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Glycosylated hemoglobin and glycosylated serum protein have been suggested as tools for evaluation of long- and short-term glycemic control, respectively. Twenty-six patients with gestational diabetes were prospectively studied to determine the relationship of glycosylated hemoglobin and glycosylated serum protein to metabolic control. To verify the accuracy of blood glucose data, a memory-based reflectance meter was used for subjects with gestational diabetes who tested 6.5 +/- 1 times per day. Our analysis revealed that despite a statistically positive correlation between glycosylated hemoglobin, glycosylated serum protein, and verified data, their use as a clinical tool is limited because of their poor predictability.

Terminal prepartum patterns from 31 patients were associated with 39% perinatal mortality rate and major degrees of perinatal asphyxia among survivors. Conditions most commonly associated with these patterns were intrauterine growth retardation, preeclampsia, and prolonged pregnancy. NST patterns in which there was absence of accelerations, absent or reduced variability, with or without variable or shallow late decelerations, portended very omnious outcomes when accompanied by absent fetal movements and/or oligohydramnios. Perinatal mortality was 39% under these circumstances. Immediate cesarean section is warranted when this situation is encountered.

A total of 26 patients with sickle cell disease were followed up through 32 pregnancies. There was no correlation between days in hospital or number of painful crises and either birth weight or birth weight percentile. The number of dense irreversibly sickled and least deformable cells was negatively correlated with birth weight percentile (r = -0.63, p less than 0.01). Patients' initial hemoglobin levels were positively correlated with birth weight percentile (r = 0.52, p less than 0.004). Hemoglobin F, on the other hand, was significantly inversely correlated with birth weight percentile. Nine pregnancies with small-for-gestational-age infants had an average hemoglobin level of 9.1% +/- 4.5%. In contrast, patients who were delivered of appropriate-for-gestational-age infants (23 pregnancies) had an average hemoglobin F level of 3.6% +/- 2.9% (p less than 0.01). We conclude that total hemoglobin levels and dense cells are correlated with birth weight percentile; moreover, the higher the maternal hemoglobin F levels the higher the risk of small-for-gestational-age infants. We speculate that although high hemoglobin levels may be beneficial to the fetus, high maternal hemoglobin F levels could increase the desaturation of non-F cells and induce placental obstruction.

To assess the efficacy of Doppler flow velocimetry in predicting fetal compromise and neonatal outcome in pregnant women with sickle cell hemoglobinopathies, a prospective study was conducted of 96 patients, 48 with sickle cell hemoglobinopathy (8 with SS and 40 with AS hemoglobin) and 48 low-risk AA hemoglobin controls. All subjects were followed biweekly from the third trimester of pregnancy through delivery with uterine and umbilical artery velocimetry, nonstress, tests, and hematocrit and blood pressure measurements. An abnormal systolic/diastolic ratio was defined as a value greater than or equal to 3. The incidence of abnormal systolic/diastolic ratios for uterine or umbilical arteries was significantly higher in pregnant women with SS hemoglobin (88%) when compared with patients with AS (7%) and AA (4%) hemoglobin. In addition, the abnormal systolic/diastolic ratios for both umbilical and uterine arteries are correlated with abnormal nonstress test results. The nonstress test results became abnormal on average 3 weeks after the systolic/diastolic ratios did. The presence of abnormal systolic/diastolic ratios for umbilical and uterine arteries is predictive of fetal distress and infants small for gestational age. The high incidence of concordant uterine and umbilical artery abnormal systolic/diastolic ratios in pregnant women with SS hemoglobinopathy, which were identified earlier than were abnormal nonstress results, suggests an important parameter in the monitoring of these high-risk pregnancies.

The effects of addition of the polystyrene resin XAD-2 to the diet of rabbits on serum cholesterol, on hepatic enzyme of cholesterol synthesis (HMG-CoA reductase), and on atherogenesis was determined. Feeding of XAD-2 caused substantial decrease of total serum cholesterol and of the cholesterol of the apo B-containing lipoproteins (50%). Atherogenesis, which was induced by mechanical injury to the arterial wall, greatly decreased (p < 0.01) in animals fed with 10% XAD-2 supplement in their diet. Average lesions volume of 4.2 +/- 2.0 mm3 per aorta was observed in animals maintained on XAD-2 diet, in comparison to 15.42 +/- 3.3 mm3 in animals maintained on regular diet. The animals maintained on XAD-2 showed elevated activity of hepatic HMG-CoA reductase. The activity of this enzyme was 3.2 fold that obtained from livers of control animals.

This study was conducted to evaluate prospectively a management protocol for fetuses with a markedly abnormal umbilical artery velocity waveform. The study population consisted of fetuses whose systolic/diastolic ratio was greater than 2 SD above the mean for gestational age. The matched control population consisted of fetuses with similar gestational ages, indications for testing, and estimated fetal weights with normal systolic/diastolic ratios. Abnormal Doppler results were used only to determine the frequency of fetal testing. Biophysical profile testing was performed semiweekly on all patients. Patients with absent or reversed end-diastolic flow were admitted for daily testing. The following criteria were used as indications for delivery: (1) worsening maternal condition, (2) oligohydramnios, (3) intrauterine growth retardation with lung maturity, and (4) biophysical profile score less than or equal to 4. Fifty-one patients (7%) had abnormal Doppler blood flow velocity studies. When the study population was compared with the control population at the time of delivery, there were no differences in umbilical artery pH, Apgar score, or incidence of intrauterine growth retardation. However, study patients were delivered at a significantly lower gestational age and lower birth weight and experienced a higher likelihood of neonatal intensive care unit admission. When study patients with documented end-diastolic flow were compared with study patients with no end-diastolic flow, there were no differences in umbilical artery pH, Apgar score, or incidence of intrauterine growth retardation. However, fetuses with no end-diastolic flow had a significantly shorter test-to-delivery interval, lower gestational age, lower birth weight, and more neonatal intensive care unit admissions. There were no perinatal deaths among the study patients. The range of systolic/diastolic ratios for the five patients who failed to follow our protocol for intensive maternal-fetal surveillance was 4.3 to infinity; all experienced fetal death within 18 days. These results suggest that immediate delivery of the fetus with diminished end-diastolic flow may not be mandatory. The combined use of fetal biophysical testing and commonly used criteria for delivery results in acceptable fetal outcome and prolongation of gestational age.

A series of recent studies in women with gestational diabetes mellitus is reviewed. During the studies, which were designed to gain a better understanding of the etiology of perinatal morbidity, a novel means of collecting ambulatory blood glucose values was employed. Subjects used specially modified reflectance meters with onboard memories to record each value with corresponding time and date. The data were transmitted to a microcomputer and rapidly analyzed to permit effective follow-up in the study population. The system enabled the investigators to characterize metabolic control, evaluate different treatment modalities, and measure the association between glycemic control and fetal outcome. These studies indicate that patients with one elevated blood glucose value during formal glucose tolerance testings have higher blood glucose values under ambulatory conditions. Furthermore, these elevated ambulatory glucose values were significantly correlated with fetal macrosomia. Treatment regimens designed to lower verified ambulatory blood glucose measurements may help reduce fetal macrosomia in women with milder forms of gestational diabetes or in women with relative glucose intolerance without a substantial increase in severe hypoglycemia.

Spectral analysis techniques were used to quantitate the association between respiration and heart rate variability in eight healthy and eight asphyxiated infants born at term gestation. Respiratory sinus arrhythmia was demonstrated in all healthy infants. This arrhythmia was significantly diminished in asphyxiated newborn infants. We conclude that newborn infants with low Apgar scores have a reduced respiratory sinus arrhythmia and that this reduction could account for the loss of short-term heart rate variability commonly associated with asphyxia.

A total of 4886 nonstress tests were reviewed to establish the relationship between antepartum variable decelerations and perinatal outcome. The association between various fetal heart rate components and variable decelerations was also studied. The incidence of variable decelerations, defined as three or more decelerations greater than or equal to 15 bpm lasting at least 15 seconds in a 20-minute period, was 1.3%. The results suggest that in the presence of variable decelerations: there is a higher incidence of fetal distress in labor, low Apgar scores, neonatal intensive care unit admissions, and nuchal cord involvement; the presence of accelerations and normal variability is associated with good neonatal outcome, whereas their absence is associated with adverse outcome; the presence of accelerations or good variability is not independently correlated with neonatal outcome.

In this study we sought to test the hypothesis that treatment of women with one abnormal oral glucose tolerance test value will result in reduction of adverse outcome. One hundred twenty-six women with one abnormal oral glucose tolerance test value and 146 women in the control group (normal oral glucose tolerance test values) participated in a prospective study during the third trimester of pregnancy. The subjects with one abnormal test result were randomized into treated (group 1) and untreated groups (group II). Group 1 subjects were treated with a strict diabetic protocol to maintain tight glycemic control by means of diet and insulin therapy. Group 2 subjects tested their capillary blood glucose for a baseline period. The study revealed that the level of glycemic control was similar before initiation of therapy (mean capillary blood glucose 118 +/- 14 vs. 119 +/- 15 mg/dl, p = NS) for groups 1 and 2, respectively. There was a significant difference in mean capillary blood glucose (95 +/- 10 vs. 119 +/- 15 mg/dl, p less than 0.0001), preprandial, and postprandial determinations between the treated and untreated groups. The overall incidence of neonatal metabolic complications (4% vs. 14%, p less than 0.05) and large infants (6% vs. 24%, p less than 0.03) was significantly lower in the treated group. Comparison between the control (normal oral glucose tolerance test) and the untreated groups showed a significantly higher incidence of large infants and metabolic complications. No difference was found between the normal and treated groups. Thus we conclude that treatment of individuals with one abnormal oral glucose tolerance test value will result in significant reduction in adverse outcome in pregnancy.

Over the past 2 yr the effectiveness of a program in primary, secondary, and tertiary prevention of diabetes in pregnancy was studied. The purpose of the program was to determine the degree to which preventive medicine in terms of early screening and diagnosis, rapid initiation of treatment, and close follow-up surveillance could reduce the morbidity and mortality associated with pregestational and gestational diabetes. The study compared the program in prevention with previous programs, and its results were measured against national criteria established by the Centers for Disease Control. A significant increase in early identification of gestational diabetes and a decrease in fetal and maternal complications were detected.

This study was undertaken to evaluate the role of umbilical artery flow velocimetry combined with sonographic estimation of fetal weight, head circumference to abdominal circumference ratio, femur length to abdominal circumference ratio, and qualitative determination of amniotic fluid volume as a comprehensive test for the detection of intrauterine growth retardation (IUGR). The following cutoff values were used to indicate abnormal test results: 1) umbilical artery peak systolic to end-diastolic ratio (S/D) above 3, 2) estimated fetal weight below the tenth percentile for gestational age, 3) head circumference to abdominal circumference ratio more than 2 SD above the mean for gestational age, 4) femur length to abdominal circumference ratio above 23.5%, and 5) qualitative amniotic fluid volume less than 2 cm. The study population consisted of 127 patients referred with a clinical suspicion of IUGR. Forty-five infants (35%) were small for gestational age. None of these five tests were uniformly successful in identifying growth-retarded infants. Overall, the best predictor appeared to be estimated fetal weight below the tenth percentile for gestational age, which correctly identified 39 of the 45 IUGR infants (sensitivity 87%, specificity 87%). The sensitivity of this test was nearly twice that of any other test. All indices performed similarly in predicting the non-IUGR infant (range of specificities 87-98%).

Reflectance meters modified by the addition of a memory microchip that stored glucose values were used to measure the difference between self-reported and actual blood glucose data in 34 pregnant diabetic women. Overall two thirds of the patients reported values that were significantly lower and less variable than those recorded in the memory meters.

This study prospectively examined the use of umbilical artery flow velocimetry for monitoring fetal health in postdate pregnancies. Forty-six patients with well-established dates were evaluated with semiweekly biophysical profiles and umbilical artery flow velocimetry (characterized by the ratio of the peak systolic to end-diastolic velocity). Their labor records were reviewed, and neonates were examined for signs of postmaturity. Twenty neonates had an abnormal test result or outcome (identified as an abnormal nonstress test, oligohydramnios, meconium, intrapartum fetal distress, or a 5-minute Apgar score less than 7). Nine neonates had a physical examination consistent with the postmaturity syndrome. Twenty-one neonates were entirely normal. Comparisons of the mean systolic/diastolic ratios for neonates with and without the complications associated with postdatism showed no significant differences. In addition, all systolic/diastolic ratios were within the normal range. Therefore, umbilical artery flow velocimetry is unlikely to be useful for the routine antenatal assessment of the postdate fetus.

Early identification of the intrauterine growth-retarded fetus is a key factor in improving associated perinatal morbidity and mortality. We investigated, in a prospective study of 43 patients at high risk of intrauterine growth retardation, the predictive value of a derived glucose index and whether hypoglycemia accompanied by hypoinsulinemia in normotensive patients is associated with intrauterine growth retardation. Our findings suggest that the glucose index and 2-hour plasma glucose concentration appear to be useful antepartum predictors of intrauterine growth retardation in normotensive high-risk pregnancies. There is an apparent link between selective maternal hypoglycemia, hypoinsulinemia, and being small for gestational age. A "flat" glucose tolerance test should be regarded as an abnormal pattern in normotensive pregnancies as it was associated with a twentyfold increased risk of intrauterine growth retardation in this study.

A matched control study of 126 women equally divided into three groups (normal oral glucose tolerance test, one abnormal test value, and gestational diabetes mellitus) was undertaken to examine the relationships among oral glucose tolerance test results, glycemic control in pregnancy, and adverse perinatal outcome. Characterization of metabolic control for the one abnormal oral glucose tolerance test value and the gestational diabetes mellitus groups (before treatment) showed no significant difference. After the start of treatment, however, a significant (p less than 0.01) difference between the groups in level of control was found. While no significant difference in the average birth weight between the three groups was discovered, the incidence of large infants (macrosomia and large for gestational age) was found to be significantly higher in the one abnormal oral glucose tolerance test group when compared with the normal (34% versus 9%; p less than 0.01) and gestational diabetes mellitus group (34% versus 12%; p less than 0.01). No significant difference for the incidence of an infant large for gestational age was found between the normal group and the patients with gestational diabetes mellitus after treatment. Neonatal metabolic disorders were found to be significantly higher for the one abnormal oral glucose tolerance test group (15%) when compared with the control and the gestational diabetes mellitus groups (3%). We conclude that, if left untreated, one abnormal value on an oral glucose tolerance test is strongly associated with adverse perinatal outcome.

The effects of intrapartum vibratory acoustic stimulation during periods of decreased fetal heart rate variability were studied in 25 healthy term fetuses. Fetal monitoring and real-time ultrasound scanning were used simultaneously to detect fetal response. Vibratory acoustic stimulation was provided by an artificial larynx generating a signal at 85 dB and 85 Hz. This stimulus was applied for 5 seconds on the maternal abdomen over the fetal head after a 20-minute period of decreased fetal heart rate variability. All fetuses reacted with an immediate fetal heart rate acceleration of at least 10 bpm (range: 10 to 35 bpm, mean +/- SD = 18.4 +/- 7.0), and 19 fetuses also had sudden fetal body movement. A deceleration of the fetal heart rate after the initial acceleration was observed in nine fetuses (range: 15 to 70 bpm, mean +/- SD = 45.5 +/- 16.5). The implications of these findings are discussed in relation to the possible use of fetal vibratory acoustic stimulation for intrapartum surveillance.

This is a preliminary, prospective study of uterine contractility in response to sexual intercourse. The study population consisted of 30 pregnant subjects. Group I included 15 women treated for an episode of preterm labor with intravenous and oral tocolysis in this pregnancy, and group II was a matched control group of low-risk volunteers. The availability of home uterine tocodynamometric systems permitted monitoring of uterine contractility for three 60-minute time periods related to coitus. A significant increase in uterine contractility in the immediate postcoital period was observed for the high-risk women, but not for the controls. This increased uterine activity subsided spontaneously within 2-3 hours, returning to baseline. These initial preliminary observations of uterine response to coitus in a home environment are interesting; however, further research is suggested to establish their clinical implications.