Biomedical subjects

O Langer

Publications and source records attributed to O Langer.

At least 73 records · Page 4Linked to original sources

PubMed1994

Normal values of urinary albumin and total protein excretion during pregnancy.

OBJECTIVE: Our purpose was to determine the normal 24-hour excretion values of urinary albumin and total protein in healthy pregnant women. STUDY DESIGN: We evaluated 270 healthy pregnant women < or = 35 years old without a history of diabetes, hypertension, pyelonephritis, preeclampsia, or renal or connective tissue disease. Adequacy of 24-hour collection was determined by creatinine excretion. RESULTS: The mean protein excretion in 24 hours was 116.9 mg, upper 95% confidence limit 259.4 mg. The mean albumin excretion in 24 hours was 11.8 mg, upper 95% confidence limit 28.7 mg. Both protein and albumin excretion increased after 20 weeks of gestation. No patient had evidence of microalbuminuria, defined as urinary albumin excretion > 30 mg/L. CONCLUSION: These data support 260 mg per 24 hours of urinary protein and 29 mg per 24 hours of albumin as the upper limit of normal in pregnancy. Albumin accounts for a small fraction of total urinary protein excretion.

Adult↗

PubMed1994

Intensified versus conventional management of gestational diabetes.

OBJECTIVE: We tested the hypothesis that intensified management of gestational diabetes mellitus on the basis of stringent glycemic control, verified glucose data, and adherence to an established criterion for insulin initiation results in near normoglycemia control and reduction of adverse outcomes. STUDY DESIGN: A prospective, population-based study compared the effect on perinatal outcome of conventional (n = 1316) and intensified (n = 1145) management. Group assignment was based on availability of memory-based reflectance meters at entry to the program. A contemporaneous randomized control group (nondiabetic, n = 4922) was selected. RESULTS: The diabetic groups were comparable in demographic characteristics and in factors associated with higher risk for adverse pregnancy outcome, such as previous macrosomia, previous gestational diabetes mellitus, and family history of diabetes. The control group was younger, less obese, and had a lower rate of previous macrosomia. The intensified management group had rates of macrosomia, cesarean section, metabolic complications, shoulder dystocia, stillbirth, neonatal intensive care unit days, and respiratory complications lower than those in the conventional management group and comparable to those of the nondiabetic controls. Other maternal complication rates, such as for preeclampsia, chronic hypertension, and infection, were similar for the three groups. Mean blood glucose levels were a good predictor of perinatal outcome. Gestational age at delivery, previous history of macrosomia, and overall mean blood glucose levels were the only significant predictors of birth weight percentile in both diabetic groups (logistic regression). CONCLUSION: The intensified management approach is significantly associated with enhanced perinatal outcome. This management strategy clarifies the relationship between glycemic control and neonatal outcome.

Birth Weight↗

PubMed1994

Is fetal heart rate variability a good predictor of fetal outcome?

OBJECTIVE: The purpose of this study was to investigate, in a prospective manner, whether fetal heart rate (FHR) variability serves as a reliable single predictor of fetal outcome. METHODS: We undertook a prospective study of 2,200 consecutive deliveries. Preterms < 37 weeks, twins, stillbirths and fetal malformations were excluded from the study. FHR tracings were analyzed for variability in every delivery. Three windows were evaluated: 1) early in labor (30 min); 2) in the active phase of labor - 1 h prior to complete cervical dilatation (30 min); and 3) throughout the second stage of delivery, in segments of 30 min. Using the tracings taken at admission and prior to delivery, FHR variability was scored according to five previously used evaluative methods, and was correlated to the following three fetal outcome parameters: a) arterial cord blood pH < 7.2, > 7.2; b) 5-min Apgar >6, < 7; and c) immediate outcome ('good' defined as newborn going home after 2-5 days, with no neonatal intensive care unit (NICU) admission). RESULTS: 1. The majority of cases with adverse fetal outcome exhibited good FHR variability (mean, 80%). 2. Low FHR variability is not common in newborns with adverse general outcome (mean, 11.5%). 3. The predictability of FHR variability (using the five most common scoring methods) for evaluating adverse fetal outcome revealed low sensitivity (mean, 20.3%) and low predictive value (mean, 11.6%). CONCLUSION: FHR variability by itself cannot serve as the only indicator of fetal wellbeing. The presence of low variability should alert the physician; however, good FHR variability should not be interpreted as reassuring.

Analysis of Variance↗

PubMed1994

Hypertensive diseases in pregnancy.

Hypertension is one of the most common complications of pregnancy, with potential adverse effects for both mother and fetus. Controversy exists in the classification and differential diagnosis of the hypertensive disorders, which include preeclampsia-eclampsia, chronic hypertension, preeclampsia superimposed on chronic hypertension, and transient hypertension. This review discusses the problems clinicians face in the diagnosis of these disorders, as well as key management issues. With proper diagnosis and treatment, pregnant hypertensive patients should be spared the most serious sequelae of hypertension, and most should enjoy a successful pregnancy outcome.

Algorithms↗

PubMed1994

Meconium-stained amniotic fluid: increased risk for adverse neonatal outcome.

OBJECTIVE: To determine the risk of adverse neonatal outcome associated with meconium-stained amniotic fluid independent of that related to antepartum or intrapartum abnormalities. METHODS: A cohort of 2200 consecutive deliveries was examined and the fetal heart rate (FHR) tracings analyzed independently. Singleton term pregnancies without fatal malformations were stratified by the consistency of meconium and compared. RESULTS: Moderate or thick meconium increased the risk for adverse outcome more than threefold (relative risk 3.2, 95% confidence interval 2.0-5.2). This risk was independent of fetal heart tracing abnormalities or maternal hypertensive, kidney, or heart disease. CONCLUSION: Thick meconium alone should alert the physician to a high-risk fetal condition. This phenomenon requires continuous FHR monitoring and reassurance of fetal well-being by acid-base assessment or the equivalent, regardless of maternal disease status or the presence of abnormal FHR tracings.

Adult↗

PubMed1994

Emotional adjustment to diagnosis and intensified treatment of gestational diabetes.

OBJECTIVE: To determine, in women having newly diagnosed gestational diabetes mellitus, the effect of intensified treatment on the patients' emotional status and the relation between metabolic control and emotional well-being. METHODS: English-speaking women with newly diagnosed gestational diabetes mellitus (N = 206) and nondiabetic controls (N = 95) were compared for maternal characteristics and test results on the Profile of Mood States-Bipolar test, a standardized Likert scale measuring mood dimensions in terms of six bipolar affective states. Women with gestational diabetes mellitus were stratified according to treatment modality (diet or insulin therapy) and level of glycemic control (good control, mean blood glucose less than 105 mg/dL; poor control, mean blood glucose 105 mg/dL or greater). Because emotional profile can be influenced by actual glucose values depicted on the memory reflectance meter, glucose determinations were categorized as hypoglycemia, normoglycemia, mild hyperglycemia, and hyperglycemia. An Average Mood Disturbance score was used to determine the relation between total mood status and categories of glucose determinations. RESULTS: There was no significant difference between women with gestational diabetes mellitus in either the diet- or insulin-managed group and nondiabetic controls on each of the subscales of the Profile of Mood States-Bipolar test. Patients with stringent glycemic control were less distressed than those having poor control. Intensified therapy (self-monitoring of blood glucose levels and liberal use of insulin) for gestational diabetes mellitus does not negatively affect patients' emotional status. Insulin therapy by multiple injection does not adversely affect mood state. Stepwise regression analysis found a significant association between Average Mood Disturbance score and the number of determinations within the normoglycemic and hyperglycemic categories, marital status, and maternal age. CONCLUSION: Intensified management of newly diagnosed gestational diabetes mellitus does not increase patient anxiety and depression. Moreover, achievement of glycemic control contributes to patient reassurance. Psychological adjustment to the temporary disease state is then equal to that of a nondiabetic individual.

Adaptation, Psychological↗

PubMed1993

Doppler velocimetry in pregnant patients with sickle cell anemia.

Women with sickle cell anemia have an increased risk of bearing low-birth-weight (LBW) progeny. To establish prognostic indicators of neonatal outcome, 15 women with sickle cell anemia were followed through their pregnancies with the use of umbilical and uterine Doppler flow velocimetry. The systolic/diastolic ratios obtained were correlated with neonatal birth weight, gestational age, and birth weight percentile. Pregravid hemoglobin levels, reticulocyte counts, dense cell numbers, percentage hemoglobin F, and indirect bilirubin and lactate dehydrogenase levels were also determined, and statistical analysis was performed to assess whether any of these parameters would be useful in conjunction with velocimetry. We report here that, in sickle cell anemia, prenatal umbilical and uterine Doppler velocimetry ratios correlate inversely and significantly with neonatal birth weight (P < 0.005 and P < 0.002, respectively). In addition, prenatal maternal HbF levels also correlate significantly with Doppler velocimetry readings, an independent indicator of LBW progeny. Neither pregravid hemoglobin levels nor dense cell concentration correlates with Doppler umbilical and uterine flow velocimetry ratios determined during pregnancy. Pregravid high levels of HbF and velocimetry readings may serve to delineate a subset of sickle cell patients who may have different requirements for prenatal care. The possible mechanism for the detrimental effects of increased levels of fetal hemoglobin has not been clearly established, but it may involve increased propensity for vasoocclusion due to the unique rheology of the human placenta.

Adult↗

PubMed1993

Is lung maturation related to fetal growth in diabetic or hypertensive pregnancies?

The purpose of this study was to determine whether infants sufficiently affected by maternal diabetes or hypertension to exhibit abnormal growth (macrosomia, growth retardation) would also display significant alteration in timing of pulmonary maturity (delay or acceleration, respectively). We studied 874 consecutive women with fetal pulmonary maturity testing prior to delivery. Patients were stratified by birth weight into fetal size categories (small for gestational age [SGA], appropriate for gestational age [AGA], large for gestational age [LGA]). Cases were compared based on maternal disease, fetal size categories and pulmonary maturity testing results. Pulmonary maturity rates based on both phosphatidylglycerol (PG) and lecithin/sphingomyelin ratio (L/S) did not differ between term LGA infants of diabetic mothers (97%) and term LGA (80%) or AGA (97%) infants of non-diabetic, non-hypertensive mothers. When compared based on PG alone, there was no difference between the rate of positive PG in term AGA infants of non-hypertensive, non-diabetic mothers (75%) and that seen in the other pregnancy groups (33-80%). Breakdown by gestational age revealed no significant differences in maturity rates between the study groups. Macrosomic diabetic infants and growth-retarded hypertensive infants are no different from controls in their timing of fetal pulmonary maturation.

Amniotic Fluid↗

PubMed1993

Does maternal diabetes delay fetal pulmonary maturity?

OBJECTIVE: The purpose of our study was to determine whether a relationship exists between diabetic glucose control and the immaturity rate of fetal pulmonary maturity test results. STUDY DESIGN: One thousand consecutive women who had fetal pulmonary maturity testing before delivery were studied. Diabetic patients were categorized according to whether their diabetes was well controlled or poorly controlled, then compared to the nondiabetic population on the basis of amniocentesis results. RESULTS: Pregnant women with poorly controlled diabetes had a significantly higher risk of immature fetal lung profiles at amniocentesis than did pregnant women without diabetes. Pregnant women with well-controlled diabetes were not significantly different from the nondiabetic population. There was no difference between gestational and pregestational diabetic pregnancies. CONCLUSIONS: Timing of fetal pulmonary maturation is linked to the level of maternal glucose control in diabetic pregnancies. Adequate glucose control may lower the risk of fetal pulmonary immaturity to that seen in the nondiabetic population.

Amniocentesis↗

PubMed1993

Management of gestational diabetes.

Researchers and care providers must recognize that different centers are not automatically comparable in results because the geographic location, the demographic characteristics of the patient population, and the program strategy will alter the rate of patients assigned to insulin therapy and adverse pregnancy outcome. For example, in San Antonio, Texas, with a chronic health problem of obesity and diabetes, the prevalence of GDM is approximately 11%, whereas the general reported rate is 2% to 3%. Despite the disparity in the prevalence of the disease in different demographic areas, pregnancy outcome should be comparable for all centers when a proper management approach has been used. Utilizing our management approach in a large-scale program resulted in an incidence of macrosomia comparable to that in the general population. As a general rule, because constant evaluation of glycemia in pregnancy is the best gauge of the efficacy of the treatment, the use of verified self-monitoring of blood glucose has become a principal component of management. Appropriate assignment of patients to treatment modality utilizing verified blood glucose determinations and targeting mean blood glucose levels throughout pregnancy to 95 mg/dL (5.3 mmol/L) that is similar to normal nondiabetic blood glucose levels will result in pregnancy outcome comparable to the general population.

Diabetes, Gestational↗

PubMed1993

Recurrent stillbirth. Significance and characteristics.

We sought to identify the significance of recurrent stillbirth and to determine the contributory etiologic factors for this phenomenon. Data were analyzed and retrospective chart review conducted for all stillbirths occurring during a 13-year period. Subjects were divided into two groups: those for whom the current stillbirth was the first and those who had had a previous stillbirth. The study included 48,479 consecutive multiparous women, of whom 403 had delivered stillborn infants (8.31/1,000 live births). For 34 of these subjects, this represented a recurrent stillbirth (84.36/1,000 live births). The recurrent-stillbirth group had a 10.15-fold higher risk for stillbirth. Additionally, this group had a twofold higher incidence of diabetes and hypertensive disease than did those women experiencing their first stillbirths; furthermore, the gestational age and birth weight of the stillborn infants were significantly lower in the recurrent-stillbirth group (P < .0004 and < .007, respectively). Such factors as socioeconomic class, chorioamnionitis and erythroblastosis fetalis, traditionally cited as contributing to repeated fetal loss, were not significant. Although recurrent stillbirth remains an unsolved problem, improving health care to specific groups within high-risk populations may reduce fetal loss.

Adult↗

PubMed1993

Acute amniotic fluid loss and changes in the amniotic fluid index. Correlation and effect on umbilical artery velocimetry.

This study was undertaken to determine whether changes in the amniotic fluid index accurately reflected measured amniotic fluid loss after artificial rupture of membranes and whether this acute loss of fluid volume affected umbilical artery resistance as measured by Doppler velocimetry. Twenty-five uncomplicated term pregnancies underwent umbilical artery velocimetry and amniotic fluid index determination in the active phase of labor before and after amniotomy. Amniotic fluid loss was measured by direct collection of fluid during and immediately following rupture of the membranes. The preamniotomy and postamniotomy data were compared using the paired t test, and the relationship between amniotic fluid index change and actual fluid loss was tested by linear regression. The change in the amniotic fluid index after amniotomy was significant (paired t test, P < .0001), and a significant relationship was found by linear regression between the actual amniotic fluid loss and the change in the amniotic fluid index (P < .01, r2 = .28). Despite significant changes in the amniotic fluid index, however, no significant change in the umbilical artery systolic/diastolic ratio could be demonstrated. Our data suggest that amniotomy in the active phase of labor in uncomplicated pregnancies does not affect umbilical artery resistance and that the amniotic fluid index is a limited, semiquantitative method of assessing acute changes in amniotic fluid volume.

Adolescent↗

PubMed1993

Diabetes in women older than 40 years of age. Social and medical aspects.

Prevention of Congenital Anomalies. Because the first few weeks after conception are a critical time in terms of embryopathy, good glycemic control should be established before conception in the pregestational diabetic and stringently maintained throughout the first trimester. Encouraging the diabetic woman to achieve stringent glycemic control before conception would virtually eliminate the excess risk of spontaneous abortion and anomalies. Prenatal Diagnosis. For all mature gravidas with diabetes, early prenatal diagnosis of chromosome abnormalities (mainly trisomies) and congenital anomalies should be determined through detailed ultrasound examination, fetal echocardiography, and alpha-fetoprotein determinations. Glycemic Control. Stringent metabolic control is mandatory throughout pregnancy to prevent the risk for macrosomia and maternal-accompanied medical complications, such as preeclampsia. Fetal Surveillance. Structured fetal surveillance evaluating fetal growth and well-being must be pursued throughout pregnancy.

Adult↗

PubMed1993

Glucose intolerance as a consequence of oral terbutaline treatment for preterm labor.

BACKGROUND: In this case series, glucose regulation is examined prospectively during treatment with terbutaline sulfate for premature labor in women who were (1) previously documented as nondiabetic, (2) found to have gestational diabetes mellitus (GDM), and (3) tested for glucose intolerance while terbutaline was being administered. The glucose profiles of women treated with terbutaline were contrasted with the profiles of nondiabetic women and women known to have GDM who were not in premature labor. METHODS: Subjects tested capillary blood glucose an average of five times a day during terbutaline treatment and for 1 week after terbutaline treatment was discontinued. They used memory-based reflectometers that stored and transmitted self-monitored blood glucose data to a personal computer. RESULTS: A significant difference (P = .001) was found between average fasting glucose values (111 +/- 23 mg/dL) for the five nondiabetic subjects treated with terbutaline and values of patients in an historical control group (41 nondiabetic pregnancies [72 +/- 22 mg/dL]) who were not in premature labor. The four diabetic subjects and the one subject who had not been previously tested also experienced higher blood glucose levels during tocolytic therapy. Glucose levels returned to preintervention values with the cessation of terbutaline therapy. CONCLUSIONS: It has been previously suggested that terbutaline increases hepatic glycogenolysis, which may aggravate glucose intolerance. This phenomenon, combined with normal pregnancy-induced insulin resistance, may explain abnormal ambulatory glucose patterns in women who are euglycemic before introduction of terbutaline therapy.

Adult↗

PubMed1993

Glucose tolerance test: degree of glucose abnormality correlates with neonatal outcome.

OBJECTIVE: To determine how well the extent of glucose abnormality, as reflected by the number of abnormal values on the 3-hour oral glucose tolerance test (GTT), correlates with the level of carbohydrate intolerance during pregnancy and with the severity of adverse outcome. METHODS: We followed 764 gestational diabetic women under a once-per-week fasting and 2-hour postprandial serum glucose monitoring system. The subjects were stratified by the number of abnormal values on their GTTs. The level of glucose control and incidence of large for gestational age (LGA) infants were then determined and compared with the findings in 636 gravidas with abnormal screening but all normal GTT values. RESULTS: Patients with one or more abnormal GTT values had comparable incidences of LGA infants, which were all significantly greater than that in the 0-abnormal group (23-27% versus 13%; P < .01). This difference was due to subjects with poor glucose control. The means of the GTT values for each sampling time were greater and the GTT periodicity (the time for the GTT curve to return to the fasting level) was longer with an increasing number of GTT abnormal values (zero versus one versus two versus three versus four abnormal values, P < .02). The mean fasting, 2-hour postprandial, and overall mean glucose values during the study were positively associated with the number of abnormal GTT values. CONCLUSIONS: One or more abnormal GTT values were associated with comparably elevated incidences of LGA infants in patients with poor glycemic control. Achievement of recommended glucose control decreased adverse outcomes to near normal levels.

Adult↗

PubMed1992

Fetal surveillance in pregnancies complicated by insulin-dependent diabetes mellitus.

OBJECTIVE: Our objective was to determine whether maternal vascular disease and/or glycemic control can be related to tests of fetal condition in diabetic pregnancies. STUDY DESIGN: A total of 114 women with insulin-dependent diabetes who used a memory-based glucose reflectance meter were prospectively evaluated. Nonstress testing was begun weekly at 28 to 30 weeks and twice weekly at 32 weeks. A nonreactive nonstress test was followed by a biophysical profile in all cases. RESULTS: A total of 1676 nonstress tests was performed (14.7 +/- 3.2 tests per patient). Eight percent (n = 134) were nonreactive, necessitating a biophysical profile. A comparison of ambulatory glucose profile data, including mean blood glucose level, variation, and excursions from the median, revealed no significant differences in patients with reactive versus nonreactive nonstress tests. Ten patients, including eight with vascular disease, were delivered because of abnormal test results of fetal condition. Nephropathy or hypertension was associated with intervention for fetal well-being in 8 of 20 women (40%) with these risk factors. Only 2 of 94 patients (2%) without nephropathy or hypertension required delivery because of abnormal results of fetal testing (p less than 0.001). One fetal death occurred. No significant differences in the various glycemic parameters were found in women delivered for suspected fetal jeopardy versus the nonintervention group. CONCLUSION: Pregnancies complicated by vascular disease are at greatest risk for abnormal results of fetal testing that necessitate early delivery. Women without vascular complications and with maintenance of good glycemic control rarely have fetal compromise.

Delivery, Obstetric↗

PubMed1992

Use of a more physiologic oral glucose solution during testing for gestational diabetes mellitus.

A lower osmolar oral glucose solution (50 g glucose in 450 mL fluid, 0.62 mol/L) was administered in addition to the standard hyperosmolar oral glucose solution (100 g glucose in 300 mL fluid, 1.85 mol/L) for oral glucose tolerance testing 1 week apart to 102 pregnant women. The standard oral glucose solution creates delayed gastric emptying and is associated with frequent nausea and vomiting. Results using the modified, lower osmolar glucose solution, when compared to the standard hyperosmolar glucose solution showed (1) statistically equivalent glucose excursion values 30 minutes after ingestion, (2) statistically significant decreased plasma glucose values greater than or equal to 60 minutes, (3) no statistically significant difference in insulin excursion values 30 minutes after ingestion, (4) equal area under the curve for glucose at 30 minutes using either solution, and (5) a markedly decreased incidence of nausea and vomiting. These data suggest that the modified, lower osmolar glucose solution empties rapidly from the stomach and allows the glucose to be absorbed and enter the peripheral circulation in an expeditious manner.

Administration, Oral↗

PubMed1992

Glucose tolerance test periodicity as a descriptor of glucose tolerance abnormality.

The periodicity of the standard 100-g glucose tolerance test (GTT) was examined in a prospective study of 194 pregnant patients to determine how well gestational diabetes could be identified. A simplified formula, the GTT periodicity, was used to estimate the time for the GTT curve to return to the fasting level. One hundred one study subjects had all normal glucose values by the National Diabetes Data Group criteria (0-abnormal group), 47 had one value greater than normal (1-abnormal group), and 46 had more than one value abnormal or gestational diabetes. The 0-abnormal patients had a significantly shorter GTT periodicity than did 1-abnormal or gestational diabetic mothers (3.6 versus 4.8 versus 6.6 hours, respectively; P less than .04). Calculating the periodicity for the corresponding insulin excursions yielded significantly increasing values in a graduated fashion for each group (5.2 versus 6.9 versus 9.6 hours, respectively; P less than .05). Examination of the oscillation of the GTT curve about the fasting level allows a physiologic description of normal and abnormal glucose responses in pregnancy. Furthermore, our findings suggest that glucose and insulin periodicities are useful predictors of gestational diabetes in patients with positive screening.

Adult↗