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Among a large cohort of women with viable singleton pregnancies who underwent elective repeat cesarean sections, more than a third of deliveries were performed before 39 weeks of gestation. As compared with deliveries at or after 39 weeks, deliveries before 39 weeks of gestation — even those during the last 3 days before week 39 — were associated with an increased risk of a composite primary outcome that included neonatal death, respiratory complications, need for mechanical ventilation, treated hypoglycemia, newborn sepsis, and admission to the neonatal intensive care unit. As compared with deliveries at or after 39 weeks, cesarean deliveries before 39 weeks of gestation were associated with an increased risk of a composite primary outcome that included neonatal death, respiratory complications, need for mechanical ventilation, treated hypoglycemia, newborn sepsis, and admission to the neonatal intensive care unit. Infants born before 39 weeks of gestation are at increased risk for neonatal adverse respiratory outcomes, and the risk increases progressively as gestational age at birth declines. 1 , 2 Thus, prelabor elective delivery (delivery in the absence of a specific maternal or fetal indication) is proscribed before 39 weeks unless fetal lung maturity has been demonstrated. 3 , 4 As compared with infants born vaginally, those born by cesarean section are at increased risk for adverse respiratory outcomes, especially when delivery occurs before the onset of labor. 1 , 2 , 5 – 11 This increased risk persists even in infants who are delivered by cesarean section . . .

Oral Antidiabetic Drugs in Pregnancy: The Other Alternative Oded Langer , MD, PhD Abstract The use of oral antidiabetic drugs in pregnancy is an accepted treatment modality for women with gestational diabetes mellitus (GDM). This efficacious option provides physicians more choices that, in turn, translate into more complex decision making for the management of GDM. However, regardless of the mode of therapy, whole patient care (glucose monitoring, education, diet adherence, and so forth) will determine overall success in managing this disease and the potential to maximize the quality of perinatal outcome. Footnotes Oded Langer, MD, PhD, is a professor and chairman of the Department of Obstetrics and Gynecology at St. Luke's-Roosevelt Hospital Center, University Hospital of Columbia University in New York. American Diabetes Association

Background Glyburide has replaced insulin as the first line of therapy in the treatment of gestational diabetes in the United States. Glyburide and metformin therapies were reported to be comparable to insulin yet also cost-effective, patient-friendly, and potentially compliance-enhancing. Recently, the efficacy of the use of these oral hypoglycemic drugs has been questioned. In this review, the questionable concerns will be addressed: Which diabetic drug(s) cross the placenta? What is the quality of evidence and the data source validity? Which treatment modalities are most effective in reducing the primary outcome in GDM? Which drug is most effective in improving secondary outcomes? Findings This review documents the methodological issues in study design that have impacted the results for the provision of health care interventions in GDM. The review summarizes the contents of the articles qualitatively and assesses the theoretical and empirical evidence. Multiple types of studies exist and every study design serves a specific purpose. Different study designs addressing the same question can yield varying results. The risk of presenting uncertain results without categorically knowing the direction and magnitude of the effect holds true for both randomized and nonrandomized controlled trials. The review further emphasizes the importance of achieving the targeted levels of glycemic control. Conclusion The implications of this review are critical to addressing the current gaps in the literature on the efficacy of the use of oral hypoglycemic agents in GDM. The emphasis needs to be placed on patient treatment in order to manage hyperglycemia to reduce fetal and maternal morbidity. In this regard, we need to delineate proper outcome criteria that will reflect disease severity and treat using appropriate pharmacological therapy.

In this multicenter, placebo-controlled, randomized trial of intravenous magnesium sulfate in women at imminent risk for delivery between 24 and 31 weeks of gestation, magnesium sulfate did not significantly reduce the primary composite outcome of moderate or severe cerebral palsy or death. However, it did result in a reduced rate of cerebral palsy among survivors (a prespecified secondary outcome), which may suggest the possibility of benefit. In women at imminent risk for delivery between 24 and 31 weeks of gestation, magnesium sulfate did not significantly reduce the primary composite outcome of moderate or severe cerebral palsy or death. However, it did result in a reduced rate of cerebral palsy among survivors. Cerebral palsy is characterized by abnormal control of movement and posture that results in limitation of activity. It is caused by nonprogressive damage or dysfunction of the developing fetal or infant brain 1 and is a leading cause of chronic childhood disability, with profound medical, emotional, and economic consequences. 2 Preterm birth is a risk factor for cerebral palsy, and the magnitude of the risk is inversely correlated with gestational age at birth. 3 During the past 20 to 30 years, the survival of infants born markedly preterm has improved dramatically, and whereas some data suggest that the rate of cerebral palsy among . . .

In this multicenter, four-year observational study of women with a history of cesarean section and a singleton gestation, a trial of labor was associated with a higher risk of symptomatic uterine rupture in the mother and hypoxic–ischemic encephalopathy in the infant than was elective cesarean delivery, although the absolute risks of these complications were low. The findings from this study should help inform women about their choices regarding the type of delivery after a prior cesarean section. The findings from this study should help inform women about their choices regarding the type of delivery after a prior cesarean section. The overall rate of cesarean delivery in the United States has risen dramatically, from 5 percent of all deliveries in 1970 to a high of 26 percent in 2002. 1 Efforts to reduce the number of cesarean births, although initially successful, failed to achieve the U.S. Public Health Service goals, set in 1990. These goals included achieving an overall rate of cesarean delivery of 15 percent, and a rate of vaginal birth after previous cesarean section of 35 percent of deliveries after previous cesarean sections, by the year 2000. 2 The Healthy People 2010 report published in 2000 proposes a target rate . . .

Hyperglycemia is associated with adverse outcomes of pregnancy in women with gestational or preexisting diabetes mellitus. The principal approach to glycemic control in pregnant women with diabetes is dietary therapy, with the addition of insulin when diet alone is not sufficient. 1 – 4 Insulin therapy is effective in achieving the appropriate levels of glycemia, but it is inconvenient and expensive. An alternative approach would be attractive. Several authoritative bodies 2 – 4 recommend that sulfonylurea drugs not be given during pregnancy because of their potential to cause neonatal hypoglycemia and fetal anomalies. 5 – 11 This recommendation is based mainly on studies done before the . . .

In the last decade, it has become clear that gestational diabetes is a clinical entity associated with perinatal mortality and morbidity. Thus, the attention to and management of gestational diabetes during pregnancy are mandatory. In this review, results of 58 original studies (spanning the past 20 years) addressing criteria for insulin management in gestational diabetes were assessed. The level of glycemic control and its evaluation through self-monitoring of blood glucose are the foundation for ascertaining optimal pregnancy outcome. This review addresses the criteria for insulin initiation: insulin requirements, identification of the right patient, the timing for insulin initiation, and the behavioral adjustment and compliance during insulin therapy. It is recommended that patients with fasting plasma glucose on the oral glucose tolerance test (OGTT) of < 96 mg/dl (and ideally nonobese) be assigned to diet therapy. Obese women or those with fasting plasma glucose > 95 mg/dl on the OGTT should be referred to insulin therapy in order to minimize exposure of the fetus to a hyperglycemic environment.

Opinions differ whether the rate of spontaneous preterm delivery (sPTD) increases in pregnancies complicated with GDM. We sought to characterize, which factors may influence the rate of sPTD in GDM. We conducted a retrospective study with 1,526 GDM patients, all treated at the same center by the same diabetic protocol using self-blood glucose monitoring. The rate of sPTD was compared to that of 10,560 non-diabetic women. Eligibility for the study was limited to women with a singleton pregnancy with spontaneous onset of delivery before 37 weeks of gestation with no history of chronic maternal illness, i.e., chronic hypertension or development of preeclampsia in the current pregnancy, and no clear indication for preterm delivery. Mean blood glucose < 105 mg dl(-1) was defined as well controlled. Overall, no difference was found in the rate of sPTD in GDM (163/1,526, 10.7%) in comparison to non-GDM patients (1193/10,560, 11.3%, P = 0.2). In the GDM group, a comparison between women with and without sPTD found no difference in maternal age (28.1 +/- 6 vs. 28.2 +/- 6), prepregnancy BMI (28.1 +/- 5 vs. 27.8 +/- 6), rate of nulliparity (38 vs. 34%) or ethnicity origin. GDM patients with sPTD were characterized by higher glucose values in the OGTT and higher mean blood glucose (114 +/- 16 vs. 106 +/- 14, P < 0.0001). Sixty-five percent of patients with sPTD versus. 46% in the non-sPTD were in poor glycemic control (P = 0.004). Multiple logistic regressions, when the dependent variable was sPTD revealed that mean blood glucose (OR 1.94 95% CI 1.25-3.0), history of sPTD (OR 3.25 95% CI 2.1-4.8) and parity (OR 1.49 95% CI 1.05-2.2) were contributing factors. The rate of sPTD in GDM is not increased in comparison to non-GDM patients, but reaching established levels of glycemic control may reduce the rate of sPTD in GDM.