of epidural abscess can be difficult, and management options must consider the well-being of both the mother and the fetus.

Uterine incarceration during the third trimester: a rare complication of pregnancy

Uterine incarceration that manifests during the third trimester or at term is a serious and rare complication of pregnancy. The pregnant patient may complain of low-abdominal pain, low-back pain, urinary retention, and constipation, or the patient may be asymptomatic until labor begins. The diagnosis is difficult, and physical findings can be misleading. Ultrasonography and magnetic resonance imaging can be helpful if the anteriorly displaced cervix is clearly depicted. If incarceration of the retroverted uterus persists until term, a cesarean section is necessary. Recurrent uterine incarceration has been reported; therefore, the patient should be monitored closely during subsequent pregnancies. Herein we describe three cases of uterine incarceration during the third trimester and review the literature with respect to incidence, differential diagnosis, management, and complications of this condition.

Spontaneous renal rupture during pregnancy

Spontaneous rupture of the renal parenchyma or renal pelvis during pregnancy has been previously reported in 16 cases. In the case we describe in this report, the patient initially had right flank pain and nausea for 48 hours, which progressed to severe abdominal symptoms that necessitated exploratory laparotomy. Cystoscopic placement of a ureteral stent relieved the obstruction and allowed spontaneous healing of the renal pelvis. Dilatation of the urinary collecting system commonly occurs during pregnancy. Spontaneous rupture of the renal parenchyma or renal pelvis, however, is unusual and often associated with diseased kidneys. Our case is the 8th one of spontaneous rupture of the renal collecting system with no identifiable underlying pathologic condition and the 17th case of spontaneous renal rupture overall.

A proposal for obstetric and pediatric management of adolescent pregnancy

Of the 1 million pregnancies among adolescents in the United States each year, approximately 500,000 result in live births. These pregnancies are at high risk but are amenable to obstetric and pediatric intervention. Medical, social, and economic risks for both the adolescent mother and her infant are substantially decreased by early and comprehensive prenatal care. A combined obstetric and pediatric protocol for the management of adolescent pregnancy can improve both the perinatal and the long-term outcome.

Panic attack syndrome

Panic attack syndrome in four generations of a family and in six additional pediatric patients is reported. The syndrome appears to have an autosomal dominant mode of inheritance. Diagnosis of panic attack syndrome in children has not been reported previously, but the existence of this disorder has been noted for at least 100 years under various synonyms. There is substantial evidence that the syndrome has an endogenous origin and is therefore a biochemical illness. The triggering effect of sodium lactate infusion and the alleviation of symptoms by use of monoamine oxidase inhibitors or beta-blocking agents support this view. Imipramine hydrochloride, propranolol hydrochloride, phenelzine sulfate, and alprazolam are often useful in the treatment of panic attacks, and except for propranolol, any of them may be effective against depression also.