Faculty Bibliography

OBJECTIVE: To examine the impact of maternal obesity on maternal and neonatal outcomes in pregnancies complicated with gestational diabetes mellitus (GDM). METHODS: Women with singleton pregnancies and GDM enrolled in an outpatient GDM education, surveillance and management program were identified. Maternal and neonatal pregnancy outcomes were compared for obese (pre-pregnancy BMI >/= 30 kg/m(2)) and non-obese (pre-pregnancy BMI < 30 kg/m(2)) women and for women across five increasing pre-pregnancy BMI categories. RESULTS: A total of 3798 patients were identified. Maternal obesity was significantly associated with the need for oral hypoglycemic agents or insulin, development of pregnancy-related hypertension, interventional delivery, and cesarean delivery. Adverse neonatal outcomes were also significantly increased including stillbirth, macrosomia, shoulder dystocia, need for NICU admission, hypoglycemia, and jaundice. When looking across five increasing BMI categories, increasing BMI was significantly associated with the same adverse maternal and neonatal outcomes. CONCLUSION: In women with GDM, increasing maternal BMI is significantly associated with worse maternal and neonatal outcomes.

We sought to estimate the association of several maternal risk factors with intrauterine growth restriction (IUGR) in twin pregnancies. This is a case-control study of 313 patients with twin pregnancies delivered greater than 24 weeks between June 2005 and January 2010. We used three definitions of IUGR: (1) either twin with a birth weight < 10th percentile for gestational age; (2) either twin with a birth weight < 5th percentile for gestational age; and (3) birth-weight discordance >/= 20%. Using each definition of IUGR, we estimated the association between IUGR and maternal age, weight, monochorionicity, in vitro fertilization, pregnancy reduction, thrombophilia, hypertension, and diabetes. Overall, 47% of patients delivered at least one twin with a birth weight <10th percentile, 27% of patients delivered at least one twin with a birth weight <5th percentile, and 16% of patients had birth-weight discordance of >/=20%. Using any of these three definitions for IUGR in twin pregnancies, there was no significant association between IUGR and any of the risk factors examined. This remained true when we excluded all patients who delivered <34 weeks. IUGR is very common in twin pregnancies. However, in twin pregnancies, IUGR cannot be predicted by maternal risk factors.

The objective of this study is to evaluate neonatal and maternal outcomes of multiple gestations undergoing delayed-interval delivery at a single institution. A 10-year retrospective review of medical records of patients followed by a Maternal-Fetal Medicine practice in a university-based setting was performed. Patients met criteria for inclusion if a single fetus was delivered spontaneously between 16 and 28 weeks of gestation and a planned attempt was made to prolong the gestation for the remaining fetus(es). Nineteen pregnancies met criteria for inclusion. The median gestational age at delivery of the first fetus was 20 (2)/ (7) weeks and the last fetus was 25 (1)/ (7) weeks. The median latency was 16 days (range 0 to 152 days). Three patients (15.8%) delivered within 24 hours. There was a 15.8% survival rate for the firstborn fetus and a 53.8% survival rate for all retained fetuses ( P = 0.01). There was a 31.6% incidence of serious maternal morbidity related to the procedure. One patient required a postpartum hysterectomy due to massive hemorrhage and uterine atony. Delayed-interval delivery is associated with a higher neonatal survival rate when retained fetuses are compared with firstborn fetuses. However, the procedure is associated with a significant risk of serious maternal morbidity

We evaluated the added benefit of a comprehensive counseling protocol for first-trimester aneuploidy risk assessment. We performed a prospective cohort study surveying patients referred for first-trimester aneuploidy risk assessment. We compared responses between women who underwent serum testing done in advance of their ultrasound such that their final risk assessment was given to them the same day as their ultrasound (comprehensive) versus women who underwent serum testing the same day as their ultrasound and who therefore received their final risk assessment later (standard). Response rate was 94.8%. The comprehensive group was significantly more likely to receive counseling in accordance with recommended American College of Obstetricians and Gynecologists (ACOG) guidelines, had significantly greater reduction in anxiety and increased satisfaction, and was more likely to report an increased understanding of their results. The comprehensive group scored significantly higher on test-style questions about aneuploidy risk assessment. Comprehensive aneuploidy risk assessment counseling including same-day results is associated with increased patient understanding and satisfaction, decreased anxiety, and increased adherence to ACOG guidelines.

OBJECTIVE: To compare maternal and neonatal outcomes in obese vs. non-obese women with gestational diabetes (GDM) treated with diet only, oral Glyburide or insulin. STUDY DESIGN: Women with a singleton gestation enrolled for outpatient perinatal services diagnosed with GDM and without history of pregnancy-related hypertension (gestational hypertension or preeclampsia) in a prior pregnancy or diagnosed with pregnancy-related hypertension at enrollment for outpatient services were identified in a database. Included were those women whoseGDMwas controlled by diet only (n=3918); oral glyburide (n=873); or insulin without prior exposure to oral hypoglycemic agents (n=2229).GDMdiagnosis and treatment was determined by each patient's individual physician. Maternal and neonatal outcomes were compared for obese (pre-pregnancy body mass index>30kg/m²) vs. non-obese women within each GDM treatment group and also compared across treatment groups within the obese and non-obese populations. RESULTS: Within each treatment group obesity was associated with higher rates of cesarean delivery, diagnosis of pregnancy-related hypertension, birth weight >4000gms, and hyperbilirubinemia (all p<0.05). Significant maternal and neonatal outcomes across treatment groups are presented in table (adjusted p<0.05 vs. ¹ Diet only, and ² Glyburide groups) CONCLUSIONS: In this large observational study of women with GDM, including 873 women receiving Glyburide, we found significantly higher rates of pregnancy-related hypertension and infant hyperbilirubinemia in pregnancies receiving Glyburide for management of GDM. These findings should be considered when pharmacologic treatment of GDM is necessary. (Table presented)

OBJECTIVE: The purpose of this study was to define normal second-trimester cervical length (CL) measurements and to estimate the association between second-trimester CL and spontaneous preterm birth (SPTB) in twin pregnancies. METHODS: A retrospective cohort of 309 asymptomatic patients with twin pregnancies who had routine outpatient CL assessment in the second trimester was studied. We looked at the gestational age periods of 16 to 17 6/7, 18 to 19 6/7, 20 to 21 6/7, and 22 to 23 6/7 weeks. We estimated the association between the CL measurement during each period and SPTB. A short CL was defined both as a CL at or below the 10th percentile for gestational age and 25 mm or less. We also performed regression analyses controlling for a number of clinically important factors: maternal age, chorionicity, in vitro fertilization, multifetal reduction, prior term births, prior preterm births, prepregnancy body mass index, and cerclage. RESULTS: The CL measurement at 16 to 17 6/7 weeks was not associated with gestational age at delivery or SPTB. At 18 to 19 6/7 and 20 to 21 6/7 weeks, the CL measurement was not significantly associated with gestational age at delivery or SPTB before 28 and 32 weeks. There was an association with SPTB before 35 weeks. At 22 to 23 6/7 weeks, the CL measurement had a significant association with gestational age at delivery and SPTB before 28, 32, and 35 weeks (P < .05). A short CL at 22 to 23 6/7 weeks was significantly associated with SPTB before 32 and 35 weeks (P < .05). CONCLUSIONS: In second-trimester twin pregnancies, the strongest association between CL and SPTB is at 22 to 23 6/7 weeks.

OBJECTIVE: To estimate whether the weight gain recommendations for twin pregnancies in the 2009 Institute of Medicine (IOM) guidelines are associated with improved perinatal outcomes. METHODS: A cohort of 297 twin pregnancies was identified from a single practice with measured prepregnancy body mass index (BMI) and weight gain during pregnancy. Recommended IOM guidelines were applied to our cohort based on prepregnancy BMI categories (normal weight, overweight, obese). Pregnancy outcomes were compared between patients whose weight gain met or exceeded the IOM recommendations and patients who did not meet these recommendations. RESULTS: Patients with normal prepregnancy BMIs whose weight gain met the IOM recommendations had significantly improved outcomes compared with patients who did not meet the IOM recommendations. They were less likely to have preterm birth before 32 weeks (5.0% compared with 13.8%) and spontaneous preterm birth before 32 weeks (3.4% compared with 11.5%). They also delivered significantly larger neontates (larger twin birth weight 2,582.1+/-493.4 g compared with 2,370.3+/-586.0 g; smaller twin birth weight 2,277.0+/-512.1 g compared with 2,109.3+/-560.9 g) and were significantly more likely to have both neonates weigh more than 2,500 g (38.8% compared with 22.5%) and more than 1,000 g (97.5% compared with 91.2%) and were less likely to deliver any twin with a birth weight lower than the fifth percentile for gestational age (21.5% compared with 35.0%). CONCLUSION: In women with twin pregnancies and normal starting BMIs, weight gain during pregnancy is significantly associated with improved outcomes, including a decreased risk of prematurity and larger birth weights. LEVEL OF EVIDENCE: II.

Omega-3 fatty acids are essential fatty acids that must be consumed in the diet. Adequate consumption of omega-3 fatty acids is vitally important during pregnancy as they are critical building blocks of fetal brain and retina. Omega-3 fatty acids may also play a role in determining the length of gestation and in preventing perinatal depression. The most biologically active forms of omega-3 fatty acids are docosahexaenoic acid and eicosapentaenoic acid, which are primarily derived from marine sources such as seafood and algae. Recent surveys, however, indicate that pregnant women in the United States and in other countries eat little fish and therefore do not consume enough omega-3 fatty acids, primarily due to concern about the adverse effects of mercury and other contaminants on the developing fetus. This review discusses the benefits of omega-3 fatty acid consumption during pregnancy and provides guidelines for obstetricians advising patients.