Contemporary approaches to hyperemesis during pregnancy.

Women with significant NVP should be identified so that they can be safely and effectively treated

The 50-g glucose challenge test and pregnancy outcome in a multiethnic Asian population at high risk for gestational diabetes

Objective: To evaluate the 50-g glucose challenge test (GCT) on pregnancy outcome in a multiethnic Asian population at high risk for gestational diabetes (GDM). Methods: GCT was positive if the 1-hour plasma glucose level was >= 7.2 mmol/L. GDM was diagonsed by a 75-g glucose tolerance test using WHO (1999) criteria. Of the 1368 women enrolled in the study, 892 were GCT negative, 308 were GCT false-positive status was associated with preterm birth (adjusted odds ration AOR 2.1; 95% CI, 3.3-7.5), cesarean delivery (AOR 2.5; 95% CI, 1.6-3.2), postpartum hemorrhage (AOR 2.1; 95% CI, 1.2-3.7), and neonatal macrosomia (AOR 2.5; 95% CI, 1.0-6.0). Conclusion: GCT false-positive women had an increased likelihood of an adeverse pregnancy outcome. The role and threshold of the GCT needs re-evaluaion. (C) 2008 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved

Labour and perinatal outcome in women at term with one previous lower-segment Caesarean: a review of 1000 consecutive cases

Objective: To compare the outcome in 1000 women at term with one lower transverse Caesarean that was suitable for a trial of labour. Methods: One thousand consecutive women with one previous scar suitable for a trial of labour delivering in our centre from June 2002 to December 2005 were identified from the labour ward register. Data were retrieved from patients' charts, and neonatal admissions were determined. Results: In the study, 76.8 of women underwent a trial of labour, with a 71.2 vaginal birth rate. Hospital stay was shorter with a trial of labour. The three perinatal deaths (0.4; P = 1.0) occurred in the trial of labour group. Compared to elective repeat Caesareans, successful vaginal births after trial of labour were associated with less neonatal admission, reduced blood transfusion requirement and shorter hospital stay; emergency Caesarean deliveries after a trial of labour were associated with more neonatal admissions and operative complications. Conclusions: Trial of labour was associated with a shorter hospital stay. A successful trial of labour after one Caesarean was associated with the best outcome underscoring the importance of patient selection for a trial of labour

Concurrent dinoprostone and oxytocin for labor induction in term premature rupture of membranes a randomized controlled trial

OBJECTIVE: To estimate the effect of concurrent vaginal dinoprostone and oxytocin infusion against oxytocin infusion for labor induction in premature rupture of membranes (PROM) on vaginal delivery within 12 hours and patient satisfaction. METHODS: Nulliparas with uncomplicated PROM at term, a Bishop score less than or equal to 6, and who required labor induction were recruited for a double-blind randomized trial. Participants were randomly assigned to 3-mg dinoprostone pessary and oxytocin infusion or placebo and oxytocin infusion. A cardiotocogram was performed before induction and maintained to delivery. Dinoprostone pessary or placebo was placed in the posterior vaginal fornix. Oxytocin intravenous infusion was commenced at 2 milliunits/min and doubled every 30 minutes to a maximum of 32 milliunits/min. Oxytocin infusion rate was titrated to achieve four contractions every 10 minutes. Primary outcomes were vaginal delivery within 12 hours and maternal satisfaction with the birth process using a visual analog scale WAS) from 0 to 10 (higher score, greater satisfaction). RESULTS: One hundred fourteen women were available for analysis. Vaginal delivery rates within 12 hours were 25 of 57 (43.9) for concurrent treatment compared with 27/57 (47.4) (relative risk 0.9, 95 confidence interval 0.6-1.4, P = .85) for oxytocin only; median VAS was 8 (interquartile range IQR 2) compared with 8 (IQR 2), P = .38. Uterine hyperstimulation was 14% compared with 5.3%, P = .20; overall vaginal delivery rates were 59.6% compared with 64.9%, P = .70; and induction to vaginal delivery interval 9.7 hours compared with 9.4 hours P = .75 for concurrent treatment compared with oxytocin, respectively. There was no significant difference for any other outcome. CONCLUSION: Concurrent vaginal dinoprostone and intravenous oxytocin for labor induction of term PROM did not expedite delivery or improve patient satisfaction. CLINICAL TRIAL REGISTRATION: Current Controlled Trials, www.controlled-trials.com, ISRCTN7437634

Effect of high levels of human chorionic gonadotropin and estradiol on the severity of hyperemesis gravidarum

Background: Serum human chorionic gonadotropin (hCG) and estradiol levels are higher in women with hyperemesis gravidarum (HG) than in unaffected pregnant controls. We postulated that higher levels of these hormones may be associated with clinically more severe HG. The aim of this study was to evaluate the effect of maternal hCG and estradiol levels on the severity of HG. Methods: A prospective study was performed on 167 first trimester women hospitalized for HG. Venous blood was taken for hCG and estradiol levels. Scattergrams were plotted for hCG or estradiol levels vs. gestational age. A curve of best fit was drawn. Women were categorized into two groups according to their position above or below the curve. Prolonged hospital stay (>= 4 days) was used as a marker for HG severity. Multivariable logistic regression analysis was used to control for differences in characteristics, laboratory results on admission, and treatment received. Results: After adjustment, high hCG level adjusted odds ratio (AOR) (2.2, 95 Cl 1.0-4.9, p=0.04) and hyponatremia AOR (2.8, 95 Cl 1.2-6.6, p=0.02) were independently associated with prolonged hospital stay. With bivariate analysis, high estradiol level was not associated with prolonged stay. Conclusions: High hCG but not estradiol is associated with more severe HG

Gamma-glutamyltransferase level in pregnancy is an independent risk factor for gestational diabetes mellitus

Aim: To evaluate the relationship between gamma-glutamyltransferase (GGT) level in pregnant women at oral glucose tolerance test (OGTT) and the diagnosis of gestational diabetes (GDM). Methods: Blood was taken for analyzing GGT level from women at high risk of GDM at the time of their scheduled OGTT. GDM was diagnosed according to World Health Organization 1999 criteria. Results: GGT level correlated positively with the 2-hour glucose level (Spearman's rho = 0.112: P < 0.05). GGT values that were stratified into quartiles demonstrated a significant trend with diagnosis of GDM (chi(2) for trend; P = 0.03). Multivariable logistic regression analysis taking into account maternal age, gestational age at OGTT, body mass index and a positive 50-g glucose challenge test (GCT) indicated that high GGT was an independent risk factor for GDM (adjusted odds ratio AOR 2.1 95% CI 1.2-3.8: P = 0.01). In the subset of women identified by a positive GCT, on multivariable logistic regression analysis, only high GGT was an independent risk factor for GDM (AOR 2.3 95% CI 1.3-4.2: P = 0.007). Conclusion: Raised GGT level is an independent risk factor for GDM in high risk pregnant women undergoing OGTT

Screening for urinary tract infection in women with hyperemesis gravidarum

Aim: The aim of this study was to evaluate urine microscopy, dipstick analysis and urinary symptoms in screening for urinary tract infection (UTI) in hyperemesis gravidarum (HG). Materials and Methods: A prospective cross-sectional study was performed on women at first hospitalization for HG. A clean-catch mid-stream urine sample from each recruit was sent for microscopy (for bacteria, leucocytes and erythrocytes), dipstick analysis (for leukocyte esterase, nitrites, protein and hemoglobin) and microbiological culture. The presence of current urinary symptoms was elicited by questionnaire. UTI is defined as at least 105 colony-forming units/mL of a single uropathogen on culture. Screening test parameters were analyzed against UTI. Results: UTI was diagnosed in 15/292 subjects (5.1). Receiver-operator characteristic curve analysis of microscopic urine leucocytes revealed area under the curve = 0.64, 95 confidence interval (CI) 0.5-0.79, P = 0.063 and erythrocytes area under the curve = 0.53, 95 CI 0.39-0.67, P = 0.67 for UTI indicating the limited screening utility of these parameters. Microscopic bacteriuria (likelihood ratio LR 1.1, 95% CI 0.7-1.5) and urine dipstick leukocyte esterase (LR 1.4, 95% CI 1.1-1.8), nitrites (LR 2.3, 95% CI 0.3-17.2), protein (LR 1.0, 95% CI 0.7-1.6) and hemoglobin (LR 0.8, 95% CI 0.4-1.5) were not useful screening tests for UTI in HG. Elicited symptoms were also not predictive of UTI. Conclusion: Urine microscopy, dipstick analysis and urinary symptoms were not useful in screening for UTI in HG. UTI should be established by urine culture in HG before starting antibiotic treatment

Hospital discharge on the first compared with the second day after a planned cesarean delivery a randomized controlled trial

OBJECTIVES: To compare patient satisfaction and exclusive breastfeeding rates for patients discharged from the hospital on postcesarean day 1 (next day) or day 2. METHODS: Healthy women admitted for planned cesarean delivery were randomized to day 1 or day 2 discharge. Postoperative assessment for suitability for discharge was based on defined criteria. Primary outcomes were patient satisfaction with their discharge timing assessed at 2 weeks and reported exclusive breastfeeding at 6 weeks after discharge. Analyses were based on intention-to-treat and per-protocol discharge. RESULTS: Of the 360 women randomized, results of 170 compared with 172 and 142 compared with 148 (day 1 compared with day 2) were available for intention-to-treat and per-protocol analyses, respectively. Nine women fulfilled discharge criteria but declined day 1 discharge, and 12 women allocated to day 2 discharge took their own discharge on day 1. Intention-to-treat analysis showed that satisfaction with discharge protocol was expressed by 148 of 170 (87.1) compared with 147 of 172 (85.5) (relative risk 1.1, 95 confidence interval CI 0.6-2.1, P=.75) and exclusive breastfeeding (at 6 weeks) was reported by 76 of 170 (44.7%) compared with 77 of 172 (44.9%) (relative risk 1.0 95% CI 0.7-1.5 P=.99 for day 1 compared with day 2 discharges, respectively). All secondary outcomes assessed at up to 6 weeks after discharge including unscheduled maternal or infant medical consultations, rehospitalizations, maternal antibiotic use, and maternal well-being, anxiety, and depression status, were similar. Results on per-protocol analysis were also similar. CONCLUSION: Day 1 discharge compared with day 2 discharge after a planned cesarean delivery resulted in equivalent outcomes