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OBJECTIVE: To investigate differences in maternal and fetal outcomes among pregnant patients with chronic hypertension requiring antihypertensives for adequate control versus those who do not require antihypertensives. STUDY DESIGN: Single-site retrospective cohort study including pregnant patients with chronic hypertension from 2015-2018. Two groups included those who required antihypertensives versus those who did not. Primary outcome is composite morbidity: pregnancy loss after 20 weeks, IUGR, maternal death, maternal stroke or TIA, pulmonary edema, renal failure, hypertensive emergency, HELLP syndrome, placental abruption or delivery before 34 weeks. Secondary outcomes included development of severe features, indication for preterm labor less than 37 weeks, incidence of severe range blood pressures, and neonatal outcomes. Student t, chi square, and Kruskal-Wallis tests where appropriate. Logistic regression used to account for potential confounders. RESULTS: Study cohort included 117 on antihypertensives and 114 not on antihypertensives. Use of antihypertensives was associated with the composite primary outcome (Odds ratio [OR], 3.88; 95% confidence interval [CI], 1.66-9.78). Use of antihypertensive medications was also associated with increased risk of prenatal diagnosis of IUGR, delivery prior to 34 weeks, development of severe features, severe blood pressure during pregnancy, earlier mean gestational age at delivery, lower mean birth weight, and higher risk of NICU admission. Logistic regression analysis showed that the association between medication requirement and our composite primary outcome persisted even after adjustment for age, BMI, and presence of gestational diabetes. CONCLUSION: Our findings show an association between the requirement of antihypertensive medication use a significantly higher risk of composite primary outcome, prenatal diagnosis of IUGR, delivery prior to 34 weeks, and the development of severe features.

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The objective of this study was to compare the frequency of abnormal fetal growth in women with diabetes mellitus (DM) using population-based birth weight (pop BW) percentiles compared with customized birth weight (cust BW) percentiles, which include adjustments for maternal race, parity, height, weight, and fetal sex. The study design comprised a retrospective cohort of singleton DM pregnancies delivered over a 1-year period (June 2007 to May 2008) from a single tertiary care university-based medical center. Inclusion criteria were gestational age >20 weeks at delivery, live birth, and absence of major chromosomal/structural abnormalities. Small for gestational age (SGA), <10th percentile, and large for gestational age (LGA), >90th percentile pregnancies were categorized based on pop BW or cust BW standards. There were significant differences in the rates of SGA (p < 0.004) and LGA (p < 0.001) between cust BW and pop BW methods. When comparing the two methods, pop BW did not identify 13/16 (81%) of SGA and 23/39 (59%) of LGA babies defined by cust BW methods. The use of cust BW calculation in a diabetic population identified a greater percentage of neonates with pathologic fetal growth compared with pop BW standards, suggesting that the population standard may underdiagnose abnormal fetal growth in diabetic pregnancies.

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We sought to determine the frequency of excessive gestational weight gain (GWG) and its impact on perinatal outcomes in women with gestational (GDM) and pregestational diabetes mellitus (DM). A retrospective cohort of diabetic women was studied. GWG was categorized by the 2009 Institute of Medicine guidelines. Perinatal outcomes were compared between those women with and without excessive GWG. There were 153 women who met study criteria. There was no difference in excessive GWG between women with GDM and pregestational DM (44.4% versus 38.5%, P = 0.51) or based on White's class ( P = 0.17). After adjusting for confounders, excessive GWG was not associated with an increased rate of adverse perinatal outcomes (odds ratio 1.49, 95% confidence interval 0.56 to 2.35) and had similar associations with both pregestational DM and GDM. Although excessive GWG was common in our diabetic population, it was not associated with an increased rate of adverse perinatal outcomes.

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We sought to examine the diversity and extent of sequence variations in GLUT1 in patients with myelomeningocele (MM) and to identify variations conferring risk of MM. Sequences of the 10 exons and exon-intron boundaries of GLUT1 for 96 patients with MM (48 Caucasians and 48 Mexican Americans) were determined by direct sequencing of DNA. Two new variants were identified. One is located within intron 7 (c.972+17t>a), 17 bases from exon 7. The other is within exon 8 (c.1016T>C) and results in an amino acid change at isoleucine 339 (p.Ile339Thr). A 10 base pair (bp) deletion within intron 9 was genotyped for 457 patients with MM and showed it to be more common in Caucasian MM patients than in Caucasian controls (P = .02). The physiologic role of the 2 newly identified variants in the GLUT1 gene and the 10 bp deletion associated with risk of MM in Caucasian patients is under investigation.

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In the United States, preterm birth rates continue to rise. Many reasons account for this increase, such as demographic changes, infertility treatments, increases in maternal age, more multiple gestations, increasing obesity rates, and maternal comorbid conditions. The American College of Obstetricians and Gynecologists suggests that preterm birth rates have also increased because of a dramatic rise in late preterm births, defined as births between 34 weeks and 36-6/7 weeks of gestation. Late preterm newborns are the fastest growing subset of neonates, accounting for approximately 74% of all preterm births and about 8% of total births. Reviewed is the current literature with regard to the growing problem of late preterm birth to provide the reader with a comprehensive overview of the burden of late preterm birth and to reassess the clinical opinion regarding timing of delivery.

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Total anomalous pulmonary venous return (TAPVR) is a congenital heart malformation that can be diagnosed in the fetus by indirect indicators on an echocardiogram, such as inability to demonstrate the pulmonary veins returning to the left atrium by color Doppler, the presence of a chamber or the pulmonary venous confluence behind the left atrium, presence of a dilated superior vena cava, discrepancy between the right and left heart chambers and great arteries, and the demonstration of the ascending or descending common pulmonary vein or vertical vein. Some cases of TAPVR can be missed in utero, especially in a mixed type of TAPVR or a TAPVR associated with complex cardiac malformation. We report a case of a mixed TAPVR with complex cardiac malformation which was diagnosed in the fetal period by direct visualization of anomalous pulmonary venous drainage and was confirmed by postnatal echocardiogram and cardiac magnetic resonance imaging.

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OBJECTIVE: To estimate the rate of vaginal birth after cesarean delivery (VBAC) success in diabetic women based on White's Classification. METHODS: This is a secondary analysis of an observational study conducted at 19 medical centers of women attempting VBAC. Diabetic women with singleton gestations, one prior cesarean delivery, and cephalic presentation who underwent a trial of labor were included. Vaginal birth after cesarean delivery success rates and maternal and neonatal complications were compared based on White's Classification. RESULTS: Of 11,856 women who underwent trial of labor, 624 met all study criteria (class A1, 356; A2, 169; B, 70; C, 21; D/R/F, 8). Vaginal birth after cesarean delivery success in each group was: A1, 68.5% (95% confidence interval [CI] 63.4-73.3%); A2, 55% (95% CI 47.2-62.7%); B, 70% (95% CI 57.9-80.4%); C, 47.6% (95% CI 25.7-70.2%); and D/F/R, 12.5% (95% CI 0.3-52.7%). Maternal and neonatal complications were rare and not found to be different among groups. CONCLUSION: Our study provides estimates for VBAC success based on White's classification and indicates a relatively low rate of perinatal complications after VBAC attempt for diabetic women. LEVEL OF EVIDENCE: III.

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White's classification system (WCS) was created 60 years ago to identify diabetic (DM) pregnancies at increased risk for perinatal morbidity and mortality. Our objective was to assess the association between WCS and adverse pregnancy outcome (APO) in contemporary DM pregnancies. We studied diabetic women with singleton pregnancies who delivered at >20 weeks at a single institution over a 1-year period (2007 to 2008). Perinatal outcomes were compared between WCS groups. APO was defined as any of the following: preterm birth <34 weeks, severe preeclampsia, shoulder dystocia, and neonatal respiratory disease. Presence of vascular disease was defined as presence of chronic hypertension, chronic renal insufficiency, retinopathy, coronary artery disease, or prior cerebrovascular event. One hundred ninety-six DM pregnancies met the criteria. No significant differences in APO existed between White's class groups among women with pregestational DM (32.7% class B versus 26.9% class C versus 57.1% class D to F; p = 0.46). Logistic regression revealed that vascular disease was associated with APO (odds ratio = 2.7, 95% confidence interval = 1.2 to 6.2). In our population, presence of vascular disease, rather than WCS, was a better predictor of APO in DM women.

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UNLABELLED: Urolithiasis complicates up to one in every 200 pregnancies; consequently, the practicing obstetrician should be aware of the symptoms of urolithiasis, the diagnostic procedures available for its diagnosis, and their associated risks. These include ultrasound, urography, and magnetic resonance imaging. Diagnosis of urolithiasis during pregnancy can be a challenge as a result of the normal physiological changes of pregnancy. Conservative management is the first-line treatment for noncomplicated urolithiasis in pregnancy. If spontaneous passage of the stone does not occur or if complications develop, urologic consultation should be obtained. Several obstetric complications have been associated with urolithiasis, including preterm labor and preterm premature rupture of membranes, although the reported rates of these complications in association with urolithiasis vary widely and overlap normal background rates. Given that urolithiasis will be encountered by most obstetricians, and that obstetricians are often on the front line of management for this condition, an appreciation of current diagnostic modalities, treatment protocols, and associated potential obstetric complications is warranted. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to recall that urolithiasis is common in pregnancy, state that there are a variety of diagnostic procedures, summarize that conservative treatment is usually successful, and explain that complications of pregnancy usually occur when there is failure of conservative treatment.

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